New data from FAIR Health found that diagnoses of sexually transmitted infections (STIs) were up 98% in rural areas compared with a 77% increase in urban areas. While these increasing numbers are alarming, local health departments (LHDs) play a critical role in providing STI treatment and prevention that can help address rising STI rates. This STD Awareness Week, NACCHO is highlighting the awesome work of Galion City Health Department, a rural LHD in Ohio that operates with just nine staff members.
Told from the perspective of nurse practitioner Sarah Miley, APRN-WHNP, this story highlights the health department’s efforts to establish an STI clinic to ensure community members could access STI services and PrEP without having to travel to a major city.
A New Idea from an Old Friend
In mid-2018, I was approached by my longtime friend, Tina, a disease intervention specialist (DIS) that I had formerly worked with at a local health department, with a proposition: “Let’s start an STD clinic,” she said.
Mirroring nationwide trends, gonorrhea and chlamydia rates had continued to increase within our community and accounted for the largest numbers of communicable diseases here. The local Planned Parenthood had shut its doors years ago, and folks were having to use local emergency rooms to get tested. Our neighboring counties have limited confidential, cost-effective STI testing sites, and many people don’t like to use their primary care providers for testing. Being in a rural area, we also wanted to make PrEP available without travel.
Although Tina and I had parted ways professionally when I went to graduate school and she took an assignment with a neighboring health department, she has always been a go-to resource for me. We maintained a unique friendship over our shared love of coffee, food, and helping people navigate the uncertain waters of STI and HIV diagnosis. And when I say we love doing this, I mean it. Tina has spent nearly 30 years working as a DIS and she can talk HIV, syphilis, and disease tracking in her sleep. But what is even more amazing is her ability to calm people when she comes calling. I was thrilled at this opportunity and challenge to build something near and dear to us.
From Ideation to Action
With grant funding and the support of Trish, our health commissioner, I was brought on board in early 2019. When I came to the small (but mighty!), nine-person Galion City Health Department, there was little in place for a clinic. Our health department offers immunization, provides school health services, and promotes environmental safety along with a list of other essential public health services, but we lacked infrastructure for in-depth clinical services. But with Tina’s experience and mine—I also work in a Title X Family Planning Clinic and see men and women for STD and reproductive concerns daily—we figured, how hard could this be? So, we got to work.
We obtained a Clinical Laboratory Improvement Amendments (CLIA) license and a lab contract, ordered supplies, and wrote protocols and procedures. I learned a new electronic medical record (EMR) system and developed templates for this with the help of our super tech-savvy business services officer, Liv. Liv spent countless hours typing the patient forms I had created and made sure they were inclusive. She ensured that our privacy statements and financial agreements were all up to HIPAA standards (and aesthetically pleasing). We reviewed forms again and worked with our EMR platform administrator to ensure that we would protect patient’s health information. To make sure our clinic was affordable, Liv painstakingly reviewed insurance reimbursement rates and developed a sliding fee scale. We wanted to be a safe landing spot that was accessible to everyone who walked through our doors.
Then came medical billing. A medical biller was not in our budget, but Liv knew some pieces and I knew a few more. Since Liv had been billing for our immunization program which was typically straightforward, she agreed to take on the task. We listened to webinars and visited other sexual health clinics to make sure we were heading in the right direction. We certainly had our work cut out for us in this process! Billing is still a work in progress, but we are thankful for the numerous resources and people that have kindly offered their help and guidance.
Finally, Tina and I knew we needed to provide PrEP to folks in our community. I was able to become a Prevention Assistance Program Interventions (PAPI) provider in Ohio to ensure that those at risk of acquiring HIV could access daily medication to stay HIV-negative without financial barriers. After many years of delivering positive HIV results and “close calls,” we are happy to be able to provide PrEP and give individuals a nearly 99% chance of staying negative. We’re even happier to be able to do this close to home so that our communities member are no longer required to one of the larger Ohio cities (Cleveland, Columbus, or Cincinnati) for this important service.
Opening the Doors
By July 2019, we were ready to start with a soft opening. We had done some light advertising through Facebook, Instagram, and a few billboards. With a limited budget, we were as creative as possible. We have designed several posters with a local printing company that we have hung in our department, at our local college campus, bars, pharmacies, and other public places that might attract clients. To date, we have had 48 encounters ranging from PrEP starts to STD treatment visits. While this might not be as high as what we were hoping for, we are optimistic that it will increase. The people we have helped are thrilled with what they have found: we don’t judge them, we listen, and we leave them with facts—but it is an STD clinic, so they don’t go tell 10 friends what an AMAZING experience they have just had.
We will keep promoting our services, reaching out to our DIS cases, and working to build up a preventive caseload through well-woman exams, new PrEP clients, and more. Our grant program covers a nine-county region, and anyone aged 13 and over from any county can utilize our services. We are working toward offering contraception and hoping to apply for Title X funds during the next grant cycle to expand services in that direction.
Preparing for the Future in an Uncertain Present
Right now, we find ourselves in the middle of the COVID-19 pandemic. I have several worries about what might be happening during this time in terms of the sexual health of my patients. We distributed extra condoms to the local campus before the students left, made sure to update our social media, and have tried to make our posters visible to the public. In the meantime, we are busy making plans (or dreaming) about how we are going to continue serving the people who need us the most—up next is our mobile syphilis treatment outreach program. We look forward to our future growth and the ways we can continue to reach our people in Galion and beyond.