Hennepin County Perinatal Hepatitis B Prevention Program

State: MN Type: Model Practice Year: 2007

Hennepin County Perinatal Hepatitis B program serves pregnant women who have been identified as being Hepatitis B carriers, antigen positive. Hennepin County serves approximately 150 women per year who are pregnant and carriers for Hepatitis B. This number is up 20% from 2002. The number of children served was approximately 450-500 children in 2002 and has increased to 500-600 children in 2007. Services address the needs of children who are at-risk for developing Hepatitis B due to exposure at birth. At-risk household contacts, including spouse and extended family members range between 500-1000 people per year. 100% of the target population is contacted. This practice addresses the issue of Hepatitis B prevention in Hennepin County. By breaking down barriers to health care, vulnerable families are able to get their children in to their clinics for immunizations and well child examinations, to monitor general health as well as risks for Hepatitis B, thereby decreasing morbidity and mortality associated with Hepatitis B.
The incidence of Hepatitis B has increased since 2002. In the past year specialists have noted changes in the disease presentation creating changes in disease management and the need for greater collaboration within the medical community. Many immigrants arriving in Hennepin County find the medical/social system to be very fragmented and confusing. In the area of Hepatitis B much education is needed to dispel cultural myths and help eliminate the stigma surrounding Hepatitis B. Greater collaboration between Local Public Health, clinics and community partners eases the stress for these families and establishes greater trusting relationships. The result is more streamlined services, greater access to medical and social services and reduced duplication of services. Services offered include: Education to remove stigma associated with Hepatitis B, Assisting families in accessing appropriate Providers/Medical Home and coordinate initial visit with the provider/clinic and family member, Case Management and referral to removes barriers to access of care, Partnering with community agencies to meet basic needs of families thus creating opportunities for parents to bring their children to the clinic for follow up, Encourage/educate regarding ongoing health maintenance, and Assisting families in accessing social service agencies. Historically, personal visits with families by Public Health Nurses have been done in the family’s home. However, women have expressed concern regarding home visits by a nurse because they do not want to be identified as a carrier of Hepatitis B. Within some cultures there are myths and a stigma surrounding Hepatitis B. Having a Public Health Nurse show up at the door creates rumors in the community and places the woman at risk of being ostracized from her community. In response to this, client visits are arranged at their clinic which is a safe, neutral environment. The Public Health Nurse is able to meet with the provider, social worker, or mental health worker in addition to the family at the clinic visit. Coordination of care is achieved at the time of the clinic visit. The health care providers and clinic staff become a primary source of support for the families. Families have a better understanding of the services provided and are appreciative for the time and care invested in their family. Families not only receive care for Hepatitis B, but also develop a relationship with the clinic which removes barriers to ongoing wellness visits. Clinic visits eliminate the need for extensive follow-up phone calls; therefore, creating more effective time management.
Agency Community RolesChanging needs of the families being served made it apparent that changes needed to be adapted within the program. Hennepin County Perinatal Prevention Program's connection to the families, providers, community, and other service providers enables the program to provide services more efficiently and with greater understanding of the complex needs. A closer working relationship with the Minnesota Department of Health has developed, which has been effective in meeting the needs of the families, clinics and providers. The Minnesota Department of Health contacts the hospitals, which has streamlined the hospital reporting by having them send the birth information directly to MDH. This has also eliminated duplication of services by Local Public Health. The Minnesota Department of Health has included an HIV program to address the needs of those women who are co-infected with HIV and Hepatitis B. The Perinatal Hepatitis B program partners with the Minnesota Department of Health, Epidemiology, Baby Tracks and ImmuLink to provide outreach to community agencies and clinics. As outreach efforts have expanded, more and more clinics are willing partners in meeting the needs of the families. The Centers for Disease Control and the Minnesota Department of Health provide funding and direction. Staff from the Perinatal Hepatitis B program and Baby Tracks program are involved with neighborhood groups in pre-identified at-risk zip code areas in an effort to increase overall immunization rates. Staff members are involved with Metro Refugee Health Task Force, Community Health Worker Networking Group and other multidisciplinary community committees that serve Perinatal at-risk families. Joint clinic visits with Child and Teen Check Up (EPSDT) and WIC have benefited both the families and the clinics. Discussions are under way to do joint clinic visits with the Office of Multicultural Services in an effort to assist families with accessing multiple community resources at one time. Community partners see Local Public Health as a collaborative partner.  