Preventive Health Program

State: NY Type: Model Practice Year: 2005

Many people are unknowingly infected with Hepatitis C and many others not immunized against Hepatitis A or B. The public is generally unknowledgeable about Hepatitis A, B or C. The intent of the practice is to decrease mortality and morbidity relative to Hepatitis A, B or C infection rate in Western New York.Goals and objectives were as follows: Goal 1 – Reduce mortality and morbidity secondary to Hepatitis infections  Objective – Patient, provider, and public education; prevention by harm reduction methodology; and improved immunization screening rate - offered to 100% of eligible client base.  Goal 2 – Screening rate of 100%  Objective – Staff commitment and client receptiveness.  Goal 3 - Continued case finding and case management  Objective – Case finding through interview and laboratory results; personal notification of infected clients; and referral for medical follow-up and/or staff social worker.
The public health issue addressed by this practice is the “hidden epidemic” of Hepatitis C as well as Hepatitis A and B. The issue was determined to be relevant based on CDC statistics and on an understanding through interview process of the lifestyle of many of the clients seen over the years in the Preventive Health Clinic. The practice of integrating Hepatitis C testing and immunization for Hepatitis A and B into the clinic setting addresses past and present risk factors in the client’s lifestyle for Hepatitis infection. This is done through interview, testing, and education regarding the various types of hepatitis; how they are contracted; and how they can be prevented or medically managed. When Hepatitis NonA/NonB became known as Hepatitis C the Preventive Health Program had already integrated routine testing for Hepatitis B and was implementing integration of Hepatitis C screening. In 1998 the State University of New York at Buffalo Research Institute requested a collaboration involving a study of approximately 3000 clients from the clinic setting of which 1600 were to be selected as subjects. A nurse-conducted, computer-based survey determined eligibility for the study. The client’s blood was drawn for Hepatitis C testing. This was followed by either an immediate intense survey by the Research Institute nurse as prompted by computer response or a later intense survey based on positive Hepatitis C results. The objective was to draw a correlation of anti-Hepatitis C positive clients to sexual behaviors and/or substance use including alcohol. It soon became evident through the expanded computer survey and intense survey that the assumption as to the potential risk of Hepatitis C infection in the clients was grossly underestimated. Erie County’s Preventive Health Program expanded its role in disease prevention, specifically Hepatitis C, in 1998 when it became the first Health Department in New York State to integrate testing into the flow of the clinic. As with other public health issues, the Preventive Health Program was a leader in this innovation, and its further expansion of services again proved successful and has since been used as a model for other counties in New York State and around the country. Under the leadership of the clinic coordinator, Cecelia Kohlmeier, RN, MS and the support of the Health Department, the integrated Hepatitis C services have brought to light many previously undiagnosed cases of Hepatitis C. Those clients found to be infected have since been referred and are, hopefully under the care of a hepatologist and will have, pending eligibility, been immunized for Hepatitis A and B.
Agency Community RolesCollaboration has played a large part in the success of this practice. The study that was done in the clinic for the Research Institute served to increase medical staff understanding of the disease as it relates to lifestyle (past and present). Whereas the slate was fairly clean at the beginning of the study, the staff quickly saw patterns emerging as the survey tool divulged client behaviors.Further collaboration has occurred between the Preventive Health Program and other county health departments as an outcome of the Hepatitis C integration success. Through a grant written by the Erie County Health Department using the Preventive Health Hepatitis C Integration as a model, funding was acquired from the Center for Disease Control (CDC) Hepatitis Grant for continued testing in Erie County and introduction of testing in 6 other counties of Western New York. Those other counties have since become independent in their funding for Hepatitis C Integration. Since the introduction of Hepatitis C Integration in the Preventive Health Clinic, testing has also been done in off-site schools and agencies with whom the program collaborates for services. The Erie County Public Health agency’s roles in this practice are funding, staffing and laboratory services. Collaboration also occurs between the Preventive Health Program and other programs within the Erie County Health Department. Those other programs educate the public through their outreach initiatives about Hepatitis A, B and C and encourage testing and prevention through lifestyle changes and immunizations. The main partner (The Research Institute) in this practice worked with the clinic staff for almost 5 years to attain enough eligible clients for the study. In addition to augmenting the pre-existing integration program, the study helped make the practices of the Erie County Health Department more attractive to the public by providing a monetary incentive for their involvement. This was done by a nurse-researcher who worked out of one the clinic offices and interacted with the staff and clients. After the predetermined number of clients was attained, the nurse researcher moved back to the Research Institute with the data she had compiled. The director of the study, Dr. Marsha Russell, who works from Berkley, California, also was strongly involved in the implementation of the study. The practice continues today minus the study. Outcomes of the study will be published at a later date by the Research Institute. Also providing input were the National Institute of Health and the National Institute on Drug Abuse. Another partner in this practice was a Hepatitis C grant program staffed by Erie County Health Department and designed to help the other Western New York counties integrate Hepatitis C testing into their clinics using the ECHD practice as a model. The Western New York HIV/AIDS Public Health Coalition also played a role as partner to the practice in that open discussion of our innovative approach to Hepatitis C and Hepatitis A/B