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Service Delivery Innovation Profile

Co-Locating Gynecologic Services Within an HIV Clinic Increases Cervical Cancer Screening Rates, Leading to Identification and Treatment of Many Cancer Cases


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Snapshot

Summary

The Christiana Care HIV Program integrates gynecologic care into overall HIV management by offering an onsite weekly women's clinic where their HIV-infected patients can receive necessary screening (i.e., Papanicolaou tests) and preventive care. The program has increased cervical cancer screening rates (from 10 to 65 percent), which, in turn, has led to the identification and treatment of many cervical cancer cases.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation cervical cancer screening rates, as well as post-implementation statistics on Pap smear results, followup gynecologic services provided, and perinatal human immunodeficiency virus (HIV) transmission rates.
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Developing Organizations

Christiana Care Health Services -- HIV Program
Wilmington, DEend do

Date First Implemented

2002
Septemberbegin pp

Patient Population

Gender > Female; Vulnerable Populations > Womenend pp

Problem Addressed

Due to their impaired immune function, HIV-positive women have a much higher risk of developing cervical and uterine cancers than do women without HIV. However, many women with HIV do not receive necessary cancer screening due to a reluctance to seek care and/or other barriers such as psychosocial factors.
  • Increased risk of cervical and uterine cancer: HIV-positive women are more likely to be infected with the types of human papillomavirus that can lead to cancer and to have cervical intraepithelial neoplasia (lesions) that can lead to invasive cervical cancer. Although the magnitude of the increased risk in HIV-positive women is not clear, the risk remains elevated even when HIV-positive women are on highly active antiretroviral therapy.1,2
  • Barriers to obtaining gynecologic care: Although 90 percent of the women seen in the Christiana Care HIV Clinic were referred annually for routine Papanicolaou tests ("Pap smears"), less than 10 percent actually attended the visit. Several barriers to receiving gynecologic care existed for this population. For example, many of these women (especially working, single mothers) found it difficult to make the time for appointments and/or to arrange travel to them. Others may have been reluctant to reveal their HIV-positive status to outside gynecologic providers.3

What They Did

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Description of the Innovative Activity

As part of its comprehensive medical management of HIV, Christiana Care's HIV program "nested" gynecologic services into their program. The weekly women's-only clinic reduces barriers to seeking services and provides a comfortable setting for HIV-positive women to obtain necessary gynecologic care. The HIV program is a statewide program and has clinical sites in all three counties in Delaware; in 2011, the HIV program provided care to more than 1,650 patients. Key elements of the clinic include the following:
  • Scheduling clinic visits: HIV program nurses review patients' medical records before each physician visit to determine whether certain components of preventive gynecologic care are needed, including annual cervical cancer screening. If a screening has not been done in the past year, the nurse will ask the patient if she has obtained screening elsewhere, or if she would like an appointment at the Friday clinic. If the patient wants an appointment, the front office staff schedules the next HIV appointment for a Friday morning so that HIV care can be provided in conjunction with a gynecologic examination. Patients receive a reminder call from a peer educator 1 or 2 days in advance of the appointment.
  • Clinic services: The Friday morning women's clinic provides both gynecologic care and additional HIV-related services as needed.
    • Gynecologic care: Gynecologic care is provided by a part-time obstetrician/gynecologist (OB/GYN) and a nurse practitioner (NP) with gynecology experience who works full-time at the HIV program. Women are provided with a routine gynecology examination, including a pelvic examination and Pap smear; an evaluation for sexually transmitted diseases; education on breast health, mammography, and breast self-examination; and family planning services, including birth control and education on reproductive health and safe sexual practices based on a standardized treatment protocol. Information provided in April 2011 indicates that for those women who find it difficult to keep multiple appointments, HIV Program nurse practitioners will perform a pelvic examination and do a PAP smear during the patients routine HIV clinical visit (if the patient is willing and time permits). This alleviates the need for an additional appointment.
    • Pregnancy management services: Information provided in March 2010 indicates the program now also provides onsite pregnancy management, with the OB/GYN delivering a significant number of babies for women seen at the HIV clinic.
    • Additional services/providers: The HIV clinic includes full-time staff members who provide interventions at the women's clinic as needed. For example, a clinical pharmacist provides medical management, including modifying HIV medications as necessary during a patient's pregnancy. During the Friday morning clinic, a clinical social worker is available to address patients' psychosocial needs and a female peer educator is available in the waiting room to provide comfort and support, including watching patients' children during the visit and answering general questions.
  • Incentives for attending: Women who attended gynecology appointments are given a "goodie" bag with small soaps, shower gels, and other products. Transportation to the clinic is provided if needed.
  • Followup care for those with abnormal findings: The gynecology nurse telephones patients whose Pap smear results are abnormal to schedule an onsite colposcopy (a visual examination of the cervix). If results suggest the need for more comprehensive followup care, patients are referred to Christiana Care's Women's Health Center, where the women's clinic OB/GYN is on staff and can provide or coordinate necessary care.

