Program Collaboration and Service Integration:

1. Program Collaboration and Service Integration: Kevin O’Connor, PTB, DSTDP National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention March, 2008

2. CDC NCHHSTP Organizational Chart Global AIDS Program Division of Sexually Transmitted Diseases Division of Viral Hepatitis Division of HIV/AIDS Prevention Division of TB Elimination

4. Overview • Rationale for PCSI • PCSI Definition/Vision • External Consultation – Brief Summary • Next Steps

5. Drug Users Surveillance/ Strategic Information MSM Corrections Maximizing Global Synergies CDC Goals and Strategic Imperatives National Center for Program Integration HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Health Disparities Director Associate Director Associate Director Kevin Fenton for Communications for Program Integration Susan Robinson r Susan DeLisle Deputy Director (Acting) Associate Director Associate Director for Health Disparities Hazel D. Dean Reducing Health Disparities for Science (Acting) Terry Chorba Raul Romaguera Program Integration Associate Director Associate Director Management Official for Laboratory Sciences for Planning & Policy Coordination Sal Butera Michael Melneck Eva Margolies Divisions Global Antenatal Modeling/ Health Results Measures HIV/AIDS Prevention HIV/AIDS Prevention Viral Hepatitis STD Tuberculosis Global AIDS Intervention Research Surveillance & Prevention Prevention Elimination Program & Support Epidemiology Director Director Director Director Director Director Robert Janssen Robert Janssen John Ward John Douglas Kenneth G. Castro Deborah Birx

6. HIV/AIDS, Hepatitis, STD and TBCommon determinants • Similar or overlapping at-risk populations • Disease interactions • Common transmission for HIV, hepatitis and STDs • STDs increase risk of HIV infection • Clinical course and outcomes influenced by concurrent disease • Social determinants • Poor access to, and quality of, health care • Stigma, discrimination, homophobia • Socioeconomic factors, such as poverty

7. Program Collaboration and Service Integration (PCSI) Operating Definition: A mechanism of organizing and blending inter-related health issues, separate activities, and services in order to maximize public health impact through new and established linkages between programs to facilitate the delivery of services

8. Program Collaboration and Service Integration (PCSI) • Integration should be focused at the field or client level where the interface between the system and the consumer takes place. • Integration results in more holistic services for clients, regardless of the agency structure.

9. Program Collaboration and Service Integration (PCSI) Goal: Provide prevention services that are holistic, science based, comprehensive, and high quality to appropriate populations at every interaction with the health care system. Vision: Remove barriers to and facilitate adoption of service delivery integration at the client level by aligning NCHHSTP activities, systems, and policies with this goal.

10. Principles of Effective PCSI • Appropriateness • Effectiveness • Flexibility • Accountability • Acceptability

11. Barriers to Service Delivery Integration(Summarized from reports, briefs, literature) • Restrictive and inflexible use of categorical funds • Prescriptive program announcements and discordant reporting requirements • Burdensome and inefficient “administrivia” • Lack of harmony, consistency, synchronization of data collection and surveillance • Lack of integrated prevention guidelines • Insufficient translation, integration of science and program • Insufficient support, both technical and financial, for cross training, evaluation and dissemination of best practices

12. CDC Consultation on PCSIOverall meeting objectives • To advise NCHHSTP on the development of Program Collaboration and Service Integration (PCSI) activities over the next five years • Assist in establishing priorities for PCSI; short term and longer term • Identify what CDC can do to assist local PCSI efforts • Identify what CDC can do to improve its own efforts toward PCSI

13. CDC Consultation on PCSIProcess for Identifying PCSI Participants • Planning Committee of national organizations • NCSD, NASTAD, NTCA, Hep. C Coord., UCHAPS, CSTE, NNPTC • Peer selection process for Non-CDC members, obtained diversity using selection criteria: • Large and small size programs (both in funding and population) • Integrated and non-integrated programs (structurally and service delivery) • Urban and rural states; High morbidity and lower morbidity states/cities • Equity across diseases (HIV, TB, STD, viral hepatitis) • NCHHSTP Divisions nominated surveillance breakout session participants, DHAP nominated 5 CBOs for consultation

14. CDC Consultation on PCSIAttendees • Broad range of external and internal stakeholders (approx.125) • Grantees – 7 from each program, 5 CBO’s (LGBT, corrections, substance abuse, AF/AM women) • NNPTC, RTMCC, AETC • CSTE and 3-4 state surveillance coordinators from each program • CHAC, ACET representation • Representatives from each NCHHSTP Division • Other federal agencies (e.g. HHS,HRSA, SAMSHA, OPA, ) • Non federal partners (e.g. ASTHO, NACCHO, ASHA) • 40 Project areas/jursidictions represented

