Program Collaboration and Service Integration (PCSI) workshop : November 29-30, 2011

GEORGIA DEPARTMENT OF PUBLIC HEALTH
PROGRAM COLLABORATION AND SERVICE INTEGRATION (PCSI) WORKSHOP
NOVEMBER 29-30, 2011
Macon Marriott City Center 240 Coliseum Drive,
Macon, Georgia 31217

[THIS PAGE INTENTIONALLY LEFT BLANK]

Table of Contents

1. Executive Summary

3

2. Workshop Agenda

5

3. Workshop Presentations

7

4. Evaluation Summary

99

1 of 102

[THIS PAGE INTENTIONALLY LEFT BLANK]
2 of 102

Executive Summary
The Infectious Disease Program Collaboration and Service Integration (PCSI) of the Georgia Department of Public Health (DPH) began work as a steering committee in August 2010. The rationale for PCSI is to maximize the health benefits that persons receive from prevention services by increasing service efficiency by combining, streamlining, and enhancing prevention services (CDC). With this rationale in mind, the committee focused on promoting collaboration and service integration between the following programs: TB, STD, HIV (Prevention, Care), Hepatitis, Peri-natal Hepatitis, Refugee Health, and Immunization. PCSI is a mechanism for organizing and blending interrelated health issues, activities, and prevention strategies to facilitate comprehensive delivery of services. Several districts have staff who serve as coordinators in multiple programs. A unified training session re-enforces the support of the public health leadership in promoting PCSI.
During committee discussions, the group identified opportunities to address communication barriers at both the state and local level. Because of the aforementioned, the group realized a need to deliver a combined workshop that provided program specific information and updates. In addition, the committee decided to include opportunities for team building, networking and cultural diversity training at the workshop.
The workshop was held on, November 29-30, 2011, at the Marriott City Center in Macon, GA. A total of 64 participants attended with representation from all districts and each PCSI state level program. Participants included state program managers, district program coordinators, clinicians, nurses, case managers, epidemiologists, communicable disease specialists, and CDC federal assignees.
The feedback from the workshop reflects an overwhelmingly positive response to the PCSI concept. The workshop presentations were found to be informative, collaborative, and motivational. The workshop comments indicated that staff desired more training in areas such as internet partner services, State Electronic Notifiable Disease Surveillance System (SENDSS), and collaboration. Additionally, the need for technical assistance was requested. Attendees suggested that this workshop become an annual event and expand to include more programs and district health directors.
The PCSI committee will continue to facilitate communication between programs and seek opportunities for collaboration both at the state and district level. Projects for 2012 have been identified to include an annual workshop, information dissemination, and inviting additional programs to the state PCSI steering committee. The committee appreciates the continued administrative support of the PCSI activities. The state PCSI steering committee welcomes future opportunities to enhance the health benefits of our shared clients.
This package includes: Workshop Agenda, Presentations, and Evaluation Summary.
3 of 102

[THIS PAGE INTENTIONALLY LEFT BLANK]
4 of 102

PROGRAM COLLABORATION AND SERVICE INTEGRATION (PCSI) MEETING
November 29-30, 2011 Macon Marriott City Center 240 Coliseum Drive,
Macon, Georgia 31217
AGENDA

Day 1: November 29, 2011

11:00
12:00
12:30 12:45 1:15 2:15 2:30 3:00 3:30
4:30 5:00

Registration Lunch Welcome Workshop Overview Introductions Transition
Program Collaboration and Service Integration (PCSI) Internet Partner Services
Break
TB Update
STD Update
HIV Update Care Prevention
Hepatitis Update
SWOT Analysis Discussion
Dinner on your own

Division of Health Protection Ann Poole
Michelle Allen Stephan Adelson
Dr. Rose-Marie Sales Michelle Allen Michael Coker Brandi Williams Ami Gandhi Valerie Underwood

5 of 102

PROGRAM COLLABORATION AND SERVICE INTEGRATION (PCSI) MEETING
November 29-30, 2011 Macon Marriott City Center 240 Coliseum Drive,
Macon, Georgia 31217
AGENDA

Day 2: November 30, 2011

7:30 8:30 9:00 10:15 10:30 12:00 1:00 2:00

Breakfast Icebreaker Case Study Break Team Building Lunch Diversity in the Workplace Wrap up/Evaluations

Michael Coker Valerie Underwood Lawsey Thomas, Sr.
Lawsey Thomas, Sr.

6 of 102

Program Collaboration and Service Integration
Program Collaboration and Service Integration (PCSI)

Presentation to: PCIS Meeting (Macon, GA) Presented by: Michelle Allen, STD Office Director

Date: November 29, 2011

Program Collaboration and Service Integration (PCSI)

Introduction
Historically, the public health approach to disease prevention begins with: define disease, define the population, identify the conditions that sustain health in the population, and determine how to address those conditions.
7 of 102

11/29/2011

Program Collaboration and Service Integration
What is PCSI?
PCSI is a mechanism for organizing and blending interrelated health issues, activities, and prevention strategies to facilitate comprehensive delivery of services.
Rationale: Program Collaboration
Minimizes duplication of services Reduces cost through joint funding Strengthens programs by increasing assess to
different types of information Sharing data can help identify emerging trends
i.e. data sharing can help an increase of rates other STDs among HIV-positive persons who find partners on the internet
Five Principles of Effective PCSI
Appropriateness Effectiveness Flexibility Accountability Acceptability
8 of 102

11/29/2011

Program Collaboration and Service Integration
Ties that Bind
HIV, viral hepatitis, and STDs share common risk factors and modes of transmission
STDs increase risk for HIV infection HIV is a risk factor for progression to TB
disease TB is an AIDS-Defining opportunistic condition
A Framework for Collaboration: 10 Essential Public Health Functions (1) Monitor community members' health status to identify and solve community health problems (2) Diagnose and investigate health problems and health hazards in the community (3) Inform, educate, and empower people about health issues (4) Mobilize community partnerships and action to identify and solve health problems
A Framework for Collaboration: 10 Essential Public Health Functions (5) Develop policies and plans that support individual and community health efforts (6) Enforce laws and regulations that protect people's health and ensure their safety (7) Link people to needed personal health services (8) Ensure the competency of the public and personal healthcare workforce
9 of 102

11/29/2011

Program Collaboration and Service Integration
A Framework for Collaboration: 10 Essential Public Health Functions (9) Evaluate the effectiveness, accessibility, and
quality of personal and population-based health services (10) Conduct research to identify innovative solutions to health problems.
The 10 essential public health functions, developed by the US Public Health Service Core Public Health Functions Steering Committee in 1994
Service Integration Goals
To make it easier for persons to access needed services by providing them with a single point of entry
To increase staff members' knowledge about available resources that are share with other programs or agencies, thereby minimizing duplication of services (while allowing agencies to specialize in its own area of expertise.

11/29/2011

10 of 102

Program Collaboration and Service Integration

11/29/2011

PCSI Applied Will...
Optimize the capabilities of each public health position
Learn the benefits of working together to improve public health infrastructure
Assist the community to receive maximum benefit of the public health system.
Projected Integrated Yields
Eliminates duplication of services i.e. public health workers will provide more than one service
Increases communication between staff Increases patient education for co-infected clients
11 of 102

Program Collaboration and Service Integration
Cross Training Staff Goals
Eliminates stagnated services in any area due to absence
Staff becomes one self sufficient Enhances communication and team work between
staff
Barriers To Integration
May increase workload of staff and supervisors (largely due to training)
Inadequate space for training Difficulty rewarding employees for extended work
hours
Next Steps
Integrate Surveillance Integrate Training Become a PCSI Champion Join the State Office Efforts
12 of 102

11/29/2011

Program Collaboration and Service Integration
What will happen when we become PCSI-ed?
By jointly addressing the needs of clients we will find that through integration, collaboration, and staff cross-training clients will have increased access to care.
The End I welcome your questions and
comments
13 of 102

11/29/2011

Internet-Based Partner Services
Internet-Based Partner Services
Stephan Adelson, Senior Advisor, MSM, Sexual Health and Technology
Georgia Department of Public Health November 30, 2011
Terms
Internet-Based Partner Services vs. Internet Partner Services The phrase `Internet Partner Services' implies usage of the Internet as the tool used to conduct Partner Services. There are many tools available though the Internet that can be used for all phases of partner services, these tools reside on the Internet; and are Internet-based.
Internet-Based Partner Services (IPS) includes activities Researching virtual identifiers and converting them to traditional contact information Improving interviews through social search (living conditions, sexual preferences, legal circumstance, employment, personal interests, social /sexual contacts, etc.) Provide Internet-based information resources (testing locations / information, definitions, symptom descriptions and images, treatment information, linkages to care and other services, etc.)
Internet-Based Partner Notification (IPN) The specific act of notification
A Duty and Privilege
Duty to warn:
Certain states have laws that in certain situations require medical or public health officials to notify known partners who are at risk for infection
Privilege to Warn:
Generally, laws permitting but not requiring practitioners to warn persons that they are at risk
Are you asking about Internet-based locating information? What are you doing with it?
Centers for Disease Control and Prevention. Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infection. MMWR October 31, 2008 / Vol. 57 / No. RR-9 / page 75
14 of 102

