2018 EVALUATION Report of the Kanawha?Charleston Health Department Harm Reduction Syringe Services Program WEST VIRGINIA Department of Resources BUREAU FOR PUBLIC HEALTH 2018 Evaluation Report ofthe Kanawha-Charleston Health Department Harm Reduction Syringe Services Program Jim Justice Governor Bill J. Crouch Cabinet Secretary West Virginia Department of Health and Human Resources Rahul Gupta, MD, MPH, MBA, FACP Commissioner Bureau for Public Health State Health Officer Loretta Haddy, State Epidemiologist Table of Contents Figures 5 Executive Summary . 6 Background . 6 Methodology 6 Highlights of Findings 6 Conclusions and 7 intended Use and Users 7 Program Description 8 Evaluation Focus 17 Data Sources and Methods 18 Demographic information 21 Syringe Services 31 Disease Surveillance and Prevention Efforts 35 Clinical Services 38 Education to Staff and Patients and Outreach to the Community 41 I Stakeholder Engagement 44 Conclusions . .49 Recommendations 51 References 53 Appendix A: Timeline 55 Appendix B: New Patient Form 57 Appendix C: Return Patient Form 58 Appendix D: Memorandum of Agreement 59 Appendix E: Website 61 Appendix F: Patient Rights and Responsibilities 62 May 2018 4 Figures Figure 1. Map showing the location of KCHD and West Virginia Health Right. Both entities function as SSPs in Charleston, West Virginia (Kanawha County). 11 Figure 2. Map of area surrounding KCHD (blue dot). 12 Figure 3. Reported risk factor by age group for acute HBV cases in 2015 12 Figure 4. West Virginia counties considered vulnerable to rapid dissemination of HIWHCV among persons who inject drugs. 13 Figure 5. Newly diagnosed HIV cases by county West Virginia, 2012-2016. 14 Figure 6. Newly diagnosed HIV cases by county with IDU as a reported risk factor West Virginia, 2012- 2016. 14 Figure 7. co-infections reported by county West Virginia, 2012-2016. 15 Figure 8. County-level distribution of drug overdose deaths in West Virginia, 2012- 2015. 16 Figure 9. Recommended framework for program evaluation. 17 Figure 10. Residency of New Patients by Quarter 23 Figure 11. KCHD Estimate of New and Returning Patients 24 Figure 12. KCHD Clinic Attendance 24 Figure 13. KCHD Visit Type 25 Figure 14. KCHD New Patient Gender . 25 Figure 15. KCHD Race of New Patients 26 Figure 16. KCHD Educational Status 26 Figure 17. KCHD Sexual Orientation 27 Figure 18. KCHD insurance Status 28 Figure 19. KCHD Drug Preference 28 Figure 20. KCHD Injection Frequency 29 Figure 21. KCHD Age of First Drug Use 29 Figure 22. KCHD Non-Fatal Overdose 30 Figure 23. KCHD Patients Waiting for Recovery Services 30 Figure 24. KCHD HCV, HBV, and HIV Status (KCHD Harm Reduction Database) 36 Figure 25. KCHD Family Planning Program Patients by Sex and Age 39 Figure 26. KCHD Family Planning Program Service Type .40 Figure 27. KCHD Family Planning Program Services 40 Figure 28. Interaction of KCHD stakeholders 45 Figure 29. Worker?s Compensation Reports for Needlestick Injury, Charleston, WV . 49 5 May 2018 Executive Summary Background Persons who inject drugs can substantially reduce their risk of getting and transmitting HIV, viral hepatitis, and other blood borne infections by using a sterile needle and syringe for every injection. In many jurisdictions, persons who inject drugs can access sterile needles and syringes through syringe services programs (SSPs) also known at the Kanawha-Charleston Health Department (KCHD) as Harm Reduction Syringe Services Program However, it is important that these programs are of high quality, well managed, and have good administrative oversight. It is also essential that programs operate in conformity to their design, reach the specific target population, and achieve its goals. In recent months, there has been concern about operations and its effect on public safety due to reports ofan increase in used needles in public spaces and needlestick injuries in Kanawha County. Both the Mayor of Charleston and the Interim Health Officer of KCHD, Dr. Dominic Gaziano, requested an evaluation of KCHD by the West Virginia Department of Health and Human Resources Bureau for Public Health (BPH). I Methodology The BPH formed an evaluation team under the leadership of the State Epidemiologist. Members ofthe team consisted of representatives from the Office of Epidemiology and Prevention Services (OEPS), Office of Maternal, Child and Family Health (OMCFH), and Center for Local Health (CLH). Members met to formulate an evaluation plan and to develop and review tools for gathering information. Once the evaluation tools were developed, the team conducted an onsite review at KCHD and interviewed representatives of the KCHD City of Charleston?s Mayor?s Office, Charleston City Council and its first responders (including police, fire and emergency medical services). As part of the review, KCHD provided the KCHD Database (2015-2018) and the Naloxone Distribution Database for analysis. Services were evaluated against criteria outlined in the KCHD Program Procedure Manual and focused on demographic information, syringe services, disease surveillance and prevention efforts, clinical services, and stakeholder engagement. Highlights of Findings 1. Many data quality issues were noted throughout the evaluation including data errors, incomplete data, inability to link patients to harm reduction services data for tracking purposes, incorrect data analysis resulting in misinformation to the public, and non-standardized data entry. 2. The current patient identification system employed at KCHD makes it possible for a patient identification number to be shared among multiple patients since it is based on the first and last name initials, month of birth, and year of birth. This presents a significant limitation to data analysis. 3. KCHD participated in a variety of community and stakeholder meetings; however, to the best knowledge of the evaluation team, a steering committee as described in their Program Procedure Manual did not exist. 4. Increase in syringe litter is viewed as a threat to public safety. Regardless of the source of the syringes, it is important that a detailed plan is in place that addresses community concerns in a timely matter to avoid needlestick injuries and allay fears. 5. Data from November 2017 to March 2018 indicated that 34% of patients visited the clinic in? person, 46% were via a proxy, and 20% were unknown. This practice was not outlined as a May 2018 6 practice in the KCHD Program Procedure Manual and creates a missed opportunity to provide linkage to treatment and other harm reduction services. 6. The current model at KCHD indicates that patients are given clean injection equipment prior to receiving primary health care services. This evaluation team believes it is important for patients to obtain primary care and behavioral health services [specifically linkage to substance use disorder treatment) before syringes are dispensed so that medical attention is seen as the top priority over syringe eXChange. Conclusions and Recommendations 1. it is recommended that the BPH OEPS suspend certification. 2. [f the KCHD resumes services, the Kanawha?Charleston Board of Health should work with identified stakeholders to incorporate the following recommendations into operations: 8) bl Offer Hepatitis A and vaccine routinely. improve data collection, storage, management, analysis, and dissemination to strengthen validity and credibility of the program. Each patient should receive a unique identifier that can be used to track clinical and behavioral care. KCHD should maintain, in a confidential manner, written records for all patients who are treated by the health department or are referred for treatment by another physician, including patient histories, examination and test results, and any treatment provided. Stakeholders should be thoroughly and routinely engaged by the program from implementation to maturity while ensuring-that program goals are aligned with community stakeholder goals; Develop a coordinated and timely plan in conjunction with key community partners first responders) to pick?up and track syringe litter in public spaces. Education campaigns should include general education about syringe services/harm reduction programs and specific education about the program, its goals, and community needs. Primary ca re services and linkage to substance use treatment should be offered and provided at each visit to harm reduction program patients pilgrto syringe dispensing. Attendance at should be mandatory to obtain clean injection equipment. Program procedures should Specifically address the identification, treatment and referral of pregnant women. 3. The BPH Commissioner should seek explicit legislative authority to implement statewide minimum standards among Harm Reduction Programs including expansion of needlestick reporting to include those that occur in non~health ca re settings. intended Use and Users In recent months, there has been concern about KCHD Operations and its effect on public safety due to reports ofan increase in used needles in public spaces and needlestick injuries in Kanawha County. Both the Mayor of Charleston and the interim Health Officer of KCH D, Dr. Dominic Gazia no, requested an evaluation of KCHD by BPH. The purpose of this document is to provide feedback to the KCHD and Mayor of Charleston regarding the Program. The evaluation seeks to assess the following public health components of the harm reduction program using the goals defined in the Program Procedure Manual. May 2018 7 1. Reduce incidence of substancenrelated health and social harms, including transmission of blood?borne pathogens through substance abuse; 2. Promote and facilitate referrals to primary health care and mental health and substance use services; 3. Reduce stigma and discrimination against people who use drugs; 4. Ensure full and equitable reach of harm reduction services and education to all who use substances; 5. Raise awareness about the risk of drug overdoses and associated fatalities; and 6. Provide safe disposal of used needles. As such, the evaluation seeks to assess the following areas of interest: 1. Demographic information; 2 Syringe services (delivery, exchange, transaction, and disposal]; 3 Disease surveillance and prevention efforts; 4. Clinical services delivery to patients; 5 Education to staff and patients and outreach to the community; and 6 Stakeholder engagement. This document was compiled in conjunction with multiple stakeholders. At the request of both the Mayor of Charleston and the KCHD Health Officer, this evaluation was led by staff from the BPH including representatives from the Commissioner?s Office, OEPS, CLH, and OMCFH. Representatives from KCHD participated in multiple interviews and provided available data regarding the in addition, representatives from Cabin Creek Health Systems participated in interviews and made Family Planning Program medical records available for review. Finally, representatives ofthe City of Charleston?s Mayor?s Office, Charleston City Council and its first responders (including police, fire and emergency medical services) participated in stakeholder interviews. This report may be used by stakeholder groups in a variety of ways. it is expected that the Charleston City Council will use the document to make policy decisions regarding whether to recriminalize needles for illegal drug use, while KCHD may use the document to identify areas of improvement should they choose to resume the Program. The BPH is likely to use the findings to provide technical assistance to other community harm reduction programs, revise the Harm Reduction Program (HRP) Guidelines and Certification Procedures, and inform the development of recommendations for public policy. Program Description Substance use disorder is a significant public health issue with social, economic, and medical consequences. Among persons who inject drugs (PWle), the consequences are even greater due to the risk of Hepatitis (HBV), Hepatitis (HCV), and are at high risk for HBV and HCV infection through the sharing of needles and drug~preparation equipment. While West Virginia is considered a low prevalence state for HIV (with less than 100 newly diagnosed cases annually), it ranks at the top in rates of acute HBV and HCV. In 2016, the incidence of acute HBV was 14.5 per 100,000 persons (compared to the national average of 1.0 per 100,000 persons). West Virginia has also ranked either first or second in the incidence of acute HCV in recent years. In 2016, West Virginia was nine times the national average incidence ofacute HCV with a rate of 7.1 per 100,000 persons. Analysis of HBV and HCV surveillance shows that injection drug use is the most reported risk factor among cases [West Virginia Bureau for Public Health, 2017b). May 2018 8 SSPs (also known as needle exchange programs and syringe exchange programs) are community-based programs that provide access to sterile needles and syringes at no cost to patients. The first government approved SSP was approved in Amsterdam, The Netherlands in 1983 following an outbreak of HBV among PWID. The worldwide HIV pandemic solidified the rationale for SSPs and a succession of programs followed. Over 40 countries have SSPS in Operation. SSPs also facilitate safe disposal of used needles and syringes and provide education on safe injection practices. Some SSPs offer additional services including: 0 Screening, care, and treatment for HIV and viral hepatitis; . HIV pree and post-exposure prophylaxis; Hepatitis A and HBV vaccination; 0 Screening for other diseases and tuberculosis; 0 Linkage to substance use disorder treatment programs; a Overdose prevention education; . Other medical, social, and mental health services. The United States has had a storied history in terms of financially supporting SSPs starting with the 1988 ban on use of federal funds on SSPs. The Consolidated Appropriations Act of 2016, signed by President Ba rack Obama in December 2015, is the most recent federal legislation allowing for use of Department of Health and Human Services (DHHS) funding to support certain components of SSPs including personnel, testing kits, syringe disposal services, educational material, and condoms. Current federal law prohibits the use of federal funds to purchase sterile needles or syringes for illicit injection drug use (Dent, 2015). As a provision to the Consolidated Appropriations Act of 2016, state, local, and territorial entities must first consult with the Centers for Disease Control and Prevention (CDC) to ?provide evidence that their jurisdiction is experiencing or at risk for significant increases in hepatitis infections or an HIV outbreak due to injection drug use.? CDC determines if an entity has adequately demonstrated need according to federal law (Centers for Disease Prevention and Control, 2016). As such, three counties in West Virginia? Berkeley, Cabell, and Kanawha?have demonstrated individual need. In April 2017, the BPH, OEPS requested and received statewide determination of need for the remaining 52 West Virginia counties, paving the way for statewide implementation of SSPs. SSPs are relatively new to West Virginia. The first SSP started in August 2015 at Milan Puskar Health Right in Morgantown, West Virginia. Since then, at least 15 SSPs have been established across West Virginia. In an effort to ensure that SSPs provide apprOpriate and competent services, the BPH developed Harm Reduction Program Guidelines and Certification Procedures to aid entities interested in implementing SSPs and allow for a mechanism for entities to receive federal funding to support SSPs upon being certified by BPH. To be BPH?certified, an HRP must meet criteria outlined in the Guidelines with the aim of reducing ?d rug-related harm while enhancing individual, family, and community wellness.? Entities are certified for two-years and can seek renewal (West Virginia Bureau for Public Health, 2017a). The Substance Abuse and Mental Health Services Administration (SAMSHA) released a funding opportunity announcement in late 2016 for the Opioid State Targeted Response (OSTR) grant. The aim of the two-year OSTR grant is "to address the opioid crisis by increasing access to treatment, reducing unmet treatment need, and reducing opioid overdose related deaths through the provision of prevention, treatment and recovery activities for opioid use disorder.? (Substance Abuse and Mental Health Services Administration, 2016) The Bureau for Behavioral Health and Health Facilities serves as May 2018 9 the lead West Virginia agency on the grant but collaborates with the BPH, OEIPS on secondary prevention services related to implementation and improvement of SSPs in the State. Of the $5,881,983 awarded to West Virginia in April 2017, $600,000 was allotted to BPH, OEPS to support SSPs. In October 2017, an announcement of funding availability (AFA) was released by BPH, OEPS. Nineteen entities applied for this funding through Harm Reduction Program Improvement and implementation grants and 11 were funded and BPH-certified. KCHD was one of the funding recipients and received $75,000 to support expansion of its services through April 30, 2018 (per a sub- recipient grant agreement with BPH, OEPS), Three goals were outlined in KCHD application: 1. To reduce the transmission of HBV and HCV among 2. To expand KCHD services to better serve increasing patient demand; and 3. To expand data collection, tracking, reporting, and evaluation capabilities of KCHD The KCHD initiated its SSP in December 2015 following the unanimous passage of a city ordinance by City Council in September 2015 (See Timeline in Appendix A). According to the ordinance (Bill No. 7666, Sec 78-381): ?It shall be unlawful for any person or persons as principal, clerk, agent or servant to sell, market, or distribute any hypodermic syringes, needles and other similar objects used or designed for injecting substances into the human body, without obtaining and having any and all licenses required under state law to do so: except that, items distributed by or exchanged at a needle exchange program sponsored or approved by the Chief of Police of the Charleston Police Department, as provided by Subdivision ill herein, are thereby approved and are not unlawful.? The ordinance also authorized SSP (Bill No. 7666, Sec. 78896): "The City of Charleston, by and through its Chief of Police, may sponsor, approve, or participate in a program or programs within the City of Charleston for the distribution or exchange of hypodermic syringes, needles and other similar objects used or designed for injecting substances into the human body.? Finally, the ordinance authorized the Chief of Police to promulgate rules related to the Operation of SSP (Bill No. 7666, Sec. 78?397): ?The Chief of Police of the City of Charleston Police Department is authorized to promulgate reasonable rules or regulations deemed necessary to implement and administer a program within the City of Charleston provided for in Section 78-396 for the distribution or exchange of hypodermic syringes, needles and other similar objects used or designed for injecting substances into the human body.? KCHD adopted the term harm reduction program to describe its comprehensive public and behavioral health strategies aimed at reducing morbidity and mortality associated with substance use generally and injection drug use specifically. SSP will further be referenced as KCHD (as indicated in its May 2017 program procedure manual). in recent months, there has been concern about KCHD operations and its effect on public safety due to reports ofan increase in used needles in public spaces and needlestick injuries in Kanawha County. May 2018 10 In early March 2018, Charleston Mayor, DannyJones, asked Charleston City Council to consider a bill that would reverse Bill No. 7666, effectively ending KCHD On March 19, 2018, City Council voted 16-11 to table a vote for 60 days until the May 21, 2018 council meeting (Kersey, 2018). The following week, Chief of Police, Steve Cooper used the authority given to him in Sec. 78?397 of Bill No. 7666 to promulgate seven rules that became effective on April 2, 2018. The syringe exchange portion ofthe KCHD was also suspended on that day (Kersey and Beck, 2018). Both the Charleston Mayor and the interim Health Officer of KCHD, Dr. Dominic Gaziano, requested an evaluation of KCHD by BPH. KCHD is one of two SSPs in the city of Charleston in Kanawha County, West Virginia. it is a fixed site, located in Charleston, West Virginia, at 108 Lee Street East. Figure 1 shows the location of KCHD and the location of West Virginia Health Right, the second SSP in Charleston. Figure 2 shows the area directly surrounding KCHD which includes the Charleston Civic Center, Charleston Town Center, and the Charleston Marriot Hotel. KCHD began operation in December 2015. Initially, the program operated once a week on Wednesdays from 10AM to 3PM. in January 2018 it expanded operations to include Thursdays from 1PM to 3PM. Figure 1. Map showing the iocation and west Virginia Health Right-9 xBoth entities function as SSPs in Charleston, West Virginia (Kanawha County). May 2018 11 . ?as. ts; Haj-I Depa?r'ignr . . 1? . - . if?ff: . .- - 82?ix T031 - Figure 2. Map of area surrounding KCHD {blue dot}. In considering the need for an SSP within a jurisdiction, it is important to use epidemiologic evidence to support transmission of bloodborne pathogens (HBV, HCV, and HIV) through needle sharing. it is also important to use data on drug use, specifically Injection Drug User (IDU), if available. BPH, OEPS collects statewide surveillance data for HBV, HCV, and HIV and has specific county-level surveillance data. Data collected by the BPH Health Statistics Center on drug overdose deaths was also used in considering the need for KCHD The West Virginia Viral Hepatitis and Surveillance Report analyzed 2012~2015 surveillance data collected by staff in the OEPS, Division of lnfectious Disease Epidemiology. The report cited injection drug use and street drug use as being the leading risk factors associated with HBV and HCV infections in West Virginia. When categorized by gender, around 30%-40% of cases during the study period reported injection drug use as a risk factor associated with acute HBV and HCV infections. Figure 3 shows risks factors by age among the 272 acute HBV cases reported in 2015 with over 60% of 20-29 year-olds reporting IDU as a risk factor for infection. Individual year data are available in the report for other years during the study period for acute HBV and acute HCV (West Virginia Bureau for Public Health Office of Epidemiology and Prevention Services, 2016). I Injection Drug Use 7U - I Used Street Drugs 60 a >24 hours 50 Contact ofa HBV Case 1'3 Tattoo 4a Previous STD 30 - in Exposure to someone's blood 20' 10 Percentage of Risk Factors Reported 20-29 30-39 40-49 SCI-59 260 ?Patient can report more than one riskfactor. I Age Figure 3. Reported risk factor by age group for acute HBV cases in 2015. May 2018 12 A HIV outbreak in rural Scott County, Indiana from 2015-2016 highlighted the intersection of the current nationwide substance use epidemic, unsafe practices, and increasing rates of bloodborne pathogens (Conrad et al., 2015). A recent CDC study identified 220 rural counties considered most vulnerable to rapid dissemination of HIV and HCV among persons who inject drugs. Kentucky, Tennessee, and West Virginia accounted for 56% ofthe counties identified as vulnerable. Twenty-eight of West Virginia?s counties were considered vulnerable, and Kanawha County ranked at 209 of the 220 counties (28th among the 28 counties in West Virginia) (Van Handel et al., 2016). Marshallr32:i:elev_ Figure 4. West Virginia counties considered vulnerable to rapid dissemination of among persons who inject drugs. In early 2018, a comprehensive HIV Epidemiologic Profile was published by BPH, OEPS Division of Infectious Disease Epidemiology that included important surveillance data on persons living with IV-AIDS in West Virginia. From 2012?2016, Kanawha County had the most number of newly diagnosed HIV cases in the state (n=44 cases) (Figure 5). The second highest county was Raleigh County with 25 newly diagnosed HIV cases. During the same study period, Kanawha County ranked in the top three counties for the number of cases diagnosed with HIV who reported IDU as a risk factor (IDU includes the risk factor men who have sex with men and IDU combined) (Figure 6). While reported co-infections are low in West Virginia, Kanawha County had the most number of total co-infections through 2016 with 31 followed by Cabeil County (n222) and Raleigh County (n=16) (Figure 7) (Services, 2017). May 2018 13 Number of new diagnoses of HIV by county in West Virginia, 2012-2016 Figure 5. Newly diagnosed cases by county West Virginia, 20122016. Number of diagnoses of HIV infection with risk factor by county in West Virginia, 2012-2016 includes maie~to~male sexual contact and injection drug use Figure 6. Newly diagnosed HIV cases by county with as a reported risk factor West Virginia, 2012? 2015. May 2018 14 Number of coinfections by county in West Virginia, 2012-2016* Number of colnfectlons Nb reported coinfections I <5 .- ?federai prisoners Included Figure 7. co-infections reported by county West Virginia, 2012-2016. Overdose death data (all overdose deaths and deaths associated with specific drug classes) from 2012- 2015 obtained from the West Virginia Health Statistics Center showed that the county with the most overdose deaths was Kanawha County with 309 deaths, followed by Cabell (198 deaths), and Raleigh (191 deaths). It is important to note that this data is not adjusted for population size and that Kanawha County, with the largest population in the state, would be expected to have the highest number of overdose deaths. Figure 8 shows the number of drug overdose deaths over the four?year period. May 2018 15 denr. uh I Van-ward! 1 Hnnmang: Hamil . 15gamma 3 ?cn ?imam . . . .. .male 1: >36'to30 MichIraifupFigure 8. County-level distribution of drug overdose deaths in West Virginia, 2012? 2015. Kanawha County ranked first among West Virginia counties during the period of 2012-2015 for: Benzodiazepine-related overdose deaths (158 deaths) 9 Opioid (one or more) only-related overdose deaths (251 deaths) - Methamphetamine-related overdose deaths (43 deaths) 0 Fentanyl-related overdose deaths (52 deaths) 0 Amphetamine-related overdose deaths (50 deaths) Another critical issue facing West Virginia is neonatal abstinence (NAS). NAS is one of the consequences of maternal drug use during pregnancy that leads to withdrawal in the newborn due to sudden discontinuation of drug exposure after birth. The rate of NAS in West Virginia is rising at an alarming rate and is nearly lO-folds compared to national estimates of5.8 per 1000 live births per year in 2012. In 2017, the state prevalence of intrauterine substance exposure was 13.99% ln=2630) and the incidence of NAS was 5.12% (n=962). For Kanawha County residents, intrauterine substance exposure was higher than the state rate at 14.59% and the rate for NAS was lower at 3.94% (Umer, 2017). Given the burden of HBV and HCV disease, drug overdoses, and risk factor data on injection drug use among HIV, HBV, and HCV, there is a strong argument for the need for harm reduction services in Kanawha County. May 2018 16 Evaluation Focus Framework for Program Evaluation in Public Health and Updated Guidelines for Evaluating Public Health Surveillance Systems was used to guide the evaluation process. Figure 9 shows the steps involved in effective program evaluation per these guidelines: Focus the Engage Evaluation Justify Stakholders Design Conclusions 0 0 Describe the Gather Credible Share Program Evidence Recommendations and Lessons Learned Figure 9. Recommended framework for program evaluation. The purpose of the current document is to evaluate the effectiveness of Of the four purposes of evaluation described in Frameworkfor Program Evaluation in Public Health, evaluations with the intent of assessing the effects of a program ?examine the relationship between program activities and observed consequences. This type of evaluation is appropriate for mature programs that can define what interventions were delivered to what prOportion of the target population.? (Koplan, Director and Higgins Peter Jenkins, 1999) The purpose of this document is to provide feedback to the KCHD and Mayor of Charleston regarding the Program. The evaluation seeks to assess the following public health components of the harm reduction program using the goals defined in the Program Procedure Manual. 1. Reduce incidence of substance?related health and social harms, including transmission of blood-borne pathogens through substance abuse; 2. Promote and facilitate referrals to primary health care and mental health and substance use services; 3. Reduce stigma and discrimination against people who use drugs; 4. Ensure full and equitable reach of harm reduction services and education to all who use substances; - 5. Raise awareness about the risk of drug overdoses and associated fatalities; and 6. Provide safe disposal of used needles. As such, the evaluation seeks to assess the following areas of interest as outlined throughout the KCHD Program Procedure Manual (KCHD Harm Reduction Syringe Services Program Procedure Manual, 2017) 0 Demographic information 0 Number of lDUs reached through outreach; 0 Patient characteristics demographics, injection drug use history, medical history, and substance abuse treatment history); 0 Drug use preferences types of drugs used, including hormones or steroids) and practices with whom and how often patients use drugs); and Overdose risk and history. 0 Syringe services (delivery, exchange, transaction, and diSposal) 0 Protect lDUs and the public from dirty needles and syringes/disposal practices; May 2018 17 Provide as close to 100% syringe coverage as possible, which means a sterile syringe for every injection of every in ajurisdiction; 0 Frequency and duration of use, including estimation of numbers of syringes distributed in a given period; and Receptive and distributive syringe sharing. a Disease surveillance and prevention efforts 0 Reduce incidence of substance related health and social harms, including transmission of bloodborne pathogens through substance abuse. 0 Clinical services delivery to patients 0 Types of services used at the 0 Access and linkage to drug treatment and medical and social services referrals and linkage to medical homes, behaviorai health services and homes and substance abuse treatment facilities); and 0 Changes in drug use, injection and treatment as a result of participation. 