immunization integration was discussed at the round-table enabling the other county health departments to better visualize how the practice should work. The initial funding for Hepatitis A immunization was supplied by the AIDS Institute, yet another partner in our efforts to prevent the spread of Hepatitis. Stakeholders have an important role in the success of the Hepatitis C Integration practice. Stakeholders are the client, the public, families of anti-Hepatitis C clients, intravenous drug users, cocaine users, health providers, the over 50 population, HIV infected clients and the homeless. If the client, the public and other health providers fail to see value in the practice, the practice would fail. Therefore, continued care and education are provided for the public and health professionals alike. The program use one-on-one patient education; public announcements distributed by the Eri Costs and Expenditures Practice Costs: Cost for nursing staff was not effected. Staff was already in place and incorporated the new tasks into their patient interaction.  Staff time was also not effected in terms of number of hours worked per nurse, but time spent with each client was increased by approximately 10 to 15 minutes.  Resources needed were additional funding from the Erie County Health Department for the tests done on blood samples at the Erie County Health Department Laboratory. Funding Sources: The Erie County Public Health Administration has been behind this project financially since the beginning.  Other revenues have been generated by participation in the Research Institute Hepatitis C study and other grant pharmaceutical sources. Implementation Tasks for achieving objectives of Goal 1: Staff attended conferences on Hepatitis C, Hepatitis C and HIV co-infection, Hepatitis A and B vaccines (schedules and criteria for immunization).  Staff received instruction regarding Research Institute computerized survey tool, interview skills and procedures for moving client through the study process.  Staff received instruction for integrating survey into normal interview format.  Erie County Health Department committed to funding expense for laboratory testing for Hepatitis C.  Laboratory expressed commitment to testing blood samples for Hepatitis C to be followed with EIA and RIBA for confirmation for as long as study took. Confirmatory testing to end at end of study.  Nurses were already skilled in difficult blood draws – able to obtain almost all blood samples except on the patient’s whose veins are severely damaged secondary to intravenous drug use. Tasks for achieving objectives of Goal 2: Staff familiarized themself with the survey tools in order to become comfortable with the questions and to ascertain sincerity of answers in order to determine even after study through ordinary history taking what might have put the client at risk of contracting Hepatitis.  After study, laboratory continues to test blood for Hepatitis C often giving ALT level for anti-Hepatitis C positive clients and reporting signal to cut-off ratio.  Clients informed personally of Hepatitis C status. Notified by investigative staff to call nurse in case they do not call back for their results. Nursing staff informs all anti-Hepatitis C positive clients to seek medical follow-up with a doctor of their choice or from a list of recommended hepatologists.  A social worker on staff in the clinic is given a referral to work with the client if the nurse feels there are significant emotional or social issues related to the client’s diagnosis.  Similar steps are taken for clients found to have a current or resolving Hepatitis B infection indicated by presence of the Hepatitis B surface antigen or core antibody.  Tasks for achieving objectives of Goal 3: Nurses and physician assistants explain to the client the reason for all tests done as part of the STD screening. If the patient is reluctant or does not seem to comprehend, further education is provided.  Nurses and physician assistants discuss with the client how behaviors reported during history taking put them at risk and how to alter those behaviors to afford less risk.  Partner protection, partner notification and understanding of how STDs are spread are stressed during all phases of the client visit.  Nurses and social worker (if indicated) work with client towards compliance in seeking further medical follow-up, emphasizing possible negative outcomes if no care obtained vs. expected prolonged good health if care is obtained.  Nurses and physician assistants educate client regarding relationship between Hepatitis C and HIV. HIV test is offered along with the routine blood draw for RPR and hepatitis B and C. Nurses and physician assistants discuss with intravenous drug users and others who use needles for self-medication needle exchange programs and needle return programs. Proper cleaning of works is also discussed.  Nurses and physician assistants educate clients about the benefits of Hepatitis A and B vaccines and encourage immunization. Completion of the series for each type of vaccine (Havrix, Energix or Twinrix) is emphasized as essential for full protection.  The client is taught that the vaccines for Hepatitis B or A/B are a means of preventing cirrhosis of the liver and cancer of the liver due to Hepatitis B. The client is also taught that immunization decreases spread
Their interests in realizing a continued benefit from this program hinge on their understanding of the impact of liver disease as it pertains to the individual, the family, the community, potential occupational exposure, and societal cost in a monetary and humanitarian sense. Education is at the heart of promoting continued support provided through one-on-one client education, public service announcements (ECHD and NYSDOH supported), word of mouth, continuing education of clinic staff and cooperation between public health and private health care providers to stress the importance of testing and immunization to clients. Patient satisfaction surveys indciate that many clients are referred by private physicians. Clients also participate in the Preventive Health Program because of information they have obtained from the ECHD or NYSDOH Internet sites. Additionally, many clients research health related topics on other Internet sites through their search engine and come to the Preventive Health Program for more information, testing and immunization.The ECHD Preventive Health Program is planning to expand services related to Hepatitis A, B or A/B immunization to the Erie County Holding Center and Wende Correctional Facility with a plan to provide post-discharge completion of the immunization series.