An interview with San Antonio Metropolitan Health District (Metro Health)
1) Describe your innovation.
The San Antonio Metropolitan Health District (Metro Health) STD/HIV Branch developed a new initiative, Healthy Beats, in 2013 that: (1) provides coordinative prenatal care and referral services to at-risk pregnant women throughout the length of their pregnancy, (2) ensures appropriate testing and treatment for syphilis occurs during patient's pregnancy at specific time intervals, and (3) provides services that include enrollment counseling, health education, referral services, prenatal and pediatric provider education and linkage to care.
2) What problem or challenge does it address?
- This initiative was created to address the significant number of congenital syphilis cases that San Antonio and Bexar County are facing. The rates of congenital syphilis (CS) in Bexar County have increased 55% over the past five years (2008-2013). The 2012 CS rate (69.4) in Bexar County was 3.4 times higher than the 2012 Texas rate (20.5) and 8.9 times higher than the 2012 US rate (7.8). Five congenital syphilis stillbirths were reported in Bexar County in 2012.
- In addition, Bexar County’s rate of infectious (primary and secondary stages) syphilis was 3.0 times higherthan the Texas and US rates.
- Congenital syphilis occurs when syphilis is passed from an infected pregnant woman to her fetus during the pregnancy or to her infant during delivery. Congenital syphilis can lead to stillbirth, neonatal death, birth defects or disorders such as deafness, neurologic impairment and bone deformities. Untreated early syphilis in pregnant women results in fetal or infant death in up to 40% of cases.
- Congenital syphilis can be prevented by early detection of maternal syphilis infection during pregnancy and treatment as soon as possible. Metro Health encourages every pregnant woman to ask for three syphilis tests during her pregnancy: 1st during the first trimester; 2nd early in the third trimester; and 3rd at delivery.
- In Texas two syphilis tests during pregnancy are required by law for all women: at the first prenatal visit and at delivery. The Centers for Disease Control and Prevention recommends that women in areas of high syphilis prevalence, such as Bexar County, get tested for syphilis during the early third trimester of their pregnancy, in addition to their first prenatal visit and at delivery.
3) When and/or how was the program or policy initiative originally conceived in your jurisdiction?
The Metro Health STD/HIV Branch developed this new initiative early in 2013 at the direction of the Health Director, Thomas Schlenker, M.D. He set the program’s guiding policy: “Metro Health STD Clinic will continue its reorganization to prioritize the detection and treatment of syphilis among pregnant women. All pregnant women who present to the clinic for any reason will be considered high risk and monitored throughout the duration of their pregnancies.”
A small initial case management program was designed without any additional funding to address this rise in congenital syphilis. It followed every pregnant woman that visited the STD Clinic. It aimed to help pregnant women remember to attend prenatal care visits, to obtain testing to identify syphilis infections, if they occur, and provide treatment as early as possible. This effort was evaluated and lessons learned were utilized to apply for funding to enhance these initial services.
Late 2013, this program became funded by the 1115 Medicaid Waiver overseen by the Centers for Medicare & Medicaid Services (CMS) and Texas Health and Human Services Commission.
4) Describe why the program or policy innovation is innovative?
This program is innovative because it provides for clinical case management and case investigation of all high risk pregnant women encountered in the STD Clinic to assure appropriate prenatal care and third trimester syphilis screenings occur to prevent transmission of syphilis cases and other STDs. Currently, there are no other case management programs in Texas that specifically target high risk pregnant women in a STD clinic in this manner.
5) How has your innovation changed previous practice and improved the organization?
This program has improved Metro Health in many ways. It has moved Metro Health more prominently into a proactive role working to educate, empower and intervene early in at-risk pregnant women’s lives to prevent the tragedy of preventable congenital syphilis case.
It has changed operations as well. The staffing complement was expanded twice to adequately provide for this new service. Clinic flow and clinic records were modified to incorporate these services. Internal collaboration was required to ensure all programs in the STD Branch worked collectively to ensure the success of the program.
6) How have you determined its success? What measurements have use used?
