Developing and Improving a Fast Track Services Program in Chicago STD Clinics William Wong, MD Division of STD/HIV/AIDS Chicago Department of Public Health City of Chicago National STD Prevention Conference Chicago, IL – March 10-13, 2008

Chicago Department of Public Health STD/HIV Specialty Clinics Largest public STD clinic system in the Midwest –Consisting of 5 STD Specialty Clinics –In 2006: 30,636 clinics visits Increasing service demands and dwindling resources result in patient turnaways –In 2006: 3,036 (9%) Patient turnaways –Turnaways referred to other site or asked to return next day Need to increase clinic efficiency to ensure access to high quality services and to focus resources on patients at highest risk for STDs and sequelae

STD/HIV Fast Track Services In 2006, CDPH introduced STD/HIV “Fast Track Services” (FTS) in two STD clinics as an alternative to comprehensive patient evaluations Eligibility based on symptom and risk assessment Benefits: –Increases clinic efficiency and capacity –Delivers screening tests to asymptomatic patients –Expands patient access to drop-in STD/HIV services –Decreases patient turnaway numbers

To develop, implement, and evaluate an STD clinic fast track service program To identify additional program components to enhance operational efficiency Objectives

Pilot Testing: Methods Developed program protocols, training materials, and screening questionnaire Conducted pilot testing: –Clinic A: November - December 2006 –Clinic B: January - December 2006 Compared utilization rate, test and treatment results Conducted focus groups among staff to identify barriers and facilitators of implementation and effectiveness Implemented intervention to improve operational efficiency

Patient Demographics Clinic A n=1115 Clinic B n=8247 Male723 (67%)4531 (55%) Female351 (33%)3716 (45%) Black339 (31%)8047 (98%) White397 (36%)48 (0.6%) Hispanic294 (26%)142 (2%) Other85 (7%)10 (0.1%) ≤ 20 years56 (5%)1290 (16%) years543 (49%)4067 (49%) ≥ 30 years516 (46%)2889 (35%)

Pilot Testing: Results n=1,115n=8,427

Laboratory Results STS: Serological Test for Syphilis

Majority of patients had clinician visit Lower rates of STDs were identified among FTS patients compared to clinician visit patients Asymptomatic chlamydial infection was the most common STD diagnosis among FTS patients, followed by previously diagnosed syphilis Acceptance of FTS differed between Clinic A (19%) and Clinic B (0.7%) Pilot Testing: Summary

Questions Why did Fast Track Service utilization differ between Clinics A & B? Did differences in clinic populations contribute to differences in FTS utilization rates? Were there any differences in the implementation process at each clinic? What additional measures could be done to optimize program performance?

Evaluation: Methods Fast Track Service data presented to staff Conducted focus groups with pilot STD clinic staff to identify implementation issues and to recommend improvements Sessions conducted May-October 2007 Responses analyzed to identify common themes

Facilitators to Implementing Fast Track Service Patients were motivated to obtain clinic services Patients liked the faster service and did not want to wait for the clinician Patients, especially men, liked the urine test (No Swab!)

Barriers to Implementing Fast Track Service Some patients didn’t understand the program, or the questions being asked Some patients didn’t recognize their symptoms –e.g. patients could not distinguish between discharge, rash, and burning sensation Patients asked many questions during screening Staff had to convince patients to use FTS Staff transitions affected continuity of services

Patient Trust Patients wanted to see the “doctor” and asked “Are you a doctor?” to the medical assistant performing FTS screening Some patients wanted a clinician’s reassurance, and did not feel comfortable with FTS Some patients did not trust the urine test

Program Recommendations and Enhancements Develop standardized protocols, signage, & training Use script to standardize messages Present information about FTS earlier in the waiting area (e.g. via health educator, signage) Ask directly whether patients are having burning, itching, discharge, etc. instead of asking “Are you having any symptoms?” Make other staff available to answer questions Have staff wear a white coat to “look official” and to gain patient confidence

Preliminary Evaluation Results of Fast Track Services Pre- and Post-Program Enhancement Clinic AClinic B 0.7 n=1115n=1688n=8427n=2577

Discussion Turnaways were reduced after intervention Smaller proportion of patients received FTS Effect of merger of 2 CDPH STD clinics (?) Differences in FTS utilization rates affected by: –Percent of patients presenting with symptoms –Prevalence of disease in the population –Percent of patients seeking STD check-ups –Patient acceptance of non-clinician visits –Effective service implementation by staff

Fast Track Services –are feasible –create quality drop-in STD/HIV screening services utilizing existing staff –expand clinic capacity –identify asymptomatic infections, especially chlamydia, among those patients at highest risk Utilization rates of risk-based triage programs will differ in different settings due to variations in morbidity, screening behaviors, and patient populations Conclusions

Acknowledgements Thank you to all the great medical assistants, clerks, supervisors, DIS, laboratory technicians, nurse practitioners, and physicians committed to delivering outstanding and efficient services for all of our patients! Co-Authors Tameeka Johnson, MHRMTammy Rutledge, MPA Leah QuinnJennifer Broad, MPH

Contact Information William Wong, MD Director, STD/HIV Prevention and Control Services Medical Director, Division of STD/HIV/AIDS Chicago Department of Public Health City of Chicago Phone:

Fast Track Program Screening Questionnaire 1.Are you having any symptoms? 2.Did someone (doctor, partner) tell you to come here today? 3.Has one of your partners told you they have an STD or HIV? 4.Have you had an STD within the last 6 months? 5.When, if ever, was the last time you traded sex for drugs or money? 6.When, if ever, was the last time you injected drugs? 7.Do you have sex with men, women, or both? 8.Are you here with your partner? 9.For women only: Are you pregnant?

Fast Track Risk Assessment Low Risk Patients High Risk Patients STD Services FAST TRACK Clinician Visit HIV Testing Services HIV Prevention Education HIV Enhanced Counseling