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Case Review: Finding and Fixing Missed Opportunities
Episode 217th February 2022 • Exploring an Epidemic • Texas DSHS
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Larry Prescott speaks with Karen Surita, DSHS STD program manager, and Amy Carter, Congenital Syphilis Supervisor with Dallas County Health and Human Services. These experts talk about steps Texas takes to understand and reduce congenital syphilis in the areas with the greatest number of cases. They discuss Texas fetal infant morbidity review boards in Houston, San Antonio and Dallas, common barriers to medical care, and missed opportunities to prevent congenital syphilis. They also invite listeners to get involved in the review board in their area.


Larry Prescott 0:00

Welcome to Exploring and Epidemic: Congenital Syphilis in Texas. I'm your host, Larry Prescott. In this podcast series, we'll be exploring what's happening with syphilis and congenital syphilis in Texas through interviews with national and local experts. We’ll talk about babies being diagnosed with congenital syphilis in Texas. And we’ll also discuss how we, as a care community, can address the rising rates of congenital syphilis in Texas. After all, this is a 100% preventable disease with tests and treatment at our disposal if we all do our part.

During this particular episode of this series we want to take an in-depth look at the Fetal Infant Morbidity Review Boards and the social determinants of health impacting congenital syphilis cases in Texas. I have with me today two experts, that are going to discuss these topics and help us to understand how these things are affecting our state of Texas.

Karen Surita 0:55

My name is Karen Surita and I am the STD prevention manager here with the Texas Department of State Health Services. I work with local and regional health departments, to reduce the transmission of STIs including congenital syphilis in Texas.

Amy Carter 1:11

I'm Amy Carter. I am a first line supervisor with Dallas County Health and Human Services. And I actually supervise the congenital syphilis team. I am one of the people that identifies the cases and my team and I are the people that do the investigating in presenting of the FIMR, and help identify the cases through the different risk factors for the moms, and what puts them at greatest risk.

Larry Prescott 1:34

And we talked about the fetal infant morbidity review boards, or we call them, I think, FIMR. What is a FIMR, infant morbidity review board?

Karen Surita 1:43

Well FIMR was created to help communities identify and address missed opportunities associated with syphilis infections in Texas.

There are three components to the FIMR, and they consist of a case review board, which is typically the local health department along with central office staff identifying cases that are of interest to the community. It entails doing some enhanced medical chart abstractions. So looking at pre-pregnancy care, also looking at prenatal care, and then postnatal care, as well as pediatric care that occurred once the infant was delivered.

And then there is a component associated with it, it's a maternal interview. So someone, as part of the core team, goes out and conducts an interview with the mother, and offers any referrals that need to be made. And then once that information is collected, then there is a case review process. And so that's the actual FIMR meeting or workshop where members of the community get together they could be infection control, or infectious disease providers, regular obstetricians or gynecologists are part of the meeting, and then also individuals that work within the local health department, or central office and disease intervention specialists, that participate as well as community members.

Larry Prescott 3:01

Tell me, are there review boards throughout the whole state of Texas? Is it everywhere or is it specific to certain areas of Texas?

Karen Surita 3:08

Actually there are three review boards that we support here at the Texas Department of State Health Services and those areas of Texas were selected because they have the highest rates of congenital syphilis in the state. The Dallas FIMR board, they cover the large metropolitan area in DFW, the Dallas-Fort Worth area. San Antonio Metropolitan Health District also has a FIMR and they also cover the city of San Antonio around Bexar County. And then you also have Houston and they cover the greater area of Southeast Texas, including Houston.

Larry Prescott 3:45

And if you could touch just a little bit more, expound on what FIMR boards are, what you consider to be the main purpose?

Karen Surita 3:54

I think the purpose is to educate individuals about what are missed opportunities and how to make improvements. And most importantly, have community input. The purpose of having the workshop itself is that you invite members from the community, and when I say community I mean people from the medical providers, community-based organizations, or any other agency that really helps to facilitate, and offer assistance to mothers, infants, and children, and then individuals who have a genuine interest in their community and how to make change. And so I think that's the takeaway message, is that this requires involvement from all three aspects of community and engages them. All PHI, or personal health information, is redacted from the case review discussion. You just focus on the facts. Focus on information that was collected, whether it was from a disease intervention specialist, a medical provider, and then also from the mother. What was the mother's experience?

You really have the opportunity to read what someone's interview was like, what their perspective was like as being part of the medical care system. And then also review notes written in a chart about the interaction with the mother. I think that's important and I think that's a really good opportunity to review the entire process. And then as a community member is to give feedback on that process and share what your ideas are and how to intervene and reduce barriers to care.

