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--> Appendix H STD-Related Services Among Managed Care Organizations Serving High-Risk Populations Kimberly H. Greene,1 Thomas R. Eng,2 Patrick H. Mattingly,3 and Paul D. Cleary3 Introduction Managed care organizations (MCOs) are increasingly enrolling persons from groups potentially at high risk for STDs, particularly Medicaid beneficiaries. There is limited information, however, regarding the scope of services for STDs among MCOs. A previous study of reproductive health services in MCOs collected limited information on STD-related services and activities (Kaiser/Group Health Association of America, 1994), and data on reproductive health and managed care (Bernstein et al., 1995; Delbanco and Smith, 1995) have recently been published. These data suggest that, although there is variability in the extent of coverage of reproductive health services, most MCOs are providing comprehensive reproductive health services. In order to obtain preliminary data regarding STD-related services among MCOs, we surveyed a limited number of MCOs that were considered likely to serve persons at high risk for STDs. The survey collected information regarding their STD-related services and potential prevention activities. Methods A convenience sample of 45 MCOs was surveyed. Thirty-nine MCOs were 1 Candidate, Masters in Public Health Program, George Washington University, Washington, D.C. 2 Senior Program Officer, Institute of Medicine, Washington, D.C. 3 Member, IOM Committee on Prevention and Control of STDs, Washington, D.C.
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--> selected on the basis of their likelihood of serving populations at high risk for STDs, such as having a high proportion of Medicaid enrollees and being located in an inner-city area. The remaining six MCOs were referred to us by MCOs who heard about the survey. Data were collected regarding MCO characteristics; STD-related data collection and analysis; STD-related preventive and curative clinical services; confidentiality policy; and community activities. Surveys were mailed and followed up with telephone calls from December 1995 through February 1996. Respondents who indicated that the MCO had significant activities in STD prevention or services were contacted to obtain details. The small sample size precluded analysis of correlations between variables. A median and range are reported for enrollment and demographic figures. Results The survey response rate was 60 percent (27/45). Of those responding to the survey, 6 MCOs (22 percent) described their structure as a sole staff/group model; 11 MCOs (40 percent) described a mixed model that included a staff/group model component; and 10 (37 percent) described their organizations as a combination of IPA, indemnity and/or PPO models. The plans had a median enrollment of 85,000 persons (range: 6,500-2,500,000). Twenty-five MCOs served Medicaid populations, representing, on average, 16 percent of their enrollment (range: 0-100 percent). For MCOs reporting demographic data (24), the median proportion of the enrolled population that was African American or Hispanic was 50 percent (range: 4-95 percent); the median proportion of adolescents age 15-24 was 15 percent (range: 10-70 percent); and the median proportion of women age 14-44 years was 27 percent (range: 10-60 percent). Forty-eight percent of the respondents were nonprofit organizations and 30 percent were among the 50 largest MCOs in the United States. Respondents were located in the Pacific (41 percent), mid-Atlantic (37 percent), New England (7 percent), East-North Central (7 percent), Mountain (4 percent), and Southern (4 percent) regions of the country. Selected responses are summarized in Table H-1. Standardized patient history forms were used by 15 organizations (65 percent) to collect information about previous STD diagnoses and by 16 organizations (73 percent) to document a history of sexual activity. This type of information was used by 14 MCOs (52 percent) to define groups at high risk of STDs. Eight MCOs (30 percent) reported using data analysis to implement changes in STD-related activities, and four organizations (16 percent) had established performance criteria for STD-related outcomes or process measures for STD-related care. Seven MCOs (26 percent) reported that they did not use any published STD treatment guidelines, and six (22 percent) used more than one published protocol. The Sexually Transmitted Diseases Treatment Guidelines published by the Centers for Disease Control and Prevention were used by 18 organizations (67 percent),
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--> TABLE H-1 STD-Related Activities of Managed Care Organizations (MCOs), 1996 Characteristic Percentage of Affirmative Responsesa MCO includes questions regarding previous diagnoses of STDs on standardized patient history forms. 73 (16/22) MCO includes questions regarding sexual activity on standardized patient history forms. 65 (15/23) MCO has performance criteria for STD-related outcomes or process measures for STD-related care. 16 (4/25) MCO has used data analysis to implement changes in STD-related activities. 30 (8/27) MCO requires parental permission for adolescents/children (under age 18) to receive treatment for an STD or other STD-related services. 8 (2/26) MCO notifies parents of STD-related care provided to their children through billing or other means. 0 (0/24) MCO has a specific policy for ensuring adolescent and adult confidentiality regarding STD-related care. 52 (13/25) MCO has a policy requiring or encouraging health care providers to discuss sexual activity and related issues during routine adolescent health care visits. 78 (21/27) MCO has STD-related activities specifically targeted towards adolescents. 46 (12/26) MCO offers routine screening for chlamydial automatically to all women of childbearing age. 39 (10/26) MCO has a specific or categorical STD prevention program. 0 (0/26) MCO provides STD-related services to the general community, including people not enrolled in the MCO. 22 (6/27) Case-finding 7 (2/27) Community screening for STDs or related conditions 4 (1/27) Partner identification/notification 15 (4/27) Other 11 (3/27) MCO has a formal training program in STD-related topics for its health care staff. 33 (9/27) a Number responding yes/total number responding to question.