11/29/2011

Internet-Based Partner Services
Evaluation of IPS for Syphilis, Washington, DC 1/07 6/08
361 early syphilis patients 888 sex partners 381 (43%) via the Internet 83% more sex partners being notified of their STD exposure 26% more medically examined and treated if needed 8% increase with at least one treated sex partner
"...without IPN these 381 partners would not have been investigated."
Evaluation of an Innovative Internet-Based Partner Notification Program for Early Syphilis Case Management, Washington, D.C., January 2007-June 2008
Key Goals
Maximize the proportion of partners who are notified of their possible exposure through the use of the Internet, particularly when the only locating information is an email address, screen name or other virtual identifier.
Gather enough traditional locating information through Internet-based tools, to close a case with "traditional" disposition code

Converting Internet cases into traditional: Experience improves outcomes

2009 NYS
162 Internet-based investigations
71% partners to STD 17% of STD partners dispo'ed as A or C
29% partners to HIV

2010 NYS
253 Internet-based investigations
83% partners to STD 40% of STD partners dispo'ed as A or C (+23%)
17% partners to HIV

(101) 62% of cases dispositioned (110) 43% of cases dispositioned

as internet code (L...)

as internet code (L...) (-19%)

(61) 38% converted to traditional dispositions

(143) 56% converted to traditional disposition (+18%)
A disposition = preventive treatment C disposition = infected, brought to treatment

15 of 102

11/29/2011

Internet-Based Partner Services
The Online Dating Game
17% of couples married in the last 3 years, or 1 in 6, met each other on an online dating site
In the last year, more than twice as many marriages occurred between people who met on an online dating site than met in bars, at clubs and other social events combined
1 out of 5 single people have dated someone they met on an online dating site
1 out of 5 people in a new committed relationship (including marriage) met their significant other on an online dating site
Married couples who met online have an average courtship period of 18.5 months. Married couples who met offline courtship period last on average 42 months**.
* Match.com and Chadwick Martin Bailey 2009 - 2010 Studies: Recent Trends: Online Dating Marriage Survey: 7000 US adults age 18+, married within the past 5 years, Online Dating Survey: 3000 US adults age 18+, who used online dating in the past 5 years ** Cast, A., "Simply Clicking: A Direct Comparison of Newly M arried Online and Offline Couples ", Iowa State University
"At Risk" Changing Culture, Venues,
Challenges
"Gay communities undergoing structural decline" with many identifying the Internet as the underlying cause...These changes in the gay community were noted as increasing the complexity of sexual decision making and HIV risk, while decreasing effective prevention".
More than 2.5 million active profiles, over 26 million monthly visits1, and 120,000 men online nightly,
More than 750 million active users, 50% login daily 250 million access through mobile devices
Rosser Simon B.R., West William and Weinmeyer Richard Are gay communities dying or just in transition?, Minneapolis : AIDS CARE, May 05, 2008. - 5 : Vol. 20. - pp. 588-595. Most Popular Websites in Lifestyle - Dating (ranked by visits); Experian Hitwise US, July, 2011
MSM cases reporting internet partners in 2004 (32) in 2007 (127) 396% increase.
Popularity CDS Attention (Interviews) In 2007, MSM accounted for 53% (372 out of 697) of all primary and secondary (P&S) cases. Of those cases, 34% of P & S cases reported having met partners via the internet.
16 of 102

11/29/2011

Internet-Based Partner Services Its NOT Just Gay Men and MSM

11/29/2011

Primary and Secondary Syphilis (2009)

Guam 1.1

2.1
1.5 0.2

0.4 0.6

3.5

1.1

5.2

2.1

3.6

3.1

0.0 2.6

0.6

1.4

0.0 0.3
1.1 2.7
6.8

0.8
0.8 5.8
2.9
9.6 8.1
16.8

6.1 2.3
2.7
3.1 2.5
0.4 3.8 2.2
6.3 6.5
2.7
9.8 8.9

0.3

VT

0.0

NH

1.1

MA

3.7

RI

1.9

CT

1.9

NJ

2.4

DE

3.1

MD

5.6

DC

27.5

Rate per 100,000 population
<0.2 (n = 5) 0.212.2 (n = 19)

Puerto Rico 5.7

5.7

>2.2 (n = 30)

NOTE: The total rate of primary and secondary syphilis for the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was 4.6 per 100,000 population.

Primary and Secondary Syphilis (2009) IPS Profiles (2011)

Guam 1.1

2.1
1.5 0.2

0.4 0.6

3.5

1.1

5.2

2.1

3.6

3.1

0.0 2.6

0.6

1.4

0.3

0.0 0.3
1.1 2.7
6.8

0.8
0.8 5.8
2.9
9.6 8.1
16.8

6.1 2.3
2.7
3.1 2.5
0.4 3.8 2.2
6.3 6.5
2.7
9.8 8.9

5.7
Puerto Rico 5.7

DC
Morbidity/Profiles None One + High Med Low

NOTE: The total rate of primary and secondary syphilis for the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was 4.6 per 100,000 population.

17 of 102

Internet-Based Partner Services
Using the Internet To Trace Contacts of a Fatal Meningococcemia Case
August 2010 HIV+ patient died of invasive menigococcal Contacted by RN as health representative of BBRT Linked RN with PS team and DIS Connected with website (BBRT)
Changed profile text If you had contact please call
15 notifications At least 1 known to be prophylactically treated
Journal of Public Health Management & Practice: Accepted for publication, October 22, 2011
Imagine
Knowing a person's social circle, viewpoint on health, home life, neighborhood, family makeup, income, employment, interest, education, etc... ...before you interview them (patient or partner) That and more, is what access and use of the Internet can provide when CDS know how to use the available tools and are supported by key decision makers and supervision
Assisting in ALL Cases

11/29/2011

18 of 102

Internet-Based Partner Services All CDS are IPS CDS

11/29/2011

What to Obtain
Screen names and associated websites
spelling matters (hotguy4u vs. hotguyforyou) Have the OP write screen names
Email addresses Physical descriptions (OP and partners) for confirmation Location of encounter The OP's screen name, websites, email and description in case
they are `named back' Dates and Times of Contact Address, Phone Numbers (check emails, text messages,
website data)
Screen Names and Email Addresses
A screen name is a virtual identifier that is used online by an individual in place of their real name. Many are permanent and unchangeable, but not all (Grindr)
An Avatar is virtual representation of an individual Screen names and email addresses are often related
Yahoo, Windows Live (MSM), and AIM screen names are also email addresses
Prettygirl on Windows Live is PretyGirl@live.com
19 of 102

Internet-Based Partner Services
Eliciting Internet Partners
What websites are you a member of? What websites do you use to meet partners? Facebook? PlentyofFIsh,
Adam4Adam? What is his/her screen name? (Ask patient to spell or write the name) When was the last time you had sex with someone you met on____? What is his/her email address? (Ask patient to spell or write the
address) What does he/she look like? How is he/she built? What does his/her
profile picture look like? Is there anything unique about their profile that makes it stand out
from others? Do you have a smart phone?
Can we log in and find their screen names through the site's mobile site or app? (Manhunt, Adam4Adam, Recon, Scruff)
IPS: Turning Internet locating Information into Traditional Locating
Information

Searching ...
Putting the pieces together.....

Search Types:
Screen Name Email Phone Name

Phone Address Reverse Phone Reverse Address

Useful Information:
Social / Sexual Network Interests Memberships Employment Likes/Dislikes HIV Status (as stated)

20 of 102

11/29/2011

Internet-Based Partner Services Detailed Searching

11/29/2011

Advanced Search: more

Screen Name = Location > Email
21 of 102

Internet-Based Partner Services Email / location = Phone

11/29/2011

You can Search NOW

Search sites for IPS Radaris.com Google.com Bing.com Yahoo.com Peekyou.com People.yahoo.com Pipl.com Spokeo.com Skipease.com Zabasearch.com Zoominfo.com 411.com Whitepages.com Intelius.com

Search for new search sites!

Websites Where Patients and Partners Meet
Message boards Similar to bulletin boards or classified section of newspaper
Social networking websites Websites that people use to network or keep in contact with friends
Dating websites Website to meet looking for relationships
Hook-up websites Website focused on finding sex partners
Mashups Xtube (and other `tubes') Cam sites
22 of 102

Internet-Based Partner Services
Websites Have Feelings
Facebook `feels' public Adam4Adam `feels' private BareBackRT `feels' extreme Twitter `feels' informative YouTube `feels' entertaining
Sex-seeking environments are best suited for notification because of their private feeling. Social Networking Sites and sites with a public `feel' should be a last resort for notification.
Notification
Not all sites are ideal for IPN
Sexually explicit sites where public/private relationships exists are the best venue for IPN Relationship:
webmasters are aware of the program, understand the sensitivity, respect the privacy of their members (they are held responsible by the members)
Privacy: most hook-up/niche/sex-seeking sites use proprietary email systems and there is limited possibility for breach in privacy
Settings: talking about STDs/HIV in an adult setting where sex-seeking behavior takes place is an appropriate setting
Social Networking sites where the intention is social are not ideal for IPN Perceived and real `public' nature of SNS sites Potential privacy breach
Parents monitoring minors Spouses/significant others checking up
Manhunt.net
303,529 unique visitors 76% of the members account for 97% of the visits Older / Less Diverse 34% 18-34 46% 35-49 80% White
http://siteanalytics.compete.com http://quantacast.com
23 of 102

11/29/2011

Internet-Based Partner Services
Adam4Adam.com
804,529 unique visitors Younger / Diverse 46% 18-34 38% 35-49 42% Black 39% White 15% Hispanic
http://siteanalytics.compete.com http://quantacast.com
BGCLive (BlackGayChat)
200,121 unique visitors

http://siteanalytics.compete.com www.quantcast.com

BareBackRT

Dedicated to UAI
What do (can) your risk reduction conversations look like?

