Plan for Referral and Transfer of Public Health Family Planning and Sexually Transmitted Disease Clinic Patients

Plan for Referral and Transfer of Public Health Family Planning and Sexually Transmitted Disease Clinic Patients The Sonoma County Public Health Family Planning and STD clinics will close on April 2, 2010.These clinics were originally established to provide medical services that were not otherwise available, or available on very limited basis, in our community. Over the last 2 decades, however, the health care delivery infrastructure in Sonoma County has changed substantially, particularly with the development and continuing expansion of a network of community clinics, including 5 federally qualified health centers (FQHCs). Public Health will cease providing these clinical services given the increase in local primary care infrastructure where patients can be linked to a medical home with the full array of prevention-focused primary care services for their health care needs. Decreased State public health funding has contributed to the need to make reductions in several of our Public Health services, including the proposed closure of the Family Planning and STD clinics. I. PATIENT REFERRAL AND TRANSFER A plan and processes to insure the referral and transfer of patients to other community medical providers are in place and will continue over the next several months. It is anticipated that a majority of Public Health Clinic patients will seek ongoing care at a local Community Health Center. Public Health is a member of the Redwood Community Health Coalition and over the last several months has provided the leadership of the clinics in Sonoma County with updates and solicited input regarding the planned clinic closure. Public Health has engaged in more detailed planning with the Santa Rosa Community Health Centers over the last several months because of the current location of the clinic and likelihood that most existing patients will seek care in the Santa Rosa area. The clinic transition will be monitored to insure the safe and respectful referral and transfer of patients and to identify and address any related issues. A. Family Planning Clinic Patients Current patients of the Family Planning Clinic have been informed of the proposed clinic closure at their regular visits or when calling to schedule an appointment. Patients who have used the Public Health Clinic for routine family planning needs have been encouraged to plan ahead and establish a relationship with a primary care provider. Patients with a primary care provider have been encouraged to use this provider for their family planning needs. Patients without a primary care provider have been given a list of community providers including, but not limited to, Community Health Centers. Patients requiring specific follow-up: The Public Health Clinics use a tracking system to identify all patients who need follow up on a mammogram, abnormal pap smear, colposcopy, LEEP, or any other procedure or certain laboratory tests. Over the last two months, Public Health Clinic staff has contacted each patient in need of any medical follow up. Public Health clinic staff has worked closely with the staff of the Santa Rosa Community Health Centers since February 2010 to develop a referral processes for Public Health Clinic patients to be scheduled for appropriate medical follow up. Appointments have been made and medical records transferred for patients who need follow up in the next several months. Patients whose follow up needs are farther into the future have been contacted by telephone to inform them of the proposed clinic closure,

and referral information has been provided Those patients who we have not been able to reach by phone have been sent a letter via US mail. All conversations and communication are documented in the medical record and signed off by a physician. Prescription refills: Beginning in February 2010, all oral contraceptive prescription refills faxed to pharmacies have included information about the proposed clinic closure and a referral list. Pharmacies were asked to inform the patient of the proposed closure, to provide the patient with the referral list, and to encourage them to plan ahead for their next refill. Public Health Clinic staff will continue to process oral contraceptive refills through April 14. B. Sexually Transmitted Disease Clinic Patients Patients who have received medical care at the STD Clinic over the last several months have been informed regarding the upcoming closure of the STD clinic. Once the clinic closes any patients seeking services for possible sexually transmitted diseases will be referred to their regular medical provider or to one of the medical providers on the list of local medical providers available through Public Health staff or on the Public Health website. C. Public Health staff will be available to speak with Public Health Clinic clients and other members of the public in English or Spanish regarding the closure of the clinics or to request a copy of their medical records at (707) 565-4820. In addition, recorded information in English and Spanish will inform callers on a 24 hour basis of the clinic closure and direct them to additional resources. The Public Health website will provide information in English and Spanish regarding clinic closure, local medical providers of family planning and STD services and instructions on obtaining copies of medical records. http://www.sonoma-county.org/health/ph/clinics/services_fp.htm An informational letter was sent to medical providers and pharmacies in Sonoma County informing them of the proposed closure of the Public Health Family Planning and STD Clinic. II. ACCESS TO MEDICAL RECORDS Public Health staff will provide for copies of medical records to clinic patients on an ongoing basis, in accordance with existing law. The expectation is that the demand for records will be high in the next several months and decrease slowly over time. The number of requests will be monitored over time to assure that adequate staffing is available to fulfill these requests in a timely fashion. Public Health staff will remain available to speak in English or Spanish with Public Health Clinic clients and other members of the public regarding the closure of the clinics or to request a copy of their medical records at (707) 565-4820. In addition, recorded information in English and Spanish will inform callers on a 24 hour basis of the clinic closure and direct them to additional resources. The Public Health website will provide information in English and Spanish regarding clinic closure, local medical providers of

