Delegated public health follow-up process

What is the Program?

In 2011, Vancouver Coastal Health Communicable Disease Control (CDC) developed a delegated public health follow-up process that has been integrated into the system of HIV care in Vancouver. The process was designed as a service to both patients and healthcare providers to facilitate HIV testing and follow-up services for patients with positive results.

The delegated public health follow-up process allows any physicians who order HIV tests to access support from public health for follow-up of positive results. A spectrum of support is available. At one end of the spectrum, support may consist simply of a phone call to the physician to plan follow-up care. At the other end of the spectrum, physicians can choose to rely on public health to provide all follow-up services to their patients on their behalf.

Public health follow-up services include: discussing the diagnosis and counselling the patient and their testing provider; providing HIV education for the patient and their primary healthcare provider, including information on available resources; ensuring that the patient is linked to HIV care and appropriate support services; and supporting voluntary partner notification services.

The goals of public health follow-up for HIV are to:

1. facilitate early diagnosis of HIV
2. support rapid linkage to treatment and care
3. provide partner notification and care

HIV, like many other communicable diseases, is reportable to the Medical Health Officer in British Columbia. The requirement to report HIV diagnoses to public health has traditionally provided an opportunity for public health nurses to support testing physicians whose patients have new diagnoses, and these traditional forms of public health follow-up continue to be used by many physicians in Vancouver.    This case study focuses on the new process of delegating some or all follow-up responsibilities to public health, including discussing the diagnosis, counselling, education, linkage to treatment and support services, and partner notification.

Why Was the Program Developed?

One component of the Vancouver STOP HIV/AIDS Project was an emphasis on improving early diagnosis through the development or enhancement of a variety of testing strategies. STOP focused on improving HIV testing services in three ways, mostly using standard blood tests:

1. implementing the routine offer of HIV testing in hospitals
2. implementing the routine offer of HIV testing in family practice
3. expanding HIV testing in programs that serve patients who experience an ongoing high risk of HIV infection

Historically, most HIV testing in British Columbia was ordered by providers or clinics caring for populations known to be at increased risk of HIV. Although this “risk based” approach remains an essential component of early diagnosis of HIV, on its own it was not achieving the goal of diagnosing HIV at the earliest possible clinical opportunity. Integration of a routine offer of HIV testing into general healthcare was an important change in the way testing was carried out in Vancouver.

Non-HIV specialists such as family physicians and hospital physicians started to routinely include HIV testing in their care. This created a need for reliable and high-quality follow-up services for patients of physicians who were not familiar with HIV care and physicians who may have provided episodic care, such as clinicians in acute care, emergency departments and walk-in clinics.

In response, Vancouver Coastal Health CDC developed a delegated follow-up process that improved integration of public health supports into the HIV system of care and allowed physicians to delegate some or all follow-up responsibilities to public health. This program was designed to enable clinicians to use a wide range of clinical encounters as opportunities for HIV diagnosis, and as such was designed as a service both to patients and to testing providers.

How Does the Program Work?

The responsibility of Medical Health Officers

HIV is reportable to the Medical Health Officer in British Columbia. Medical Health Officers are responsible for the prevention and control of communicable diseases in their region. The day-to-day follow-up of communicable diseases, including HIV, is carried out by public health nurses in consultation with a Medical Health Officer.

The role of nurses

Vancouver Coastal Health CDC employs one full-time nurse designated to lead the provision of HIV follow-up services to the entire Vancouver Coastal Health region. Originally, HIV follow-up services were provided equally by all communicable disease control (public health) nurses. During the STOP HIV/AIDS pilot project, Vancouver Coastal Health hired a public health nurse with specialized skills in HIV follow-up to provide clinical leadership and expertise. Now, HIV public health follow-up is provided by the full-time clinical lead for HIV and by the team of public health nurses who provide public health follow-up of all reportable communicable diseases.

To ensure timely diagnosis and follow-up care, nurses who provide HIV public health follow-up need to be well integrated into the healthcare system and know how to navigate it, both in hospitals and in the community, where many patients use services such as community health centres and walk-in clinics. They also need to be familiar with other services that patients use, such as drop-in centres and shelters. Referrals to the appropriate HIV treatment and support services, including peer support, housing and outreach, are a core component of the services provided. Nurses also need to be able to link patients to primary care services if needed.

Nurses in this area of work require a unique set of skills, including very strong interpersonal skills to successfully engage patients at a challenging time. Receiving an HIV diagnosis can be very difficult for patients, and especially for those who are facing other challenges in their lives. It is critical that nurses in this role are able to work in a non-judgemental way with diverse client populations including gay men, people who are street-involved, people who use substances, individuals with mental illness, refugees, immigrants and Aboriginal people.

Delegated follow-up process

The delegated follow-up process, where a physician delegates some or all follow-up responsibilities to Vancouver Coastal Health CDC, builds on an existing mechanism in the public health system in Vancouver Coastal Health: the reporting of all new positive HIV results to the appropriate Medical Health Officer.