July 2011 83,895 unique visitors Rank #24,926

http://siteanalytics.compete.com

24 of 102

11/29/2011

Internet-Based Partner Services

Facebook, Social Hub of the World

More than 750 million active users

50% log on daily

Average user has 130 friends

250 access through mobile

Mobile users are twice as active as non-mobile users

10,000 new websites interact with Facebook

EVERY DAY

http://www.facebook.com/press/info.php?stat istics

Facebook for Hookup
What is your motivation to use social networking sites? Mark all that apply.

Community Research, Inc. LGBT Consumer Index, 2009-10
FaceBook

11/29/2011

25 of 102

Internet-Based Partner Services
Facebook for More Information
You must be a member to search Great for verifying location, pictures, personal
info Should not be the first choice for notification
Log On Together
Confirm spelling of screen names, email addresses Obtain forgotten information Confirm physical description, pictures, see network Review likes, dislikes, behavioral preferences
There is a fantasy element to profiles and sex-seeking sites, profiles are marketing tools. What you see in profiles may be fantasy or specifically written to attract sex partners.
Homework for the OP?
What screen names are on your computer at home? Who is on your buddy list? What about your blog list? (Maybe give them a form that asks for screen names, email addresses and other virtual identifiers to remind them)
26 of 102

11/29/2011

Internet-Based Partner Services
Documenting IPS:
Document exact spelling of screen name Document what site(s) partner uses (@adam4adam.com) Have the positive client write it down for you to double check
for accuracy. Make sure you can read what was written.
Craigslist / Bulletin Board

11/29/2011

Craigs List and MSM
Bulletin boards
Postings are `disposable' No membership required Contact is anonymous Locations can be faked
27 of 102

Internet-Based Partner Services

MSM On Craigslist

Total number of ads under the MSM personals section, using specific search terms over a 7 day period, a casual sample of 7 cities

City Atlanta Boston Dallas Detroit Louisville Miami Seattle

"married" "bi" "discreet"

420 450 615

340 570 880

425 570 870

90

110 180

50

60

80

85

180 320

188 188 406

Bulletin Board for PS? IPN
Not for notification... but
Many men will post the same ad over and over Can be used for record searching
Phone numbers are written (sex one seven...) Photos are often the same
Confirm locations Local behavioral surveillance
There are many websites that can be used for surveillance, http://listings.cruisingforsex.com is an example. These `venues' are ideal for MSM, married, or discrete men.
What's Different Now?
`Assimilation' with the population go the behaviors Sexual network mixing through online venues and communities
*18% of Americans have had sex with someone met over the internet `Private' exposure Public action (cams, videos, chat) Ubiquitous availability of a variety of partner `types' (Niche sites) Dramatically increased capacity to act on impulse through non-
traditional Internet sources (all sites) 1 in 10 men say they're straight and have occasional sex with men (70%
heterosexually married) Removal of societal constraints / education / norms
Increases in communication / behavioral awareness through technology- based tools
Role and options in religions / denominations Decrease in religion as a behavioral intervention
Role or marriage and expectations of married couples
Sex Census, Trojan, June 14, 2011 Neuroscientists Ogi Ogas and Sai Gaddam . Publication May 5, 2011 Discordance between Sexual Behavior and Self-Reported Sexual Identity: A Population-Based Survey of New York City Men , Annals of Internal Medicine,
September 19, 2006
28 of 102

11/29/2011

Internet-Based Partner Services
Sexual Orientation: Not The Full Story
Sexual Behavior: What has been done sexually, attraction to a specific gender or body part is not required
Sexual Orientation: Physical attraction linked to identity but not identity Sexual Identity: How one thinks of themselves as a sexual being.
Influenced by social preferences, community norms, family of origin, sexual behavior, denial, shame and guilt. Sexual Attraction: To whom (and what) a person is sexually attracted 17% of heterosexual adults admit being attracted to someone of the same
gender Sexual Fantasies: Often outside of orientation, behavior and identity.
(Occur during masturbation, daydreaming, as part of real life, or purely in the imagination.) conscious and unconscious fantasies about our bodies and our sexuality
influence the development of stable patterns of sexual identity, and with that, sexual behaviors.
Adam & Eve Sex Survey, October 29, 2010 International Psychoanalytical Association.
Final Thoughts On Male Desire
Internet venues and online media outlets, provide anonymity (perceived and real) in essence; removing the awareness of societal / peer / and external moral constraints. The exposure to `new' and/or taboo behaviors at the height of sexual arousal , the removal of societal constraints combined with availability, and the ease of acting impulsively through fast passed communication technologies, allow for suppressed desires and fantasies to be acted on with little thought and may be based on the community `standards' found within the users CURRENT online `community'.
Is male desire is evolving as a result of technology?
If this is true, how can Public Health Respond?
Smart Phones / Apps
Application
29 of 102

11/29/2011

Internet-Based Partner Services
Understanding Apps
Location-based (near me) Search options vary
A4A, screen name search (N/A: Grindr, Manhunt)
Rapid / local communication
Types of Apps
Web-based applications Native "downloadable" applications
Apple Store Android Market
Shared database
Adam4Adam, GayDar, Manhunt
Stand alone
Text Message for PN (txtPN)
The goal of text messaging by CDS is to motivate the recipient to communicate via voice.
To used text message for partner services you must be issued a local health department wireless phone and you must adhere to the templates provided in the guidance.
CDS are never permitted to exchange disease specific information through text messaging.
Text messages can be received at any time of day or night and you should be aware that you may receive a reply to your text message at any time of day or night.
30 of 102

11/29/2011

Internet-Based Partner Services
Verify Cell Phone Number
Intelius.com USSearch.com Peoplelookup.com
TXT Outcome
January 2011-September 2011 162 clients were sent a text immediately after a phone call
56% of cases responded with a call after receiving the SMS. Response rate over 50% for HIV, early syphilis, and gonorrhea Cases respond to SMS within 10-15 minutes (opposed to 3-4 days for a response to a letter) Only one case responded that they did not want to be contacted by SMS.
Multnomah County Health Department and Oregon Public Health Division, Portland, Oregon
Txt Content

11/29/2011

31 of 102

Internet-Based Partner Services
Coming Soon...
Module 1: IPS Program Overview Module 2: The Internet, Chat Rooms, IM and Mobile Module 3: General Operating Procedures Module 4: IPN and Patient Response Guidelines Module 5: Joining Websites and Creating Profiles Module 6: IPS Training and Staff Agreements Module 7: IPS Quick Guides and Reference Information Module 8: IPS Workflow and Diagrams / Data Systems Module 9: PN Email Templates Module 10: IPN CDS Logs
Resources
ICCR IPS / IPS Presentations IPS / IO Protocols guides - agreements Screen name Databases (Access) txtPN resources
Stephan Adelson
Senior Advisor, MSM, Sexual Health and Technology National Coalition of STD Directors sadelson@sadelson.com 617-953-9366
32 of 102

11/29/2011

HIV Care Update
HIV Care & Collaboration
Presentation to: PCSI Workshop Presented by: Michael (Mac) Coker, RN, MSN, ACRN
Date: November 29, 2011
HIV Care Overview
Care for PLWHA
Must be HIV-infected Uncomplicated primary care ADAP Lab support Prevention for Positives Medical Case Management Referrals as needed Programs & Collaboration may differ by district
TB: How do we collaborate?
Intake: TB hx assessed and TST/IGRA initiated
TB screening questions on CM intake form Screening performed yearly Ensure tx for LTBI and active disease (per TB)
On treatment
Must collaborate on medications: many interactions!
May require dosing or medication changes Encourage adherence Monitor for side effects Medical Case Management (HIV) continues to follow client to
address ongoing medical and psychosocial needs
33 of 102

11/29/2011

HIV Care Update
TB: How can we collaborate better?
From HIV chart reviews*:
TSTs (not done, placed on those with hx., placed & not read, and refusals)
Treatment of LTBI Better coordination when HIV and TB are
closely linked Positive findings: TST report forms, some TB
records in HIV charts * Slide from Rosemary Donnelly
STD: How do we collaborate?
STD screening done yearly & as needed on all clients
GC, CT, RPR, herpes, genital warts, hepatitis serology
Tx provided but may need to refer
For example warts that need surgical removal
Partner Notification
Through HIV or in partnership with CDS
STD: How can we collaborate better?
Better linkage to care for HIV+ clients out of care and accessing STD clinic
"I have HIV and last saw my provider 2 years ago" Role of medical case management (HIV) Refer to CDS to link to care?
Communication with HIV clinic when client accesses STD clinic
Better continuity of care, decrease cost by sharing test results so don't have to repeat
34 of 102

11/29/2011

HIV Care Update
Questions
HIV Care Contacts
Eva Williams, MSN, FNP, MPH HIV Nurse Consultant - Team Lead
(404) 657-3113 Pamela Phillips, MHA HIV Quality Management Coordinator
(404) 463-0390 Michael (Mac) Coker, MSN, RN, ACRN
HIV Nurse Consultant (404) 463-0387

11/29/2011

35 of 102

HIV Prevention Update
HIV Prevention Update
Presented by: Brandi Williams

11/29/2011

36 of 102

HIV Prevention Update
Counseling and Testing
(Jan. Sept.) T.E.S.T. Georgia 14,425 115 positives identified SEATEC CTL Trainings Walgreens Initiative
Contracts
T.E.S.T. Georgia General Prevention RFP ECHPP/ General Prevention