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--> and four MCOs (15 percent) followed internally produced guidelines. Twenty MCOs (74 percent) guaranteed acute care for all conditions within 48 hours; however, these policies did not usually specify STDs or any other specific clinical condition. Within the MCO staff, primary care providers most frequently provided STD-related care (100 percent), followed by obstetricians/gynecologists (96 percent). Other providers of STD-related care included specialists (48 percent), publicly sponsored STD clinics (41 percent), and non-MCO health facilities (19 percent). Four health plans (15 percent) required patients to obtain referrals to other physicians or providers to obtain STD-related care. Most MCOs (92 percent) permitted adolescents to obtain STD-related care without obtaining parental permission, and none notified parents of this care. Thirteen plans (52 percent) adhered to a specific policy that guaranteed adolescent and adult confidentiality, but most of these were general nondisclosure policies that did not specifically refer to STDs or STD-related care. However, preventive medicine guidelines were more specific: 21 MCOs (78 percent) required or encouraged health care providers to discuss sexual activity during routine adolescent health care visits; 12 (46 percent) had an STD-related activity specifically targeted towards adolescents; and 10 (39 percent) automatically offered chlamydial screening to all women of childbearing age (15-44 years). None of these health plans had a specific or categorical STD prevention program at the time the survey was conducted. Five MCOs (19 percent) provided STD-related services to nonenrolled populations in their communities by participating in case-finding, screening for STDs or related conditions, and partner identification/notification. Three organizations (11 percent) routinely referred patients with STDs to public facilities for treatment and/or preventive services; and seven (26 percent) referred their patients for such public health activities as contact-tracing and partner notification. Contractual agreements that specified STD-related care were rare: one MCO had a contract with a purchasing group that specified STD-related services to be provided, and six MCOs (22 percent) had contracts or agreements with government agencies that specifically addressed STD-related services. However, these contracts and agreements almost always referred specifically to HIV-related services. Five MCOs (19 percent) conducted STD-related clinical or epidemiological research. Most frequently, this research addressed HIV-related issues. Nine MCOs (33 percent) reported a formal training program in STD-related topics for health care staff, usually in the form of continuing medical education; and 13 (48 percent) had plans for future STD-related programs or activities. Conclusions There are several limitations to these survey data. Because of the small sample size and sample selection, these data should be considered preliminary and may not be representative of MCOs serving high-risk populations. In addition,
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--> although the survey specifically requested that all questions be answered for STDs other than HIV, some respondents may not have consistently adhered to this request. Thus, there is a possibility of asymmetric data collection. Nevertheless, this survey does provide a modicum of insight into the STD-related activities of some MCOs serving high-risk populations. Most MCOs reported providing a basic level of services. However, because a significant proportion of the survey respondents served populations at high risk for STDs, it is likely that typical MCOs in the United States would have substantially lower levels of involvement in STD prevention activities than those reported in this survey. In general, surveyed MCOs screened for prior STD diagnosis and sexual activity; made STD-related care accessible through primary care providers; used treatment guidelines; and guaranteed availability of acute care within 48 hours. However, few MCOs provided services beyond the expected scope of clinical practice. For example, only 22 percent of MCOs reported providing services to the general community or to sexual partners who were not plan enrollees. No MCO had a specific or dedicated STD prevention program. Only a third of MCOs had STD-related topics in a formal training program. Further interviews with MCOs suggested that three main factors prompted the planning of STD-specific continuing medical education programs and departmental meetings: desire to improve the quality of care; physician requests for further education; and recognition of organizational weaknesses by MCO-affiliated/employed health care providers. A few MCOs have relied upon printed materials for educational outreach. For example, FHP in San Diego, CA, developed preventive health guidelines for adolescents that are distributed to all primary care providers; Human Health Care Chicago has developed a teen care manual; and Kaiser Permanente provided, in its quarterly newsletter, information for its physicians on confidentiality and consent/disclosure requirements for minors. When MCOs with special activities in STD prevention were interviewed, they frequently discussed and highlighted various programs or activities for adolescents. For example, The Community Health Plan of Los Angeles has created a teen clinic that focuses on preventive care, particularly the psychosocial component of health issues, such as family planning, HIV testing, depression, and sexual activity. Several other organizations sponsored teen clinics that were in various stages of development and received varying levels of support. Particularly interesting STD-related programs or activities are briefly described in the following pages. The effectiveness of many of these programs has not been formally evaluated. However, these programs and activities may serve as models for other MCOs that wish to develop activities in STD prevention.