family planning and STD services and instructions on obtaining copies of medical records. http://www.sonoma-county.org/health/ph/clinics/services_fp.htm III. MONITORING OF CLOSURE OF FAMILY PLANNING AND STD CLINICS Public Health will monitor the process of referral and transfer of patients from the Family Planning and STD Clinics to other clinic providers over the next several months in the following manner: -Public Health will continue to update and solicit feedback from the Leadership of the Redwood Community Health Coalition regarding referral and transfer of patients -Public Health will continue to work with clinic operations staff of the Santa Rosa Community Health Center to facilitate patient referral and transfer and identify and address any issues that arise -The Public Health Officer and Deputy Health Officer will meet with the Medical Directors of the Redwood Community Health Coalition to facilitate the transition and identify and address any issues that arise -Public Health will monitor the phone calls and other communications from clients and the public to continue to facilitate the transition and identify and address any issues that arise IV. ONGOING ROLE OF PUBLIC HEALTH Public Health will continue to provide public health essential services related to the STD Disease Control and access to primary care, including family planning services, in Sonoma County. These include: Family Planning and other Primary Care: -Continue to monitor access to care in Sonoma County, including monitoring primary care infrastructure, access to care for the population with public and commercial health insurance and the uninsured -Continue collaboration with various local partners to ensure and expand access to medical care in Sonoma County, including the Health Action Primary Care Collaborative, Healthy Kids Sonoma County, Partnership Health Plan of California, the Redwood Community Health Coalition, the Sonoma County Medical Association, the Specialty Access Task Force and others -Continue to advocate for ongoing and increased funding for the provision of medical services for low income individuals in Sonoma County through expanded community clinic infrastructure, maintenance of key funding programs such as Family PACT, Breast Cancer screening and treatment and other programs, addressing the Locality 99 MediCare funding inequity in Sonoma County and implementation of health care reform to maximize access and quality of medical care in Sonoma

Sexually Transmitted Diseases: Public Health will continue to provide essential services related to STD Disease Prevention and Control. These include local STD reporting, surveillance, case finding, contact investigation and case management and interface with State and national STD control. Public Health will continue to provide access to STD medical consultation for local medical providers for complex STD cases. Public Health will continue to educate and collaborate with local medical providers regarding the epidemiology of STDs, federal Centers for Disease Control and Prevention (CDC) guidelines for screening, diagnosis and treatment and legally required reporting of sexually transmitted diseases. Public Health will continue to support the provision of STD continuing medical education for local physicians and other providers through presentations at medical grand rounds at local hospitals. Public Health will provide specific training to the medical staff of local community clinics regarding the epidemiology of STDs, federal Centers for Disease Control and Prevention (CDC) guidelines for screening, diagnosis and treatment and legally required reporting of sexually transmitted diseases.

Attachment A: Sonoma County Health Services Public Health Division HIV Medical Care Planning Process Work Group Members NAME Agency Role Sharon Keating Claros Group Facilitator Lynn Woznicki SSU Student Student Intern Mark Netherda, MD DHS - Public Health Deputy Health Officer - Project Lead Shari Brenner DHS - Public Health Section Manager - Project Staff Jack Neureuter Alliance Medical Center Executive Director David Whalen Community Member Member, Commission on AIDS Marshall Kubota, MD DHS - Center for HIV Prevention and Care, AIDS Education and Training Center Public Health Physician Anna Baylor, MD DHS - Center for HIV Prevention and Care Medical Director Brian Griffiths DHS - Center for HIV Prevention and Care Social Worker Kirsten Balano DHS - Center for HIV Prevention and Care Clinical Pharmacist Susan Castillo DHS - Mental Health Mental Health Section Manager Ellen Swedberg DHS - Prevention and Planning Health Information Specialist Lynn Campanario Drug Abuse Alternative Center Director, Outpatient Services Rick Dean Face To Face, AIDS Service Organization Executive Director Tara Scott, MD Family Practice Residency Program Dir. Of Leadership & Professional Development Victoria Dreifuss Indian Health Project RN Nurse Educator Gary Green, MD Kaiser Permanente Medical Director Laura Tinti-Andrade Kaiser Permanente Assistant Medical Group Administrator Chris Camisa, MD Partnership Health Plan Medical Director Linda Melsheimer Partnership Health Plan Manager of Health Services Care Coordination Team Nurit Licht, MD Petaluma Health Center Medical Director Cindy Dickinson Southwest Community Health Center Chief of Clinical Services Gabriela Bernal Southwest Community Health Center Site Director, Chanate Family Practice Rob de Bara, MD Sutter Medical Group Medical Director Steve Bromer, MD UCSF - HIV Specialist HIV Specialist Mary Szeczey West County Health Centers Executive Director Sil Machado West County Health Centers HIV Case Manager