Capacity Building
Counseling and Testing Intervention Trainings CRIS System

37 of 102

11/29/2011

HIV Prevention Update
Evaluation
Evaluation Web 2012 HIV Test Forms PEMS

Special Projects

ECHPP Implementation:

SAMSHA

Phase II: 9/30/2011 to 9/29/2013 Awarded: $1,542,206 ($664,717)
HIV testing Condom Distribution Prevention with Positives Linkage to Care Partner Services Prenatal Social Marketing

10/1/2011 to 9/30/2016 Awarded: $1,327,647
Mental Health Substance Abuse Substance Abuse Prevention

11/29/2011

38 of 102

HIV Prevention Update
PS12-1201
Five (5) year HIV Prevention Funding Aligned with NHAS Reduce HIV incidence
Focusing on areas with higher incidence Increase HIV CTL Increase access to HIV care Improve healthcare outcomes Increase awareness and educate Expand efforts to prevent HIV
PS12-1201 (cont'd)
Category A HIV Prevention Programs for Health Departments
Category B Expanded HIV Testing
Category C Demonstration Projects

HIV Prevention 2012 Category A (funding allocation)

75% Prevention for positives CTL Condom Distribution HIV Policy

25%
Prevention for high-risk negatives
Social Marketing/Community Mobilization
PrEP

39 of 102

11/29/2011

HIV Prevention Update

Grant In AID Funding Comparison

2011
$1,751,110 22% High risk negatives HIV CTL
** Additional $2.5M Salaries

2012 (Proposed)
$1/2,000,000 (Depending on
funding level)
Comprehensive prevention for positives
HIV CTL Condom Distribution

75% of Funding (CDC requirement)
Salaries Counseling and Testing Supplies Condoms Distribution Lab Processing (State and Chatham) Community Planning Misc. (i.e. travel, administrative costs, supplies,
indirect, etc.)

25% of Funding (CDC requirement)
Prevention high-risk negatives Social Marketing Community Mobilization PrEP/PEP

40 of 102

11/29/2011

HIV Prevention Update

CBO Contract Comparisons

2011 $1,497,062 19% Contracts

2012 (Proposed) $1,200,000 16% Contracts

2011 Contract Allocations
0% 11%
89% 89% Prevention for High-risk negatives 11% Prevention for positives

Positive Negative

Current CBO Prevention Allocations

1,400,000

1,200,000

1,000,000

800,000

600,000

400,000

200,000

0
Positive Negative

Allocations 158,362 1,338,700

41 of 102

11/29/2011

HIV Prevention Update

2012 CBO Funding Allocations 1.2 M

700,000 600,000 500,000 400,000 300,000 200,000 100,000
0 Positive Negative

500,000 700,000

Category B: Expanded HIV Testing
Increase the number of people tested Increase the number of people who are unaware of
their HIV status
Provide routine testing in healthcare settings Expand targeted HIV testing in non-healthcare settings Ensure that positive clients are linked to care

Expanded Testing Comparison

2011 $2.6 M (Awarded)

2012 (Proposed) $1.5 M (Requested) Difference $1.1 M.

42 of 102

11/29/2011

HIV Prevention Update
Funding restrictions (CDC requirement)
70% Healthcare settings
0.1% rate of newly diagnosed positives
30% Targeted non-healthcare settings
2% rate of newly diagnosed positives
Category C: Demonstration Project
Innovative/creative approach (CDC requirements)
Decreasing incidence Cost effectiveness of HIV testing Enhancing linkage and retention to care Enhanced use of technology Programmatic and epidemiological use of CD4 viral load
and other surveillance data
"Georgia's Test-Treat-Care Network"
Linkage and access to care system Identify and link; improve primary care Network of Linkage Care Coordinators
43 of 102

11/29/2011

HIV Prevention Update
Brandi Williams blwilliams4@dhr.state.ga.us
404-657-3100

11/29/2011

44 of 102

Viral Hepatitis Update
Viral Hepatitis

Presentation to: PCSI Meeting
Presented by: Ami P. Gandhi, MPH
Adult Viral Hepatitis Prevention Coordinator Georgia Department of Public Health, Epidemiology

Date: November 29, 2011

Hepatitis A

Hepatitis B

Hepatitis C

Fever; Fatigue; Loss of Appetite; Nausea; Vomiting; Abdominal Pain ;Gray-colored bowel movements; Dark Urine; Joint Pain; Jaundice

Fecal-oral

Blood, body fluids

Blood

Vaccination Contaminated food or
water International travel Household or sexual
contact Men who have sex
with men Injection drug use

Vaccination Sexual contact Sharing needles or syringes or other drug equipment Perinatal exposure Close household contact Occupation exposure

No vaccination available Sharing needles or syringes or
other drug equipment Getting tattoos from an unlicensed, professional parlor Blood transfusions prior 1992 Clotting factors prior 1987 Long-term hemodialysis
Perinatal exposure Occupation exposure
Sexual exposure

No chronic infection
Immunity after recovery

Immunity if recovery from acute infection
10% adults - chronic infection
90% chronic if infected at birth

80% chronic infection
No lifelong immunity if recover from acute infection

No treatment

Treatment available

Treatment available

HOW DOES VIRAL HEPATITIS FIT IN TO THE PCSI MODEL?

45 of 102

11/29/2011

Viral Hepatitis Update
Why PCSI?
COST-EFFECTIVE Overlap in high risk populations, risk
behaviors Target populations at risk for multiple
infections Preventing missed opportunities
Viral Hepatitis and STDs
65% of hepatitis B cases are sexually transmitted Hepatitis A can be transmitted sexually (oral/anal sex
behaviors) Hepatitis C can be transmitted sexually but rare
(~5% of cases)
Highest risk in those with multiple sex partners, MSM
Viral Hepatitis and HIV
~1/3 of HIV+ individuals co-infected with HCV Up to 90% HIV+ IDU are co-infected with HCV Same transmission risks (blood, body fluids) Same high risk behaviors and populations (IDU, MSM,
multiple sex partners) Hepatitis B and hepatitis C are more infectious than HIV HIV co-infection allows HCV infection to progress more
rapidly
46 of 102

11/29/2011

Viral Hepatitis Update
Viral Hepatitis and Tuberculosis
Similar high risk populations (immigrant, refugees, incarcerated)
Important to test TB patients for viral hepatitis and vaccinate against hepatitis A and B prior to treatment

WHAT'S HAPPENING IN GEORGIA?

Confirmed Hepatitis A, Georgia

1000 900 800 700 600 500 400 300 200 100 0

913 499
2001 2002

751
306 124 2003 2004 2005

56 2006

69 2007

53 2008

54 2009

38 2010

The increase in Hepatitis A cases in 2001 was due to an outbreak in MSM populations in Georgia. The increase in Hepatitis A cases in 2003 was due to a multi-state outbreak involving contaminated green onions.

47 of 102

11/29/2011

Viral Hepatitis Update

Confirmed Hepatitis B, Georgia

2500 2000 1500 1000
500 0

1112
204 2005

1892

1597

198 2006

158 2007

Confirmed Acute HBV

1983

2088

1735

183 2008

142 2009

Confirmed Chronic HBV

156 2010

Confirmed Hepatitis C, Georgia

1000 900 800 700 600 500 400 300 200 100 0

852

724

667

701

8 2005

328

9

19

2006

2007

Confirmed Acute HCV

17

31

2008

2009

Confirmed Chronic HCV

915
31 2010

* Note that surveillance data for confirmed cases of acute and chronic hepatitis C is limited. Therefore, data does not depict true prevalence in Georgia.

Hepatitis C Virus (HCV)
1.6% of the US population have been infected with HCV (4-5 million people)
Estimated up to 75% of HCV+ unaware of status 50-90% of injection drug users are infected with HCV 14-42% of incarcerated people are infected with HCV ~42% of homeless people may be infected with HCV HCV is leading cause of liver transplants in the US

48 of 102

11/29/2011

Viral Hepatitis Update

At the Federal Level......
1st ever Action Plan dedicated to Viral Hepatitis released by a collaboration of Federal agencies in May 2011
http://www.hhs.gov/ash/initiati ves/hepatitis/actionplan_viral hepatitis2011.pdf

Budget Allocation from CDC/National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

TB, 13%

Viral Hepatitis, 2%

STD, 14%

Domestic HIV, 72%

Adult Viral Hepatitis Prevention
CDC funds 1 AVHPC in each jurisdiction Collaborate with and integrate hepatitis prevention
into existing public health programs Prevention activities, training, & education Raising awareness of viral hepatitis and impact on
high risk populations

49 of 102

11/29/2011

Viral Hepatitis Update

Adult Viral Hepatitis Prevention

Limited federal resources for prevention
No state funding for hepatitis prevention in Georgia

Emphasizes the need for program collaboration and service integration (PCSI)

So....where to begin?
PCSI!!!!!! Focus on building collaborative partnerships with
programs within the health department Awareness and education/training Educating public health staff to prevent missed
opportunities
Current and Future Collaborations
Collaborate with GA Immunization Program to promote availability of hepatitis vaccinations for adults in public health clinics
Collaborating with STD program and GA Immunization Program to increase testing and vaccination in STD clinics
Ryan White
Continue to support current protocols Provide education/training to staff on hepatitis testing,
vaccination & care issues in relation to HIV care
50 of 102

