Assessing Effectiveness Brochure: LHD/NHHE Progam Working Together AND STD Prevention Services

Form approved:

OMB No. 0920-0879

Expiration Date 08/31/2014

Attachment A: MS Word version of Data Collection instrument

Assessing STD Programs and Services in State and Local Health Departments

Thank you for responding to this data collection. We are asking you for this information because it is important to understand the level of publicly-funded STD prevention services (gray highlighted phrases are hover over definitions reflected in Attachment A1) that are offered by health departments in the US. Provision of STD testing, treatment, and partner services are one of the core functions of public health. Your responses will help us understand the current state of publicly-funded STD care, and help serve as a baseline for future assessments.

If you are with a state health department, please answer the questions for clinics or staff under your direct control. If your state’s health department is decentralized, with local-level control, please do not include any areas under local control in your responses. If you are with a county or city health department, please answer the questions for clinics in your jurisdiction or service area.

Data collection Contents:

1. STD Prevention Programmatic Activities (Pages 1-5)

2. Workforce (Pages 5-7)

3. Budgets and the Impact of Budget Cuts on Services (Pages 7-9)

1a (Screener): Does your health department currently provide any STD prevention services (either directly or through contracts)?

1. Yes  Go to Q#2

2. No

1b (Screener): Did your health department provide any STD prevention services (either directly or through contracts) during your 2011 or 2012 fiscal years?

1. Yes  Go to Q#3

2. No  Go to Q#15

I. STD Prevention Programmatic Activities

2. The first set of questions asks about the current provision of clinical and non-clinical STD prevention services and STD programmatic prevention activities. Are you able to provide this information about services in your jurisdiction?

1. Yes

2. No  go to Q#15

1. Number of clinics operated directly by the health department: ______ [numeric response]

2. Number of clinics operated via contract: ______ [numeric response]

3. Number of additional STD clinics not operated by the health department or via contract: _______ [numeric response]

3. What is the primary point of care to which you refer patients in your jurisdiction for STD care?

1. Specialty STD clinic

2. Specialty family planning clinic

3. Combination STD/family planning clinic

4. Federally-qualified health center (FQHC)

5. General public health clinic (a clinic which sees patients requesting all types of care)

6. University-affiliated health clinic

7. Other, please specify: _______________

8. Not applicable-we do not refer patients for STD care

9. I don’t know

4. For the following question, please answer only for those services provided as part of your STD program at your main clinic. [For example, hepatitis B vaccination may be provided by other parts of your health department, such as perinatal services. However, please do not indicate that you provide hepatitis B vaccine unless you also do so as part of your STD program.] Check all that apply.

1. HBV vaccination

2. HPV vaccination

3. Darkfield microscopy

4. Stat (on-site) RPR testing

5. Stat (on-site) Gram stain testing for symptomatic men

6. Extra-genital chlamydia &/or gonorrhea testing

7. Gonorrhea culture

8. Pap testing

9. Walk-in care (the ability to see a clinician with no prior appointment)

10. Not applicable-we do not have a main clinic

11. I don’t know

5. Did your STD program conduct screening in any non-clinical settings (e.g., outreach screening) in your 2012 fiscal year?

1. Yes

2. No  Go to #7

3. I don’t know  Go to #7

6. Please provide the approximate number of patients screened and # of cases detected through non-clinical screening in your 2012 fiscal year in the table below.

	Chlamydia		Gonorrhea		Early Syphilis
	Check if did not screen	Number	Check if did not screen	Number	Check if did not screen	Number
# Screened
# Cases detected

7. In your 2012 fiscal year, did your program provide partner services by health department staff, such as disease investigation specialists (DIS) or communicable disease investigators (CDI)?

a. Yes

b. No  Go to Q#11

c. I don’t know  Go to Q#11

8. Who in the health department is the main provider of partner services?

a. DIS / CDI

b. Public health nurse

c. Community health outreach worker

d. Other, please specify: ___________________

e. I don’t know

9. Please provide the approximate number of cases interviewed in your 2012 fiscal year and the number of new cases identified through partner services in your 2012 fiscal year.

Disease	Check If Your Program Conducted No Interviews in 2012 Fiscal Year	# Interviewed in 2012 Fiscal Year	Check If Your Program Found No New Cases through Partner Services in 2012 Fiscal Year	# New Cases Found through Partner Services in 2012 Fiscal Year
Early syphilis
Gonorrhea
Chlamydia
HIV

10. Are your staff who provide partner services able to perform phlebotomy in the field (i.e., collect blood specimens for testing)?

1. Yes – all partner services staff are trained

2. Yes - but only some partner services staff are trained

3. No

4. State law does not allow for field collection of blood specimens

5. I don’t know

11. Does your program conduct any other types of partner services? Please check all that apply.

1. Expedited partner therapy (EPT) for chlamydia

2. Expedited partner therapy (EPT) for gonorrhea

3. Field-delivered treatment for chlamydia or gonorrhea

4. Internet partner services

5. Serologic testing of syphilis contacts in the field

6. Field HIV testing for STD contacts  if checked, ask Q#12

7. Other, please specify: ____________

8. I don’t know

12. [Ask if (f) checked in Q#11] Does your program link to care persons who test positive for HIV during partner-services field testing?

