Welcome! MSHO Pneumococcal Performance Improvement Project. Objectives for Training. History. Pneumococcal Vaccination

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1 MSHO Performance Improvement Project March 3 26 & April 6, 26 Project Overview March 3, 26 & April 6, 26 Welcome! Introductions Food/Facilities Project Overview CEU s Evaluations 1 2 Objectives for Training History Understand the Performance Improvement Project (PIP) process Increase knowledge of the importance of pneumococcal vaccine (PPV) for MSHO members Understand the PPV administration protocol and the options available Understand the Care Coordinators role and documentation requirements for the project CMS requirement for Medicaid programs administered by states Annual program Must be approved by DHS in collaboration with MPRO Program must demonstrate sustained statistical improvement Several health plans may work together on MSHO projects UCare, Medica, and MHP 3 4 Rationale for choosing disease causes approximately 4, deaths Vaccination MSHO Performance Improvement Project each year in this country [1] 5% of unvaccinated elderly didn't know they need PPV 59% say their provider didn t recommend it 47% believe they are not likely to get pneumonia [2] In 24, 67.9% of Minnesotans reported having received the Kristin L. Nichol, MD, MPH, MBA Professor of Medicine, University of Minnesota Chief of Medicine, Minneapolis VA Medical Cente Chair, MCAI pneumococcal vaccination [3] Claim rate from the Health Plans in estimated to be low 2% 5 6 1

2 Bottom Line Annual Disease Burden disease is one of the big two vaccine preventable diseases The elderly and other chronically ill persons are at increased risk Vaccines are safe, effective, and underused Evidence-based strategies can help us improve Community-acquired pneumonia Etiologic agent in 25% to 5% of cases Case fatality rates in persons hospitalized with positive sterile site culture 13% to 23% in elderly 18% with comorbidities (vs 5% without) Invasive disease (US) Bacteremia 5, cases Meningitis 3 cases Feikin DR et al. Am J Public Health. 2;9: MMWR 1997; 46 (RR-8). CXR: Pneumonia Gangrene from Bacteremia Risk Factors for Invasive Disease Adults Ages 18 to 64 Years Risk Factors for Death Due to Invasive Disease Factor Male sex Black race Chronic illness Current smoker Children in daycare < 6 yrs old Nuorti JP. NEJM 2; 342: 681. Odds Ratio (95% CI) 2.7 ( ) 3.4 (2. 5.6) 2.6 ( ) 4.1 ( ) 3. ( ) Disease Cirrhosis Congestive Heart Failure Diabetes Chronic Lung Disease Asplenia AIDS HIV without AIDS Solid Organ Malignancy Hematologic Malignancy Feikin DR, et al. Am J Public Health 2; 9: Relative Risk (95% CI) 5.8 (3.7, 9.2) 4.7 (3.3, 6.7) 2.9 (2., 4.3) 2.8 (1.9, 4.) 3.2 (1.1, 9.3) 2.3 (1.5, 3.6) 1.1 (.6, 2.) 3.7 (2.5, 5.4) 2.2 (1.2, 4.3) 2

3 & Diseases are the Big Two Causes of VPD Deaths Cases & Deaths, US Disease Hepatitis A Hepatitis B Measles Mumps Rubella Pertussis Tetanus Cases (millions) (millions) 282,65 146,644 6,189 24, , Deaths > 5, ~ 12, MMWR 21; 48 (RR-53); Thompson et al. JAMA 23; 289: 179; Feikin DR, et al. Am J Public Health 2; 9: % in the elderly 11k from (actual is 5x to 1x higher) VPD s Take the Highest Death Toll Among Adults Annual VPD Deaths Adult Childhood VPD = Vaccine Preventable Disease Source: CDC, IOM Adults: 99% of VPD Deaths 3, to 7, deaths each year Children: 1% of VPD Deaths 1 to 3 deaths each year VPD Deaths in Adults are Similar to Other Important Causes of Death in Adults PPV Protects Against 23 Invasive Disease Serotypes in Adults 1, 2, 3, 4, 5, 6, 7, Most Common Serotypes Invasive Pneumo Disease, US 1998 VPD's Adults Colorectal CA Breast CA Prostate CA Suicide Parkinson's HIV Range of VPD deaths in adults Serotypes in vaccines 7-valent 9-valent 11-valent All Ages (n = 361) 62.% 64.5% 7.6% < 2 (n = 735) 82.2% 82.6% 83.5% 2 64 (n = 1844) 57.2% 61.% 68.4% 65+ (n = 131) 56.2% 58.% 65.3% VPD's Kids 23-valent 88.1% NA 88.2% 85.9% Source: CDC, NCHS (online data for 2). Robinson KA, et al. JAMA 21; 285: Effectiveness of PPV Against Invasive Disease Safety and Acceptability of PPV in NTS Overall Patients with: Diabetes CV disease CHF COPD Anatomic asplenia Immunocompetent elderly Butler JC. JAMA. 1993;27: % (45% to 66%) 84% (5% to 95%) 73% (23% to 9%) 69% (17% to 88%) 65% (26% to 83%) 77% (14% to 95%) 75% (57% to 85%) Survey of 636 / 1136 (56%) elderly persons vaccinated in MN MVNA Clinics Post Vaccination Control Period P Systemic Symptoms Fever Under the weather Muscle aches URI Symptoms Cut down on usual activities Overall health Same as usual Better than usual Worse than usual Any Local Symptoms D Heilly S et al. Am J Infect Control. 22;3:261. 3% 2.2% 1.4%.9%.6% 94.8% 2.4% 2.8% 23.1%.3% 4.2% 3.6% 5.8% 2.8% 92.%.6% 7.4% < <.1 <.5 <.1 3