11/29/2011

Viral Hepatitis Update
Current and Future Collaborations
HIV Prevention:
Training/education on viral hepatitis and relationship to HIV to CBOs/funded agencies
Inclusion of viral hepatitis prevention messages during HIV counseling and testing
Linkages to health department for testing/vaccination
Where to go from here...?
Further integration of services Evaluate burden of HIV/HCV co-infection Hepatitis C testing along with HIV testing among high risk
populations OraQuick HCV Rapid Antibody Test Ensure staff/agencies providing STD and services are trained to identify those at risk for viral hepatitis and trained to provide accurate information on testing, vaccination, & care Develop linkages for follow up testing and care
CONTACT INFORMATION
Ami P. Gandhi, MPH Adult Viral Hepatitis Prevention Coordinator Georgia Department of Public Health, Epidemiology apgandhi@dhr.state.ga.us 404-463-0849
51 of 102

11/29/2011

Tuberculosis Update
An Overview of the Georgia Tuberculosis Program
Presented by: Dr. Rose-Marie Sales TB Program Director/TB Epidemiology Section Chief, GA-DPH
What is Tuberculosis (TB)?
Tuberculosis (TB) is an infectious disease caused by the germ Mycobacterium tuberculosis or tubercle bacilli. It usually affects the lungs but can affect any part of the body.
TB is transmitted when persons with pulmonary or laryngeal TB cough, sneeze, speak, or sing, and expel droplets containing TB bacilli. A susceptible person may inhale the tubercle bacilli and get infected.
Signs and Symptoms of TB
Persistent, productive cough for more than 2-3 weeks Coughing up blood Fever Night sweats Weakness Weight loss
52 of 102

11/29/2011

Tuberculosis Update
How to stop TB transmission
Immediate respiratory isolation of infectious TB patients Starting effective treatment and completing treatment Identifying and screening contacts of TB patients
Risk Factors for TB
Close contacts of a person with infectious TB HIV infected individuals Immunosuppressed persons Foreign-born persons from endemic countries Injecting drug users Residents and employees of homeless shelters,
nursing homes, jails, and prisons
Risk Factors for TB
Mycobacterial laboratory personnel and health care workers who serve high-risk clients
Persons with diabetes mellitus, silicosis, end stage renal disease, gastrectomy, jejunoileal bypass, leukemia, lymphoma, or cancer of the head or neck
53 of 102

11/29/2011

Tuberculosis Update
Difference between active TB disease and latent TB infection (LTBI)
Active TB disease: Person is symptomatic and TB bacilli are actively multiplying. Persons with active TB disease can infect other people
Latent TB infection: TB bacilli are present in the body but are inactive and not multiplying. Persons with LTBI have no symptoms and are not contagious, but may develop TB disease later in life if they do not receive treatment for LTBI.
The Georgia Tuberculosis Program
The mission of the Georgia Tuberculosis Program is to control transmission of, prevent illness from, and ensure treatment completion of tuberculosis (TB)
This is accomplished by the following: Identifying and treating persons who have active TB Finding, screening and treating contacts of TB cases Screening high-risk populations
What does the TB Program Do?
Conducts case reviews to ensure that all TB cases in Georgia are evaluated and treated appropriately
Provides individualized case management to TB patients Identifies, locates, and evaluates persons exposed to TB Provides tuberculin skin testing, bacteriology, radiologic
services, and anti-TB medications to persons with active TB and their contacts
54 of 102

11/29/2011

Tuberculosis Update
What does the TB Program Do? (2)
Provides education and treatment to contacts with latent TB infection (LTBI) to prevent future illness
Maintains statewide TB surveillance system and ensures complete, accurate, and timely reporting of newly diagnosed and suspected TB cases
Provides QA/QI oversight and builds capacity of health providers to identify, treat, and control transmission of TB through education, training, and technical assistance
TB Program Services
Physician/nurse consultation Directly observed therapy (DOT) Individualized case management Free anti-TB medications, bacteriology exams,
radiographic services and screening of contacts Housing for homeless TB clients Incentives and enablers Oral nutritional supplements Social services consultation and referral Language Line Services with over 170 languages
TB Program Services (2)
Provides assistance to Health Districts for involuntary commitment of noncompliant TB clients
Tracks movement of TB cases to ensure continuity and completion of treatment
Assures timely reporting of TB cases Maintains computerized register of TB cases in Georgia Analyzes and monitors epidemiologic trends Leads outbreak investigations
55 of 102

11/29/2011

Tuberculosis Update
State TB Program Staff
Administrative Physician consultant Education, training and outreach Program evaluation and incidence response Medical records and surveillance Epidemiology Pharmacy
TB Prevention & Control Funding
Provides personnel for state, health districts and county health department staff
Travel to perform TB prevention and control activities (e.g., DOT, contact investigation, TB education for healthcare providers, outbreak investigations)
Contracts to provide special services (e.g., medical consultation, temporary housing for homeless patients, Grady laboratory for smears and culture identification
Georgia Public Health Laboratory TB lab Training and education activities
Training and Education
TB Update & Skin Test Certification Course Contact Investigation and DOT Course TB Case Management Course Training for Correctional Facilities Quarterly TB Task Force Meetings Nurse protocol training Training for cohort reviews Technical assistance for outbreak response
56 of 102

11/29/2011

Tuberculosis Update
What is Reportable by Georgia Law?
Any laboratory confirmed or clinical case of TB TB suspects on at least two anti-TB drugs LTBI in children under 5 years of age
"In-patient or out-patient treatment of a case of active TB and treatment of a suspected case with two or more anti-TB drugs shall be reported to the Epidemiology and Prevention Branch of the Department through the local county health department or its designee."
- Rules and Regulations of the State of Georgia Chapter 290-5-16
TB Surveillance Case Definitions
Laboratory Case Definition
Isolation of M. tuberculosis complex* from clinical specimen
Demonstration of M. tuberculosis complex from clinical specimen by nucleic acid amplification test, e.g. MTD test
Demonstration of acid fast bacilli from clinical specimen when culture can not be obtained (usually post-mortem setting)
*Mycobacterium tuberculosis complex: Group of closely related mycobacteria that can cause active TB (e.g., M. tuberculosis, M. africanum, M. bovis)
TB Surveillance Case Definitions (2)
Clinical Case Definition
In absence of laboratory confirmation, case meets all of the following criteria:
TB infection based on positive tuberculin skin test or interferon gamma release assay test
Signs/symptoms compatible with current TB (e.g., abnormal CXR/CT scan/other chest imaging study, or clinical evidence of current disease
Current treatment with two or more anti-TB meds Completed diagnostic evaluation
57 of 102

11/29/2011

Tuberculosis Update
Provider Diagnosis
CDC accepts cases to be included in a state's morbidity count when a health provider has assessed the patient to have TB and patient is under treatment for TB even if patient may not meet surveillance case definition criteria

Number of TB Cases and TB Case Rates Georgia,1982-2010

Number of Cases

Case rate/100,000

Number of TB Cases by Health Districts Georgia, 2010

Haralson

1-2

2-0

Gordon
1-1 Bartow

Polk Paulding

3-2 3-4

10-0

3-1

3-5

Rockdale 3-3

4-0 5-2

Number of TB Cases:
Low incidence: 2-10 Medium incidence: 11-20 High incidence: >20 (29-86)
6-0

7-0
8-2
Seminole Decatur

5-1 9-1
9-2 8-1

58 of 102

11/29/2011

Tuberculosis Update

11/29/2011

TB Case Rates by Health Districts Georgia, 2010

1-2

Gordon

2-0

1-1 Bartow

Polk Paulding

3-2 3-4

Haralson

3-1

3-5

Rockdale 3-3

10-0

4-0 5-2

Case rates/100,000 population:
<= 3.5 (2000 national target) 3.6 to 4.2 > 4.2 (2010 state average)
6-0

7-0
8-2
Seminole

5-1
9-1 9-2 8-1

US-born and Foreign-born TB Cases Georgia,1993-2010
Number

59 of 102

Tuberculosis Update

HIV Status of TB Cases Georgia,1993-2010

Unknown Negative Positive

Number

900 800 700 600 500 400 300 200 100
0
1993 1995 1997 1999 2001 2003 2005 2007 2009
Year

Primary Drug Resistance and MDR-TB Georgia, 2006-2010

Number Percent

45

16

40

14

14

35

12

30

10

25

9

20

7

15

6

8 7
6

10

4

5

0

2

1

2

32

0

0

2006 2007 2008 2009 2010

Year

MDR-TB: multidrug-resistant TB (resistant to at least INH and Rifampin)

INH RIF MDR-TB % INH-R

Timely (In 12 Months) TB Treatment Completion and Directly Observed Therapy (DOT) Georgia, 1993-2009
67
DOT became standard of care

60 of 102

11/29/2011

Tuberculosis Update

Completion of Latent TB Infection Therapy Georgia, 2005-2009

80

70 66

66

68

60

57

60

50 Completed LTBI Therapy

40

Missing data

30

20

14

10 0

1

4

6

8

2005 2006 2007 2008 2009

Year

Percent

Program Evaluation Plan 2011 - 2015
National Tuberculosis Indicator Program (NTIP) Goals: NTIP Goal #1: For patients with newly diagnosed TB for whom 12 months or less of treatment is indicated, increase the proportion of patients who complete treatment within 12 months to 93% by 2015 (Not met: 87%) NTIP Goal #8: Increase the proportion of patients who are started on the recommended initial four-drug regimen when suspected of having of TB disease to 93% by 2015 (Met: 92%) Benchmarks Number of case reviews held in the state per year and number of cases reviewed. Number of cohort reviews held in the state per year and the number of cases reviewed. Number of record audits performed in the state per year and number of records audited. Include summary of audits. Percentage of public health staff who provide TB services who are TST certified.
World TB Day, March 24, 2011