1. Yes, by health department staff

2. Yes, by referral  Go to Q#14

3. No Go to Q#15

4. I don’t know  Go to Q#15

13. Who in your health department is/are the primary staff person(s) linking newly-diagnosed HIV patients to care?

a. DIS / CDI

b. Public health nurse

c. Community health outreach worker

d. Other, please specify: ___________________

e. I don’t know

14. Does someone in your health department follow up with newly-diagnosed HIV patients to ensure that they have been successfully linked to care?

1. Yes

2. No

3. I don’t know

15. What types of health promotion activities does your program currently provide? Check all that apply.

1. Health communication, education and STD prevention materials in print or on a health department website If checked, ask Q#16

2. News releasesIf checked, ask Q#16

3. Promote external Web sites through methods other than linking from your own health department’s Web site(external STD prevention sites include InSpot, Get Yourself Tested (GYT), CDC, American Social Health Association (ASHA), AIDS.gov, Advocates for Youth, and others)

4. Distribution of condoms to individuals or venues such as bars or bathhouses  Go to Q#17

5. Other, please specify: __________

6. I don’t know

16. [Ask if (a) or (b) checked in Q#15] What forms of media outreach does your program currently engage in? Check all that apply.

a. Develop focused communications (e.g., fact sheets, talking points, media strategy)

b. Build and maintain professional relationships with reporters

c. Engage in outreach communication via social media (e.g., Facebook, Twitter, LinkedIn)

d. Host news conferences (proactive or reactive)

e. Monitor media coverage of local STD issues and data releases

f. Other, please describe: _______________________

g. I don’t know.

17. [Ask if (d) is checked in Q#15] You indicated that your health department distributes condoms. Approximately how many condoms were distributed in your 2012 fiscal year?

a. Number of condoms __________

b. I don’t know

18. Does your program have health department STD program staff or contractors visit clinical providers in your jurisdiction to market health department services, provide public health updates, or other STD information?

1. Yes

2. No  Go to Q#20

3. I don’t know  Go to Q#20

19. What types of health providers did your program visit in your 2012 fiscal year? Check all that apply

1. Family planning providers

2. Correctional health care providers

3. HIV care providers

4. Providers in Federally-Qualified Health Centers (FHQCs)

5. Private practice providers

6. Providers in school-based clinics

7. Providers in emergency departments or urgent care

8. Other, please specify: ____________

9. I don’t know

20. What epidemiology and surveillance activities are currently conducted by your program (mark all that apply)?

1. Geocode case report data

2. Match STD case report data with HIV data to analyze syndemics / overlaps

3. Assess STD health care services in your jurisdiction to identify gaps in coverage

4. Assess safety net needs of at-risk populations who are not accessing care (those who lack insurance coverage or those who have coverage but are not accessing care)

5. Target prevention activities to highest-risk populations

6. Publish and disseminate data on a health department Web site at least annually

7. Publish and disseminate an epidemiologic profile for your jurisdiction at least annually

8. Other, please specify: _____

9. I don’t know

II. Workforce

We would like to know about recent changes to the size and composition of your STD workforce. To calculate FTEs, count a full-time employee as 1 FTE, a half-time employee as a 0.5 FTE, etc. Please include ALL regular full-time and part-time employees, but DO NOT include contractors. If an employee is shared with another health department program, count only the time devoted to STD activities.

21. How many FTEs are in your current STD workforce?

a. Approximate number: ________

b. I don’t know

22. Did your program experience changes in staffing levels during the 2012 fiscal year? If so, please indicate the net change in FTEs.

a. Net decrease of __________FTEs [If decrease indicated, ask Q#24]

b. Net increase of __________FTEs

c. No staffing change in the 2012 fiscal year

d. I don’t know

23. Did your program experienced changes in staffing levels during your 2006 through 2011 fiscal years (i.e., fiscal years 2006, 2007, 2008, 2009, 2010, and 2011)? If so, please indicate the approximate net change in FTEs.

a. Net decrease of __________FTEs [If decrease indicated, ask Q#26]

b. Net increase of __________FTEs

c. No staffing change

d. I don’t know

24. [Ask if decrease indicated in Q#22] Please indicate any staffing categories in which FTEs decreased in your 2012 fiscal year.

a. DIS [If checked, ask Q #25]

b. Clinician (MD or nursing)

c. Epidemiologist

d. IT staff

e. Program manager

f. Non-managerial administrative staff

g. Evaluator

h. Health educator

i. Other, please specify: _______________

j. I don’t know

25. [Ask if (a) checked in Q#24] How many DIS FTEs were lost in your 2012 fiscal year?

