Strike Team

State: TX Type: Model Practice Year: 2009

In 2007, the national Primary and Secondary (P&S) syphilis rate among African Americans increased for the fourth consecutive year, following more than a decade of declines. Between 2006 and 2007, the rate among African Americans increased 25 percent (from 11.2 to 14.0 per 100,000 population), with the largest increase among African American males (18.1 to 23.2, an increase of 28.2 percent). By comparison, the rate among African American females increased 14.3 percent (4.9 to 5.6) (CDC, 2008). In 2008, CDC ranked the Houston, Harris County, second in the nation with 454 new P&S cases; a rate of 11.7 per 100,000 population during 2007 (CDC, 2008). Among minority populations residing in Harris County, Houston Department of Health and Human Services (HDHHS) reports 2007 P&S in African Americans as 64 percent (293/458) vs. 58 percent (221/378) in 2006, Hispanics 17 percent (76/458) vs. 19 percent (71/378) in 2006, and Asians remaining the same at 1 percent (3/458) vs. 1 percent (4/378) in 2006 (HDHHS, 2008). This reflects an increase of 26 percent (76/296) in minorities with P&S cases from 2006 to 2007. The trend continued during the first half of 2008 with HDHHS reporting 81 percent (138/171) P&S in minorities (HDHHS, 2008). HDHHS also confirmed an increase in cases regarding gender and reported risk behaviors during this same time period. Females increased by 42 cases (76 percent) change from 2006 to 2007 and crack/drug usage increased by 35 cases (52 percent) change during the same period (HDHHS, 2008). The mission is to assist and continually move the HIV/STD and Viral Hepatitis program forward in achieving goals and objectives that protect and serve Houstonians in disease prevention. The Strike Team uses the emergency preparedness and response principles of the federal National Incident Management Structure (NIMS). Identified objectives are to conduct weekly quality assurance case reviews on all cases submitted for closure; identify possible training opportunities for DIS/Supervisor skill development; ensure no missed opportunities exist; achieve an 85 percent goal on the Funding Period STD Intervention Objectives (FPO); and commence Strike activities when the FPO reaches a threshold of 65 percent. Each team member reviews cases ensuring that case classification is correct, disease intervention has taken place, and related screening opportunities are exhausted. Each case is reviewed for DIS and Supervisory management improvement, training opportunities, and prospects for community screenings. The Strike Team strategies have ensured successful goal achievement of the Funding Period STD Intervention Objectives above the required 80 percent each consecutive month since implementation. This is a major success for the program and for intervention of disease in the community.
The public health issue addressed by the Strike Team is that of improving all syphilis case rates, identifying and removing barriers to care through mobile screening, and improving the overall health of Houstonians, particularly minorities who are most affected. Data obtained from the STD database (STD*MIS) and FPO analysis were used to determine the initial areas to focus immediate improvements and allocate resources for training. In addition, management and operations staff researched and identified evidenced based and data driven best practices that would be cost effective, easy to implement, and could be time sensitive with immediate results. Although the initial focus is on disease prevention and intervention through reaching FPO objectives, the entire STD program staff benefits from the strike team strategy through increased targeted training and analytical skill building. This also affects STD prevalence and leads to decreased morbidity throughout the community. The mobile clinic screening procedures were based on various studies and public health programs that highlighted the success of intensive targeted outreach activities regarding community screenings. In review of literature, mobile clinics have been used successfully throughout the United States in rural and urban communities. One study identified success with more targeted screening and intervention activities surrounding syphilis when conducted in the community. The public health issue addressed by the Strike Team is the improvement of case management activities that directly affect the local and state rates of infectious syphilis, application of creative and innovative intervention processes, and improvement of the overall health of Houston’s families affected and infected with communicable diseases. Data obtained, analyzed, and used were generated from the STD*MIS system and FPO reports. These data were used to determine the initial areas to allocate resources for the implementation of Strike activities that would best reflect a positive change. Traditionally, STD programs perform routine duties of partner services, education, and outreach coordination for disease intervention. The Strike Team conducts these activities in a creative and innovative way, which teaches the DIS to be more case conscientious and supervisors to be assiduous in reaching disease intervention. Listed below is one citation of supporting evidence of effective practice for STD intervention. Chen, J. L., Kodagoda, D., Lawrence, M. A., and Kerndt, P. R. (2002). Rapid public health intervention in response to an outbreak of syphilis in Los Angeles. Sexually Transmitted Diseases: 29(5)May 2002, 277–284. The Strike Team concept was based upon the CDC Syphilis Elimination Rapid Response Team and the Incident Command Structure. It focuses on alternative STD programs strategies that address the current trends and identified risk behaviors of affected and infected clients for prevention efforts. The Strike Team operates similar to an Incident Command center and operation and data manager chiefs function as a supervisory coach with supervisory staff. First by functioning as a coach, the Strike Team builds a relationship of trust with DIS staff and the operation is seen as a positive quality assurance method with training strategies for skills building. The Strike Team is responsive because it allows for the expansion of quality preventatitve and treatment services that are free and confidential to include; counseling and testing, and examination and treatment services to be taken directly to affected communities. The emergency response approach also consists of enhanced surveillance activities, including private provider survey and public health, stronger partnerships with the mobile clinic and sentinel clinical sites for patient care, DIS case and field management activities, and DIS and supervisory skills building. The case evaluation and FPO analysis component of Strike Team is quite exte