15. External Consultation Charge • Obtain top three priorities in….. • Opportunities for PCSI implementation • Policy improvements related to opportunities • Performance measures for levels of service integration • Workforce developmentand training needs

16. Priority Opportunities • Integrated surveillance and data efforts • Integrated training efforts • Integrated funding

17. 1. Integrated Surveillance and Data • Integrated surveillance reports • Standards for sharing of data • Guidelines for integrated data with common demographics, variables, and definitions • Address confidentiality issues – create a gold standard • Surveillance systems that work with and across programs

18. 2. Integrated Training efforts • Flexible funding for training • Integrated and comprehensive guidelines • Program announcements that include common language and objectives to address Center’s diseases • Training centers required to have integrated training curricula

19. 3. Integrated funding • Integrative program announcements (PA’s) (leverage integration through PA’s) • Collaboration on program announcements and post award management • Incentives for state and federal funding to support integration • Incentives for “in-kind funds” and/or require matching funds • Reprioritization of funds at CDC level • Reporting and evaluation components • Fund pilots or demonstrations

20. Addressing Barriers to PCSI • Meeting Report, presentations on web • www.cdc.gov/nchhstp/programintegration • Develop a national policy framework for PCSI • Green paper è White paper èSpring, 2008 • Stakeholder input è Ongoing • Explore funding for program collaboration and service integration • Analyze budget authorities è Initiated • Explore opportunities for seed money • Realignment of funds to support PCSI demos/ evaluation

21. Addressing Barriers to PCSI (continued) • Harmonize and synchronize data collection and surveillance • Establish cross center work group èCompleted • Publish integrated annual surveillance reports è 2008 • Develop common standard for confidentiality and sharing of surveillance and program data èInitiated • Publish STD/HIV integrated interview record èCompleted • Harmonize Partner Services Guidelines • STD/HIV Partner Services guidelines èJune, 2008

22. Addressing Barriers to PCSI (continued) • Develop integrated prevention guidelines • Commission workgroups to develop guidelines • Cross-Center workgroups established on: Program integration, Corrections, MSM, Drug users, Surveillance • Coordinate CDC program announcements and reporting requirements • Ensure new program announcements promote program integration èGoals architecture; consistent language • Review PAs to ensure PCSI includedè New SOP’s in place (2 completed)

23. Addressing Barriers to PCSI (continued) • Provide support, both technical and financial, for cross training, evaluation and dissemination of best practices • Collaborate with National Training Centers • Meeting scheduled June, 2008

24. Areas for future work • Widening circle of engagement on PCSI • Involving community prevention services • Summarize wealth of evidence and experience • Working with specialist partners • CDC level activities • Develop implementation plan • Develop research, monitoring, and evaluation strategy • State, city and local partner activities • Conversations, mobilization, support and engagement • Create opportunities for sharing promising practices

25. Next Steps • Meeting Report, presentations on web • www.cdc.gov/nchhstp/programintegration • Winter 2008 • Publication of NCHHSTP Action Plan for PCSI • Spring 2008 • Publication of NCHHSTP white paper on PCSI • Ongoing • Engagement with partners • Integration “tracks” at national meetings

26. Dr. Kevin FentonNCHHSTP Director(Fantastic!)

29. CDC NCHHSTP Organizational Chart Global AIDS Program Division of Sexually Transmitted Diseases Division of Viral Hepatitis Division of HIV/AIDS Prevention Division of TB Elimination

30. NCHHSTP Programmatic ImperativesProgram Collaboration and Service Integration • Definition: Integration - A mechanism of organizing and blending inter-related health issues, separate activities, and services in order to maximize public health impact through new and established linkages to facilitate the delivery of services • Integration should be focused at the field or client level where the interface between the system and the consumer takes place. • Integration results in more holistic services for clients, regardless of the agency structure.

32. PCSI Current issues: • Adult Hepatitis B Vaccination Initiative • Joint PS guidelines • Access to surveillance data • STDs among HIV+ • Addressing health disparities comprehensively

33. Often Cited Barriers to Program Integration • Restrictive and inflexible use of categorical funds • Prescriptive program announcements and discordant reporting requirements • Burdensome and inefficient “administrivia” • Lack of harmony, consistency, and synchronization of data collection and surveillance • Lack of integrated prevention guidelines • Insufficient translation and integration of science and program • Insufficient support, both technical and financial, for cross training, evaluation and dissemination of best practices

34. NCHHSTP Integration ActivitiesAlready Underway • Joint Project Officer Meetings – quarterly • Program Integration Meetings – bi-weekly • Joint Branch Chiefs Meetings –quarterly • Branch Seminars - weekly • Hepatitis B integration letter and Division commitments (Fenton/Schuchat letter) • Joint site visits – listening tours • NY, Chicago, CA • External Consultation on Program Integration