1,514 registered, 950 t-shirts were distributed at the Walk
61 of 102

11/29/2011

Tuberculosis Update
New Initiatives for the New Year
Implementing electronic medical records Implementing statewide cohort reviews Using peer educators to improve LTBI treatment
completion in metropolitan Atlanta counties Developing Program Evaluation Manual Updating TB Policy and Procedure Manual and
Georgia Reference Guide

11/29/2011

62 of 102

STD Update
Georgia On My Mind:
State of The State STD Office
Presented by: Michelle L. Allen, STD Office Director Date: November 29, 2011
Overview
During this presentation, you will be provided information as follows: State STD Office Mission and Vision Current Rankings Georgia Program Updates Healthy People 2020
STD Office
MISSION & VISION STATEMENT
Mission: To provide technical assistance and programmatic support to the Public Health Districts and Community Based Organizations to prevent Sexually Transmitted Infections ensuring the availability of quality prevention, intervention, and treatment.
Vision: We envision healthy Georgia communities free of Sexually Transmitted Infections.
63 of 102

11/29/2011

STD Update
CDC 2010 STD Surveillance Report Highlights
Georgia ranks... 2nd for Primary and Secondary Syphilis 7th for Gonorrhea 12th for Congenital Syphilis 15th for Chlamydia
Source: Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2010. Atlanta: U.S. Department of Health and Human Services; 2011.
STD Office Programs
Comprehensive STD Prevention Systems (CSPS) Infertility Prevention Project (IPP) Syphilis Elimination Effort (SEE) Gonoccocal Isolate Surveillance Project (GISP) The program activities implemented in carrying out these program
components support the achievement of many STD-related Healthy People 2020 objectives.
Does the STD Office Support My District? Yes
GC\CT Testing Supplies and Lab Services STD Treatment STD 101 CDS and CDS Supervisor Training Microscope Training Staff***(FTEs) GIA (metro and beyond) STD Nursing Protocols Condoms, Lube, and Literature Equipment and Supplies
64 of 102

11/29/2011

STD Update
Services and Activities
Services -Provides technical assistance to health districts and CBOs -Programmatic Support -Rapid Response -Training
Activities -Conducts SEE Bimonthly Meetings -Funds two Metro Atlanta CBOs AID Atlanta ARCA -Participates in community outreach -Capacity Building - MSM Forums
Program Updates
STD Surveillance (Surveillance Manager Latasha Terry) Case Management ICCR\OOJ Transactions EPI STD Program (Program Manager Linda Allen-Johnson) SENDSS Technical Assistance Data Request\Data Analysis GA Public Health Lab Syphilis and HIV Testing Update Budget cuts -$$
Program Updates
MSM Forums Georgia on My Mind Updates Selected HIV Testing Sites to become GC\CT Testing Sites Revising STD Nursing Protocols HIV Office \HBCU Tour with Greater Than AIDS Campaign National HIV Testing Day Emory MPH Students Disease Intervention 101 Collaboration DJJ \ Corrections Collaboration Provider Workgroup STD 101 PCSI Conference Billing Advisory Workgroup
65 of 102

11/29/2011

STD Update
Program Collaboration and
Service Integration
Healthy People 2020 Objectives
Sexually Transmitted Disease STD-1 Reduce the proportion of adolescents with Chlamydia
infections. STD-2 Reduce Chlamydia rates among females aged 15 to 44
years. STD-6 Reduce Gonorrhea rates. Family Planning Increase the proportion of sexually active persons aged 15 to
19 years who use condoms to both effectively prevent pregnancy and provide barrier protection against disease.
Healthy People 2020 Objectives
Sexually Transmitted Disease STD-9 Reduce the proportion of females HPV.
Immunization and Infectious Disease IID-25.2 Reduce new hep B infections among at-risk populations Injections drug users (IDU). IID-25.3 Reduce new hep B infections among at-risk populations Men who have sex with men (MSM).
66 of 102

11/29/2011

STD Update
2010 STD Treatment Guidelines
Several STDs can be effectively prevented through pre-exposure vaccination, including HAV, HBV, and HPV.
Clients treated for an STD should receive vaccination (unless already vaccinated). MSM and IDUs should also receive Hep A.
Contact Information
Georgia Department of Public Health Division of Health Protection
Infectious Disease and Immunization Program Michelle L. Allen STD Office Director 2 Peachtree Street 13th Floor Atlanta, GA 30303 Phone (404) 404-657-3155 Fax (404) 657-3133 mlallen2@dhr.state.ga.us http://health.state.ga.us
ThankI Ywoeulcome your questions & comments...
67 of 102

11/29/2011

SWOT Analysis 2011
SWOT Analysis

Presentation to: Program Collaboration and Service Integration (PCSI)

Presented by: Valerie Underwood

Date: 11/29/11

SWOT Analysis
A Strengths, Weaknesses, Opportunities, Threats (SWOT) Analysis is a tool used to understand programs and provide decision-making strategies for achieving program goals
Surveys Received= 15
State Office = 3 District Level = 12

Programmatic
Think about your individual program. If you work for multiple programs, please include answers based on each program:
What do you perceive are the strengths of your program? What do you perceive are the weaknesses of your program? What do you perceive are the opportunities of your program? What do you perceive are the threats of your program?

68 of 102

11/29/2011

SWOT Analysis 2011
Strengths
Teamwork (6) Expertise (5) Technical assistance (5) Client focused (4) Communication (4) Committed staff (3) Innovation (2) Partnerships (2) Support staff (2)

Weaknesses
Funding (10) Training opportunities (6) Understaffing (6) Data-IT systems (4) Leadership/Politics (4) Clinical structural division (2) Private Providers (2) Referral systems (2) Salary (2)
Opportunities
Progressive mindset (7) Training (6) Collaboration (5) Community Education/Involvement (5) Leadership development (4) Partnership (4) Service/systems improvement (3) Data use (2) New hires (2)

69 of 102

11/29/2011

SWOT Analysis 2011
Threats
Budget cuts (12) Loss of employees (5) Increased morbidity (4) Providing services (4) Lack of foundation (3) Overworked (3) Staff turnover Stagnant salary (3)
Collaborative
Now, think about how the HIV, STD, and TB units work together? Answer based on the collaboration and integration of services with your program(s) and the other infectious disease programs (HIV, STD, TB):
What do you perceive are the strengths of the current program collaboration? What do you perceive are the weaknesses of the current program collaboration? What do you perceive are the opportunities of the current program collaboration? What do you perceive are the threats of the current program collaboration?
Strengths
Linking clients (6) Shared facility/management (4) Integrated approach (3) Helping on large scale outbreaks (2) Expertise (2)
70 of 102

11/29/2011

SWOT Analysis 2011
Weaknesses
Little to no collaboration (4) Separation of programs (4) Communication (2) Follow-up (2) Unclear Goals/Objectives (2)

Opportunities
Collaboration (7) Serve clients (6) Cohesive departments (5) Communication (4) Training (4) Meet PH goal (2)

Threats
Funding (10) Competing priorities (5) State office hands-off leadership approach (4) Understaffed (4) Separation of programs (3) Continuity of care (2) Lack of effective collaboration (2) Lack of clear communication (2)

71 of 102

11/29/2011

SWOT Analysis 2011
Discussion
How can we use this information to help our programs?
What is my role in program collaboration? What training is needed? Does my organization have a strategic plan? Work
plan?

HIV Prevention HIV Care

Thank You!
Tuberculosis

Hepatitis

Refugee Health

Sexually Transmitted Diseases

11/29/2011

72 of 102

Team Building
TEAM BUILDING

Presentation to: Program Collaboration and Service Integration (PCSI)

Presented by: Lawsey Thomas, Sr.

Date: November 30, 2011

Team Building

11/30/2011

Objectives
To identify ways that a group can accomplish more than an individual
To identify what it means to be an effective team player
To identify and define the four team-player styles
73 of 102

Team Building
Objectives
To identify the preferred individual team-player style
To recognize the positive and negative effects of each team-player style
To explore the five strategies for becoming a better team player and maximizing team effectiveness
Objectives
To identify the keys to making diversity a constructive force in developing team work
To describe personal and organizational benefits of building more successful teams
In The Cards

11/30/2011

74 of 102

Team Building
Team Building
What things can a team accomplish that one person cannot accomplish alone?
Question?
Identify instances when the team's effectiveness suffered due to personality/style clashes among members
Debrief
What are the team-player styles? What were the problems in the
beginning of the team's project? How did they resolve them? How do diverse team members work
together to form a cohesive and effective team?
75 of 102

11/30/2011

Team Building
Contributor
Task-oriented, perfectionist Focuses on details Highly skilled and stable Expects higher standards Proficient and dependable Views the team as experts
Collaborator
Appreciates "big" picture Resists the specifics Focuses on overall goal Keeps organization's vision in mind
Communicator
"People" person Focuses on human relations and group
process Resolves conflict Creates an inviting atmosphere
76 of 102

11/30/2011

Team Building
Challenger
Asks the tough questions Provides reality checks Keeps group on course Saves the team from bad ideas
Team-Player Styles
Strengths and Contributions
Detailed characteristics, using adjectives
Weaknesses and Excesses
Detailed characteristics, using adjectives
Learner Styles
Usually have a more preferred style Not confined to just one Does not exclude all other styles Everyone has a mixture of all four
77 of 102

