Improving Access
RN Managed STI Screening Clinic Dian Peavey University of Texas at Austin In 2015-2016 49% of Students at UT accessed care at UHS.
In 2016 UHS shifted to Open Access Scheduling. Goal: Increase primary care appointment availability
Initial Planning:
Evaluate current services and utilization
Identify fundamental medical needs of our population
Align services with national strategic plans (Healthy People/Campus 2020, National HIV/AIDS Strategy, National Prevention Strategy)
Structure services to improve access. 2014 CDC Called for In recent years more than Improved collaboration half of state STD programs between public health and have budget cuts primary care.
Improve Access
ACA improved acces to Healthy People 20/20 Goals preventive care and screening. ACHA/NCHA Goals Including STD testing
Only 30% of sexually active young people age 14-24 are screened for STIs Barriers to STI Screening?
Lack of knowledge of STIs and available services
Cost
Shame/ embarrassment associated with seeking services
Long clinic waiting times
Discrimination
Specimen collection methods
Understanding STD/HIV Risk
• Multiple Partners and/or partners with multiple partners • Anonymous sex partners • Unprotected sex - lack of barrier protection (condoms) • Young age (<25y/o) • MSM • Drug and alcohol use • Living in high prevalence community • Having an STD or a partner with an STD • Gender, race, ethnicity • Gender/power inequities • Having HIV National Response to STD Epidemic
•Providers: make STD screening a standard part of medical care
•Public: talk openly about STDs, get tested regularly, and reduce risk by using condoms or practicing mutual monogamy if sexually active.
•Parents and providers: offer young people safe, effective ways to access needed information and services.
•partners to maximize their impact. CDC Strategies for Prevention and Control of STIs
• Perform an accurate risk assessment and provide education and counseling on ways to avoid STIs through changes in behaviors and use of recommended prevention services.
• Provide pre-exposure vaccination of persons at risk for vaccine-preventable STIs
• Perform screening to identify asymptomatically infected persons.
• Effective diagnosis, treatment, counseling, and follow up of infected persons.
• Evaluation, treatment, and counseling of sex partners of persons who are infected with an STI. Plan for Nurse Facilitated STI Screening Clinic
RNs will perform STI risk assessments, laboratory testing, and risk reduction counseling to asymptomatic patients. Lab testing is performed under Standing Delegation Orders.
Standing delegation orders (SDOs): are written orders, or procedures prepared by a physician and designed for a patient population with specific diseases, disorders, health problems, or sets of symptoms.
Texas Administrative Code: SDOs provide authority and a plan for use with patients presenting themselves prior to being examined or evaluated by a physician. SDOs are distinct from specific orders written for a particular patient. Texas Administrative Code also allows SDOs for treatment of STIs
The prescription shall be for one of the following classes or types of drugs: oral contraceptives, contraceptive creams and jellies topical anti-infectives for vaginal use; (iv) oral anti-parasitic drugs for treatment of pinworms; (v) topical anti-parasitic drugs; or (vi) antibiotic drugs for treatment of venereal disease. (C) The prescriptions may not be issued for any controlled substance. (D) The providing of the drugs shall be in compliance with the Texas Pharmacy Act and rules adopted by the Texas State Board of Pharmacy.
(5) the administration of immunization vaccines providing the recipient is free of any condition for which the immunization is contraindicated; shall be in compliance with the Texas Pharmacy Act and rules adopted by the Texas State Board of Pharmacy. Program Development Challenges
• Collaborative agreements have traditionally involved advanced practice nurses. • Medical Director support/supervision • Defining Nursing scope of practice – Assure alignment with Nursing Practice Act, and state medical and nursing boards.
• Defining and develop Nursing Competencies
• Staffing - Nurse recruitment from existing position for expanded roles .