35. Collaboration within NCHHSTP • HIV testing guidelines – Roxanne Barrow and Franklin Fletcher • New HIV testing PA – STD clinics – Chris Lupoi and Ron Turski • Adult hepatitis B immunization action plans • Partner services guide • Prevention Training Centers (PTCs) • Joint Project Officer workgroup • Meth workgroup – Susan Arrowsmith

36. STD/HIV Program Collaboration and Integration • Revised HIV testing guidelines • Routinize testing in a variety of clinical care settings • Consent advised to be part of general consent for clinical services • Risk reduction counseling encouraged but not a requirement • Data systems • STD interview record • Attempts to enhance linkages between data systems for STD (STD-MIS, STD-PAM) and HIV (PEMS) • Partner services • Harmonize guidance

37. Enhanced STD (inc. HIV) interview form • STD case reports to CDC lack standardized behavioral variables (e.g., gender of sex partner, drug use, exchanging money/drugs for sex) • Needs: • add new variables but limit number to avoid burden on field staff • harmonize STD and HIV interview forms to decrease duplication • Key new components: • gender of sex partner • recreational drug use (e.g., methamphetamine, Viagra) • venues used to meet and have sex with partners • Next steps: • integrate variables with DHAP activities (i.e., PEMS) • finalize form and methods for training/implementation

38. HIV PCRS and STD PN integration • Principles for STD partner notification and HIV PCRS are almost identical. • Same 11 common principles (plus two extra for PCRS). • But differences in HIV vs. STD training and application have led to practical approaches that have different emphases. • This has created tension for combined HIV/STD PN/PCRS programs and when programs see persons co-infected with HIV and STD. • A CDC working group is integrating the 1998 HIV PCRS guide with the 2000 STD Program Operations Guidelines (POG) Partner Services Chapter. • The POG becomes the base document. • What is common to HIV and STD partner management remains in the POG. • What is unique to HIV is placed in a separate module. • The module contains HIV-specific elements from the 1998 PCRS guide. • The module contains updated information relevant to HIV PCRS (e.g., case-finding through network-based approaches). • The POG Partner Services chapter will be revised concurrently.

39. ‘Dear Colleague’ Letter

40. Integration Strategies for MSM Services • Use the 2006 STD Treatment Guidelines • Use media materials at www.cdc.gov/hepatitis • Inform MSM about these recommendations • Get the word out to public and private • practitioners • Get the word to your clinicians, counselors • Link behavioral interventions to clinical services • Prevention activities targeting MSM should • include the message from the ‘Dear Colleague’ letter

41. HIV/STD Integration Strategies • HIV CPGs ?? Prevention Plans ¨¨ CBOs • ¨¨ community members • HIV ¨¨ DEBI ¨ CBOs, HD, community • STD ¨¨¨practitioners: private& others • Offer comprehensive clinical services and integrated PN • Promote common, comprehensive • messages and services

42. www.cdc.gov/hepatitis

43. www.cdc.gov/hepatitis

44. HIVP Program Structure CDC CPG DoH Health Ed/ Risk Reduction Counseling & Testing

45. HIVP Program Structure CDC DoH Behavioral Intervention HIV Test ? STD Screening? A & B Vaccinations?

46. Suggested Program Structure CDC DoH HE/RR HE/RR HE/RR HE/RR = CTR/STD/Hepatitis services

47. Test - HIV/STD/HCV Immunize - HAV HBV Medical Evaluation/Treatment; Partner Services High- Risk Individuals HIV + STD + HCV + Status Appropriate Prevention Counseling & Social Services Comprehensive Approach to Fighting EVERYTHING! If negative CAFÉ Grande

48. CAFÉ GrandeBenefits: • Clients learn HIV sero-status • At risk get HAV & HBV immunized • STDs identified and treated • Overlapping epidemics are addressed • Clients get better services/counseling • Reinforces positive behavior change • Address scrutiny by documenting services • Increases efficiency, improves services, reduces redundancy…

49. Reasons to Combine Viral Hepatitis, HIV/AIDS and STD Prevention • Routes of transmission & at risk populations overlap • Major public health problems • Effective prevention tools • Referral is inherently inefficient • Lack of integrated prevention activities leads to transmission of viral hepatitis, syphilis, gonorrhea, chlamydia, and HIV • Counseling will be based on a more comprehensive medical & risk assessment

50. Conclusions • Offer comprehensive ‘one stop’ service to clients who are being reached but not fully served • Learn to say: ‘HIV/STD/hepatitis’ like its one word!!!