0 Education to staff and patients and outreach to the community Reduce stigma and discrimination against people who use drugs; 0 Ensure full and equitable reach of harm reduction services and education to all who use substances; 0 Raise awareness about the risk of drug overdoses and associated fatalities; and 0 Build capacity of staff. I Stakeholder Engagement 0 Increase community support for 0 increase stakeholder knowledge; and Assure understanding of operation plan. Data Sources and Methods The BPH formed an evaluation team under the leadership of the State Epidemiologist. Members of the team consisted of representatives from the DEPS, OMCFH, and CLH. Members met to formulate an evaluation plan and develop and review tools to gather information. Once the evaluation tools were developed the team conducted an onsite review at KCHD on April 23?25, 2018 and interviewed representatives of the City of Charleston?s Mayor?s Office, Charleston City Council and its first responders (including police, fire and emergency medical services). As part of the review, KCHD provided the KCHD Database (2015-2018) and the Naloxone Distribution Database for analysis. Services were evaluated against criteria outlined in the KCHD Program Procedures Manual and focused on demographic information, syringe services, disease surveillance and prevention efforts, clinical services, and stakeholder engagement. Data was gathered using a variety of data collection toois. New patients complete a new patient intake form, while returning patients complete a returning patient form (Appendix and C) while in the KCHD lobby area. Both forms contain a section for internal use by KCHD staff/volunteers with data elements that document interest in clinical care by patients and syringes collected and dispensed. Data from intake forms are entered in a spreadsheet entitled Harm Reduction Database (through March 2018) which contains data tabs for each year of the program. individual patient intake forms are not maintained and were therefore unavailable for review during the evaluation. May 2018 18 Once it is a patient?s turn in the queue, he/she is asked about any services they may be interested in, in addition to clean syringes by volunteers and program staff. Based on both the new patient and returning patient intake forms, the following additional servicesare offered: a Hepatitis and testing 0 IUD (Female Birth Control Device) - testing 0 Signing up for Health Insurance 0 Speaking to a Recovery Coach - Flu Shot 0 Condomstontraceptive Counseling 0 Information on STD Testing/Results Naloxone Wound Assessment With regard to evaluation of clinical services, the OMCFH Quality Assurance Monitoring Team developed an abbreviated monitoring tool based on program components outlined in the KCHD Procedure Manual. To supplement this information, public health epidemiologists analyzed data available through the Family Planning Program data system for patients associated with KCHD Records from Cabin Creek Health Systems were included in the evaluation because the agency provides primary health care services, including reproductive health care and ambulatory mental health services at the KCHD location through a Memorandum of Agreement (MOA) (See Appendix D). According to the MOA dated June 28, 2017, the target pOpulation are thepatients who participate in the KCHD A secondary purpose of the partnership between KCHD and Cabin Creek Health Systems is to better understand the primary care needs of the harm reduction program patient population and to determine effective methods of providing primary care (see Appendix D). In order to obtain an identified list of patients associated with the the Family Planning Program analyzed the overall utilization of state sponsored reproductive health services provided by Cabin Creek Health Systems at the KCHD location. This review identified 152 unduplicated patients served at that location between July 19, 2017 to December 31, 2017. Fourteen records were selected for a medical record review. Clinical information associated with the West Virginia Family Planning Program was readily available in the Cabin Creek Health Systems electronic medical record. Other information was accessible only through a spreadsheet provided by KCHD. Data from forms are entered in a Spreadsheet entitled Harm Reduction Database [through March 2018) which contains data tabs for each year of the program. Individual patient intake forms are not maintained and were therefore unavailable for review during the evaluation. The spreadsheet provided demographic information, visit type, education, contraceptive methods, drug choice, sexually transmitted disease status, and interest in other services. At the time of this evaluation, syringe services were suspended, and no patients were present during the onsite review; therefore, services could not be observed, which presents a significant limitation. Evaluation questions were presented to the Prevention Wellness Director, and an inspection of the health department iocation was conducted. Finally, a small group from the evaluation team met with eleven Charleston city representatives of the KCHD City of Charleston?s Mayor?s Office, Charleston City Council and its first responders (including police, fire and emergency medical services), some of whom were important in the passing of the 2015 "enabling law? for legal syringe exchange within the city. The following types of data were used in this evaluation: 0 Interviews May 2018 19 KCHD program staff (Tina Ramirez) 0 City of Charleston officials (Mayor?s Office, Charleston Police Department, Charleston Fire Department, Charleston City Council) 0 Documents KCHD Program Procedure Manual (obtained from the internet and from KCHD staff, May 2017) KCHD Harm Reduction Program improvement and implementation application (internal, 2018) KCHD sub~recipient grant agreement with BPH (internal, 2018) KCHD website prior to su5pension of the program in March 2018 (obtained from KCHD staff) 0 Memorandum of Agreement between Kanawha County Health Department and Cabin Creek Health Systems 0 Guide to Developing and Managing Syringe Access Programs (Harm Reduction Coalition, 2010) BPH Harm Reduction Program Guidelines and Certification Procedures Newspaper articles 0 Board of health minutes 0 Data and Databases 0 KCHD database (2015?2018) 0 Naloxone distribution database (obtained from KCHD staff) 0 Abstracted medical records from Cabin Creek Health Systems To decrease burden on both the clinic staff and harm reduction patients, data was primarily collected on the initial harm reduction visit. To maintain anonymity, the KCHD attempted to create a unique identifier by combining the first and last name initial with month and year of birth. However, it is possible that multiple patients had the same identifier. This imposes limitations on data analysis and conclusions. Data from the initial visit is unable to be iinked to return visits. Consequently, the characteristics of the individuals that remain engaged with the KCHD are unable to be described. Another consequence of the identifier is that an accurate count of unique individuals served is not available and further limits assessment of outcomes. For instance, a change in hepatitis status cannot be tracked because hepatitis status is only assessed on the initial visit. Furthermore, even if a patient indicates a change in status has occurred, the lack of a true unique identifier would not allow this change to be associated with the record ofthe patient?s initial visit. In 2017, there was a possible 441 duplicate visits where the patient identifier had multiple same-day visits associated with that identifier. There was at least one day when it appears that a data entry mistake occurred, and ?18 records were recorded four times. Data quality checks prior to the shredding of intake forms would allow the clinic to ensure accurate data entry. The inability to link a return visit with the initial visit resulted in most analysis being conducted with new patient data only. It is possible that new patients and return patients have different characteristics, but this was not able to be assessed due to the above?mention ed data considerations. Data from the database appears to be free entry, which increases data entry errors, and decreases the quality of data, which in turn further limits conclusions. Not counting missing data, at least 25% ofthe visits recorded in the 2017 KCHD database had errors comprised of misspellings, entries that matched other fields, inconsistency in reporting style, etc. This issue could be easily corrected with the May 2018 . 20 implementation of a database with dropdown tabs or set choice and designing a form to match this methodology. Another consideration is the amount ofdata fields with missing data. Even when only using data from new patients, some fields had up to 20% of its data missing. This introduces a large amount of uncertainty into the conclusions drawn from the data analysis. it also appears that some of the data reported to the media is associated with patient self?reported data from the initial intake form. Additionally, the new patient form only assesses interest in other services. There are no additional fields in the database to indicate if services were received. BPH is unable to determine linkage to care, recovery services, and lives saved by naloxone via the data supplied by the KCHD. Demographic Information On page 82 of the Program Procedures Manual, the KCHD states that monitoring patient characteristics and demographics are important components of outcome monitoring. Table 1 provides a summary of the evaluation methods for this section. Table 1. Evaluation Methods for Demographic information Evaluation Quest-ion Indicator Data Source Comments Number of lDUs Number reached by KCHD Harm Evaluation staff could estimate the reached through KCHD including the Reduction number of patients that received outreach. number served by Database; services at the Unable to the Stakeholder determine the number of IDUs reached Interviews that did not receive services in the Patient characteristics Description of KCHD Harm While data quality problems were demographics, patients served by Reduction observed, information for new patients injection drug use including Database was generally available. Medical history, medical gender, sexual history was available only for those history, and substance orientation, age at patients Served by Cabin Creek Health abuse treatment first use, insurance Systems. history). status and recovery history. Drug use preferences Description of KCHD Harm Drug preference and frequency of types of drugs preferred drug type Reduction injection was available in the database. used, including and daily number of Database However, data quality concerns were hormones or steroids) injections. noted. and practices with whom and how often patients use drugs). Overdose risk and Description of KCHD Harm Overdose history was available in the history. overdose history. Reduction database, but information regarding Database linkages to treatment was not available. Residency Members of the evaluation team conducted a detailed review of demographic information for 2017 provided through the KCHD Harm Reduction Database to assess the extent to which each of the above May 2018 21 outlined questions could be answered. Table 1 provides key demographic information related to both the number of new patients that visited the KCHD and where they live. In addition, information about where patients lived was extremely important to local stakeholders. While most patients indicated that they resided within Kanawha County, 17%-18% of records were missing this information. KCHD staff reported during interviews that 86% of patients are residents of Kanawha County based on zip code information. While the BPH evaluation team reports in Table 2 that 71% of patients were Kanawha County residents, the KCHD report of 86% can be replicated if records with missing information are excluded from the calculation. Table 2. County of Residence of New Harm Reduction Patients by Quarter for 2016 and 2017 'Kanawha' Missing Out of Bordering Other WV- Total . County State/Country WV Counties Counties 2016 1st Quarter 84% 5% 3% 5% 2% 100% (147) (11) (5) (9) (4) (175) 2rid Quarter 73% 16% 3% 7% 1% 100% (218) (47) (10) (20) (3) (298) 8rd Quarter 59% 21% 3% 6% 1% 100% (331) (102) (13) (29) (7) (482) 4th Quarter 68% 18% 2% 10% 2% 100% (388) (104) (13) (58) (10) (573) Total Residency 71% 17% 3% 8% 2% 100% Status for (1084) (264) (41) (116) (24) (1529) 2016 2017 1St Quarter 71% 21% 2% 6% 1% 100% (552) [166) (14) (46) (4) (782) 2nd Quarter 72% 17% 1% 9% 1% 100% (666) (154) (12) (87) (10) (929) 31d Quarter 72% 17% 1% 9% 1% 100% (582) (138) (12) (73) (6) (811) 4th Quarter 70% 17% 2% 9% 2% 100% (596i (146) (17} (79) (15) (853) Total Residency 71% 18% 2% 8% 1% 100% Status for (2396) (604) (55) (285) (35) (3375) 2017 May 2018 22 Residency of New Patients by Quarter for 2016 and 2017 Ka nawha Missing Out of Bordering Other WV State/Country Counties County El 2016 Li 2nd 2016 3rd 2016 4th 2016 L3 2017 El 2nd 2017 3rd 2017 I401 2017 Figure 10. Residency of New Patients by Quarter Patient Visits Page 31 of the KCHD Program Procedure Manual indicates that there is a unique patient code (KCHD Harm Reduction Syringe Services Program Procedure Manual, 2017). However, a review of the spreadsheet appears to indicate that multiple people may have been assigned the same identifier as a result of the methodology used for developing the numbering system. The unique patient code is based on the patient?s first and last name initials, birth month, and birth year. It is possible that more than one patient shared a patient lD since the letter-number combinations are limited. The number of reported unique identifiers can be assessed, but this is likely an underestimate of actual patients. There were 5,559 unique identifiers in 2017 (including new and returning patients), which provides an estimate of the number of individuals served. All visits associated with that ID number are counted as one person despite the possibility of more than one person with the same lD number. In 2017, approximately 57% were new to the Program, while 43% returned from a previous year (Figure 11). This information was calculated using unduplicated total visitsl. Due to the lack of data associated with return visits, evaluation staff could not unduplicate the full data set. Furthermore, minimal analysis could be conducted on the complete data set because most data was only coilected on the first visit and there is no way to link subsequent visits. 1 For detailed new client analysis, efforts were made to unduplicate data to the fullest extent possible. May 2018 23 Estimated New and Returning Patients In New in 2017 a Return Patient 57% Figure 11. KCHD Estimate of New and Returning Patients Two thirds of individuals attended only one harm reduction clinic in 2017, while an additional 22% attended 2-5 clinics (Figure 12). The range for the number of clinics attended was 1?69.. Number of Harm Reduction Clinics Attended by Patients in 2017 1% 1% I 1 a 2-5 6-10 I 11-15 I 15-20 I >20 Figure 12. CHD Clinic Attendance According to the Harm Reduction Database, there were 15,521 visits in 2017, by approximately 5,559 individuals. Most visits were return visits, which included individuals that were new in'2017 (and had a subsequent visit) and individuals that initiated harm reduction services in a previous year (Figure 13). Previous studies have found that roughly two-thirds of harm reduction patients return within 12 months of the initial visit (Gindi et 2009). Due to data limitations, this analysis could not be replicated. However, the type of visit, return or new, was analyzed for all visits to the harm reduction clinic in 2017. Return visits, which included clients that were new in 2017 and had a return visit and those that returned from previous years, made up 76% of the visits to the clinic. While not directly comparable to other May 2018 24 studies, it does suggest that KCHD may have retained patients better than other programs. However, better data quality, linkage to prior visits, and a unique identi?er would help to confirm this finding. Visit Type for in 2017 a Total Return Visits a Total New Visits . Visit Type Missing Figure 13. KCHD Visit Type Patient Characteristics Demographic information for patients in the is remarkably similar to the demographic information of West Virginia residents that suffered a fatal overdose in 2016. in 2016, 67% of overdoses occurring in West Virginia were among males, the remaining 33% were among females (West Virginia Bureau for Public Health, 2017). This is comparable to new patients. Missing data accounted for 20.6% of responses for sex/gender, while 34% of new patients were reported as females and 45% identi?ed as male. When records missing gender data were excluded, males made up nearly 60% of the new patient pOpulation served. New Patient Gender 2017 I Female I Male Missing Figure 14. KCHD New Patient Gender May 2018 25 Reported race for new clients is similar to the overall West Virginia population for individuals reported as Black However, data among white patients varied compared to overdose decedents and the overall West Virginia population New patients that had missing data/unusable race/ethnicity data could be the reason for the difference across populations (Figure 15). A larger proportion of Asian/other/multiple race individuals was reported among patients. However, due to poor data quality, it is unclear ifthis minority population was better represented, in need of more services, or if this