Larry Prescott 5:22

When you mentioned feedback that prompts me to ask you about outcomes. Are there any expected outcomes from the FIMR review boards?

Karen Surita 5:29

Yes, the FIMR review board is expected to have community action items. These are action items that, collectively, members can contribute to. They could be what we would consider simple examples of provider education, actual outreach conducted by community-based organizations or the local health departments, or even medical providers. And then looking at ways to make changes within an organization.

The organization being a hospital district. It could be the local health department or the regional health department. And then also looking at opportunities to make changes within a system. So it may mean that the community action item is to make a recommendation, a legislative change. Or a way that a hospital may offer testing when a woman of childbearing capacity arrives at an emergency department.

Larry Prescott 6:21

And right, now I want to switch gears and hear from our other special guest today, Amy Carter. Amy, thank you for being here with us today. Karen mentioned missed opportunities and I want to ask you, what are the most common missed opportunities in preventing congenital syphilis here in our state?

Amy Carter 6:41

So the most common missed opportunities that we have been seeing throughout our FIMRs across the state have been late or no access to prenatal care. A lot of times women will go in and have that pregnancy confirmed, but then they don't go back for a prenatal care visit until much later in their pregnancy, if at all. We also have some barriers with timely reporting from either the OB/GYN office or the hospital to the local health authority, and not knowing if a partner was adequately treated or if the pregnant person

themself was adequately treated, because they go based solely off of what their patient says, and they don't call back to the health department and ask if we have any records, if we have any history, what is their status, what did we look at surveillance wise to close out their case.

Larry Prescott 7:25

These missed opportunities, are they all the same, basically across the state or do they differ from FIMR to FIMR?

Amy Carter 7:31

There are some that are the same across the state. So the prenatal care, we see in Dallas, we see in San Antonio, we see in Houston. But, there are some things that are very specific to some of the areas. Whether it's more housing instability in one area or having a higher volume of substance use.

We also have experience with the medical providers. We have training hospitals here in Dallas. So we have newer doctors who maybe don't see it yet and don't know that, you know, the health departments are a resource for them to call them.

Larry Prescott 8:00

I guess you’re sorta relating it to a lack of referrals from a social support system.

Amy Carter 8:04

Yeah. So we see a little bit of those lack of referrals. If it's listed in the medical chart that they got a referral, it's just they told them to call this place. For an example, WIC services is a cold handoff instead of actually helping them make that appointment.

And so there's not that follow-up to actually receiving those services or receiving the services if they need to go to an allergist because they have a penicillin allergy and you can only be treated with penicillin during pregnancy. And so we see those delays in care.

So with the cold handoffs, a little bit of what we do is, as an example, if someone comes into the sexual health clinic, that we're unable to treat and they need to be referred to one of our larger hospitals that has a maternal-fetal medicine clinic, we actually call, schedule their appointment, let them know this is when your appointment is, this is who it's with. And if they have an additional barrier of transportation, our disease intervention specialists will talk to them and say, okay, your appointments on Thursday at 8:00 AM, I'll be at your house at seven to pick you up and they will take them to that appointment and help them get home or help them set a reminder of “you have this appointment, this is what time you need to be there.” Instead of it just being “you need to go to maternal-fetal medicine. And here's the phone number for maternal-fetal medicine.” That appointment is made, and we let them know exactly where they're going and help them get there.

Larry Prescott 9:25

Do you see any situations where time to report them from the health authorities is an issue? Are you get any kickback or resistance?

Amy Carter 9:32

So we get a little bit of resistance because Texas is a dual reporting state. So some of the providers think “oh, the lab already reported it,” they don't have to report it. And they may not have penicillin in their pharmacy at their provider. For us in Dallas, our health department does not treat over 20 weeks. So that creates a delay. If we don't get it timely, we can't even treat them in our clinic. It creates some delays in getting those pregnant people treated. That creates that delay because they think it's already been reported or they think that there's not a lag. And we may have a lag from the state as well. Just because of the nature of our lab import from the databases that we use.

Larry Prescott:

Well, Amy, let me ask you about the barriers to engagement in prenatal care. Have there been any barriers identified through the FIMRs that we can talk about right now?

Amy Carter:

Yeah. One of the barriers to prenatal care that we have identified has been insurance status. And so what we have seen is our pregnant people will go into an OB/GYN’s office, have their pregnancy confirmed, and it'll be six to eight weeks or more before they go in for their first prenatal visit, because they're waiting on Medicaid or they're waiting on their insurance, or they're waiting on the financial side of things to kick in before they're seen at their provider.