PARAMETERS Sonoma County Health Services- Public Health Division HIV Medical Care Planning Process Description of a Quality HIV medical care program RECOMMENDATIONS The model will provide access to compassionate, culturally appropriate, quality medical care for all people with HIV in Sonoma County. The model will ensure provider access to HIV specialty expertise as part of the implementation plan. The model will minimize silos and enhance collaboration, coordination and integration across the system of care. The model will adhere to Federal Department of Health and Human Services guidelines for the treatment of people with HIV. The model will be responsive to local, state and federal funding sources. Resources from multiple sources will be maximized, with money being used as defined by each funding source. Credible data will be used in decision making. All options are on the table for discussion. Existing agreements with Sutter Hospital, under the Health Care Access Agreement, for inpatient HIV care, will remain in place. Meeting Ryan White and/or other funders administrative requirements must be feasible The planning process will model partnership, transparency, inclusion and proactive communication with all identified stakeholders. A SUCCESSFUL MODEL FOR COMPREHENSIVE HIV CARE 1. Access to primary care which includes: Routine health care maintenance including screenings, health education, immunizations, etc. Management of non-hiv chronic medical conditions Oversight of non-hiv related hospitalizations Pediatric care Ob/gyn, Hepatitis, osteoporosis, diabetes, etc. (overlaps with HIV specialty care) Universal screening - routine HIV testing 2. Access to HIV specialty care which includes revised 12/11 09 Antiretroviral management, including medication interactions and adverse events CD4 and VL monitoring OI prophylaxis and treatment Health education including self-management Oversight of HIV related hospitalizations Ob/gyn, Hepatitis, osteoporosis, diabetes, etc. (overlaps with primary care) ARV management in pregnancy Management of HIV exposed newborn 3. Medical case management Panel management to assure Retention in care Adherence with medications Linkage with other services Referrals to medical specialty care other than HIV Referrals to non-medical services Health education including prevention with positives Benefits counseling for health insurance Screening for mental health needs and linkage to care Screening for substance use needs and linkage to care 4. Pharmacy consultation services a. Consultation re: medication interaction b. Oversight of anti-retroviral medications during hospitalizations

5. Mental health services Psychiatric evaluation Ongoing therapy (individual and groups) 6. Substance use services Harm reduction counseling 7. Medical Nutritional Therapy 8. Quality Management Identification of clinical indicators Measurement and reporting of clinical indicators 9. Provider education HIV medicine system of care changing laws, rules changing treatment guidelines WHO WOULD BE SERVED WITH PRIMARY CARE? All Sonoma County residents with HIV (Kaiser members served at Kaiser) Non-Sonoma County patients on a case by case basis Diagnosis based eligibility criteria to be defined by providers, for: Mental Health Services Substance Abuse services Medical Nutritional Therapy HOW SERVICES WILL BE PROVIDED: Three Community Health Centers, Southwest Community Health Center, WCHC and Alliance Medical Center, have indicated their interest in expanding or adding HIV services. Southwest would provide services at their Chanate site (or in their new building which will open fall 2010), Alliance Medical Center would offer HIV services in their Healdsburg site and West County Health Centers would expand HIV services into their new Sebastopol site. Primary Care and Mental Health services are currently provided at all three clinics. These services would continue to be provided, and people with HIV could easily be added into their patient population, using established protocols and systems. Centralized systems will be created, utilizing best practices, for all other services. Centralized services are defined as those utilizing a centralized system (standards, forms, databases, tools, etc.), although resources will be distributed throughout different geographic sites. The system is scalable, and able to add additional providers as capacity, need and provider interest allow. Petaluma Health Center and Sutter Medical Group are exploring their capacity and may be added to the system at some point in the near future. Every person with HIV will be able to choose the clinic they would like to serve as their medical home. (Kaiser members would continue to receive services through Kaiser Santa Rosa.) Regardless of which clinic they use, the services will be of the same high quality, utilizing the tools developed through the centralized system. HIV specialists would serve the system, and can continue to be employed by the County until the clinics have the opportunity to recruit HIV specialists. Sonoma County Public Health would also continue to monitor the epidemic through surveillance activities, epidemiological reporting and monitoring of data throughout the county. NEXT STEPS 1. Create implementation group to develop a more detailed implementation plan and transition plan, comprised of Center staff and new provider agencies 2. Prepare report for Board of Supervisors for April 2010 revised 12/11 09