Costs and ExpendituresUnder supervision and direction of the Minnesota Department of Health, (MDH), grant monies from the Centers for Disease Control (CDC) are awarded to Local Public Health Departments for case management services.  ImplementationWhen a woman is identified as being pregnant and a carrier for Hepatitis B, the information is sent from the clinic or lab to the Minnesota Department of Health. The Minnesota Department of Health then notifies the hospital where the woman is planning to deliver to ensure that the infant gets the HBIG and first Hepatitis B vaccine in the hospital. The Minnesota Department of Health also forwards the information to the appropriate Local Public Health Agency for Case Management by a Public Health Nurse. Traditionally, Case Management was done in the home. Women have expressed concern because of a stigma associated with Hepatitis B, therefore the setting has been changed to the clinic where women feel more comfortable. Medical Case Management involves: Referring Hepatitis B antigen positive mothers to Primary Care/Infectious Disease/GI Specialist during pregnancy for follow up, Following up with the infant’s family and health care provider to ensure that the Hepatitis B immunizations are up to date, Ensuring that the child has a Hepatitis B serology test done at one year of age to check immune status,  Hepatitis B contact investigation for household members, Referral of household contacts for primary care and immunizations, and Track older foreign born children for immunizations/serology and primary care. The timeframe for carrying out these tasks includes:Letters of introduction are sent to the women 2 months before their expected delivery, Reminder letters for immunizations are sent to the families 2-3 weeks prior to the next appointment, immunization, or serology, Reminder letters are faxed to the clinics 2-3 weeks prior to the next required appointment, immunization, or serology, >br> Immunizations and serology results are faxed to the Minnesota Department of health on a weekly basis, and  Contact families within 2 weeks of failed appointments.
Objective 1: Case Management Performance Measures: 100% of families contacted and Contact Investigation done of household members. Referral to community resources-(only with permission of family) 80%.  Clinic visits/coordination. Successfully met all families, who agreed to joint visits, at clinics. Outcome: Families have basic needs met and are therefore able to address their family’s medical needs. Objective 2: Immunization and serology rates for infants Performance Measures: 90% completion rate of Hepatitis B immunizations and serology, required by CDC, for infants, by 15 months of age. ImmuLink/State Registry, clinics, hospitals, Minnesota Department of Health, Baby Tracks. Data is collected and analyzed on a daily basis and forwarded on to the Minnesota Department of Health on a weekly basis. Outcome: Year end statistics sent to MDH/CDC, 98 % completion rate achieved. Objective 3:Partner collaboration Performance Measures: Partnerships with clinics, Baby Tracks, WIC, Child and Teen Check Up (EPSDT), Way to Grow, Minnesota Department of Health, Economic Assistance (TANF/Medicaid), GI, Epidemiology, Office of Multicultural Services, Refugee Health Task Force, ImmuLink, Minneapolis Urban League, Sub-Saharan African Youth and Family Services in Minnesota, Northwest Hennepin Human Services Council and Northwest Hennepin Family Services Collaborative have been on an “as needed” basis varying from daily to monthly. Outcome: Partnering has streamlined comprehensive services for families. Education of community regarding the services available to families. Reduced duplication of services.
SustainabilityAs clinics are recognizing the positive outcomes after visits by the Perinatal Hepatitis B Public Health Nurse, staff have started making requests for the nurse to visit with other shared clients. The clinics set aside time and space for meetings or clinic visits to take place. Adjunct staff such as: social workers and mental health counselors are available at time of the clinic visit to meet with family. As the program grows, more clinics are getting involved. Continued funding through the Centers for Disease Control is expected since Hepatitis B is on the increase and there are growing needs of the populations involved. Continue collaboration efforts with OB, Pediatric, Family Practice and GI clinics for improved family health. Lessons LearnedThe current Perinatal Hepatitis B Prevention Program was implemented in 2002. The program has changed dramatically in the past few years as new refugee arrivals have increased. As the demographics of the populations served have changed, the needs of the families have grown. Most of the refugees have come from areas of the world where Hepatitis B is endemic in the population. The immigrants and refugees arriving in Hennepin County include but are not limited to Liberian, Somali, Hmong, Ethiopian, Chinese and Russian families. As the target population was changing, the Perinatal Hepatitis B Prevention Program began a new collaboration with the Baby Tracks program, an immunization tracking and reminder program for at-risk families. By reducing duplication of services the Perinatal Hepatitis B Public Health Nurse is able to concentrate efforts on community collaboration and unique case management services.