When the Medical Health Officer receives notification of a new positive HIV test, the public health nurse contacts the testing physician on the same day. During that conversation, the public health nurse establishes whether the physician would like to delegate some or all of their public health follow-up responsibilities, including discussing the diagnosis, counselling, education, linkage to treatment and support services and partner notification.

The delegated process is in place to support those physicians who do not have an ongoing clinical relationship with the patient or who may not wish to provide these supports because of time constraints or lack of expertise. The delegated follow-up process is most frequently used by hospital-based physicians. By pre-arranged agreement, all new diagnoses in Vancouver’s emergency departments are followed up by public health through the delegated follow-up system. Family physicians and other primary care providers can also choose to delegate their responsibilities to public health staff on a case-by-case basis.

Doctors who delegate follow-up to public health receive a letter (see Program Materials) from the Medical Health Officer describing the actions public health has taken, so that the physicians can ensure their patient was informed of the diagnosis, counselled and linked to care. Critically, the College of Physicians and Surgeons of British Columbia reviewed this follow-up process and identified no concerns from a regulatory perspective.

Doctors who prefer to provide follow-up services, either partially or completely, still do so. Many physicians in Vancouver are experts in HIV, and for their patients, public health follow-up focuses on partner notification and care. In other instances, public health nurses can provide supports such as assisting the physician to develop a care plan or being present when the patient receives their diagnosis. Usually, the public health nurse will follow up with the physician after the patient has received their diagnosis to offer resources, discuss initial lab test results and/or provide other care planning supports.

Receiving the diagnosis

Timely receipt of the laboratory diagnosis is an important gateway to care and treatment services that can improve health and prevent the transmission of HIV to others. Under the delegated follow-up process a patient can be informed of their diagnosis by the public health nurse or by the ordering physician. For patients in hospital, this can happen while the patient is still in the hospital. If the patient has been discharged, the public health nurse will arrange to meet them in the community.

Partner notification services

Partner notification is a crucial part of the public health follow-up process. It is voluntary. The goal is to help patients inform their past and ongoing sexual and/or drug-using partners about a potential exposure to HIV.

The first priority for partner notification and care is to address any ongoing risk of transmission and to reach those partners who could benefit from post-exposure prophylaxis. At the time of diagnosis, the public health nurse will usually only ask about a person’s sexual partners from the last 72 hours and about partners who may be at ongoing risk, such as primary partners. If patients with an acute infection identify any partners with whom they had sexual and/or needle-sharing contact in the last three days, or if patients with a chronic infection identify a new partner in the previous 72 hours, a nurse will try to notify those partners as quickly as possible so they can seek care from Vancouver’s non-occupational post-exposure prophylaxis (nPEP) pilot program. Through this program, a partner would be assessed by a doctor and, if medically appropriate, start a course of nPEP.

Typically, the public health nurse has a more comprehensive conversation with the patient about who should be informed during subsequent meetings. These meetings can happen over the phone or in person, depending on the patient’s preference. During these meetings, the public health nurse helps the patient identify any risk to their sexual and/or needle-sharing partners.

Once the patient and the public health nurse have determined which partners should be informed of a potential exposure and the need for testing, the public health nurse’s role is to support the patient to inform their partners. This can be done by the nurse without identifying the patient, by the patient alone or by the patient and the nurse. Ultimately, it is up to the patient to decide how they would like to inform their partners, and the nurse can provide education and support through this process.

For partners who are not at ongoing risk, such as former sexual or drug-use partners, if a patient chooses to have them notified by a public health nurse, these partners are informed only that they could have been exposed to HIV and that they need to seek care. They are not told how or when they were exposed, as this information is not essential for their care. To ensure confidentiality, the nurse who notifies the partners most often does not know identifying details about the individual with HIV.

Partners can access HIV testing in two ways: public health nurses can directly provide testing to the partners, or partners can follow up with their family physician or another testing provider. The nurse can suggest where a partner can get tested and may even help them schedule a same-day appointment. Positivity rates among partners of people newly diagnosed with HIV are high. In the second half of 2013, 9% of partners in Vancouver were diagnosed with HIV.

The public health nurse follows up with partners within a week of the initial notification to see if they were tested and to offer any additional support and counselling, making sure that partners needing support or referrals receive them.

Over the course of contacting the partners of a patient newly diagnosed with HIV, public health nurses often connect with someone who is already known to be living with HIV but who may not be receiving care or treatment. In Vancouver in 2013, 17% of all partners of people newly diagnosed with HIV were known to be living with HIV. Some of these individuals were not in care, and partner notification was an important opportunity for public health to offer education, counselling and linkage to treatment and support services to them, as such individuals may be at high risk of poor health outcomes. Actively integrating public health services into the HIV system of care offers people living with HIV continuous support to enter and re-enter into and remain in HIV care.