Agency Community RolesThe Strike Team is an integral part of HDHHS’ overall strategy toward the holistic approach of a disease intervention and prevention and achieving the FPO on a routine basis. The number one priority of HDHHS is controlling the spread of communicable diseases. One of the primary objectives of this Strike Team approach is to reduce the amount of uncapitalized opportunities for intervention activities within communities with high syphilis morbidity. For instance, HDHHS has provided convenient STD/HIV mobile clinic service delivery during nontraditional hours for Houston’s hard to reach and high risk populations. The shift in traditional STD prevention strategies has allowed for sustainability with the Strike Team and resulted in diverse expertise in accomplishing program objectives. Skills building training opportunities have improved supervisory staff and DIS staff, and the Strike Team initiative is used less often and has become the routine operations with DIS and Supervisory staff. Future capitalization of this endeavor is being considered and strategies are being developed. HDHHS’ external partners of consideration include local private provider sites, CBOs, and NGOs who currently work on syphilis elimination campaigns and other HDHHS syphilis and HIV prevention and intervention activities. The HDHHS-Bureau of HIV/STD and Viral Hepatitis prevention provides STD and HIV training to enhance current CBO/NGO outreach activities. Future collaboration would be inclusive of CBO/NGO medical staff that could assist in sustaining the mobile clinic during nontraditional hours of operation. The mission of HDHHS is to provide leadership in the promotion and protection of the health and social well being of the Houston community through advocacy, education, and community-based health services. This program initiative is one that promotes that mission through internal strategies for program and staff enhancement. Costs and ExpendituresThis strategy is budget neutral as the strike team activities were developed, implemented, and evaluated using existing program management and staff. ImplementationThe Strike Team is composed of experienced managers and supervisors that perform quality assurance strategies for intensive STD intervention. The Strike Team reviews the weekly Funding Period STD Intervention Objectives (FPO) to assess where the program stands in disease prevention and intervention and to identify how many missed opportunities could have been capitalized upon. With this document and the open case listing, the Strike Team reviews each case and its notes for identifying uncapitalized opportunities. All contacts and clusters with adverse dispositions and marginal partners are re-evaluated for disease intervention and cases with identified hangouts and contacts in high morbidity areas are scrutinized for linkage for community screenings. This enhanced emergency response activity exhausts all possible avenues for disease intervention, which increases HDHHS presence and involvement in public health action within the communities most affected. HDHHS mobile clinic plays an integral part in community screening in high morbidity areas. Specific Strike Team operational processes are identifying Operations Chief (OC) and Data Manager Chief (DMC); developing calendar for team coordination with SMART Objectives, goals, and impact evaluation process; developing and generating DMC FPOs with analysis and recommendations for met vs. unmet objectives, STD*MIS open case line listing for three months and open (delinquent) field record listing for evaluation and Q/A on a weekly or biweekly basis, OC identifying participating parties for the Strike Team, organizing Q/A initiative on cases presented for closure, conducting Q/A on a weekly or bi-weekly basis, ensuring that cases have disease intervention and cluster activity, and ensuring that the FPOs are met on a weekly basis; DMC generating new FPO reports after the Q/A was completed to evaluate the effect of the enhanced intervention activities;OC generating a monthly report stipulating the effect of the Strike Team efforts with quantifying and qualifying data, identifying strengths and weaknesses in skill sets of staff, facilitating training for skills building for staff, and providing supervisors with technical assistance in enhanced case/field management Q/A. This program activity is accomplished by performing all aforementioned objectives; thereby increasing disease intervention compliance, increasing disease awareness in the communities most affected, and positively affecting the disease morbidity in Harris County. Recognizing this type of concerted effort is only a time-limited immediate resource to address critical performance issues, the Strike Team stipulates the initiation of activities commence when the FPO threshold reaches 65 percent by the second week of the reporting month. Strike Team efforts offer intensive follow-up on all case management activities to improve disease intervention and prevention endeavors performed by DIS and to address the increase morbidity in Harris County. It also provides technical guidance to supervisors for real-time case evaluation for identifying intervention and screening possibilities.
Adapting and using emergency management principles can be effective to improve program performance practices and ultimately community health outcomes.
Because the implementation of the Strike Team, HDHHS has committed to nontraditional process to addressing a disease that has increased nationally. It has expanded the alternative strategies for disease prevention and intervention. The Strike Team now operates on a “stand-down” mode because the HIV/STD and Viral Hepatitis Program has met the FPO and state objectives for the past six months; with operational plans in place to commence when necessary. HDHHS uses the City’s general funds and has incorporated grant funds from CDC and Texas Department of State Health Services to sustain the program.