finding was another consequence of data quality. Race of New Patients in 2017 3% 3 1% I- 3% a Black :1 Missing Multiple races indicated a Other I White 90% Figure 15. KCHD Race of New Patients West Virginians with an overdose death in 2016 typically had a higher education status than new patients attending the clinic. Of new patients, 50.9% (Figure 16) had a high school education or above compared to 78.7% of decedents who overdosed in West Virginia and 85% of all West Virginians. Variation between these populations could be a result of missing/unusable data or could be a true difference between p0pulations. Educational Status of New Patients in 2017 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Less than high Some college 4 year degree+ Missing school 93 New HR Clients Overdose deaths WV Figure 16. CHD HRSS Educational Status May 2018 26 Of new patients in 2017, 70% identi?ed as heterosexual. The remaining 30% were split evenly among declined to answer, missing, and lesbian, gay, bisexual, transgender, and questioning at 10% each. The percent of patients identifying as is higher than in the general population. The estimation of in the general population varies but is generally around 2% to According to the 2015 National Survey on Drug Use and Health 4.3% of adults age 18 or older identified as Of individuals surveyed, individuals were more likely than heterosexuals to report use of an illicit substance in the past year (39% and 17%, respectively)- illicit and misused drugs such as Heroin, Methamphetamine, and prescription drugs follow the same trends for use among individuals as all illicit drugs, when compared individually [Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality, 2016). These drugs were among the most common listed as drug of choice for new patients. Sexual Orientation of New Patients in 2017 10% 10% 10% Declined a Heterosexual I Missing 70% Figure 17. KCHD Sexual Orientation May 2018 27 Nearly half of new harm reduction patients in 2017 did not have insurance. Public insurance, which includes Medicaid and Medicare, was the most common type of insurance for new patients at 41%. Only 4% of new patients had private insurance (Figure 18). The large proportion of new patients with no insurance provides an opportunity for linkage to social services. Insurance Status of New Patients in 2017 9% 5 None 46% a Public Private I Missing Figure 18. CHD insurance Status Drug Preference and Injection Frequency Figure 19 illustrates the drug preference of KCHD patients. Drug preference is assessed at the first visit. Most patients indicated that they preferred more than one drug type Two thirds indicated that heroin is their drug of choice, followed by methamphetamine These findings are consistent with preliminary overdose death data from the Health Statistics Center indicating that involvement in overdose death increased in 2017. Drug Preference of New Patients in 2017 6653,6 ooQ? 65? 6? 0 .299 9" Q?e' Figure 19. KCHD Drug Preference May 2018 28 To determine injection frequency, an average was used when a range of injection frequency was recorded. This data field should be interpreted with caution as inconsistencies in documentation were noted. Figure 20 shows that approximately 80% of new harm reduction patients injected less than 11 times per day. However, 1% of new harm reduction patients injected over 20 times a day. Frequency of Injection per Day for New Patients in 2017 0 1% - was no . 1-5 6-10 .- 11-15 -15-20 - H20 430/, a Blank Figure 20. KCHD injection Frequency Figure 21 illustrates the age of first drug use for new KCHD patients in 2017. Over 75% initiated drug use prior to 20 years of age. The age group with the largest percent was 11-15 years while the second highest age group was 15?17 years This is consistent with prior research indicating that early initiation of substance use is associated with an increased risk of substance use disorder. Age of First Drug Use for New Patients 2017 45% 40% 35% 30% 25% 20% 15% 38.4% 10% 5% 0% Less 11-15 15-17 18-19 20-24 25-29 30-34 35-39 40+ Missing than 10 Figure 21. KCHD Age of First Drug Use May 2018 29 Overdose Risk and History The vulnerability of the population served by the KCHD is further illustrated by nonefatal overdose data. Thirty~three percent of new patients indicated that they had a previous non-fatal overdose (see Figure 22), which increases their risk ofdeath. In addition, 56% of KCHD patients had witnessed the overdose of another person. This emphasizes the need for treatment and prevention of future overdoses as there is an association between non?fatal overdose and fatal overdose (Caudarella et 201st History of Non?Fatal Overdose for New Patients in 2017 a No a Yes 59% . Missing Figure 22. KCHD Non-Fatal Overdose [t is widely known that West Virginia has experienced a lack of treatment availability for persons with substance use disorder, and multiple attempts at recovery are often needed before someone with a substance use disorder can achieve success. Forty?five percent of new KCHD patients in 2017 reported that they had been in recovery. While only 3% of patients indicated that they are waiting for recovery services (see Figure 23), this presented an enormous opportunity for intervention for those individuals. One ofthe challenges associated with treatment and recovery is the need to transition people who are ready to enter treatment quickly. New Patients in 2017 Waiting for Recovery Services I. NO 3% a Yes Missing Figure 23. KCHD Patients Waiting for Recovery Services May 2018 . 30 Syringe Services On pages 7, 11, and 82 ofthe Program Procedures Manual, the KCHD outlines the important components of syringe services. Table 3 provides a summary of the evaluation methods for this section. Tobie 3. Evaluation Methods for Syringe Services Evaluation Question Indicator Data Source Comments Protect lDUs and the public from dirty needles and syringes/disposal practices (page 11). Describe syringe disposal practices. KCHD Harm Reduction Database; KCHD staff interviews; Stakeholder interviews KCHD syringe distribution and di5posal practices are well defined for the health department site. Syringe litter and its disposal remains a concern. 421,208 syringes were returned (a 66% return rate), leaving 220,919 syringes unreturned. Provide asclose to 100 percent syringe coverage as possible, which means a sterile syringe for every injection of every IDU in a jurisdiction (page 7). Describe frequency and duration of use, including estimation of numbers of syringes distributed in a given period (page 82). KCHD Harm Reduction Database Syringe distribution is well documented within the database. Receptive and distributive syringe sharing (page 82). Describe patients that injected with a syringe that had previously been used by someone else (receptive) and patients that gave another a syringe that they had previously used (distributive). KCHD Harm Reduction Database This data is recorded in the database; however, there is no corresponding data collection fields on the forms provided to the evaluation team. Thus, it is unclear how this data was collected. KCHD uses the one-for-one-plus syringe exchange model, meaning that for every one syringe returned by a patient, it is possible for the patient to receive more than one sterile syringe as pre-defined by program policy. May 2018 31 Table 4 was adapted from KCHD Harm Reduction improvement and Implementation application and shows the number of syringes that can be given to a patient based on the number of syringes returned. Tobie 4. CHD syringe dispensing scheme based on number of syringes returned (per 05TH funding application). 0?9 10 10?14 15 15-19 20 20?24 25 25 30 On an initial visit, a patient is provided a minimum of 10 syringes and a maximum of 30 syringes, depending on reported injection drug use. Patients are offered short or long syringes or both. During the interview with program staff, they stated that if a patient returned 11 syringes, 20 syringes are received. This is a change from what was included in the OSTR application, likely due to the fact that syringes are purchased in packages of 10. Patients can be given fuily sealed packages if syringes are distributed in multiples of 10. lfa patient does not return any syringes, they receive 10 syringes. The number of syringes dispensed are documented on the back of a patient ID card which is checked each visit to see how many syringes were dispensed on the previous visit. The ID card is anonymous and has a patient code based on the patients first and last name initials, birth month, and birth year. It is possible that more than one patient shared a patient ID since the letter-number combinations are limited. In 2017, a patient could leave KCHD with a maximum of 300 clean syringes if 30 syringes were brought to exchange for themselves and 30 to exchange for each of up to nine other individuals. To be able to pick up syringes for others, the patient must have visited the program at least once and the patient picking up syringes for others must have each patient?s ID card. The Harm Reduction Database does not distinguish whether the visit was in-person or via a proxy until November 2017. Data from November 2017 to March 2018 indicated that 34% were in-person visits, 46% were via a proxy, and 20% were unknown. This practice was not outlined as practice in the KCHD Program Manual. Several weeks prior to the suspension of services in March 2018, KCHD changed this policy, allowing patients to pick up syringes for themselves only. Interviewed staff reported that ifthe program reopens, patients will no longer be able to obtain clean syringes for other patients. 2017 data from the Harm Reduction Database were cleaned by program evaluation staff for further analyses. The range for the number of syringes dispensed was 0-170 syringes by an individual patient on an individual day. There were 22 entries in which a patient was given greater than 30 syringes. Given that 30 syringes are the most a single patient should receive in a given visit, possible reasons for numbers >30 syringes include: 1. Patient received syringes for additional patients and these numbers were tallied in the data. 2. The patient received more than the 30~syringe cap. 3. There were data entry errors. May 2018 32 Table 5 shows data collected by KCHD on patients and syringe delivery and return from 2015 to 2018 (prior to suspension of the program in March 2018). Based on 2016 and 2017 (the only years with full program-year data), the numbers for the total number of patients increased by 308%, new patients increased by 225%, the number of syringes returned increased by 371%, and the number of syringes dispensed increased by 313%. These data indicate a high demand for the program by patients. Table 5. Yearly metrics on KCHD from 2015 to 2018 (data provided by KCHD as yearly totals). Ttliif New Sr' Srin es 0.3 0 y-Inges Return Rate Difference Patients Patients Given Returned 2015 67 431,694 282 17% 1,412 2016 5,039 1,652 130,480 72,929 56% 57,551 20172 15,521 3,720 408,711 270,250 66% 138,461 2018 (through 3,899 583 101,242 77,747 77% 23,495 03/2018) 2015- 231:)l 24,526 5,998 642,127 421,208 66% 220,919 During the duration of the needle exchange program, 642,127 syringes were dispensed according to the Harm Reduction Database. During this same time frame, an estimated 421,208 syringes were returned (a 66% return rate), leaving 220,919 syringes unreturned. This return is different from the rate documented in the September 2017 KCHD Board of Health meeting minutes (Brumage, 2017). After a review of available literature, the evaluation team replicated this higher return rate by using cumulative return visits from December 2015 to August 2017. This method shows that patients who repeatedly visited the program have a higher rate of syringe return. The evaluation team cannot say with certainty that this was the same methodology used by KCH D. It is important to understand both methodologies to assure good communication and trust among stakeholders. An additional factor that may affect the syringe return rate is dispensing of clean syringes without the exchange for used ones. This occurs when new patients are given up to 30 syringes to start and returning patients who do not return syringes being given a maximum of 10 syringes (per the KCHD Harm Reduction Manual). In order to assess factors that may contribute to a return rate of less than 100%, cleaned 2017 data were filtered to only include entries in which no syringes were returned by both new and returning patients. This resulted in 5,281 unique entries totaling 121,636 syringes dispensed without any being returned; 1,891 entries were from returning patients (20,872 syringes dispensed), and 3,384 entries were from new patients (100,684 syringes diSpensed). Based on the cleaned 2017 data, there 2 Within the KCHD Harm Reduction Database, there were 90 visits for 8/9/2017. However, in the total visit tab for the same date, 287 visits were reported. The missing 197 visits are not included in this table. May 2018 33 were 408,711 total syringes returned in 2017, meaning that 29.8% of syringes were given to patients without an exchange for used ones. KCHD staff reported that when patients were asked the reason used syringes were not returned, many stated the syringes had been confiscated by law enforcement, given to/taken by someone else, or safely disposed of at home. This was anecdotal information and could not be verified during the evaluation. KCHD staff also reported that at each visit, patients are offered the following harm reduction supplies in addition to clean syringes: cooker, tourniquet, dental cotton, condoms, bag, alcohol wipes, sharps container, sterile water, and bleach. Patients are given the supplies for which they express a need. They also receive education on the importance of using their own supplies as well as the dangers of sharing syringes and supplies which could result in disease transmission. KCHD staff indicated that the time in which a patient is receiving harm reduction services can vary greatly. For those seeking only clean syringes, they can be in and out of KCHD in as little as 5 minutes. For those seeking other services, it can be as much as 20-30 minutes during a single visit, with follow-up visits likely, eSpecially if testing was conducted. At no time does any staff member or volunteer handle biohazard waste, nor do patients remove syringes from their disposal (sharps) containers, according to KCHD staff. Patients are asked to open their sharps containers so that a room interviewer can obtain a visual estimate of the number of syringes returned. The patient is then asked to dump the syringes into a larger hard plastic sharps container. if a container cannot be opened for some reason, the patient places the sealed sharps container in a cardboard box with a plastic biohazard bag. The room interviewer also estimates, by weight, the number of syringes returned in unopened sealed containers. The two containers are sealed and collected by a . waste management company on a weekly basis. Cost is determined per pound collected. The Sterilis machine originally intended for the KCHD is only used for waste generated in-house and not for patient syringes due to the ambiguity as to what other objects may be placed in the patient sharps container which could possibly damage the machine. The KCHD has a syringe disposal kiosk on Lee Street in front of the KCHD. Two additional kiosks have been purchased and are currently in storage waiting to be placed in two Cabin Creek Clinic locations yet to be determined. Maintenance employees empty the kiosks when they are full, weigh the disposed syringes, and the weight is recorded in the database by staff. The total number ofsyringes from the evening kiosk was 142 pounds, or 26,696 syringes. This number is not included in the total number of syringes returned by patients. if KCHD receives a call that a used syringe has been found in the community, the call is transferred to the Environmental Department (304-348?8050) at KCHD. Reported response time is within 1 hour during business