Linkage to care

One of the final steps in the public health follow-up process is linking the patient to care. The public health nurse aims to link patients as quickly as possible. This can include linkage to primary care, if a client does not have a doctor or nurse they see regularly, and linkage to community-based HIV treatment and support services.

Vancouver has a broad range of tailored HIV clinical and support services, including clinics and supports for women, indigenous peoples, and gay men and other men who have sex with men, which aim to provide culturally safe care. Once a referral to a clinic has been made, the nurse will follow up with the clinic and the patient to make sure that the patient has been successfully linked to care.

The ongoing participation of public health in the continuum of care has helped improve patient engagement and linkage to HIV care. Fewer people are lost to care using this approach because prompt and continuous engagement ensures patients receive timely diagnosis, linkage to primary care, treatment and other supports such as a peer navigator or the STOP Outreach Team. It has also enabled providers in a wide range of clinical settings to incorporate HIV testing into their practice.

Required Resources

1. HIV-designated public health nurse(s). Provide follow-up services for individuals newly diagnosed with HIV. Notify partners of people recently diagnosed with HIV and help connect them to services. Provide support to clinicians diagnosing HIV.
2. Medical Health Officer. Provide medical and public health consultation to nurses and the public.
3. Strong integrated HIV prevention, testing, treatment and support system in which healthcare and public health work in collaboration.

Challenges

Vancouver Coastal Health identified three challenges with the new public health follow-up process:

1. Offering timely diagnosis. Vancouver Coastal Health CDC is currently developing a process to determine how a patient with acute HIV infection should be informed of their HIV diagnosis when the ordering physician is unavailable (in cases where the physician has not yet delegated responsibilities). While a positive HIV test is not a medical emergency, there is an increased probability of transmission in those with an acute HIV diagnosis and thus informing patients with an acute HIV diagnosis is a public health urgency. Public health needs to balance the urgency to inform a person with an acute HIV diagnosis against the need to maintain the very important patient-provider relationship.
2. Ensuring adequate staffing. HIV should be diagnosed as soon as possible and people recently diagnosed with HIV should receive follow-up services, including linkage to care. However, a number of new positive test results may arrive all at once. Ensuring that each client receives appropriate and timely services from an experienced nurse means having public health nurses with appropriate training available to help the HIV-designated nurse as needed.
3. Informing doctors about the follow-up process. Although the delegated follow-up process has been in place for three years, there may still be physicians in Vancouver who are unaware of the delegated follow-up process and how it can support them to offer HIV testing even if they are not HIV experts or if they provide episodic care. Vancouver Coastal Health continues to offer training and support to doctors implementing the new routine testing guidelines; it discusses the role of public health and the supports available in these sessions.

Evaluation

Vancouver Coastal Health monitors a number of measures related to public health follow-up:

• 82% of people newly diagnosed with HIV had a record of public health follow-up between July 1, 2013, and December 31, 2013. This is an increase from the average of 72% observed since the program began on July 1, 2010.
• 71% of partners who were notified of their exposure were tested for HIV between July 1, 2013, and December 31, 2013, an increase from 40% in the previous six-month period.
• The average HIV positivity rate of partners, who were known to be tested for HIV and were not known to be previously positive, is 9% since program evaluation began.
• Between 2010 and 2013 in Vancouver, 75% of men and women were linked to care within 30 days. The median number of days was eight for men and nine for women.

Lessons Learned

Vancouver Coastal Health identified two lessons learned from the development of a new public health follow-up process:

1. Integrated system. The active and ongoing integration of public health services in the continuum of HIV care ensures that HIV testing is offered in a broad range of clinical settings, and patients receive a timely diagnosis and linkage to care no matter where they received their test. It also supports re-engagement in care for partners known to be HIV positive. At a systems level, it is important to recognize the specialty services provided by public health and to integrate those services in healthcare to support patients and the population.
2. Experienced nurses. Nurses who provide public health follow-up services need to understand the healthcare system structure, understand and be able to respond to the clinical and social needs of patients recently diagnosed with HIV, and provide services to partners and the community with regards to prevention and testing. This contributes to optimal client care. Nurses should have strong interpersonal skills and should understand how to navigate hospital and community services. They also should understand how to provide care for patients with complex needs.

Program Materials

• Physician notification letter
• Public Health Follow-Up Diagram
• STOP HIV/AIDS Semi-Annual Monitoring Report (July 1 to December 31, 2013)

Other Useful Materials

Information found on the CATIE website

• HIV Partner Notification: A review of the evidence with recommendations to move the field forward: Evidence Review
• New Technologies for Partner Notifications for Sexually Transmitted Infections: Evidence Review
• Outcomes Related to STI Partner Notification: Evidence Review

Contact Information

Dr. Réka Gustafson, Medical Health Officer
Vancouver Coastal Health
604-675-3900
Reka.Gustafson@vch.ca