11/30/2011

Team Building
Five Team-Player Strategies
Identify your style and others Use style to maximum advantage Avoid carrying too far Acknowledge value of others Learn to switch style
Identify Your Style & Others
What are your team-player style strengths?
What are your team-player style weaknesses?
Identify Your Style & Others
What are your team-player style strengths?
What are your team-player style weaknesses?
78 of 102

11/30/2011

Team Building
Question
How do you relate to other team members whose team-player style is most like yours?
How do you relate to other team members whose team-player style least like yours?
Use Style to Maximum Advantage
Know team's strengths and weaknesses
Assign tasks based on team member's strengths
Use your style to the team's advantage
Avoid Carrying Too Far
Diminishes the team's effectiveness Causes dissention Brings down team moral Similar to a cake: Too much of any
one ingredient ruins the whole cake
79 of 102

11/30/2011

Team Building
Acknowledge Other's Value
Recognize other's talents Respect other's contributions/ideas Understand the need for balance
among the various styles Remember the sum is always greater
than one
Learn To Switch Styles
Always remain flexible Do not be afraid to leave comfort zone How does your willingness to change impact
the team's success/failure?
Balancing Team
How would having imbalances on your team impede the performance of the team?
80 of 102

11/30/2011

Team Building Lost at Sea

11/30/2011

Key Learning Points
Teamwork is critical for group development, recognize the impact of one person monopolizing the group
Be aware of the negative effects of excluding members, therefore get input from silent members
Key Learning Points
Be aware of verbal and non-verbal communication in order to have effective two-way communication
The key to effective problem-solving is having a process for decision-making
When ideas are shared, the results are better solutions and greater ownership
81 of 102

Team Building
Keys to Making Team Diversity Work
Self-Awareness Interpersonal Honesty Mutual Respect Trust Flexibility
Self Awareness
Individual awareness of what constitutes his/her essential nature and distinguishes him/her from all others
Interpersonal Honesty
Effectively Communicating with others - Using Listening and feedback skills
Being open and honest Helps to create trust
82 of 102

11/30/2011

Team Building
Mutual Respect
The Golden Rule: Treat Others As You Would Like To Be Treated!!!
Regard other member's worth, value and contributions
The PLATIUM RULE Treat others as they want to be treated.
Trust
Foundation to all interrelationships Makes a team a cohesive unit No trust = No team
Flexibility
Ability to adapt and adjust Workable and able to bend Ability to bounce back Capable of being shaped, bent or molded
83 of 102

11/30/2011

Team Building

11/30/2011

By Milton Olson adapted by Angeles Arrien
Lesson One
Each goose flaps wings to uplift those that follow Flying in "V" formation adds 71% greater flying range than
each flying alone People who share a common direction get to the goal
quicker and easier because they are traveling on the trust of one another
Lesson Two
When a goose falls out of formation, it feels the drag and resistance of flying alone
It quickly moves back in formation for the lifting power of the bird in front
If we have as much sense as a goose we'll stay in formation with those headed where we want to go
We will accept their help and give our help to others
84 of 102

Team Building
Lesson Three
When the lead goose tires, it rotates back and another goose flies to the point position
As with geese, people are interdependent on each other's skills, capabilities, talents, and resources.
It pays to take turns doing the hard tasks and to share leadership
Lesson Four
Geese flying in formation honk to encourage those up front to keep up their speed
We need to make sure our honking is encouraging.
In groups where there is encouragement, the production is greater
Lesson Five
When a goose gets sick or wounded, two geese drop out of formation and stay with it until it can fly again or dies.
Then they launch out with another formation or catch up with the flock
If we have as much sense as geese, we will stand by each other in difficult times as well as when we are strong.
85 of 102

11/30/2011

Team Building
Lesson Five
When a goose gets sick or wounded, two geese drop out of formation and stay with it until it can fly again or dies.
Then they launch out with another formation or catch up with the flock
If we have as much sense as geese, we will stand by each other in difficult times as well as when we are strong.
"IT IS INDEED A REWARD, A CHALLENGE AND A PRIVILEGE TO BE A CONTRIBUTING
MEMBER OF A TEAM"

11/30/2011

86 of 102

Understanding and Valuing Diversity in the Work Place
Understanding and Valuing Diversity
In the Work Place

Presentation to: Program Collaboration and Service Integration (PCSI)

Presented by: Lawsey Thomas, Sr.

Date: November 30, 2011

Understanding and Valuing Diversity In the Work Place

TERMINAL PERFORMANCE OBJECTIVES
Upon completion of this course of instruction, the student will be able to recognize diversity in the work environment and complete a written test with 70%
accuracy.
87 of 102

11/30/2011

Understanding and Valuing Diversity in the Work Place
Enabling Objectives
a. Define Diversity b. List three (3) types of diversity and give examples of
each. c. Demonstrate diversity as it relates to DPH d. Describe diversity as it relates to the facility. e. Describe the new diversity within the workplace
Diversity Defined
Diversity is an environment that allows for the total spectrum of differences to be valued and integrated in support of the organization's mission and overall business operations.
Types of Diversity
1. Cultural Diversity 2. Racial Diversity 3. Age Diversity
88 of 102

11/30/2011

Understanding and Valuing Diversity in the Work Place
The Importance of Culture
"We have become not a melting pot but a beautiful mosaic. Different people, different beliefs, different yearnings, different hopes, different dreams".
Jimmy Carter

Working Together Works
Working together can never be a policy. It can only be an idea. It can never be a code of rules. It can only be a way of looking at the world. We can say, "This is mine," and be good, or we can add, "This is ours" and become better. We can think, "I'll do my share," and be satisfied, or we can ask, Can I do more?" And become prosperous. We can work alongside each other and function, or we can work With Each other and grow.

UNDERSTANDING AND VALUING DIVERSITY

55.0% 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0%
5.0% 0.0%

52.8% 24.3%

White, NH Hispanic Afr-Amer Asian/ PI Native Amer

13.2% 8.9%
Year 2050 Projected

89 of 102

11/30/2011

Understanding and Valuing Diversity in the Work Place
Our Country's History
Our country's history makes it clear that combining all efforts into one has been the only way to achieve that progress and that strength we take such pride in our unity. Pride not only in what we've achieved but pride in knowing that we've achieved it together, with our own work and our own visions. That's really the key. Because when all is said and done, working together doesn't only bring out the best in all of us, it brings us all the best.
What is Valuing Diversity
Respecting the differences which exist among us due to our respective life experiences; allowing for an atmosphere which values customers and employees in such a way that the mission is enhanced.
CULTURAL COMPETENCE
is Communicating in
Open
HONEST
And
Caring ways
To promote healthy conflict management.
90 of 102

11/30/2011

Understanding and Valuing Diversity in the Work Place
What is Valuing Diversity
"Without each other's help through change we choose to stagnate." COME LET US REASON TOGETHER AS
MEMBERS OF THE GREATEST RACE ----THE HUMAN RACE---
C. Everett Koop
What is Valuing Diversity
If we have no peace, it is because we may have forgotten that we belong to each other
Mother Theresa
Change----Enemy or friend You choose------One or the other
Yoshira Zama
Who is Responsible for Diversity
GLOBAL TECHNOLOGY AND SERVICE DRIVEN ECONOMY
91 of 102

11/30/2011

Understanding and Valuing Diversity in the Work Place
Who is Responsible for Diversity
Women and others in the workplace
CRASH-Course Concepts
Culture Respect Assess / Affirm Sensitivity / Self-awareness Humility
Culture
Race Ethnicity National Origin Geographic Region History Religion
92 of 102

11/30/2011

Understanding and Valuing Diversity in the Work Place

Culture Expressed Through Individuals

Gender Age

Race Ethnicity National Origin Geographic Region History Religion

Family Dynamics
Personal Psychology

Culture Expressed Through Individuals Over Time

Gender
Marriage Family
Age

Social Status &
Power
Race Ethnicity National Origin Geographic Region History Religion
Acculturation

Family Dynamics
Education & Vocation
Personal Psychology

Self-Awareness:
Becoming aware of our own cultural norms, values, and "hot-button" issues that lead us to mis-judge or to miscommunicate with others.

93 of 102

11/30/2011

Understanding and Valuing Diversity in the Work Place
CONFLICT
A process of social interaction involving a struggle over claims to resources, power and status, belief, and other preferences and desires. A disparity existing among parties over facts, methods, goals, and values.
ASSUMPTIONS
Conflict and disagreements will develop Some conflict can be minimized There are some unavoidable conflict The resolution of conflict does not have to result in a winner or a loser

Types of Conflict

Type

Defining Characteristics

_______________________________________________

Interest/communication

conflict characterized by a genuine class of opposing interests or commitments

Induced conflicts

conflicts intentionally created in order to achieve other than explicit objectives

94 of 102

11/30/2011

Understanding and Valuing Diversity in the Work Place

Types of Conflict

Misattributed conflicts Illusionary conflicts

conflicts involving incorrect attributions as to the behaviors, participants, issues, or causes.
conflicts based on misperceptions of misunderstandings

Types of Conflict

Displaced conflicts Expressive conflicts

conflicts in which the opposition of antagonism is directed toward persons or concerns other than the actual offending parties or the issues conflicts characterized by a desire to express hostility, antagonism or other strong feelings.