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--> Educational Theater Programs Kaiser Foundation Health Plan, Inc. Pasadena, CA Kaiser Permanente Medical Care Corporation Oakland, CA4 Kaiser Permanente's educational theater programs use live theater in an innovative approach to community health promotion for children and adolescents. Kaiser Permanente supports five programs promoting communication and healthy decision-making: ''Secrets," "Nightmare on Puberty Street," "Intersections," "R.A.V.E.S.," and "Professor Bodywise's Traveling Menagerie." Respectively, these address sexual health and HIV/STD issues; peer pressure, emotions, and sexuality; communication and conflict resolution; "real alternatives to violence for every student"; and health, hygiene, and resistance to peer pressure. These prevention programs are intended mainly for young audiences. They are shown to high school students ("Secrets" and "Intersections"), middle school students ("Nightmare on Puberty Street," "Intersections," and "Secrets") and elementary school students ("Professor Bodywise" and "R.A.V.E.S."). All of the programs are available for adult and community audiences. In order to encourage participation in the process of health promotion, Kaiser Permanente distributes educational and other materials to parents. In addition, children receive supplemental materials in school, and supportive classroom resources are provided to educators. All five productions are funded as a nonprofit community service of Kaiser Permanente. The plays were created with the assistance of an advisory committee of health care practitioners, community leaders, school officials, teachers, parents, students, and a team of theater professionals. When a play is launched, both Kaiser enrollees and the general community are sent promotional information and are invited to free screenings. Subsequently, HMO and community members are welcome to attend program showings, but specific invitations are not tendered. Each Kaiser Permanente region selects those productions it wishes to support; hence, not every production is shown in every region. "Secrets," "Nightmare on Puberty Street," and "Intersections" all touch on issues related to STDs, but "Secrets" is particularly relevant. It addresses the issues of self-control, self-esteem, and prevention as they pertain to sexuality and sexual health, and it advocates both abstinence and safer sex. The program focuses on HIV/STD transmission, symptoms, and treatment, and it emphasizes adolescent susceptibility to infection. Each performance is followed by a question-and-answer 4 Other Kaiser Permanente regions may also produce some or all of these educational theater programs. The support materials that accompany performances are designed to meet each community's needs and may vary from region to region.
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--> session during which the actors, who are also trained HIV/AIDS educators, respond to audience queries. "Secrets" is performed daily at area schools and is often incorporated into the standard sex education curriculum. Two weeks prior to a showing, a team member from Kaiser Permanente visits the school to distribute resource manuals, provide teacher and parent guides, and supply a copy of the Kaiser Permanente video entitled "It Won't Happen to Me." This award-winning video is a recording of an interview with an HIV-infected woman who gave birth to an HIV-infected child. There has been no formal evaluation of "Secrets," but anecdotal evidence and focus groups reflect a positive response in the community. Teenage Health Center Kaiser Permanente of Southern California Panorama City, CA Kaiser Permanente of Southern California responded to the special needs of patients age 13 to 20 by forming the Teenage Health Center. The center's goal is to provide a full range of health care services to teens and to help them maintain and improve their physical and emotional health. The clinic seeks to increase access to appropriate care for adolescents and deliver health services in a proactive and preventive manner. For example, no referrals are required to use the center, and patients can call a hotline number for medical advice. In order to achieve its goals, the center employs two physicians, two nurses, a social worker, and two health educators. Many of the staff members have been specifically trained to work with adolescents. The center's varied health services include routine gynecological care and treatment of sexually transmitted diseases. Social and psychological services are available, and the center sponsors a number of health education opportunities, addressing such issues as reproductive health, birth control, HIV testing and counseling, and STDs. A critical and unique element of treatment at the Teenage Health Center is the psychosocial assessment administered to all incoming patients. This questionnaire seeks information on sexuality, contraception, history of STDs and childbearing, and other health-related topics. The intention of the questionnaire is to identify potential or existing problems such as depression, suicide, or pregnancy in order to provide truly comprehensive health services. A survey tool was recently used to evaluate the effectiveness of the Teenage Health Center as compared to traditional primary care. Data indicate that those teens seeking care at the Teenage Health Center were significantly more satisfied with the care they received than adolescents seeking health services through traditional routes. Greater satisfaction was linked with increased likelihood that the adolescent patient would discuss sensitive issues with his/her health care provider. This is of critical importance in STD-related care.