hours or within 24 hours outside of business hours. Syringes are picked up with a kit containing gloves, a graSper device, a sharps container, and other material deemed necessary. if the hypodermic needle is not found after a minimum 10-minute search, the investigation is deemed completed (per April 2018 correspondence with KCHD staff). The exact coordinates of the syringe(s) is determined by GIS mapping, and a photo of the site is taken. Complaints are documented and tabulated in a report to the director of the Division of Environmental Services. May 2018 34 Only one needlestick injury on KCHD property has been reported since the inception of the The needlestick occurred when a volunteer was stocking carts and was stuck with a sterile unused needle through its manufacturing bag. KCHD does not track needlestick injuries outside of their location. KCHD completes state mandated forms for needlesticks, reported to BPH on a basis. The clinic follows the OEPS tracking and reporting guidelines. in addition to local health departments, only needlestick injuries in hospitals, nursing homes, and home health agencies are reported to BPH- Community needlesticks are not reported through this mechanism, nor is BPH mandated to receive these reports. Disease Surveillance and Prevention Efforts On page 8 of the Program Procedures Manual, the KCHD outlines the importance of reducing the transmission of bloodborne pathogens through substance abuse. Table 6 provides a summary of the evaluation methods for this section. Table 6. Evaluation Methods for Disease Surveillance and Prevention Efforts Evaluation Question indicator Data Source Comments Reduce incidence of Describe the number KCHD Harm Reduction Prior to late 2017, substance related and percentage of Database; RedCap KCHD did not health and social patients tested for Database directly track screening harms, including HCV, and HBV. and results for the transmission of number of persons bloodborne pathogens tested for HIV, HBV, through substance and HCV because abuse. patients were anonymous. in addition, KCHD does not track the number of condoms distributed or the number of persons given condoms at the While KCHD services were provided on Wednesdays, KCHD staff report that the is interwoven into the greater KCH D, meaning that some aspects ofthe program utilize services ofthe health department as part of program practice. Because ofthis, patients can receive broader services in addition to syringe exchange. Since June 2017, KCHD has offered STD clinics on Tuesdays and Thursdays 12PM to 3PM by appointment. HIV testing is offered by appointment from 8AM to 3PM Monday through Friday, or through the STD clinic. Prior to late 2017, KCHD did not track screening and results for the number of persons tested for HIV, HBV, and HCV because patients were anonymous. The number of persons who were tested through the is difficult to elucidate, which poses a significant limitation to this evaluation. The Harm Reduction Database provides some information about testing and other services offered to patients. One of the column headings is named ?Other Services? and is based on the question located on the new and returning patient intake forms seeking to determine additional needs of patients. Because of this question (and the specific field ?Hepatitis and Testing?), all patients appear to be offered testing at May 2018 35 least non-verbally at each visit. The number of condoms distributed, and the number of persons given condoms at the KCHD are also not tracked by KCHD According to the Harm Reduction Database, over 50% of new harm reduction patients in 2017 did not have a reSponse to the hepatitis and HIV questions recorded in the Harm Reduction Database. Despite this lack of data, and being self-reported, which tends to result in under reporting, 27% of new harm reduction patients reported they had Hepatitis C. Hepatitis was self-reported in 3% of new patients, and HIV was reported in less than 1% of new patients. Multiple diagnosis is possible, 2% of new patients reported more than one diagnosis. Of the new patients that responded to the question, more patients indicated a diagnosis than indicated they had been tested but had negative results. Even though 57% of diagnosis status was missing, there was indication of prior testing in 71% of new harm reductions patients (Figure 24). Due to the increase risk of Hepatitis and HIV in PWID regular testing would provide more accurate incidence rates- Furthermore, it may lead to less spread of disease due to knowledge of disease status and subsequent behavioral changes. Hepatitis B, Hepatitis C, and HIV Status of New Patients in 2017HCV HBV HIV Negative Blank Figure 24. KCHD HCV, HBV, and Status (KCHD Harm Reduction Database) in late 2017, KCHD partnered with the Gilead FOCUS Program. The FOCUS Program launched in 2010 ?to develop replicable model program that embody best practices in HIV screening and linkage to care.? (Gilead?s FOCUS Program: Increasing Routine and HC Screening and Linkage to Care, no date) Routine screening integrates HIV and hepatitis testing into the KCHD setting to address undiagnosed infection and engage individuals in care and treatment for these diseases. This program targets PWID for screening at no cost to the patient. The Gilead FOCUS Program provided funding beginning December 1,2017, through December 31, 2018, to pay for HIV, HCV, and HBV testing. Training began in December 2017 for KCHD clinic staff to prepare them for the launch ofthe program on January 1, 2018. KCHD in conjunction with Cabin Creek Health Systems began offering testing to every patient who was seen during the January 1, 2018. Cabin Creek Health Systems participated weekly with the KCHD and offered family planning services, including long acting contraception, and other primary care services to harm reduction patients. As of March 2018, KCHD began using a RedCap Database for data collection. A separate RedCap database is kept for the Gilead FOCUS Program, which provides opt-out testing for HCV and HIV. For testing to occur, demographic data on patients must be collected (making patients named individuals/patients). May 2018 36 Table 7 shows the reported number of and percentage of patients tested for HIV, HCV, and HBV from January 1, 2018 through March 8, 2018 through the Gilead FOCUS Program. Table 7. Number and percentage ofpotients testedfor HIV, and HBl/Jonuory 1 - March 8, 2018. HIV HCV HBV No. No. No. Persons offered screening 581 100 581 100 581 100 Persons screened 238 41 276 48 260 45 Positive diagnoses 1 0.4 95 34 8 3 linked to care 1 100 7 7 1 13 Source: Kanawha?Charleston Health Department? RedCap database *Number of unique individuals IVIOA with Cabin Creek Health Systems states that the purpose of their agreement is, ?for Cabin Creek Health Systems and KCHD to provide primary health care services, including family planning services, and ambulatory mental health services for KCHD patients at the KCHD Primary care would be provided on an urgent basis for any consenting patient and continuing care would be provided for consenting patients who do not have an established source of primary care and who choose to receive primary care at the KCHD facility. Other options for ongoing primary care will be offered to patients including care at [federally?qualified health centers] in the region (Appendix Through its partnership with Cabin Creek Health Systems, KCHD can provide positive patients with a nurse navigator for linkage to care. Cabin Creek refers patients to local physicians, the Ryan White Program, West Virginia Health Right, and drug treatment centers. KCHD currently does not offer HIV pre-exposure prophylaxis In addition to the use of clean injection equipment and use of condoms to decrease the risk of transmission of HIV, is another way to reduce disease transmission among high risk individuals. People who do not have HIV but who practice high risk behavior (such as injection drug use) may take Truvada, a combination of tenofovir and emtricitabine. When someone is exposed to HIV through sex or injection drug use, these medicines can work to keep the virus from establishing permanent infection. Currently, only one local health department in West Virginia, Beckley-Raleigh Health Department, offers HIV staff expressed an interest in receiving training for how to stand up a delivery program during an in-person interview. KCHD previous practice of providing syringes to patients on behalf of others was suspended in March 2018. The purpose of this practice was to provide patients who may not be able to make it to KCHD during the hours ofoperation while sterile injection equipment. Conversely, this method of syringe distribution limits access to other services (disease screening, immunization, condoms} and reduces face-to-face interactions that patients have with persons seeking to get them into care, treatment, and recovery. May 2018 37 Clinical Services On page 82 of the Program Procedure Manual, the KCHD outlines the importance ofaccess and linkage Table 8 provides a summary of the evaluation to drug treatment and medical and social services. methods for clinical services. Table 8. Evaluation Methods for Clinical Services Evaluation Question Indicator Data SourCe Comments Describe the types of services made available to patients. Types of services used at the KCHD Harm Reduction Database; Family Planning Program Database; Abstracted Medical Records The Program Procedure Manual indicates that a wide variety of services are offered to program patients. However, the Harm Reduction Database only documents interest in service, not service delivery. Describe wound assessment, flu shot, signing up for health insurance, naloxone, or speaking to a recovery coach. Access and linkage to drug treatment and medical and social services (eg. referrals and linkage to medical homes, behavioral health services and homes and substance abuse treatment facilities). KCHD Harm Reduction Database; Abstracted Medical Records The Database only documents interest in service, not service delivery. Abstracted medical records from Cabin Creek Health Systems were complete and included documentation about the services provided by their agency. However, not all services were provided. Describe changes in drug use, injection and treatment. Changes in drug use, injection and treatment as a result of participation- KCHD Harm Reduction Database This information was not collected in the database until February 2018. information was only documented for 25% of patients after this data field was implemented. Cabin Creek Health Systems provided state sponsored reproductive health care to 152 unduplicated patients at the KCHD location during 2017. Due to the documentation procedures for the the Quality Assurance Monitoring Team could not verify through source documentation which Cabin Creek Health Systems patients were patients in the However, the MOA states that harm reduction patients are the target population. Therefore, both the Family Planning data system and medical records were reviewed to determine whether services were provided that were consistent with the KCHD Program Procedure Manual. May 2018 38 The Family Planning Program data system indicated that there were 78 females and 74 males with a total of 172 visits in 2017. Services were provided between July 19, 2017 and December 28, 2017. The county of residence was reported as Kanawha County for 99.4% of patients. Remaining patients were from border counties. Overall, 11 females received long acting reversible contraceptives. Utilization of long acting reversible contraception is higher than would be expected when compared to West Virginia Family Planning clinics overall This observation is further supported by the document ?Contraceptive use and method choice among women with Opioid and other substance use disorders: A systematic review,? in which the authors assert that peOple with SUD use contraception less often than non-drug users (56% vs. 81%, respectively) {Terplan et al., 2015). Cabin Creek Health Systems provided Family Planning Program services to a higher proportion of females that attended the in general. This would be expected given the emphasis of reproductive health services. However, the proportion of males that received reproductive health services is significantly higher than the overall West Virginia Family Planning Program see Figure 25. People who inject drugs often exhibit behaviors that put them at risk for sexually transmitted disease. Family Planning Program Patients by Age and Sex 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% Th" . 0.00% Total 518-19 {120-24 .25-29 '30-34 I35-39 340-44 {345+ Figure 25. CHD Family Planning Program Patients by Sex and Age May 2018 39 The ?gure below demonstrates that Cabin Creek Health Center provided a wide variety of services to 152 patients. High rates of screening for chlamydia and gonorrhea are especially noteworthy (Figure 26). Services/Screenings Provided to at least One Patient Visit for Each Patient 100% 80% 60% 40% 20% 0% Figure 26. CHD Family Planning Program Service Type Data reported by the Family Planning Program supports that Cabin Creek Health Systems provided primary health care services as outlined in the MOA with KCHD (Figure 27). Overview of Services Provided by Cabin Creek Health Systems Both l?l'fj Primary Care/Basic Service I :l Reproductive Health Related service 85.0% 88.0% 90.0% 92.0% 94.0% 96.0% 98.0% 100.0% Figure 2 7. CHD Family Planning Program Services in addition to a review of Family Planning Program, the Quality Assurance Monitoring Team reviewed the actual medical records for 14 patients, 7 males and 7 females that were associated with the during calendar year 2017. The age range for this subset was 20 to 49 years of age. The chart reviews were May 2018 40 consistent with the overall population described in the tables above. Eighty~six percent of patients received testing, 71% received condoms/contraceptive counseling, and 43% of females received long acting reversible contraceptives. Wrap around services are often found at harm reduction clinics. Other medical program components including Hepatitis and testing, Hepatitis A and vaccinations, wound assessment, flu shot, signing up for health insurance, naloxone, or speaking to a recovery coach was not documented in the Cabin Creek Health Systems medical records. The KCHD assessed patient interest in other services. However, patients did not have documentation for these services within the Harm Reduction Database. Furthermore, there was no documentation of linkage to the services patients eXpressed interest in receiving. It is possible that patients received these services, but without supporting documentation, it cannot be confirmed. Patient education can increase the uptake of additional services to decrease the risk of overdose, and transmission of disease. Furthermore, services beyond the needle syringe were conducted on alternate days, only referrals to additional services were provided at the harm reduction clinic. There was no data associated with the referrals that the harm reduction clinic made. Education to Staff and Patients and Outreach to the Community On page 58, 82 and 85 of the Program Procedures Manual, the KCHD outlines the important components of education and outreach to patients, staff and the community. Table 9 provides a summary of the evaluation methods for education and outreach. Table 9. Evaluation Methods for Education to Staff and Patients and Outreach to the Community Evaluation indicator Data Source Comments Qgestibn . - . Reduce stigma and Describe efforts STR Grant KCHD plans to launch an anti?stigma campaign discrimination to reduce Application; on HIV and hepatitis stigma. This campaign against people who stigma. KCHD wili also include information on HIV/hepatitis use drugs. staff testing and the principles of harm reduction. interviews Ensure full and Describe KCHD KCHD staff report that they provide education equitable reach of outreach staff on what is expected, testing services, patient Harm Reduction efforts. interviews rights