CONFLICT IS CONSTRUCTIVE WHEN IT:
Opens up issues of importance, resulting in their clarification. Results in the solution of problems Increases the involvement of individuals in issues of importance to
them. Causes authentic communication to occur. Serves as a release to pent-up emotion, anxiety and stress Helps build cohesiveness among people by sharing the conflict,
celebrating in its settlement and learning more about each other. Helps individuals grow personally and apply what they learned to
future situations.
95 of 102

11/30/2011

Understanding and Valuing Diversity in the Work Place
CONFLICT IS DESTRUCTIVE WHEN IT:
Diverts energy from more important activities and issues. Destroys the morale of people or reinforce poor self-concepts. Polarizes groups so they increase internal cohesiveness and reduce
intergroup cooperation. Deepens differences in values. Produces irresponsible and regrettable behavior such as name-calling
and fighting.
Self-Awareness
When people won't make eye contact with me, ______________________.
When patients show up late for their appointments, ___________________.
When people touch me a lot or get in my personal space, ___________________.
When dealing with conflict, people should ____________________________.
Success Factors
Demand that stereotypes be dropped, that ideas be given consideration on their merit regardless of source, and that good working relationships be maintained. Positive feelings about others are both a cause and an effect of collaborations and coalition building. "Learn to always use kind words No one resents them."
Maya Angelou
96 of 102

11/30/2011

Understanding and Valuing Diversity in the Work Place
UNDERSTANDING BIASES AND STEREOTYPES SELF-APPRAISAL
What is my vision and supporting values and beliefs? How did I come by those values and beliefs? What positive messages did I receive about aspects of my identity which
are still motivating and sustaining forces for me even now? What were the sources of those messages? What negative messages (stereotypes) did I receive early on about different others? How did those affect me then? How do those continue to affect me now? What concrete steps am I taking to continually discover my biases? What am I doing that is working? What more should I be doing?
Humility:
Recognizing that none of us ever fully attains "cultural competence"
Making a commitment to life-long learning Peeling back "layers of the onion" of
our own perceptions and biases Being quick to apologize and accept responsibility for cultural
mis-steps Embracing the adventure of learning from others' first-hand
accounts of their own experience.
BIAS DISCOVERY Realizing you are holding on to a bias in
the face of evidence to the contrary
BIAS RECOVERY Taking steps to appropriately remove bias.
97 of 102

11/30/2011

Understanding and Valuing Diversity in the Work Place
MENTAL MODEL FRAMEWORK
No matter what the other person is doing or saying, my response must be:
What is the most kind, caring, helpful and loving way I can respond
RIGHT NOW!!!!!

11/30/2011

98 of 102

Scantron
Report: Program Collaboration Service Integration (PCSI) Evaluation
This report contains 51 evaluation results for the Georgia Department of Public Health Division of Health Protection - PCSI Training held in Macon, GA, November 29-30, 2011. The question categories are listed first, followed by individual question values using the follwoing Likert Scale:
5 = Excellent 4 = Very Good 3 = Good 2 = Fair 1 = Poor Free text comments are verbatim as transcribed from evaluations.

12/01/2011

Class Climate evaluation 99 of 102

Page 1

PCSI Training
November 29-30, 2011 No. of responses = 51

PCSI 2011

Tuesday - November 29, 2011 Registration Ice Breaker Welcome / Workshop Overview Program Collaboration Service Integration (PCSI) Internet Partner Service Notification TB Update STD Update HIV Update Hepatitis Update
12/01/2011

0% 2% 10% 40% 48%

Poor

Excellent

1

2

3

4

5

0% 4% 8% 52% 35%

Poor

Excellent

1

2

3

4

5

0% 2% 13% 47% 38%

Poor

Excellent

1

2

3

4

5

0% 2% 6% 28% 64%

Poor

Excellent

1

2

3

4

5

0% 0% 8% 27% 65%

Poor

Excellent

1

2

3

4

5

0% 0% 11% 41% 48%

Poor

Excellent

1

2

3

4

5

0% 0% 9% 43% 49%

Poor

Excellent

1

2

3

4

5

0% 2% 18% 49% 31%

Poor

Excellent

1

2

3

4

5

0% 0% 20% 45% 35%

Poor

Excellent

1

2

3

4

5

Class Climate evaluation 100 of 102

n=48 av.=4.33 md=4 dev.=0.75 n=48 av.=4.19 md=4 dev.=0.76 n=47 av.=4.21 md=4 dev.=0.75 n=47 av.=4.53 md=5 dev.=0.72 n=49 av.=4.57 md=5 dev.=0.65 n=46 av.=4.37 md=4 dev.=0.68 n=47 av.=4.4 md=4 dev.=0.65 n=49 av.=4.08 md=4 dev.=0.76 n=49 av.=4.14 md=4 dev.=0.74
Page 2

SWOT Analysis
Wednesday - November 30, 2011 Icebreaker Case Study Program Capacity Building or Team Building Cultural Sensitivity
Other Thoughts

0% 5% 21% 37% 37%

Poor

Excellent

1

2

3

4

5

PCSI 2011 n=43 av.=4.07 md=4 dev.=0.88

2% 0% 25% 33% 40%

Poor

Excellent

1

2

3

4

5

2% 2% 24% 30% 41%

Poor

Excellent

1

2

3

4

5

0% 2% 16% 35% 47%

Poor

Excellent

1

2

3

4

5

0% 5% 16% 30% 50%

Poor

Excellent

1

2

3

4

5

n=48 av.=4.08 md=4 dev.=0.92 n=46 av.=4.07 md=4 dev.=0.98 n=49 av.=4.27 md=4 dev.=0.81 n=44 av.=4.25 md=4.5 dev.=0.89

Any other thoughts you'd like to share with the PCSI Steering Committee?

Create a "Train the Trainer" or share info on how we could create & implement this training in our own district. (2 Counts)
Excellent! We need to have this every year! More case studies & speakers like Mr. Adelson. Program updates helpful to understand how different programs work. (1 Count)
Would love to hear more information about the use of internet partner search. (1 Count)
Nice enthusiastic speakers, but not necessarily all benificial - games! (1 Count)
Great meeting - great information. (1 Count)
Great conference!!! (1 Count)
-Needed more interaction with capacity building. -All updates were very informative. (1 Count)
Overall a well organized conference. The enue was appropriate and the food was good. Look to see other program areas included in PCSI in the future. (1 Count)
Great Training (1 Count)
This was a wonderful training. I would like more input on how to actually implement collaboration with our daily work. Also, with presentations please suggest that they take a role that everyone does not know the "lingo" in our respective sections. (1 Count) (PPENFFUJOH*XPVMEMJLFUPIBWFNPSFDPMMBCPSBUJWFBDUJWJUJFTBUUIFNFFUJOH*XPVME MJLFUPEJTDVTTDPMMBCPSBUJWFXPSLHSPVQTBOEOFYUTUFQTBUUIFOFYUNFFUJOH

12/01/2011

Class Climate evaluation 101 of 102

Page 3

PCSI 2011
1st Day - This great conference should be reproduced for Health Directors over the state (G.P.H.A.?) They are the gatekeepers for what is allowed to occur in the district. 2nd Day - Speaker too wordy, too long, & boring for those of us who have had similar trainings over the last 10 years. This is old news & time could be better utilized toward other efforts. He seemed to have some good useful slides that he did not address. Too bad! (1 Count)
Excellent program - please continue annually. (1 Count)
Invite other programs. (1 Count)
Well planned, very informative, one of my favorite conferences. (1 Count)
Nice venue, good conference, nice to have breakfast & lunch provided, I liked the way you kept to the schedule. (1 Count)
Very good & gave items to think about. More collaboration & communication is needed among programs (esp. due to budget restrictions). *FYI - Rm was too cool - everything else was very nice. (1 Count)
- Add a motivational speaker for a segment of the meeting to encourage & enpower us as we work that difficult times within our areas/differences. - Suggest that this meeting be continued. -Include Refugee Health. (1 Count)
PCSI is new concept for me. Awesome meeting. Gives new perspective on collaboration efforts. (1 Count)
Thanks for the workshop. I really enjoyed it. The speakers were all excellent - really enjoyed the laughter from Mr. Thomas's speech. (1 Count)
May be nice to develop a program for sharing within districts. (1 Count)
Great Training! (1 Count)
Have more of these meetings. (1 Count)
Great for everyone from the different programs to get together. We need more of these type of meetings. (1 Count)
Would like to see activities/presentations that result in "actionable" items. For example, exercises that incorporate specific barriers to PCSI. (1 Count)
The event was well organized. I look forward to next year. (1 Count)
The meeting with the combined program was na excellent idea. I learned a great deal and was able to network with so many other colleagues. I belive that the addition of Women's Health * Immunization programs would be helpful. This was a wonderful session (conference). Thanks you. (1 Count)
Really enoyed coming together with fellow case workers. We all agree the meetings of the minds from our various disciplines is needed. Great Job! More SENDSS Training!! (1 Count)
Looking forward to next year!! (1 Count)
I would like to commend those individual who brought this training opportunity into being. The concept was great and I wishit will continue. The updates and the presentatins were
very good. (1 Count)
Exceptional job steering committee! I received a wealth of information to share with my health district. Also, the speakers were awesome! I am looking forward to the next PCSI training in 2012. Training request: Grant writing to compete for funding opportunities. (1 Count) &YDFMMFOUXPSLTIPQ&OKPZFEUIFPQQPSUVOJUZUPDPMMBCPSBUFMFBSO5IJTXBTNVDIOFFEFE *USVMMZFOKPZFEUIJTXPSLTIPQMPPLGPSXBSEUPNBOZNPSFJOUIFGVUVSF (SFBUGPPE HSFBUUJNFNBOBHFNFOU &YDFMMFOUDPPSEJOBUJPOPGFWFOUT WFSZQSPGFTTJPOBM

12/01/2011

Class Climate evaluation 102 of 102

Page 4