Context of the Innovation

The Christiana Care Health Services HIV Program, the largest provider of HIV/acquired immunodeficiency syndrome care in Delaware, provides care to more than 1,600 patients per year at seven different sites, representing approximately 65 percent of all HIV patients who receive care in the state (updated April 2011). Most patients are insured through Medicaid or Medicare, although some have private insurance and some are uninsured; approximately 37 percent are female (updated April 2011). The Christiana Care HIV Program, as a Ryan White Part D grantee,4 supports the provision of family-centered care to HIV-infected women who are either pregnant, currently abusing drugs, have advanced HIV disease, or have mental illness. The women's clinic program was developed in response to research indicating that many women referred for cervical cancer screening did not obtain that screening; program developers believed that screening rates would increase through the development of an onsite clinic where patients could easily and sensitively access women's health services.

Did It Work?

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Results

The program has increased cervical cancer screening rates, which, in turn, has led to the identification and treatment of many cervical cancer cases.
  • Increase in cervical cancer screening: Before the women's clinic, only approximately 10 percent of referred patients obtained cervical cancer screening. In the first 10 months of clinic operations, 21 percent of the HIV program's female patients had attended a gynecology appointment. As of fall 2008, 61 percent of the clinic's female patients had received a Pap smear in the past year. Information provided in March 2010 indicated that in 2009, patient visits in the women's clinic totaled 382; 57 percent of women accessing care within the HIV program had documented Pap results in the medical record. Information provided in April 2011 indicated the HIV Program provided medical care to 578 women in 2010; the percentage of women with documented Pap results rose to 65 percent in 2010. Information provided in March 2012 indicates this number remained constant in 2011. Information provided in February 2013 indicates that the percentage of women with documented Pap results fell to 56% in 2012; however, the HIV Program converted to a new electronic medical record in 2012 and it is possible that some Pap results were not preloaded during this conversion.
  • Leading to greater detection and treatment: In 2008, more than half of HIV program patients (52 percent) receiving a Pap smear in the first 10 months of the women's clinic had abnormal results. Of these, 60 percent received colposcopy and followup care at the Christiana Care Women's Health Clinic. Approximately half of these patients have been diagnosed with cervical cancer and are in various stages of treatment. Information provided in March 2010 indicates that of the 57 percent of women with documented Pap results in 2009, 36 percent had abnormal results that required followup; the percentage of women with abnormal results who received appropriate followup rose to 84 percent, compared with 52 percent in 2008. Information provided in April 2011 indicated the percentage of women with abnormal results dropped from 36 percent in 2009 to 24 percent in 2010; appropriate followup was provided for 84 percent of women with abnormal results. Information provided in February 2013 indicates these numbers remained constant in 2012.
  • No perinatal HIV transmission in pregnant patients receiving care: Information provided in February 2013 indicates that, through 2012, 82 pregnant women have received obstetric care through the program; there were no instances of perinatal transmission of HIV in this population.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation cervical cancer screening rates, as well as post-implementation statistics on Pap smear results, followup gynecologic services provided, and perinatal human immunodeficiency virus (HIV) transmission rates.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Recruiting an in-house OB/GYN: HIV program leaders initially contacted the Christiana Care Women's Health Service to determine whether an OB/GYN would be willing to donate time to the Friday clinics. Recognizing the importance of the program, the Women's Health Service funded an OB/GYN to treat patients at the HIV program clinic a few times a month. However, due to conflicting demands, this OB/GYN could not consistently participate in the clinic.
  • Allocating funding to ensure OB/GYN availability: HIV program leaders modified their budget to include funding for an OB/GYN who could provide consistent staffing for the women's clinic.
  • Hiring an experienced nurse: When the opportunity arose, the HIV program recruited a nurse with OB/GYN experience to assist in the women's clinic, who works in the HIV primary care clinic during the rest of the week.
  • NP training: The HIV NP went to additional training so that she could perform onsite colposcopies to reduce the need to send patients with abnormal Pap smears to offsite providers.
  • Developing a followup process: HIV program leaders outlined a process of care that allowed for the identification of women who needed cervical cancer screening, appropriate followup for those with abnormal results, and referrals to outside specialty services as necessary.
  • Investigate patient needs: Program leaders conducted a survey to determine patient's educational needs around women's health issues.
  • Adopting treatment protocol: The clinic adopted the evidence-based medicine standardized treatment protocols based on clinical guidelines that were current at the time the program was developed.
  • Expansion: Information provided in March 2010 indicates that, based on program success at two sites, the decision was made to spread the HIV program to the Kent County site to serve women accessing care in the two southern Delaware counties. Due to limited funding, services are provided at this site 2 days per month. The Ryan White Part D budget was adjusted to pay for the additional physician hours. In addition, the nurse practitioner at this site attended training to do onsite colposcopies and is now certified by the American Association of Colposcopy and Cervical Pathology.