The program’s success is measured with multiple metrics. One measure (10/2013-9/2014) is that 120 high risk pregnant women were provided clinical case management services. Another measure over the same time frame was to expand STD clinic capacity (hours and/or staff per shift) to receive additional patients identified through community outreach activities and provide prompt and appropriate screening and treatment for syphilis and other sexually transmitted diseases.
7) Please describe the most significant obstacle(s) encountered thus far by your program. How have they been dealt with? Which ones remain?
a) It continues to be a challenge to retain qualified nursing staff for the case manager position. The salary range for the position was increased to attract qualified nurses.
b) Most of the pregnant women enrolled in case management services were identified during a visit to the STD clinic. Many more pregnant women at high-risk for contracting syphilis don’t visit the STD clinic. Two additional staff were hired to support outreach operations; however, the case manager position is still vacant.
c) The program currently provides referrals for services; it lacks intensive counseling and the ability to conduct home visits, which would better address psychosocial needs. Hiring additional nursing staff, will help the program expand services.
d) Full support and cooperation from many of the units in the STD/HIV Branch helps ensure pregnant women are afforded an opportunity to participate in this program. This took time to develop, but is occurring now.
e) Limited dedicated staff to assist with data entry. One staff, the PHA, was hired during this project and is able to assist with much of the data entry. Additional staff are to be hired soon to support the administrative work load.
f) Staff faced opposition from many of the pregnant women; they were not interested in our services because of the program name in use at the time “case management.” Based on their feedback, we changed the name to “Healthy Beats.” Women are more receptive to this name. Changing the brand has helped tremendously.
No dedicated staff to assist with data entry.
8) What outcomes did this program or policy have?
The most critical metric was to enroll 120 pregnant females into the case management program during 10/2013 to 9/2014. Staff enrolled 167 at risk pregnant females into the program, established eight new collaborative internal and external partnerships, and hosted a newly developed maternal health education and syphilis/HIV screening event for 15 pregnant mothers. With the addition of the case management services, we have seen great improvement in healthcare services within our clinic.
For example, in calendar year 2013, 63% of the pregnant women that visited the STD clinic were enrolled in this case management program. This percent increased by 16% to 73% in the first seven months of 2014. Only 12 – 13% of the pregnant women enrolled in the case management program (Jan. 2013 – Jul. 2014) were diagnosed with syphilis during their pregnancy. Of these 30 women, 92 – 94% were successfully treated to prevent a case of congenital syphilis in their infant. The program utilized epidemiological data to determine the number of individuals who received treatment for P&S syphilis and completed follow-up testing at 6 months. This allowed a baseline to be established and development of processes to improve our follow-up rates.
9) What does the future of the program hold?
Metro Health envisions a full case management program that can provide expanded services to the high-risk pregnant females across Bexar County. An outreach component will be developed to provide services to pregnant women who are unable to come to the clinic, ensuring that enrolled women will receive follow-up services through the program. Staff are also developing a provider education tool kit which will be used to educate health care providers in Bexar County regarding the importance of third trimester testing to prevent future congenital syphilis cases. Education and awareness regarding congenital syphilis in the community is important. Therefore, educational campaigns through outreach and advertisement will increase once more staff are on board.
10) What lessons would you suggest for local government interested in adapting this idea?
1) Ensure that all stakeholders have a clear understanding of what needs to be accomplished and make sure VOC processes are part of the initiating phase and throughout the project.
2) Clearly defined policies and procedures for project are imperative.
3) Apply continuous quality management tools to the project
4) Continue to conduct prenatal case management services to prevent congenital syphilis and to enhance resources available for women in need of STD/HIV prevention by keeping them connected with the health care system.
5) Deploy project management tools and processes from the conception of the initiative in order to produce the best product for the community and ensure the highest level of return on investment.
6) Consider adding field enrollment to reach more at-risk women.
7) Consider adding temporary staff to assist with data entry.
11) Anything else you’d like to add?
“Congenital Syphilis Is preventable,” said Dr. Mangla, “If syphilitic mothers will take adequate treatment during the last five months of pregnancy and providers are aware and provide the early third trimester syphilis test to women, this simple change in policy will make a major difference in decreasing the congenital syphilis cases in Bexar county.”
CDC, Sexually Transmitted Diseases Surveillance 2013, National Profile, Syphilis, updated 12-17-2014