We're also seeing the barrier because they maybe have multiple children. This is not their first birth. They didn't have prenatal care with any of their other pregnancies or later in their pregnancies so they don't go in.

The other barrier with prenatal care that we see a lot of is, if they are a substance user, there's a lot of fear around CPS involvement. And so they delay their prenatal care because they think that CPS is going to be called because they are a drug user or they have a substance use disorder. And so there's a fear that their baby is going to be taken. They're going to have a CPS-involved birth. And so they delay that care until they actually deliver.

Larry Prescott:

So we are speaking about maybe a social stigma in this instance and we can classify it as such?

Amy Carter:


Larry Prescott:

Well, Amy, you mentioned something about provider mistrust. Tell me what role does FIMR play in gaining and resolving some of that mistrust.

Amy Carter:

In our FIMRs, we give a voice to our parenting and pregnant people who are diagnosed with syphilis. And so we actually get to hear from them, “this is what was said to me by my provider. This is how I felt, the judgments I may have experienced,” whether it's during prenatal care, with their diagnosis of syphilis during their prenatal care, or if it's while they're in the hospital after they delivered.

You actually hear that person's voice. You hear the things that they feel and that they said that may not even be a conscious and purposeful act, but it's just because of the way that it comes across. We're giving a voice, not only to the provider to be able to say, this is what's in the notes, this is what we see, but also to that person who experienced the diagnosis of syphilis during their pregnancy and having a child that was exposed to syphilis and the things that can be said that may or may not be conscious from their provider or other medical staff. But have that effect on them for why they may not seek care further in their pregnancy or if they get pregnant again.

Larry Prescott:

Karen, I'd like to come back to you and ask you who can participate in these FIMRs?

Karen Surita:

Anyone can participate. You know, this is community-driven. We want to see participants. We want to see medical providers attend the workshops. We want to see individuals from the local health departments, as well as the regional health departments, because Texas is decentralized. And also you want to have individuals who are not only working in the field of STI or even HIV treatment, but individuals who are working in other programs within a health system, such as WIC, like Amy said, or immunizations. Anyone that has access to or works with mothers, infants, and children can participate.

But not only obstetricians or gynecologists, but you want general practitioners to attend and participate. The information that they can share can be helpful to others. And then you also want community members. So we'd like to see

community members participate. Anyone who works in a community-based organization or any organization that could benefit from learning about this information and how it may impact the clients that they serve.

Anyone who may have been a mother and had gone through this experience and continues to be an advocate. And then also, I would say, a partner of someone who's gone through this experience. Anyone from the community can participate, and if you're interested, you can contact your local health department. Typically you would want to contact your STI or partner services program at the local or regional program for more information about FIMR activities in your area.

Larry Prescott:

We know that the more you dig, the more you're going to find. And the follow up on that advisory committee comment that we were making, what avenues are you utilizing to get the information out that people can join and participate in any future FIMRs?

Karen Surita:

We have on our Texas DSHS website, specifically the HIV STD program or STI program, we have a dedicated page to congenital syphilis efforts in Texas. Anyone can easily go to our webpage and search “congenital syphilis” and you will find additional information about the FIMRs, the dates and the times, and how to sign up. Again, you can contact your local health department by calling them and their congenital syphilis expert or a program manager can easily refer you to the proper contact person to sign up for the FIMR workshop.

Larry Prescott:

Before we conclude this, what message would you want to leave to listeners on our podcast today in regards to the FIMR review boards?

Amy Carter:

The message that I'd like to give to our listeners is that there's a lot of really good information that we share in this FIMRs. Its great for building the links between providers and between the health department. Like Karen has said, pick up the phone, give us a call. We are here as a resource. We would be more than happy to assist you and the more that we talk about this, the more that we know about it, the more it's easier to recognize, and we can get these babies treated before they're born.

Karen Surita:

FIMRs are an opportunity to continue to network with other providers, peers, but also just network with individuals who can assist your clients, can assist your patients, and deliver the best care for our community. And I think that’s the important thing about FIMR, is that it's a group that meets quarterly, but there's a lot of information that comes out of it with actionable items that can be impactful. And so that networking is also extremely important as we continue the work in each of these areas to work to decrease the number of congenital syphilis cases in Texas.

Larry Prescott:

I want to thank our guests Karen Surita and Amy Carter for joining us today to discuss these congenital syphilis aspects and the social determinants that are impacting congenital syphilis here in the state of Texas. And we ask our audience to join us as we continue our podcast.

Exploring an Epidemic: Congenital Syphilis in Texas was developed by the Texas Department of State Health Services in collaboration with the Denver Prevention Training Center.