and responsibilities, availability of services and contraceptives, and an explanation of the education to ail who syringe exchange model and how the number use substances. of syringes they receive is dependent upon how many they return. Raise awareness Describe Spreadsheet Since April 2016, KCHD has dispensed about the risk of education for naloxone 2091 naloxone kits and trained 1,469 people drug overdoses and related to training on how to administer naloxone. associated fatalities. overdose risk. Build Capacity of Describe staff KCHD staff reportedly conduct volunteer staff. training. staff orientations which include volunteer protocol, interviews biohazard waste procedures, confidentiality form, room interviewer protocol, needlestick response procedures, and naloxone dispensation. May 2018 41 KCHD is limited by staff and resources. There are only two full time staff members for the who have additional job reSponsibilities outside of the Tina Ramirez, Director of Health and Wellness, indicated that her work with the is based on a community health assessment that identified substance use disorder as a top priority for Kanawha County. Because diabetes and obesity are also top areas of need, she also does work to address these public health areas. KCH has approximately 10-15 volunteers a week who typically rotate out every six to eight-weeks. Volunteers include students from the University of Charleston pharmacy, physician assistant, and nursing), Marshall University (social work and behavioral services), West Virginia University (medical students), and members from the Charleston area community. Their roles as volunteers include: baggers in syringe exchange rooms, room interviewers, assembling supplies; assisting patients with forms, fielding calls, helping with the intake process, and data entry. staff conduct volunteer orientations which include volunteer protocol, biohaza rd waste procedures, confidentiality form, roorn interviewer protocol, and needlestick response procedures. Volunteers and staff are also trained on naloxone dispensation by the University of Charleston School of Pharmacy. In addition to syringe exchange services, the KCHD offers the following harm reduction services: recovery coaches; hepatitis, HIV, and STD screening; referrals to behavioral health,- naloxone training; acute and primary care services; vaccinations; and health insurance navigation. These services are offered to patients each visit before they receive syringes, except for naloxone training which is offered once on Wednesday afternoon and is open to patients as well as to other members of the community. They can also obtain naloxone refills in the event their existing naloxone has expired or has been used. Based on data collected from a Spreadsheet on naloxone trainings, since April 2016, KCHD has dispensed 2091 naloxone kits and trained 1,469 people on how to administer naloxone. Table 10 shows the reason for which naloxone refills were given to training patients (based on the naloxone database that was shared with evaluation team by staff). Table 10. Reason for naloxone refiils (based on Naloxone Database provided by CHD stof?l. Reason for Refill (April 2016 March 2018) Saves Expired Gave Away Dispensed Lost Stolen 337 24 157 59 10 Patients are informed oftraining opportunities by staff when their intake form is reviewed. KCHD focuses on educating and empowering patients about their role in the community and operations. Patients, especially those new to the program, are provided education on what is expected, testing services, patient rights and responsibilities, availability of contraceptives, and an explanation of the syringe exchange model and how the number of syringes they receive is dependent upon how many they return. Educational materials are available on topics such as safe needle disposal, needlestick injury prevention and response, overdose response, and naloxone dispensing. KCHD plans to launch an anti~stigma campaign on HIV and hepatitis stigma using OSTR funding (as outlined in the application). This campaign will also include information on HIV/hepatitis testing and the principles of harm reduction. Some of the material in development include: 0 Pocket guides on hepatitis, and locations; 0 Video about HIV and hepatitis and misconceptions; and May 2018 42 0 Approximately 25 public service announcements (PSAs) featuring physicians and other health ca re providers, persons living with the diseases or who have been treated, and others talking about stigma of HIV/hepatitis, getting tested, and living with it. This will be a yearlong campaign to educate the community with the purpose of decreasing stigma about these diseases and populations. About half to the individuals featured in the PSAs were patients of KCHD who are in recovery. KCHD works closely with substance abuse coalitions such as Kanawha Communities that Care and offers community classes which include a movie on addiction and drugs. Naloxone training is provided, and the class ends with a facilitated group discussion. These classes are requested by groups in the community, such as churches. State police and fire have also been provided naloxone through KCHD The KCHD staff attends several community-based organization meetings to speak about naloxone training. In addition, KCHD staff participate in town halls that are hosted to educate the community on harm reduction clinics and naloxone trainings. Other meetings staff attend include: Great Rivers Coalition meeting the statewide Harm Reduction Coalition meeting Family Resource Network meetings substance abuse coalition (Kanawha Communities that Care); Putnam Wellness Steering Committee meetings (quarterly); meetings with through the threat preparedness KCHD has also been a part of prevention, intervention, and treatment panel discussions at town hall meetings in Kanawha and Putnam counties. Before the KCHD was suspended, the KCHD website had a webpage devoted to information on its John Law is the Public Information Officer for KCHD and handles all print, media, and web content. Appendix displays a screenshot of the webpage which describes the program as a r?harm reduction? "syringe services program.? A link to its manual was made available to the public as were links with information on syringe services programs and information about opioids. Hours ofoperation were listed as well as the names of key staff involved in the data on the number of patients served available to visitors of the site. In a section titled, "What you can except,? site visitors were informed of steps for syringe exchange and diSposal for new and returning patients. Also included was a patient responsibility section that detailed expectations from KCHD staff (Appendix F). With regard to the relationship between KCHD and the City of Charleston, KCHD staff indicated many reasons for the strained relationship. The location of the health department is seen as the major issue given its proximity to the new Charleston Civic Center and the ("failing?) Charleston Town Center Mall. When asked if the program would be successful if it moved from its current location, staff were unsure because of the current pushback for mobile services. It was noted that KCHD staff met with the new Charleston Chief of Police and that he came to tour the facility. Staff believe that it cannot be proven or disproven that crime is going down since KCHD was suspended. They believe that the program will resume on June 1 (after the May 21, 2018 city council vote) and plan to work with the new elected administration on issue and concerns. May 2018 43 Stakeholder Engagement On page 9 ofthe Program Procedures Manual, the KCHD outlines building community stakeholder support for Table 11 provides a summary of the evaluation methods for the stakeholder engagement. Table 11. Evaluation methods for Stakeholder Engagement Evaluation Question Indicator Data Source Comments lncrease community Describe community Stakeholder interviews External stakeholders support for were in support of ?harm reduction? as a pathway to recovery but assert there is limited data to show linkage to drug treatment and recovery, especially when compared to program located at West Virginia Health Right. Increase stakeholder knowledge. Describe stakeholder knowledge of Stakeholder interviews internal and external stakeholders were very knowledgeable about the However, there is strong concerns from external stakeholders related to syringe litter, communications, trust, public safety, disease prevention, and economic impact. Assure understanding ofoperation plan. Describe stakeholder understanding of operation plan. Stakeholder interviews External stakeholders do not support through distribution of syringes to proxies. Page 9 of the KCHD Program Procedure Manual discusses the importance of understanding and addressing the concerns of resistant stakeholders in the community, and states that a may fail if it is framed negatively or communities resist it.? (KCHD Harm Reduction Syringe Services Program Procedure Manual, 2017]. Figure 28 illustrates the stakeholders identified as having an investment in the evaluation of KCHD Also shown are some ofthe roles stakeholders play in the KCHD system. May 2018 44 . . . State Health Allow legal HRP senrices within jurisdiction Department I I General PUbllC Of?CIals Respond to residents? concerns aboutI-IRP ?l Provide funding Collect dam on HBV CV Hivumin and -. .- palm: testrewl?ts Provide education on HEP v" First responders Provide naloxanc Ohm" community Respond to overdoses among Support additional HRP R?mnd to reports of used I 1 services LARCI needles In public spaces Report needles?ck Injuries pwro TM HRP i . Report injuries clean 33:33:: 3:35:23: LBW Enforcement Respond to calls about illegal drug use Seek drug treatment and recovery services Links participants to drug Seek 5T0 testing and/or treatment and recomarv hepa?tls A and vaccination 5? Seek medical care Off?m .?r?t?fnmg and Provide care and treatmentforHlV, HBV, ma"; ?5 Clinical and and/oruwto mo Provide referral for medical care Engage community partners in activities Figure 28. in teractlon of CHD stakeholders Behavioral Health . Provide care,treatmentand recover for substance use disorder to PWID 1 Provide other medical needs to PWID Stakeholders were identified as those involved in program operations (internal stakeholders), those served or affected by the program (external stakeholders), and the primary users of the evaluation (internal and external stakeholders). Table 12 shows the stakeholders and their roles in this evaluation. Table 12. Proposed stakeholders in evaluating KCHD and their roles in the evaluation I ..I lntefhalSt?akeho/ders Dominic Gaziano 0 Define purpose of evaluation Interim Director, KCHD Disseminate findings to key stakeholders Tina Ramiresziara Ruske 0 Define the purpose of the Lead Staff 0 Assist in describing the and gathering credible evidence 0 Provide answers to evaluation questions - Provide data forthe evaluation Cabin Creek Health Systems . Provide data for the evaluation 0 Provide answers to evaluation questions Ex ternai Stakeholders BPH 0 Lead evaluation of 0 Identify key stakeholders - Provide recommendations to for further dissemination Patients 0 Assist in describing the and gathering credible evidence City of Charleston 0 inclusion of stakeholders affected by the Local Law Enforcement 0 Inclusion of stakeholders affected by the Because KCHD is currently suspended, patients were not engaged as stakeholders, a significant limitation to the program evaluation. May 2018 45 A small group ofthe evaluation team met with 11 Charleston city representatives from the Mayor?s Office, Charleston Fire Department, Charleston Police Department, and Charleston City Council, some of whom were important in the passing of the 2015 ?enabling law? for legal syringe exchange within the city. It is important to note that none of the representative were in support of?resuming KCHD operations. All the City of Charleston stakeholders were in support of ?ha rm reduction? as a pathway to recovery from substance use disorder. They did not believe there was a need for two syringe exchange programs and reinforced consistently during the interview that West Virginia Health Right?s program was the better program because patients are viewed as identifiable, named patients. Syringe exchange is secondary to primary care. The stakeholders reported that West Virginia Health Right is able to link one-third of patients to recovery compared to 1.5% from KCHD though they indicated that KCHD number were not credible. City officials believe that West Virginia Health Right would be able to serve KCHD patients in addition to their current patient load. Reportedly, Health Right currently serves 25,000 patients. Use of retractable needles has been a highly controversial issue and was recently mandated by the City of Charleston for purposes of syringe exchange. The City of Charleston is very concerned about syringe litter and its impact on public safety. in October 2017, City officials engaged KCHD to start a retractable needle pilot project with two aims: to determine if syringe litter was coming from KCHD and see if safer, retractable syringes could replace less safe single?use syringes. Retractable syringes can cost four times as much as non?retractable syringes. Additionaliy, since federal funding cannot be used to procure syringes and other drug paraphernalia, only private grants and donations can be used to make such purchases. City officials identified a retractable needle manufacturer in Texas who was interested in the pilot project and offered to donate 250,000 syringes to KCHD The manufacturer wanted to collect data with the end goal of developing safer syringes that could be used at harm reduction programs in West Virginia and across the United States. Reportedly, all (KCHD City of Charleston, and the manufacturer) were all in agreement to the terms described. Reportedly, the manufacturer contacted the main point of contact from the city regarding the pilot project to inform him that the data collection wouid be outsourced to Johns Hopkins University and that a focus group with a maximum of 12 patients would receive the new retractable syringes. The city official was later told by KCHD staff that there was a miscornrnunication and that the project was to proceed as originally planned with a start date oprril l, 2018. City officials relayed to their stakeholders, including the Mayor, that the pilot project would be initiated as planned to alleviate concerns about increased syringe litter and resulting consequences. it was later learned that KCHD had made the decision to proceed with the focus group route for April 1. Both City of Charleston officials and the manufacturer felt that they were misled. City officials believe they were made to look like liars to their constituents. As a result, they developed a list of seven rules that were promulgated by Police Chief Steve Cooper that became effective immediately; one rule explicitly stated that only retractable syringes could be distributed at syringe exchange programs. As results of the new rules, KCHD suspended the program. West Virginia Health Right is still operating and is dispensing retractable needles. Over the course of the four and a half?hour interview, representatives of the City voiced concerns spanning the spectrum of increased syringe litter to increased serious crimes within the City of Charleston attributable to KCHD as outlined in Table 13. May 2018 46 Concern I 1 . Reported Reasanfei i"om-eniM? I . . 