STDs Opt-Out Testing in Yuba County Jail

Yuba County is a small, mainly rural county in northern CA with an approximate population of 83,421 residents per the US Census. Sexually transmitted diseases (STDs) have increased exponentially in the past several years locally in Yuba County. In the past five years, the rates of chlamydia has increased in Yuba County from 401.6 to 415.4 cases per 100,000 residents. The rates of syphilis has significantly increased from 17 to 84.1 cases per 100,000 residents nearly a 5-fold increase.

In California, incarcerated individuals are among the individuals most impacted by STDs and among one of the high-risk groups recommended by the CA Department of Public Health for targeted interventions. Beginning in 2021, Yuba County Public Health initiated conversations with Yuba County Jail and their jail medical provider (WellPath) to discuss the implementation of an STD opt-out testing program to allow for timely diagnosis and if positive, treatment of chlamydia, gonorrhea and syphilis among Yuba County jail inmates. Timely treatment for STDs not only allows for reduction in further medical complications for the inmates, but also assist in reducing the risk of transmission to others in Yuba County general population.

The intent of this project is to provide opt-out testing for each inmate for chlamydia, gonorrhea and syphilis as soon as possible after booking into the Yuba County Jail. Opt-out testing is defined as performing STDs testing after notifying the patient/inmate that the tests will be conducted and that they may decline or defer testing. Opt-out testing is conducted regardless of symptoms presence since often patients with STDs do not have symptoms.

If the STDs testing is positive, medical evaluation including treatment will be provided by WellPath as the contracted Jail medical provider. A public health nurse will provide further linkage to care on release from the jail, including case management, referral to outpatient clinics if needed, and initiation of contact tracing of sexual contacts. A public health social worker will assist with connection to community supports including but not limited to assistance with connections to Medicaid enrollment, housing connections, etc. The objective of this project is is to address not only the STDs medical needs of the inmates, but also other medical/behavioral health needs and social determinants of health, ultimately addressing these high-risk patients utilizing a whole-person approach.

The agreement between the Sheriff Department and Health Human Services Department with WellPath took a year to be executed. Negotiations took a long time since it occurred between two county departments, and then when finalized within the county, between Yuba County and WellPath. Finally, the agreement was presented publicly to the Yuba County Board of Supervisors in September 2022 and once approved by the Board, the project implemented in mid-September 2022. Since then, the STD Opt-Out testing has been successfully implemented with key monthly metrics submitted back to Yuba County Public Health as below:

Monthly Data Submitted to Yuba County Public Health:

·       Number of inmates booked in a 30 day period

·       Number of inmates tested for chlamydia, gonorrhea, and syphilis in a 30 day period

·       Number of inmates who tested positive for chlamydia, gonorrhea, and syphilis in a 30 day period

·       Number of inmates who tested positive and treated for chlamydia, gonorrhea, and syphilis in a 30 day period

In the few months of the opt-out implementation, we have seen remarkable results. Of the new inmates coming into the Jail, from 13-20% of new inmates have agreed to STDs testing. Of those who agreed to testing, the test positivity rate for chlamydia and gonorrhea was 7-9% and the test positivity rate for syphilis was 7-13%. All positive cases were successfully treated fully within the Jail.

The success of this program relies on close engagement between Yuba County Public Health and the Sheriff Department and WellPath from project planning to implementation. Throughout 2021 and 2022, Yuba County Public Health met several times with the Sheriff Department and WellPath to explain our proposal and the need for STD opt-out testing to ensure timely diagnosis and treatment of asymptomatic patients with STDs. In addition, we were able to utilize STD grant funding to accommodate the additional STD testing and treatment costs thereby alleviating any concerns from the Sheriff Department that this will increase their medical payments to WellPath. In addition, we stressed that the monitoring metrics will be easy to collect through Survey Monkey and all the analysis will be with our Public Health Department. Finally, we initiated monthly check-in meetings with the Sheriff Department and WellPath to ensure that we can identify any areas of improvement in a timely manner. For instance after the decline of STD opt-out testing in October 2022, we heard from WellPath that inmates were concerned that the test samples would be utilized for drug testing, in addition to STDs. Upon hearing that, our team was able to draft scripted messages to provide to WellPath staff to reassure inmates that these tests can only be utilized for its intended purpose and no drug testing can be done without the inmates' consent.

We have not implemented the embedding of social workers and public health nurses within Yuba County Jail but are planning on doing so by January 2023. Once they are embedded within the Jail, Yuba County Public Health will be working with the Jail and WellPath to track the post-release referrals categorized as medical referrals, behavioral health referrals, insurance referrals, housing referrals, etc.

Yuba County Public Health does not have its own website, however below is the website for Yuba County Health and Human Services:

https://www.yuba.org/departments/health_and_human_services/index.php

As noted earlier, STDs have dramatically increased in Yuba County within the past five years, mirroring the national trend. In the past five years, the rates of chlamydia has increased in Yuba County from 401.6 to 415.4 cases per 100,000 residents. The rates of syphilis has significantly increased from 17 to 84.1 cases per 100,000 residents – nearly a 5-fold increase.

