Family Planning Services at Denver Metro Health Clinic

State: CO Type: Model Practice Year: 2004

Unintended pregnancy is an important and complex problem that has significant public health consequences. Women at-risk for unintended pregnancy may be simultaneously at-risk for sexually transmitted disease (STD). As a result of research conducted at the Denver Metro Health Clinic (DMHC) to determine the effectiveness of initiating contraception in an STD clinic setting, the DMHC, in collaboration with the Colorado Department of Public Health and Environment’s Women’s Health Section (CDPHE), developed a Title X clinic at the STD clinic. The Title X clinic provides reproductive health care services to eligible women as part of their STD evaluation. While the focus of the program is family planning services for women, eligible male patients seen by Title X staff also receive services. In 2003, 44 percent of screened clients received some form of family planning services. For all eligible female patients seen within the DMHC, services include preconception counseling, pregnancy testing, and initial contraceptive services. After initial services are provided, the clinician will make a referral to a primary care provider for ongoing reproductive health care needs. In addition, as part of the assessment, the clinician determines if the client meets the criteria for being at very high-risk unintended pregnancy. Those patient are eligible to receive ongoing contraceptive and STD services through the Title X continuity clinic. For eligible men, services provided include training in testicular self-examination and contraceptive counseling. To develop this type of program, one needs: Staff that are interested in providing family planning services to high-risk individuals and who can provide care in a non-judgmental manner.  STD clinic staff that consider these services necessary and encourage the integration of these services into the clinical setting.
Women at-risk for unintended pregnancy may be simultaneously at-risk for sexually transmitted disease (STD). Poor, minority women under 25 have the highest rates of both STDs and unintended pregnancies. Most family planning programs and STD clinic programs in the United States began as separate entities to address specific programmatic needs, with limited overlap of services. Family planning clinics have combined the treatment model to include STD screening and treatment services with contraceptive services. However, STD clinics, which serve a different population, which is often less socially organized and less interested in preventive health care, have not combined these services. At the DMHC, all women seen for services are interviewed regarding their reproductive health and contraceptive use, as well as their STD history. In the mid 1990s, before the described program began, women in need of contraceptive care who were <19 years of age were referred to the teen clinic, while those women >19 years were provided with condoms and offered a referral for family planning services through an outside community health clinic. During this time, staff suspected that, given the generally poor preventive health care behaviors of STD clinic patients, it was likely that a substantial proportion so referred delayed or avoided contraceptive care, leaving them vulnerable to unplanned pregnancy. To address these issues, the staff conducted a randomized controlled trial at the STD clinic to determine whether offering contraceptive services at the clinic would contribute to consistent, ongoing contraceptive care and prevention of unintended pregnancy. The study was conducted to determine the effectiveness of STD clinic-initiated contraceptive care followed by transition to an ongoing PCP, compared to a traditional referral model for improvement in establishing contact with an ongoing PCP. The goal was to improve the number of clients beginning and adhering to an effective method of contraception, and to lower the rate of unintended pregnancy. In summary, these results indicated that women presenting to an STD clinic are at high-risk for a pregnancy. Although the intervention did not significantly lower the unintended pregnancy rate, the results did indicate an initial benefit from the intervention, with substantially more women starting effective contraception and transitioning to primary care. The results also indicated that novel strategies are needed to address reproductive health problems for these women.
Agency Community RolesBased on the results of the study, information was shared with a number of organizations throughout the Denver community in order to increase awareness of the issues facing women seen at the DMHC facility. In June 2000, the Women’s Health Section of the CDPHE expressed an interest in expanding their Title X services, using novel approaches to reach high-risk women. DMHC was asked to apply. In their application, DMHC proposed implementing the study’s intervention, with the hope of reaching high-risk women who had little access to contraceptive services. The CDPHE Women’s Health section funded the program. Initially services were only for initiating contraception for all interested women seen in the STD clinic and for ongoing services for the teen clinic. However, thanks to the success of the program and the availability of additional funding, CDPHE solicited ideas for an expansion of services in July 2002. DMHC proposed an expansion of the clinical services to include 1) a continuity clinic, with referrals for women who met the criteria of being at high-risk for pregnancy, based on the study on predicators of pregnancy and 2) provision of clinical services for eligible male clients. Funding increased in September 2002, allowing expanded services for 1) initial care for both women and heterosexual men, and 2) continuity care for all teens and high-risk women. Family planning staff are cross-trained in the protocols used in the DMHC, which allows the nurses to provide both family planning care and STD clinical care, depending on the needs of the clinic. To increase access to family planning services, DMHC has partnered with a number of outside organizations to increase exposure of the services available and allow them to refer women to the clinic. These groups represent community-based organizations, schools, peer educators, and teen groups throughout the Denver Metro area. Additionally, staff have provided training to groups seen through the partnering community-based organizations.  Costs and ExpendituresThe major costs associated with this program include the contraceptive supplies and the staff required to provide the clinical services. Funds available through Title X enable DMHC to fund 1.75 RNs who are able to provide family planning services as well as STD services. In addition, they are able to partially fund a clerk and a data analyst and provide funds for physician support. Contraceptive supplies are purchased through Title X and include emergency contraception, oral contraceptives, and Depo-Provera injections. Newer contraceptives are too costly and are not available. The DMHC funds 0.25 RN and provides all clinic infrastructure, including clinic facilities, registration support, all laboratory services, condoms, and any necessary STD treatments.  ImplementationAfter research study (described above) was completed, , the possibility was discussed of permanently establishing this type of contraception program at the clinic. The DMHC was willing to provide the clinical support services and infrastructure necessary to support the program. What was still needed was financial support to pay for the clinicians’ time. Funding for staff was obtained through the Women’s Health Section of the CDPHE, which expressed an interest in expanding their Title X services using novel approaches to reach high-risk women. They accepted DMHC’s proposal of implementing the previously tested intervention, with the hope of reaching high-risk women who had little access to contraceptive services. The program has had stable funding for the past four years.
The staff developed a form, which allows them to identify family planning clients, and link their information to the STD clinical encounter. From these databases, they have been able to characterize the population seen in the program as compared to the general STD clientele. In addition, they are able to complete required reports to the CDPHE on the Title X activities. Currently, of the 1600 patients seen in 2003, 75% were <25 years of age with the majority being non-white (22% African-American, 38% Hispanic and 40% white). The majority of the patients were poor with almost 75% having an income level <150% poverty level indicating limited resources to help themselves. In 2003, most female patients received contraceptive supplies. However, based on the predictors of pregnancy model, approximately half of the female participants have over a 50% chance of having an unintended pregnancy within a year indicating a need for ongoing continuity of services. These findings indicate that these types of services are needed and that the program is reaching high-risk individuals. All Title X programs receive an annual review of either the clinical or the administrative services provided. For the clinical review, this assessment reviews all clinical procedures and protocols to ensure that clinical care is appropriate. In the administrative review, an appraisal is made on documentation, follow-up provided, collection of data, registration of clients, etc. While these reviews are time consuming, they do ensure that the program is providing appropriate care for the clients. Over the past two years, the clinic has received high ratings for clinical and administrative services.
Both the Women’s Health Section of the CDPHE and the DMHC are committed to this program. Both groups feel this program has been very successful in reaching high-risk individuals. CDPHE established reasonable targets for the program to meet each year in order to continue to receive funding. DMHC has required that family planning personnel provide STD services in addition to family planning, a feasible obligation to meet.