0 Many persons arrested at the Charleston Town Center Mall had drug paraphernalia on their person; 0 Reported increase in shoplifting at the Charleston Town Center Mall; 0 Businesses closing/leaving Charleston; 9 Increased crime reported the day before and the day after KCHD 0 Increase in methamphetamine use in Charleston due to availability of free injection equipment; 0 Increase in illicit drug transaction within city limits; and 0 Increase illicit drugs brought in from other states. Little impact on 0 West Virginia still ranks first in acute HBV and and decreasing and 0 Rates in Kanawha County did not change greatly as a result of the HCV program. Patients able to pick up 0 Reference one patient having 13 other ID cards and picking up drug paraphernalia for syringes for others; and others in the program 0 ?Patients are herded through like cattle? leaving little time for offering extended services above clean syringes. Economic impact on the a $100 million Civic Center construction nearly completed; City Of Charleston 0 Visitors/tourist do not want to visit a city with syringe litter; and KCHD is operating as a regional or semi-state health department, resulting in increased burden on the City of Charleston to serve non?Kanawha County residents. KCHD as a regional or 0 Increased burden on the City of Charleston to serve non?Kanawha semi-state health County residents. department In addition to participating in an interview with evaluation staff, representatives provided written documentation for structure fires and worker?s compensation reports. This information is presented below: According to data provided by the Charleston Fire Department, vacant structure fires have increased by 64% from 2015 to 2017. When comparing January through November 2015, which is prior to the start date of the to January through November 2017, a 100% increase in vacant structure fires is evident. Even more striking is the comparison between the first quarters of 2015 and 2018, in which vacant structure ?res rose 250%. In addition, the Charleston Fire Department reported they experienced 28 days without a structure fire after syringe services were suspended (Table 14). This evaluation cannot conclusively state that the structure fires are the result of the KCHD However, the data does support why the Charleston Fire Department and other City officials have concerns about the program. Table 14- Vacant Structure Fires in Charleston, WV Time Period 2015 2016 2017 2018 January-November 13 24 26 -- January-March 6 6 7 21 Calendar Year 17 28 28 May 2018 48 The Mayor?s Office provided information regarding incident reports to worker?s compensation associated with needlestick injury. Out of 20 total worker?s compensation cases related to needlestick incidents in Charleston from 2003-2017, 15 were associated with discarded needles. There were 10 total accidental needlesticks in 2016 and 2017 that may be associated with the increased availability of syringes following the implementation of the KCHD in December 2015. This is a 150% increase from 2015 to 2017 and a 400% increase from 2013 to 2017 (Figure 29). The overall rise in injection drug use in West Virginia should also be considered when reviewing this data, as Heroin overdose deaths began increasing in 2010 and Fentanyl and Tramadol related deaths began to rise in 2013, ail ofwhich are commonly taken through injection via a syringe (CDC Dotti: Overdose Deaths involving Opioids, by Type of Opioid, United States, 2000-2016, 2017). Discarded Needlestick? Accidents Reported to Worker's Compensation 2003?2017 2 1L DC 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 TT Til?m .T . 0 Figure 29. Worker?s Compensation Reports for Need/estick Injury, Charleston, WV Conclusions In December of 2015, the KCHD launched a with the support of the Board of Health and the City of Charleston. Initially, the program was well received by its stakeholders, but that support eroded as the program expanded and matured. Once the Program lost stakeholder support, the Program suspended its syringe exchange and patients no longer attend the for other harm reduction services. A review of the available evidence shows that the KCHD grew rapidly during its first year of implementation, and that data quality began to suffer as the program expanded. Despite challenges with data quality, there is strong evidence to support that the KCHD was serving a vulnerable population, and that patients were returning for follow-up visits. Stakeholders viewed the as a ?gateway to treatment,? but the data systems were not designed to track interest in services beyond syringe exchange. In addition, representatives of the City of Charleston reportedly believed that the Program offered a one-to?one needle exchange, while the KCHD was providing a one-to-one plus. In other words, the KCHD was distributing more needles than was returned to meet their goal of assuring that [005 always had a clean needle available for use. This lead to communication problems and distrust among the program?s stakeholders. May 2018 49 These problems were compounded by the quantity of syringe litter that was reported by community members and first responders. Stakeholders stated that syringe litter should be treated as an emergency situation, but KCHD procedures were not designed to meet stakeholder expectations. The issues associated with the reached a tipping point when KCHD did not fully implement a plan for retractable needles that was supported by the City of Charleston. This lead to the Chief of Police issuing new rules for Charleston requiring that only retractable needles could be distributed. The KCHD suspended needle exchange services in response to the new rules. A summary ofthe evaluation findings is presented below: 1. Many data quality issues were noted throughout the evaluation including data errors, incomplete data, inability to link patients to harm reduction services data for tracking purposes, incorrect data analysis resulting in misinformation to the public, and non?standardized data entry. These data quality issues also made it very difficult for the evaluation staff to confirm that the KCHD implemented its with fidelity to its Program Procedures Manual. In addition, the KCHD database does not adequately describe access to and provision of ?other services,? eSpecially provision of recovery/treatment services, reproductive health services, whether patients were assisted with health insurance, flu shots, and wound assessment, which were key stakeholder concerns. This concern is further supported by the West Virginia Board of Medicine?s rules related to the licensing and discipline of physicians which provides that the Board may deny an application for a license, place a licensee on probation, suspend a license, limit or restrict a license, or revoke any license issued by the Board, upon satisfactory proof that the licensee has "[fJailed to keep written records justifying the course of treatment of the patient, including, but not limited to, patient histories, examination results and test results and treatment rendered, if any?. Code R. ll-lA-12.1. u. The current patient identification system employed at KCHD makes it possible for a patient identification number to be shared among multiple patients since it is based on the first and last name initials, month of birth, and year of birth. This poses a challenge to tracking a patient?s progress to recovery from substance use disorder, which is a primary goal of City stakeholders. KCHD has gained acceptance among patients since it first started in late 2015, based on more than doubling of patients from 2016 to 2017 (per Harm Reduction Database). However, it has lost the support of some important community stakeholders, namely, officials from the City of Charleston. Per KCHD Program Manual: ?it is important to establish a steering committee with internal and external stakeholders that will help make decisions about the after its inception. The steering committee will help with logistics, syringe exchange model decisions, procedural decisions, etc. It is also important to keep your community members informed. Community members will include lay persons from the community by also partnering organizations such as law enforcement, poison control, etc. During these meetings, it is a time to highlight the success ofthe programs, the progress made thus far, and to reaffirm community partner collaboration for the KCHD participated in a variety of community and stakeholder meetings; however, to the best knowledge of the evaluation team, a steering committee as described in the manual did not exist. The City of Charleston is a major stakeholder in the KCHD not only because the program is located within Charleston city limits but most significantly because of the City?s role in May 2018 50 the program?s existence. It is imperative to the success of harm reduction programs that relationships between program and the city and county in which they operate are strong. increase in syringe litter is viewed as a threat to public safety. With over 421,000 syringes reportedly dispensed in 2017 and a return rate of 56%, it is plausible that much of the syringe litter were ones that were dispensed by KCHD Regardless of the source of the syringes, it is important that a detailed plan is in place that addresses community concerns in a timely matter to avoid needlestick injuries and allay fears. Reportedly, KCHD staff were available to pick up syringe litter within 24 hours on weekdays and within 48 hours on weekends. This time period was not acceptable to officials from the City of Charleston who stated that syringe litter should be picked up within 10 minutes. This then put the burden on the City of Charleston to meet its expectations for timely syringe litter pick?up, resulting in concerns about KCHD operations. Data from November 2017 to March 2018 indicated that 34% of patients visited the clinic in- person, 46% were via a proxy, and 20% of were unknown. This practice was not outlined as a practice in the KCHD Program Procedure Manual and creates a missed opportunity to provide linkage to treatment and other harm reduction services. The evaluation team overwhelmingly agree that patients should be present to obtain clean injection equipment and that one patient should not be able to pick up for other patients. Clinic attendance provides opportunities for blood borne pathogen screening and a wealth of other services. Attendance may also be a segue to substance use disorder treatment and recovery programs. Patients who do not visit KCHD are missing important linkage opportunities that are important to broader harm reduction strategies. Additionally, the concept of ?syringe exchange? is not being Optimally practiced. instead, "syringe access? is employed. Access to clean syringes should be supplemental with additional harm reduction services. The current model at KCHD indicates that patients are given clean injection equipment prior to receiving primary health care services. The evaluation team believes it is important for patients to obtain primary care and behavioral health services before syringes are diSpensed so that medical attention is seen as the top priority over syringe exchange. Recommendations 1. 2. It is recommended that the BPH OEPS suspend Certification. if the KCHD resumes services, the Kanawha-Charleston Board of Health shouid work with identified stakeholders to incorporate the following recommendations into operations: a) Offer Hepatitis A and vaccine routinely. b) improve data collection, storage, management, analysis, and dissemination to strengthen validity and credibility of the program. c) Each patient should receive a unique identifier that can be used to track clinical and behavioral care. d) KCHD should maintain in a confidential manner, written records for all patients who are treated by the health department or are referred for treatment by another physician, including patient histories, examination and test results, and any treatment provided. e) Stakeholders should be thoroughly and routinely engaged by the program from implementation to maturity while ensuring that program goals are aligned with community stakeholder goals. f] Develop a coordinated and timely plan in conjunction with key community partners first reSponders) to pick-up and track syringe litter in public spaces. May 2018 51 g) Education campaigns should include general education about syringe services/harm reduction programs and specific education about the program, its goals, and community needs. h) Primary care services and linkage to substance use treatment should be offered and provided at each visit to harm reduction program patients p?o_r to syringe dispensing. i) Attendance at should be mandatory to obtain clean injection equipment. j) Program procedures should specifically address the identification, treatment and referral of pregnant women. 3. The BPH Commissioner should seek explicit legislative authority to implement statewide minimum standards among harm reduction programs, including expansion of needlestick reporting to include those that occur in non?health care settings. May 2018 52 References Brumage, M. (2017) KanawhaaCharleston Board of Health Meeting Minutes. Charleston, WV. Available at: (Accessed: 8 May 2018). Caudarella, A. et al. (2016) ?Non-fatal overdose as a risk factor for subsequent fatal overdose among people who inject drugs?, Drug and Alcohol Dependence, 162, pp. 51?55- doi: CDC Data: Overdose Deaths involving Opioids, by Type of Opioid, United States, 2000-2016 (2017). Available at: (Accessed: 8 May 2018). Centers for Disease Prevention and Co ntroi, N. (2016) Department of Health and Human Services implementation Guidance to Support Certain Components of Syringe Services Programs, 2016. Available at: (Accessed: 8 May 2018). Conrad, C. et al. (2015) ?Community Outbreak of HIV infection Linked to Injection Drug Use of Oxymorphone Indiana, 2015?, MMWR. Indiana. Available at: (Accessed: 4 May 2018)- Dent, C. (2015) H. 8.2029 ConsolidatedAppropriations Act, 2016. 114th Congress (2015-2016). Available at: (Accessed: 4 May 2018). Gilead?s FOCUS Program: increasing Routine and and Linkage to Care (no date). Available at: 8 May 2018). Gindi, R. M. et al. (2009) ?Utilization patterns and correlates of retention among clients of the needle exchange program in Baltimore, Maryland?, Drug andAlcohOl Dependence, 103(3), pp. 93w98. doi; Van Handel, M- M. et al. (2016) ?County-Level Vulnerability Assessment for Rapid Dissemination of HIV or HCV Infections among Persons Who inject Drugs, United States?, Journal ofAcauired immune Deficiency 73(3), pp. 323?331. doi; KCHD Harm Reduction Syringe Services Program Procedure Manual (2017). Available at: (Accessed: 8 May 2018) Kersey, L. (2018) Charleston council delays vote on needle-exchange program, passes refuse bill hike I Kanawha County wvgazettemail.com, Charleston Gazette?Mail. Available at: (Accessed: 8 May 2018). Kersey, L. and Beck, E. (2018) ?Health Department suspends needle-exchange portion of harm reduction clinic?, Charleston Gazette-Mail, 26 March. Available at: Koplan, J. P., Director, M. and Higgins Peter Jenkins, M. M. (1999) ?Framework for Program Evaluation?, MMWR, 48(11). Available at: (Accessed: 4 May 2018). May 2018 53 Services(2017) Epidemiological Profile oleV/AiDS in West Virginia. Available at: Surveillance Summary 2017.pdf (Accessed: 4 May 2018). Substance Abuse and Mental Health Services Administration (2016) State Targeted Response to the Opioid Crisis Grants. Available at: (Accessed: 8 May 2018). Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality (2016) Results from the 2015 National Survey on Drug Use and Health: Detailed Tables. Rockville. Available at: (Accessed: 4 May 2018). Terplan, M. et al. (2015) ?Contraceptive use and method choice among women with opioid and other substance use disorders: A systematic review.?, Preventive medicine, 80, pp. 23?31. doi: 10.1016/j.ypmed.2015.04.008. Umer, A. (2017) Intrauterine Substrance Exposure and Neonatal Abstinence in West Virginia, 201 7. West Virginia Bureau for Public Health (2017) 2016 West Virginia Overdose Fatality Analysis: Healthcare Systems Utilization, Risk Factors, and Opportunities for intervention. Available at: Reports 2017/2016 West Virginia Overdose Fatality Analysis_004302018.pdf (Accessed: 9 May 2018). West Virginia Bureau for Public Health (2017) Harm Reduction Program Guidelines and Certification Procedures. Available at: program~guidelines.pdf. West Virginia Bureau for Public Health (2017) West Virginia Viral Hepatitis Epidemiologic Profile 2017. Charleston, WV. Available at: 2017.pdf (Accessed: 4 May 2018). West Virginia Bureau for Public Health Office of Epidemiology and Prevention Services (2016) West Virginia Viral Hepatitis and Surveillance: A surveillance overview of the incidence and risk factors associated with cases of viral hepatitis and from 2012-2015 in West Virginia. Charleston, WV. Available at: (Accessed: 4 May 2018). May 2018 54 Appendix A: Timeline -..