1. Approximate number: ________

2. I don’t know

26. [Ask if decrease indicated in Q#23] How many DIS FTEs were lost during your 2006 through 2011 fiscal years (i.e., fiscal years 2006, 2007, 2008, 2009, 2010, and 2011)?

a. Approximate number: ________

b. I don’t know

27. Please categorize your workforce at the end of your 2012 fiscal year by the percentage of FTEs who were health department staff (civil service) and contractors (non-health department employees)

a. Percentage of health department staff ______%

b. Percentage of contractors__________%

c. I don’t know

28. Did the percentage of your workforce that are contractors increase or decrease in your 2012 fiscal year compared to your 2011 fiscal year?

1. Increased

2. Decreased

3. Stayed about the same

4. I don’t know

29. Were any STD program FTEs detailed or pulled for non-STD-related activities during your 2012 fiscal year (e.g., to provide surge capacity for non-STD outbreak responses, adverse events, or other health emergencies)?

a. Yes

b. No  Go to Q#31

c. I don’t know Go to Q#31

d. My HD did not offer any STD prevention services during the 2012 fiscal year  Go to Q#31

30. How would you characterize the impact on your STD programmatic activities of having these staff detailed or pulled in 2012?

a. No impact

b. Minor impact

c. Major impact

d. I don’t know

e. My HD did not offer any STD prevention services during the 2012 fiscal year

III. Budgets and the Impact of Budget Cuts on Services

The next set of questions asks about your STD program budget. This refers to funds available for STD prevention from government sources. It may include sources such as HIV/AIDS funds intended for use in the STD program if they are from a governmental entity, and may also include any one-time funds you received in the time periods noted below. Please do not include any private grants that your program may have received.

31. Does your financial system allow you to separate the STD program budget or specific STD line-item expenditures from your overall budget?

1. Yes  Go to Q#33

2. No

3. I don’t know

32. Can you provide reasonable estimates of your STD program budget or specific STD line-item expenditures for your current and last fiscal years?

1. Yes

2. No  Go to Q#35

33. What was your total STD program budget for the 2011 fiscal year? $________

34. What was your total STD program budget for the 2012 fiscal year? $________

35. Does your STD program charge a fee or copay for clinical or lab services?

1. Yes, both clinical and lab [if checked, ask Q#38]

2. Yes, clinical only [if checked, ask Q#38]

3. Yes, lab only [if checked, ask Q#38]

4. No

5. I don’t know

36. Does your program bill third parties (e.g., Medicaid or other insurers) for services?

1. Yes  Go to Q#38

2. No [If checked, ask Q#37 ]

3. I don’t know  Go to Q#38 or Q#40, based on response to Q#35 above

37. [Ask if (b) checked in Q#36] Please indicate the reason(s) your STD program does not bill for third party reimbursement. Check all that apply.

1. State/local laws do not allow for third-party billing

2. Health department policy does not allow for third-party billing

3. STD program does not have enough staff to handle reimbursement process

4. STD program does not have a billing system available to handle billing and reimbursement.

5. Historical precedent for offering free services

6. Other (please explain) _________________

38. [Ask if (yes) checked for either Q#35 or Q#36] From what payer(s) does your program bill or collect fees? Please check all that apply.

1. Patients via a fee, copay, or sliding scale

2. Medicaid

3. Other insurance

4. Donations

5. Other, please specify: ___________

6. I don’t know

39. Does any of the revenue received through billing or paid via fees remain with the clinic?

a. Yes—all revenue remains with the clinic

b. Yes—part of the revenue remains with the clinic

c. No

d. I don’t know

40. Think back to any cuts to your STD program in your 2011 or 2012 fiscal year. Have these cuts negatively impacted programmatic activities in any of the following ways? Check all that apply.

1. Our STD program did not have any cuts in the 2011 or 2012 fiscal years  Go to Q#44

2. STD program was eliminated  End of data collection

3. Reduced clinical services

1. Specialty STD clinic closures [If checked, ask Q#41]

2. Fewer clinic hours

3. Reduction in routine screening

1. Initiated or increased patient fees or co-pays

1. Initiated patient fees or co-pays for clinical services

2. Increased existing fees or co-pays for clinical services

1. Reduced partner services [If any choices below checked, ask Q#42]

1. Fewer early syphilis cases followed-up for treatment

2. Reduced partner services for early syphilis

3. Fewer STD cases (other than early syphilis) followed-up for treatment

4. Fewer partner services for chlamydia, gonorrhea , or other STD cases

6. Although our health department experienced budget cuts, programs were not negatively impacted in any of the above ways.  Go to Q#44

7. I don’t know if budget cuts have caused any of the above negative impacts Go to Q#44

41. [Ask if (c)1 checked in Q#40] How many specialty STD clinics have closed since the beginning of your 2011 fiscal year?

a. __________ [provide number]

b. I cannot provide this information

42. [Ask if any choices in Q#40(e) checked] Please describe the changes in your partner services or follow-up procedures for syphilis, gonorrhea, and chlamydia [open response]

43. How did you determine which programmatic activities to cut (check all that apply)?

a. Cuts were made across the board

b. Cuts were designed to preserve clinical services to the greatest extent possible

c. Cuts were dictated by changes in staffing

d. Cuts were determined using other criteria

e. Other, please specify: _____________________

f. I don’t know

44. Please describe your program’s greatest success in your 2012 fiscal year [open response]

End of data collection

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).