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--> Safer Sex Campaign Group Health Cooperative of Puget Sound Seattle, WA In 1992, a prime-time television documentary entitled "Sexual Survival" aired on KING 5 TV in Seattle. This program specifically targeted adolescents and explicitly described the acquisition, symptoms, identification, and treatment of a number of STDs. It was a component of the "Safer Sex Campaign," which was cosponsored by the Group Health Cooperative (GHC), Planned Parenthood, and KING 5 TV; the program was developed with the assistance of an advisory board composed of representatives from local community-based organizations. "Sexual Survival" was supplemented by two workshops called "Parent Talk: Teaching Your Child About Sexuality,'' and "Safer Choices: Sex in the 90's." In addition, GHC, KING 5 TV, and Planned Parenthood developed three educational pamphlets and two videos for distribution. Community response to the program was evaluated by quantifying program viewers and workshop participants. "Sexual Survival" had a market share of 39 percent, with an estimated 500,000-750,000 viewers. There were four favorable responses for every unfavorable one among the 350 calls received in the hour-and-a-half following the broadcast (10-11:30 PM). The ratio jumped in the following week, when favorable calls outnumbered the unfavorable by 10 to 1. Workshop participation was high: "Parent Talk" was conducted 66 times and served 1,000 people; "Safer Choices" had 235 participants in 23 workshops. In addition to these measures of participation, the campaign was featured on "NBC Nightly News," and GHC received hundreds of letters of support. GHC continues to distribute the pamphlets created as a part of the Safer Sex Campaign in its clinics. One of the pamphlets ("What is an STD?") defines the term "sexually transmitted diseases"; supplies summaries of the six most common STDs, including HIV; provides a risk assessment quiz; furnishes descriptions of common STD-related symptoms, high-risk behaviors, and STD prevention measures; and lists area clinics and resources. The second pamphlet ("Parent Talk: Teaching Your Child About Sexuality") makes both general and specific suggestions to help parents serve as their children's primary sexuality educators. Age- and developmentally appropriate information and approaches are recommended and selected community resources are cited. The third pamplet ("Safer Choices: Sex in the 90's") defines safer sex, furnishes a list of high-risk behaviors, and discusses attitudes and communication techniques as they relate to effective safer sex negotiations. Despite the relative success of the program, GHC does not plan to replicate it and is now shifting its STD prevention focus from the community to the individual patient. Currently, GHC's intention is to encourage providers to make prevention education a regular part of the patient-provider interaction. GHC has recently received funding to study the best ways to incorporate HIV/STD risk
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--> assessment and prevention counseling into primary care visits. The study will use a systems approach, focusing on the entire health care team. Training, materials, and other practice supports will be developed to help primary care providers play a more consistent role in HIV/STD prevention efforts. MY Health: Minority Youth Health Project Group Health Cooperative of Puget Sound Seattle, WA The Minority Youth Health Project (MY Health), a Group Health Cooperative (GHC) community program, is one of seven such interventions funded by the National Institutes of Health (NIH). Its purpose is to "prevent violence, pregnancy, sexually transmitted diseases, and substance abuse in 10-14 year old youths in Seattle." Seattle's diverse racial and ethnic groups include Vietnamese, Latino, and African American populations, making this project's target audience especially unique. In order to appropriately target this audience and to encourage innovative approaches to changing youth health behaviors, GHC has worked with the University of Washington, the city of Seattle, a local minority health coalition, and target population focus groups. MY Health takes three main approaches to encourage behavior modification: parenting, youth intervention, and community coalition mobilization efforts. Attention has primarily been focused upon the promising youth intervention and community coalition mobilization efforts. These efforts approach behavior change in very different ways. In the youth intervention program, a small group of students is exposed to health education messages. With the assistance of group leaders, they create an innovative health promotion product. Through their work, they learn entrepreneurial skills and enhance their knowledge of health. The community coalition mobilization effort convened community focus groups to assess significant youth health problems in their communities, providing each group with $8,000 per year to implement creative interventions to these issues. The African American community focus group, one of those selecting STDs as a priority issue, designed and executed a particularly creative project. Approximately two dozen adolescents, chosen from Garfield High School, worked closely with experts in music and video production to produce unique music videos focusing on health promotion and disease prevention. This approach employs the peer education approach that has become popular and that appears, anecdotally, to be moderately successful. A second round of this program is just beginning. Current and past efforts to support and enhance the MY Health Project derive from GHC's commitment to both health promotion/disease prevention and community service in its tightly knit health care community. The project's goals fit in with GHC's general program objectives. In addition, both the director of the municipal hospital and the local minority health coalition identified minority