• This will not happen without nursing engagement! Program Planning and Development
October 2015 January 2015 June 2015 Competency Evaluations Training at Health Department Scheduling Templates/Webbooking Goal: Increase Capacity Begin Continuing Ed EHR Template
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
March 2015 Proposal RN STI Screening Clinic July 2015 November 2016 First Patients Scheduled Texas Medical Board Standing Delegation Orders (align with Texas Board of Nursing current standards) Risk Assessment worksheet Nursing Scope of Practice Patient Information/Social Media Pre-visit Questionnaire STI Screening Visit
• Obtain Sexual History: Review pre-visit questionnaire, Follow CDC guidelines for obtaining sexual history during patient interview.
• Evaluate STI and Hepatitis risk: Patients past Partners, sexual Practices, Protection from STIs, past history of STIs, Protection from Pregnancy.
• Recommend Appropriate testing and obtain verbal consent (Opt in).
• Counsel: Actions to reduce STI/HIV risk and the importance of partner treatment.
Follow CDC guidelines for CT/GC screening & test the site of exposure
Practices Recommended Testing
Insertive Urine NAAT (oral vaginal, anal) Rectal swab NAAT (Nurse collected) Anal Receptive (Currently conducting validation study for self- collected rectal and pharyngeal swabs)
Vaginal receptive Self Collected Vaginal swab NAAT
MSM- Pharyngeal swab NAAT Oral (Male and female heterosexual contact- testing is generally not recommended, but we recommend if that was only contact)
NAAT: Nucleic Acid Amplification Tests STI Screening Clinic Services
Nursing Actions The ACHA-National College Health Assessment (NCHA) fall 2016 HIV and STI testing 28 % Reported ever being tested for (HIV) infection Hepatitis B and A Vaccine 69 %* Reported receiving vaccination against hepatitis B Reported receiving vaccination against HPV Vaccine 52%* Human Papillomavirus/HPV
Screening for Sexual 2 % Sexual penetration without their consent violence/abuse/assault 2 % A physically abusive intimate relationship 2 % A sexually abusive intimate relationship Contraceptive Counseling 56%* Female Contraceptive use with vaginal sex. Reported having a routine gynecological Womens Health evaluation 42% exam in the last 12 months referral
After review of positive rates
Promotion efforts to high risk groups
Provide risk reduction counseling specific to population UHS Positive Rates Positive Rates
2012-2013 2013-2014 2014-2015 2015-2016
Chlamydia
Male Female Male Female Male Female Male Female
84 103 93 126 118 187 159 232
Gonorrhea
16 6 29 3 69 5 103 7
Syphilis
6 0 6 0 3 0 13 0
HIV
3 0 2 0 6 0 5 0 Men that have sex with men continue to be the most affected by the HIV epidemic in the U.S.
At current rates, 1 in 6 MSM will be diagnosed with HIV in their lifetime, including:
• 1 in 2 Black MSM
• 1 in 4 Latino MSM
• 1 in 11 White MSM
More than Half of Young HIV-infected Americans Are Not Aware of their Status STI Screening Clinic and Provider Appointment Volume
Patient Visits for STI Screening or STI Concern 1400 1278 1200 1067 Improving Access 1000 893 800 584 600 497 400 200 107 0 2015 2016 2017 (1-1-17 thru 5/5/2017)
General Medicine and Womens Health STI Nurse Screening Clinic
Patient Satisfaction
How satisfied are you with the following? satisfied or very satisfied
The nurse who conducted the testing 99%
Explanation of charges 86%
Privacy of Visit 98%
Overall experience with STI testing at UHS 98%
The length of time between scheduling my appointment and my actual appointment. 100%
The nurse made me feel comfortable 98%
The nurse listened to my concerns 100%
As a result of my conversation with the nurse, I am more likely to implement strategies to lower my risk of contracting a sexually transmitted infection 93% Other Services
Austin Travis County Health Department
Austin Mobile Van
AIDS Services of Austin Q Mpowerment
Austin Harm Reduction Services
Online Testing SDOs for treatment of Next Steps positive CT/GC results
Continute to expand RN role using standing delegation orders that Truvada Patient align with Texas Medical Board and Texas Navigation Department of Health template for standing orders for nurses. Campus Outreach Clinics/lectures