Our project's target population for this project are Yuba County jail inmates. We know that incarcerated individuals experience a disproportionate share of STDs due to many other health and social inequities. To work to end the STDs epidemic requires us in Yuba County Public Health to go where the patients are, starting with our Yuba County Jail. We knew that the testing and timely treatment of STDs must be made extremely accessible, with minimal barriers for the inmates to avail of these services. Though the Yuba County Jail has a contracted medical provider embedded within the Jail, they do not have the staffing capacity nor the public health expertise to conduct contact tracing and services centered on addressing the social determinants of health. Hence, we knew that our project had to include those services such as referrals to housing, medical insurance, and linkages to medical and behavioral health services post-release.

Transitions of care from jail pre-release to post-release providers can lead to gaps in continuity of care. This project seeks to ensure that does not happen by keeping social services referrals within a closed-loop” as much as possible with the social workers initiating the referrals while the inmates are in custody will be the same social workers following the inmates upon release. We will also ensure we facilitate as strong as possible warm hand-offs for medical and behavioral health follow-up appointments.

Though the approach of STD opt-out testing in jail is well-known, we are proud that our project is able to address not only the STD testing and treatment but an overall holistic approach to caring for the whole person.

The overall goal of this project is to reduce the disproportionate burden of STDs within Yuba County Jail inmates and by extension to address the STDs epidemic in our community. The success of this program relies on close engagement between Yuba County Public Health and the Sheriff Department and WellPath from project planning to implementation. In 2021, the Yuba County Public Health Officer approached the Yuba County Jail and their medical provider (WellPath) with the STD opt-out testing proposal, which they received enthusiastically. The Jail and WellPath's asks centered on minimizing administrative burden associated with the project and to keep at minimum disruptions to the Jail's normal operations. Keeping those requests in mind, throughout 2021 and 2022, Yuba County Public Health put together a plan that was simple to implement, limiting the opt-out testing program to only three key STDs (syphilis, chlamydia, and gonorrhea), and ensured that data input for the project extremely simple through a monthly SurveyMonkey, with no more than 10 input data fields. Other services including referrals for social services and warm hand-offs to medical and behavioral health will be conducted by Yuba County Public Health staff who will come into the Jail, thereby minimizing the need for the Jail or WellPath staff to add this to their limited bandwidth.

The length of the planning phase was also heavily impacted by the need to negotiate with the CA Department of Public Health (CDPH) regarding our STD Grant funding, which stipulated that we had to work with a non-profit organization which WellPath is not. After a series of meetings and document attesting that we have tried but failed to identify a local non-profit organization which would be suitable to enter the Jail to provide STD opt-out testing and linkages to care, in early 2022, CDPH was finally able to provide approval for us to use STD grant funding in an agreement with WellPath for this project.

The agreement took several months for review by both legal departments of Yuba County and WellPath, but finally in September 2022, the agreement was executed upon approval by the Yuba County Board of Supervisors. The agreement is for $156,838 for WellPath to render STDs opt-out testing from July 1, 2022 to June 30, 2024.

The overall goal of this project is to reduce the disproportionate burden of STDs within Yuba County Jail inmates and by extension to address the STDs epidemic in our community.

Monthly data are submitted to Yuba County Public Health by the health services administrator for WellPath (ex: data from 10/1/22-10/31/22) through a password protected SurveyLink comprised of the following questions:

·       Number of inmates booked in a 30 day period

·       Number of inmates tested for chlamydia, gonorrhea, and syphilis in a 30 day period

·       Number of inmates who tested positive for chlamydia, gonorrhea, and syphilis in a 30 day period

·       Number of inmates who tested positive and treated for chlamydia, gonorrhea, and syphilis in a 30 day period

Once the monthly data survey is completed by WellPath, the results are analyzed by our infectious diseases epidemiologist. In the few months of the opt-out implementation, we have seen remarkable results. Of the new inmates coming into the Jail, from 13-20% of new inmates have agreed to STDs testing. Of those who agreed to testing, the test positivity rate for chlamydia and gonorrhea was 7-9% and the test positivity rate for syphilis was 7-13%. All positive cases were successfully treated fully within the Jail.

We meet on a monthly basis to discuss the prior month's testing data and use that meeting to identify any needs, gaps, and areas for improvement. For instance after the decline of STD opt-out testing in October 2022, we heard from WellPath that inmates were concerned that the test samples would be utilized for drug testing, in addition to STDs. Upon hearing that, our team was able to draft scripted messages to provide to WellPath staff to reassure inmates that these tests can only be utilized for its intended purpose and no drug testing can be done without the inmates' consent.

The STD grant funding is through mid-2025 so we are confident the STD opt-out testing program can continue until at least then. In addition, California is embarking on an ambitious program called California Advancing and Innovating Medi-Cal (CalAIM), an initiative to fully transform the delivery of Medi-Cal (Medicaid) services. Since its implementation in early 2022, CalAIM has allowed for Medi-Cal payments for services that we all in public health already do but were never reimbursed for such as community supports to address housing access, housing tenancy, and enhanced care management. Pending approval of a Centers for Medicare and Medicaid Services (CMS) 1115 waiver, CalAIM's enhanced care management and community support services will be implemented within correctional facilities throughout California. We are cautiously optimistic that when CalAIM is implemented for the justice-involved population, this will allow us to transition away from STD grant funding to Medi-Cal billing.