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--> youth health as a priority issue and encouraged GHC to pursue the Minority Youth Health Project. Developing Long-Term Substance Abuse Prevention and Career Development Programs for African American Youth Healthcare Management Alternatives, Inc. Philadelphia, PA In 1990, Healthcare Management Alternatives, Inc. (HMA) developed and piloted a general prevention program for "at-risk" students (identified by faculty and administrators) at Audenried High School in Philadelphia. Although HMA continues to sponsor the intervention, it is no longer involved in daily administration activities. Currently, 30 students are enrolled in the program. During the school year, they attend weekly classes led by an HMA-trained counselor where they discuss and learn about STDs and HIV/AIDS, pregnancy prevention, violence, decision-making, self-esteem, substance abuse, goal-setting, conflict resolution, and career development. One of the program's goals is to improve health knowledge and attitudes about risky behaviors, including those related to adolescent sexuality, STDs, and HIV/AIDS. In order to measure the effect of the classroom activities on attitudes and behaviors, enrolled students are asked to fill out a pre- and postprogram behavior assessment questionnaire (adapted from the national Youth Risk Behavior Survey) at the beginning and end of each school year. In 1993, data collected using the pre- and postprogram questionnaires were used to assess the program's impact. The evaluation found a small decrease in the number of sexually active students; a moderate increase in the proportion of students utilizing condoms, birth control pills, or both; and a significant decline in the percentage of students with multiple sex partners and in the number of students engaging in unprotected sex. Overall, the 1993 evaluators concluded that the program had a positive impact on the students. The current ninth-grade participants will be followed through high school in order to perform a similar evaluation. A long-term assessment of the 1993 participants who have graduated from high school is planned. Watts/Jordan School-Based Health Clinic Watts Health Foundation Los Angeles, CA Watts Health Foundation (WHF), in conjunction with the Los Angeles Board of Education, established a health care clinic at Jordan High School in 1987. It is one of three such clinics that, with parental consent, supplies free and comprehensive medical care, psychological services, and health education to students. During 1993 and 1994, the three clinics handled 10,400 patient visits. Patients
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--> sought assistance in three major areas during these visits: medical services (57 percent of visits); mental health services (27 percent); and health education (7 percent). Other (unspecified) concerns prompted the remaining 9 percent of visits. Patients sought reproductive health care, including contraceptives and pregnancy tests, in 22 percent of these visits. The Watts/Jordan School-Based Health Clinic serves a low-income population in South Central Los Angeles that is 70 percent Latino and 30 percent African American. The 11 pregnant and 18 parenting girls currently seen by the clinic represent the relevance of teen pregnancy, parenting, and sexuality to these adolescents. Therefore, the clinic conducts HIV/STD education as a part of its health education program. These prearranged sessions are run by either a health educator or peer educator, and require advance registration by interested students. Sessions consist of a group discussion on STDs (e.g., chlamydial infection, syphilis, gonorrhea, vaginitis, and HIV/AIDS), which is supplemented by educational activities. A good portion of the clinic's publicity and success derives from the work of its teen advocates. Each year, four students undergo a six-week summer training program in reproductive health. They speak to classes, conduct outreach, run the above-mentioned educational groups, and are responsible for bringing into the clinic teens who are not "consented" (i.e., those whose parents have not yet consented to allow them to access care through the school-based clinic). The teen advocates provide an invaluable service because they are able to reach students who would not willingly speak with adults and who are not aware that the clinic exists. The Watts/Jordan School-Based Health Clinic, like the other two clinics, does not bill students for services. Medical is billed to help cover the uninsured but does not fully cover medical services. References Bernstein A, Dial T, Smith M. Women's reproductive health services in health maintenance organizations. West J Med 1995;163[Suppl]:15-18. Delbanco S, Smith M, eds. Reproductive health and managed care: a supplement to the Western Journal of Medicine. West J Med 1995;163[Suppl]. Kaiser/Group Health Association of America. Survey on HIV/AIDS and reproductive health care. Menlo Park, CA: The Henry J. Kaiser Family Foundation, 1994.
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