-.. -- September 17,2015 KCHD announces launch of for December of 2015 i I September 21 2615 I'CHa?H??si?h City'O-rdi'nanceis page I December 16, 2015 KCHD launches to be held every Wednesday from 1PM- 3PM March 5616" kcHo announces same received. Iro'r?i?'riawha i donation of200 doses of naloxone from Kaleo Pharma and focal health officer serve as naloxone program medical director April 2016 Program expands to offer haloxone training In partnership With university of . Chquesjgon . . . . . .1. .. . I May 201S CPD presence established at I July 2016 IKCHD announces program expan5ion to extend hours of operation from I 3PM to 10AM- 3PM and receives determination of need from the CDC which allows the agency. to recewe federal funding to support services. I November 2016 I KCHD presented information to Charleston City Councils Finance ._Committee (seesi?caUr.addressesnesdles public PlaceSI- . January 2017 KCHD announced formation of Great Rivers Harm Reduction Coalition, i awarded $7,500 from the Comer Family Foundation and announced receipt i of 1200 doses of naloxone (200 from CHHD and 1000 from Kaleo)- Drop off container installed to address City?s concern of needles In public . places and Johns Hopkins is engaged to conduct a program review. 1 implementation of a participant survey is recommended, and number of participants served by KCHD Is compared to those being served by a program I April 2017 KCHD reported launch of West Virginia Harm Reduction Coalition, awarded 5' S30, 000 from Claude W. Benedum Foundation, $50,000 from Greater Kanawha Valley Foundation (to support community syringe kiosks) and 500 naloxone kits from WVU. KCHD reported potential program changes to 4 include mobile unit and ?resiliency training for first responders. KCHD Policy Manual ?dated May 1, .2017 available on KCHD July 2017 KCHD reported formation of partnership with Cabin Creek to include full spectrum of primary care services to be offered during harm reduction clinic, 1' awarded $50, 000 to support resiliency/mindfulness training for first reSponders, and findings from John Hopkins evaluation reported at Harm Reduction Workshop which includes patients from 188 zip codes, 26 states, 3 September 2017 KCHD reported expansion of Ca bin Creek clinic to include second day (Thursdays) of STI treatment and family planning SEWICES and reported tours :_of the _prog_ram_ by CPD Po_lice "Ch_i_ef_ and Regional Administrator I I November 2017 announces award of $75, 000 to KCHD to support the expansion of i I January 2018 KCHD awarded S300, 000 from Gilead Sciences, inc to support the FOCUS Program Pilot which supports opt out testing for Hepatitis C. and? May 2018 55 February 2018 March 1 20513 i lulMErEhl?Ei, i313 i is; 2915:? . March 20, 2018 l' March 31;?2613 I'March'27, 2013 May 2013 health officer resigned to accept appointment as Director of Office ?r as interim health officer. mCharleston Mayor announces intent 'to reverse the process and make." it illegal to pass out needles? through the passage of a new regulation and KCHD released media statement announcing robust review _of the program KCHD announced program changes in response to public concerns [partICIpant required to be pIIreIsentI to obtain needles) reports 30% 40% drop in program participation. Charleston City Council votes (16/11) to postpones vote on bill to recriminalize needles for 60 days. offered by West Virginia Health Right announces pilot program to Lise only retractable needles. Charleston Mayor calls for audit by of KCHD and Charleston I City Police announces new regulations to become effective April 2, 2018 and include: 0 Using retractable needles; 0 Advising participants of offered rehabilitation services; a Requiring participants to show photo . Testing participants for blood-borne illnesses; - Implementing a one-for~one exchange; it Submitting a report to the chief; and a _Only allowing KanIaItha County residents to participate. KCHD board t0 the needle exchange portion of the . pending Ia legal review of the City Is new regulations. I IDrug Control Policy and board approved appointment of Dr Dominic Gaziano i 56 Appendix B: New Patient Form Date: Kanewha?Chz?estcn m?enmm Sy?nge?ccess Egogram h?mPeiiE-lt ID Humber: CircIe 3,1313 ?rm or $951.13] G?enta?cn: F?standlastini?zl: THEM Hefercsemal RaceJZEt'hmicigy: ?amsmal Berth month. a we 13 Black I: Esme 3 Asian Namemm Questioning Paci?c Islander O?ier El Declined Last Grade of School CemEIeted: Latino [3 Hispanic Contraceg?te Method: Residence: Drug of Choice: Route: Insurance: El Condoms El ?gment Heroin CI 01:11 El Private l3 Birfh Central Home - Rx?piei?s El Inject El Medicare Pillea'lnjec?on. It! Homeless gin-came be :1 Smart a Medicaid '3 . ethane: m? Rome El . code; El Gaunt Arerou interested in other services? 1* Hepatitis B: Pcsi?'s?o?ega?ve El Hepa?trs and Hepe??s C: Posi?vefNega?ve El smm? Testing HIV: El Speeh?ng In a Recovery Coach I When were you last 1:25de :1 Com Co . Age Use: NW Hate you aerbeen in recovery? Yes Cl HID {Female Birth Emmet Device} II He?! you ever mrerdnsed? Yes or No a Signing Up sari-lean]: Immense Hate you ever been with someone who :3 Fin has m-?ezdcsed? ca-Nc i Ame you waiting foo: abea in 3 mm a Wi?mmsm program? Yes arHa :1 Wand Amgma?t I Ho lung is ymu wait? Months 5% (If times you infect per when you use: Shoat or Long Below Fog Clinical Use 0131:; Was your patient seen by a nurse er Yes or No Did your patient receive any cfthe above other eenicee? If so:J what? ?1.5 rammed today: cfneedles given today: new-em May 2018 57 Appendix C: Return Patient Form Kanewhe-Cha?estou Health Depmtment at Syringe Access Program RETURN PATIENT [Ea . . . anumbe-r? . . . . Any changes? YE or No Explain: #c-f ?mesyou inject per day- when Ilntzuu use: length ofneed?e preferred: Short or Long rm; some use ovum Eras your patient seen Er;- a nurse or doctor? Yes or Ho- Did your patient receis?e any of the Below other senices? If so, what? it ofneed?es rammed today: it of needles given today". Supply List: (please check which items you would like) Syringes Alcohol Swabs Cotton Pellets Toumiqu-et Cooker Shams Containers Reooverfu .t'ontrhes om overtook today to spoof: with ,1 on ifs-oz; 11'on its iazrgamrsof mom-org: Are you interested in other Hepatitis and Testing El Testing El Speaking to a Recovery Coach Counseling 13' Melatone 5 (Fem-ale Birth Control Device} Signing Up for Health "Insurance El Flu Shot El Information on STD Testingf??utts El Wound Assessments 3" May 2018 58 Appendix D: Memorandum of Agreement Memorandum of Agreement The Parties: ital-lawn: County Health Department a Local Health DepartmEnL lumLed in Charleston, KW ['Kanawl'ra counwi . Business address: 1103 Lee 51., Charleston. WV 25301 and The Cabin Creek Health Systems lair-l5], a Federally Quali?ed Health Ce nter, with health center site; in five cemmunifies nf Kanawha County. Businesis address: lip): Dawes, WV 250% Purpnse: The purpnse efthis agreementis for CCHS and to wide primary health care services. including family plan ninar services, and ambulemnl mental health services far KCHD clients at the facility. The particular target pepulatinn are the clients who participate in the KCHD Ha rm Redu ctipn Program at the KCHD facliinr. Primary car: would be prnvidad an an urgent basis for any consenting HHF client and centfnuing care would he provided for consenting HRP clients whc- do not have an aria biished source of primary.r care and who Impose to receive primary care at the KCHD facility. Either apiions far angeing primary care will be effererl in clients including care at PEER-Cs in the region. the purpose of this partnership Ir. to belie: understand the minim-inn.r care needs of the IIRP client pnpuiatinn and to determine effective ui pm'uitling primary tare. Scope at Practice: The (CH5 she]! seal: to include services at the KEHD In Its. scape pi prartiga as an FQHC. The scene will, ?rst, be. far the purnase of providing short term primary care services an an intermittent been far pr twin days per week. appears feasible to provide I13 I't-flme services an a icing term basis achange-in-smpe will be shughtte include :he KCHD as a lung term site lorseruires tn the rile ntr. cf the Kc] ID program. Referrer were?: Patients may be referred to the CCHS services by HCHD clinical stail members. Such referrals will only he initiated with the patient"; agreement. HHP clients may also self-refer by preaentinz themselves to the CCHS reneptimisf. Financial Aeneas and Billing: Patients receiving primary care newlines untierthis agreementwni be registered as patients of CCHS 'lrr err-is staff membe rs. All CCHS seminar will be provided regardless ofthe ability to pay; public and p?rate insu rance wrerage pragra with Which has naiticipation agreements will he hil led by CCHS. Patients with nut medical coverage, and with incomes at or belnw 200% cf the Federal Forerw Level will be billed based an a sliding fee scale. Far eligible consenting patients and with approval ?fths may! bill ll?ie?iIW? Fa mll'r Planning and . pmgrams. Refe'ente lateral-orig be provid ed 11h weak a CCHS prepayment arra ngem ant and paiienrs will not be for reference [abnratow tests or far laboratnnr tests performed on site. May 2018 59 Patients of [Cl-:5 will be eligible for discount-a far prescripticn medication provided fram CCHS pharmacies, ?laugh there is mt a CCHS pharmacy an site and preacription medicatiun must he delivered by U5. mail fur paEiEnts will: aimse tr:- renelue their metiicatiun from CCH5 pharmacies. Medina] Regards and Patient Con?dentiality: CCHS and Kati-1D shall maintain separate electronic medical IED?rds. Patient?con?dentfn?tywilf Be Db??r'u'ed mid PmiEdEd pa?ant information will En: by either pa rt-lr without the Print written consent of this patient. mganiza?nnal Practice and Cant-ail Both parties maintain their own aperatianal pu?cies and procedures, practices and U: and Terminz?un NE Daft? res-parisible Far legal incurred by ill-IE.- other. Either party may terminate this agreement with an clays notice. Distinguishing Pmui?eirs and ?laff: The CCHS providers and sup?anrt sta?f will he ciea rilr distinguished Kiri-in staff by means nf internal 3 nd extern al signage and staff name tag; and printed Service Hunts Will be established by mutual agreementoft?n 9. parties a nd will nut exceed two clays per week. Space. supplies and Equipment RCH will make available space far patient arched uling, remain-m and mgistratian; -:li nicai assessment and vital signs,- and exam and cansultatian. 'i?here will be cost charged in CCHS far the use nfspace nor aw :05: charged Ln CCHS Will provide. all clinical and af?oe supplies required to provide services and prwide all clinical and elf-Hm equipment and furnishings noiprovided bi! KCHD. Service; Evaluatinn Seminar. will bq-c'ualualcd tn determine the service utilization by diagnosis, patient and quality at care. Evaluatiun reparts will he provided lzn,r CCHS at least quarterly ta the ECHO. Appraved far Kill-ED Approved fa CH5 Michael Brumage. Craig PH Positiun: Exemutiire Officer Pasitinri: gxecutive Director Date: June 23 20:? Date: 7' a .191 May 2018 60 Appendix E: Website About Us Contact Us News Calendar Log 0m Search this website Environmental Epidemiology Pretrentionwieiiness Emergency Preparedness You are here: Home: Programs and Services Harm Reducrion - ?rings Service Program Prevention a 'i?i-z-llness Harm Reduction - Syringe Service Program Harm Reduction Manual hat is a Syringe Services Program Wednesday from 10:0tiam to 3:00pm. The Kanawha-Charleston Health Department (KCHD) seeks to provide exceptional care to every c?ent We want to work together with you to ensure you receive the clinical care, compassion and services that you need. individuals visiting the clinic are atso eligible to receive other services including hepatitis testing and vaccination, speaking with a recovery coach, help in signing up for health insurance, contraceptives, flu shots, IUD services, STD and HIVtesting, endior wound assessments. In addition. KGHD holds Natoxone auto injector trainings at 1 230m each Wednesday. it you would lie further information on the Harm Reduction Clinic, Naloxone Trainings, or how you can become a volunteer; please contact Tina Ramirez at 304-348~5493 . or tin a.l.ra mirez@wv.gov. If you would iike to make a donation to the Harm Reduction Clinic to support its life saving efforts. please contact Kristi Justice. the Executive Director of the Kanavrha County substance abuse coalition. Kanawha Communities that Care at 304-68141 7? . or director@kanawhactc.org. May 2018 Appendix F: Patient Rights and Responsibilities Kanawha?Charieston Health Department Patient Rights and Responsibilities The Kanawha-Eharleston Health Department seeks to provide exte-ptional care to every dicot. We want to work together with you to ensure you receive the clinical care, Compassion and services that ynu r_1 Edd. Use and distribution ofillicI-t drugs isstric?g growl-zines] onme Kanawha-Ciiadeston Health Eepartrnent property. if caught, you new lace immediate rem-oval from the program and. may! he subjectto arsestand erosecution. Please remember the Harm Reduction Syringe Exchange program is a volunteer and donation based program, illegal utility on the premise could cause the permanent closure oithe harm reduction clinic. What you can expect ?rst visit a. You will he asked to create a member son that 1.ioui will use every time you participate in the crease m. 2- You will he asked several questions that will be used for statistical data. 3. too will be educated abon'l: the program including your rights and responsibilities, needle archangel referrals and available testing. a. You will be given the number of needles you need as well as supplies. {create drug use. 5. You will be given a ca_rd_v.r_is_h 579.11!? member ilig? that identifies Igoo asa garlicipan; in the germ needle exdiange program in: WE HAVE TO roe A new cone, iT WILL toss too 5 memes} Return visit 1. You will be asked your main her mil. 2. You will he asked follow-up questions. 3. You will dispose of your used needles in the sharps containers. o. ?i'ou will be given the number of needles. and supplies that you will need until the next clinic. 5. too are reg uirad to return used needles. . . ll Willi? 10' WM- 35 all?? T0 ?595:5 nine Ell? liDT Needles will only he risk-up and dispose! on Wis-doesdoysfrom Ill-Md maid-gum. Services are any: available to those 13 years of one and older. You hove the right I Be treated with respect and dignity regardless of race, ethnicity, sex or gender orientation, national origin, religion, class, medical status; or physical or menial ability. I Feel sale in an environment free from violence, threats and hateful language. 1 Receive available services, supplies, information and education to keep you safe? 9 Be respected and have the right to privacy. Be provided con?dential case ma liege-men's upon request. You have the responsibility row I Be responsible for the syringes you are given and to return used syringes to lime in safe disposable containers. - Treat staff, interns, volunteers and community members. with courtesy and respect without physical, sexual, verbal andfor emotional abuse, threats ?intimidation. it Keep the area around the health dope rtmentsafa and do not engage in any drug activity thatouts the at risk of closure. a! Bio not buy, sell or loan mime?,I orpropertv while on the premises; - Protect the confidentiality of other participants encountered while participating in the harm reduction program. I Take on 11,1 what is needed and disposeoi used materials and Supplies proparhr. I notify the KCHD of any areas in the common in; wharf: used needles are located. I one 3915 3' 5 - Flamed December 201E May 2018 62