Resources Used and Skills Needed

  • Staffing: Staffing includes an OB/GYN working 1.5 days per week, as well as two full-time NPs currently certified to provide onsite colposcopies and a nurse, who each devote 50 percent of their time to direct gynecologic patient care and the other 50 percent to the HIV primary care clinic.
  • Costs: Program expenses include labor (for the OB/GYN, NPs, and nurse) and equipment (colposcope, ultrasound machine, and associated tools and disposable supplies needed for gynecologic care). Equipment costs run approximately $45,000.
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Funding Sources

Health Resources and Services Administration; Ryan White CARE Act; Christiana Care Health Services
Equipment costs were funded internally. Gynecologic services provided during the Friday clinic are reimbursable through public or private insurers (for patients with coverage); Ryan White Part D funds are used to support staff in the care of the uninsured; Christiana Care funds the cost of diagnostics and procedures for patients who do not have insurance and fall below 200 percent of the Federal poverty levels.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Develop a multidisciplinary care team: Multiple caregivers are needed to adequately serve HIV-positive women, including an OB/GYN, NP, social worker, pharmacist, and peer educator.
  • Identify an OB/GYN who understands the needs of HIV-positive women: The OB/GYN should be supportive of patient-centered care, teamwork, and coordination and integration of care that takes into account both HIV status and gynecologic care needs.
  • Remove barriers to care: Clients will be more likely to keep scheduled appointments for gynecologic care if they are co-located in the HIV program and scheduled concurrently with HIV followup visits. Providing childcare and transportation can also be important in ensuring attendance.
  • Create a patient-centered culture: The culture of the women's health program has to be focused on the specific needs of women and strive to meet those needs in a responsive environment.

Sustaining This Innovation

  • Demonstrate success: Measure clinical outcomes, patient satisfaction, and appropriate billing practices to demonstrate success to administration and staff.
  • Incorporate patient feedback: Incorporating patient feedback into service delivery demonstrates to patients that the clinic is committed to providing patient-centered care.

More Information

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Contact the Innovator

Arlene Bincsik, RN, MS, CCRC, ACRN
Program Director
Christiana Care Health Services
HIV Program—Wilmington Annex
1400 Washington Street
Wilmington, DE 19801
E-mail: abincsik@christianacare.org

Robin Bidwell, BSN, CCRC
CQI Coordinator
Christiana Care Health Services
HIV Program—Wilmington Annex
1400 Washington Street
Wilmington, DE 19801
E-mail: rbidwell@christianacare.org

Innovator Disclosures

Ms. Bincsik and Ms. Bidwell reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.

References/Related Articles

Institute for Healthcare Improvement. Improvement Report: Women's Only Clinic for HIV Positive Women. Available at: http://www.ihi.org/knowledge/Pages/ImprovementStories
/MemberReportWomensOnlyClinicforHIVPositiveWomen.aspx

Footnotes

1 de Sanjose S, Palefsky J. Cervical and anal HPV infections in HIV positive women and men. Virus Res. 2002;89(2):201-11. [PubMed]
2 Gaffikin L, Ahmed S, Chen YQ, et al. Risk factors as the basis for triage in low-resource cervical cancer screening programs. Int J Gynaecol Obstet. 2003;80(1):41-7. [PubMed]
3 Interview with Arlene Bincsik and Robin Bidwell, November 13, 2008.
4 Part D of the Ryan White Modernization Act, enacted in 1990, provides grants for family-centered maternal and pediatric HIV services and coordination with clinical research affecting women, children, adolescents, and families.
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Original publication: April 27, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 12, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.