4 Safety of Revaccination Safety and Acceptability of PPV in NTS Occurrence of sizeable local reaction 11% (revacc) vs 3% (initial vacc) RR = 3.3 (95% CI ) Days to resolution Median = 3 days * Jackson et al. JAMA 1999; 281: 243. Local redness or swelling higher w/ re-vaccination (p =.1) Re-vacc: 13.1% First time: 4.4% Unsure: 1.4% In multivariate analyses: Local symptoms fever (OR 13.15, P <.1) Re-vaccination local symptoms (adjusted OR 3.77, p <.1) Patient satisfaction: Very convenient: 96.2% Very satisfied: 97.% Would recommend to family/friend: 99.4% D Heilly S et al. Am J Infect Control. 22;3:261. Target Groups for & Vaccinations PPV -- Revaccination Vaccinations High priority groups High risk Likely to be high risk People who can transmit Others may also be vaccinated Frequency: annual Vaccinations High priority groups High risk Frequency Generally 1x Revaccination Once if > 65 now & previously vacc > 5 yrs ago when < 65 Others Antibody levels decline over 5 to 1 years Polysaccharide antigens do not induce immune memory Revaccination Increases antibody levels (but no anamnestic response) Recommended after 5 years for Asplenia, immunocompromised, if >= 65 and < 65 when 1 st vaccinated MMWR 23; 52 (RR-8); MMWR 1997; 46 (RR-8) and Vaccination Rates Are Still Too Low Disparities by Age: & Vaccination of High Risk Persons, 23 Percent Vaccinated Flu 65+ Pneumo 65+ Flu 5 to Goal Elderly Diabetes < 65 Asthma < MMWR 21;5(25): ; NHIS ( 1, 3, Jan Jun 4). MMWR 24; 53: 17 4

5 Disparities by Race: & Vaccination of Elderly Persons, 24 Vaccination Rates of Persons 65+, 24 BRFSS Hispanic White Black Ave: 67.8 Best: 78.8 (CO) MN: NHIS early release estimates, Jan Jun 24 Ave: 64.5 Best: 71.6 (MT) MN: 67.9 Improving Vaccination Rates Provider Issues Provider Recommendation Can Overcome Negative Attitudes Among Patients Vaccination Rates Among HR Patients With Negative Attitudes Know the facts Recommend vaccinations to your patients Get organized & use systems approaches Ensure offering & administration of vaccine Automatic processes that empower nurses are effective Address convenience, efficiency, durability Evaluate & provide feedback Consider new paradigms Vaccination Rate (%) PPV No MD Recommendation MD Recommendation Nichol KL et al. J Gen Intern Med. 1996;11:673. Improving Vaccination Coverage Task Force on Community Preventive Services Standing Orders Are Among the Most Effective Strategies Increase demand Patient reminders Multifaceted programs including education Regulation Enhance access Reduce cost Walk-in clinics Address provider barriers Reminders / Feedback Standing orders & policies Nonphysicians offer and administer vaccinations No direct MD involvement at the time of the visit Established with physician approved policies and protocols Locations: Clinics, hospitals, and nursing homes MMWR 1999; 48 (RR-8) MMWR 2; 49 (RR-1) 5

6 Standing Orders More Effective than Education or MD Reminders for Inpatients Inpatient Computer-Based Standing Orders vs. MD Reminders Percent of Inpatients Offered Vaccine By Type of Intervention 1 Percent Percent Vaccinated MD Education MD Reminder Standing Orders Reminder Standing Order Crouse B, et al. J Fam Pract 1994; 38: 258. Dexter PR et al. JAMA 24; 292: Standing Orders Programs for & Vaccinations in LTCFs 1999 Survey of Generalist and Medical Subspecialty MDs Percent of LTCFs SOP 93 7 PPV No SOP N = 1874 / 5858 Use systems strategies to promote vaccination (patient reminders, special clinics, or standing orders) Generalists Very strongly recommend vaccinations to elderly patients 86% 81% <3% <3% Medical Subspecialists 75% 64% <2% <2% Shefer A, et al. J Am Med Dir Assoc 25; 6: Nichol KL. Arch Intern Med. 21;161:272. Multifaceted Program Improved Success & Sustainability Standing Orders as Part of a Multifaceted Vaccination Program Increase Demand Enhance Access Address Provider Barriers Annual reminder to pts Walk-in Clinics Institutional Policy Standing Orders Standardized Forms Efficient Clinic Flow Ongoing Measurement & Evaluation Nichol. Am J Med 1998; 15:

7 Ramsey Lake Bottom Line disease is one of the big two vaccine preventable diseases The elderly and other chronically ill persons are at increased risk Vaccines are safe, effective, and underused Evidence-based strategies can help us improve This project is important. It will make a difference! Internet Resources CDC s National Immunization Program CMS Immunization Action Coalition MN Dept of Health Stratis Health MIIC Minnesota Immunization Information Connection presented by Karen White Epidemiologist/Business Analyst 4 Minnesota Immunization Information Connection A statewide network of regional immunization services Kittson Roseau Lake of the Woods Marshall Beltrami Polk Pennington Red Lake Clear Water Koochiching Itasca St. Louis Cook MIIC Objectives for 12/31/25 Norman Mahnomen Hubbard Cass Clay Becker Aitkin Crow Otter Wadena Wing Carlton Wilkin Tail Pine Todd Mille Lacs Grant Douglas Morrison Kanabec Traverse Benton Stevens Pope Stearns Big Sherburne Isanti Chisago Stone Swift Kandiyohi Anoka Wright Washington Lac Chippewa Meeker Qui Parle Hennepin 1 Renville McLeod Carver Yellow Medicine Scott Dakota Sibley Lincoln Redwood Le Goodhue Lyon Nicollet Rice Sueur Wabasha Brown Murray Blue Earth Dodge Pipestone Cottonwood Waseca Watonwan Steele Olmsted Winona Rock Nobles Jackson Houston Martin Faribault Freeborn Mower Fillmore Central Minnesota Immunization Connection (CMIC) Communities Caring for Children (CCC) Community Health Information Collaborative (CHIC) ImmuLink/Metro Registry Immtrack For more information, miichelp@health.state.mn.us at the Minnesota Department of Health. Southeast Minnesota Immunization Connection (SEMIC) Southwest Minnesota Immunization Information Connection (SW-MIIC) May Objectives 1% of local health departments 65% of primary care providers 75% of children -5 years of age with 1+ shots Status 1% of local health departments 72% of primary care providers 69% of children -5 years of age 7

8 Number of Clients 3,5, 3,, 2,5, 2,, 1,5, 1,, Clients in MIIC from July 23 through February 3, 26 Total Clients Clients with 1+ shots Clients with 2+ shots Deaths excluded Across the lifespan Proportion of MIIC Clients* by Age Group February 3, yrs 12% -1 yrs 4% 2-5 yrs 9% 5, Jul-3 Oct-3 Jan-4 Apr-4 Jul-4 Oct-4 Date Jan-5 Apr-5 Jul-5 Oct-5 Jan yrs 44% 6-2 yrs 31% * with one or more shots Across the lifespan Median Number of Shots per Person by Age Group February 3, 26 Median Number of Shots Age Group

9 Project Goal Improve pneumococcal immunization rate by 5% for MSHO community members Create permanent record in MIIC of pneumococcal (PPV) status members that have received the vaccination

10 Implementation Measurement Assess every community member for PPV vaccination Overall Rate status Provide member education Baseline - estimate low 2% Measure 1 Q1, Understand the protocol for vaccination recommendations Determine the most appropriate method for member to receive vaccination Share data with MIIC (Minnesota Immunization Information Connection) for permanent record in the immunization registry 56 Sustained remeasure 1 Q1, 28 Sustained remeasure 2 Q1, 29 Process Measures Self-report, refused, contraindicated, home visit, community clinic, claim + MIIC rate, etc. Project Timeline ICSI Guideline for Pneumoccocal administration 3/31/9 Sustained Remeasure 2 3/3/6 3/31/7 3/31/8 Go-Live First Measurement Sustained Remeasure 1 Project complete 1/1/7 1/1/8 1/1/9 3/3/6 6/3/9 Vaccine (PPV 23) Years 4-64 Years Immunize high-risk groups once. Re-immunize those at risk of losing immunity after 5 years. 65 Years and Older Immunize at 65 if not done previously. Re-immunize if 1st received >5 years ago and before age Intervention Options Intervention Options Health Care Clinic Primary means for members to get their PPV administration Clinics may share vaccine status with MIIC Home visit Frail and elderly MVNA available for referral throughout state Health plans will coordinate process with MVNA If using alternative Home Health Agency, you will need to coordinate and inform Health Plan of

11 Intervention Options Expectations 61 Community Clinic Community clinics offered throughout state by MVNA (during flu season) Project will be evaluating need for hosting community clinics for ethnic populations and provide as needed State Fair! Check in your community for additional opportunities 62 Action list sent to primary Care Coordinator (CC) contact One time list of members who have been vaccinated Ongoing (every other month) list of members who have no claim from Health Plan CC s use list and MIIC registry to help determine who may need PPV Real-time report to health plan of home visits/mvna referrals CC s report back electronically on assessment results and status Health Plans update database with CC and claim data and send out updated list MSHO PIP Begins PPV Process Flow Q1, 26 Health plans identify eligible study group members through admin. claims data pull HP creates a list of all members who are currently eligible and have NO RECORD of a valid PPV Data analyst or project lead loads members into project database Project lead splits the list and distributes them to care system/ county Care coordinators contact member during the next assessment or at next visit Cross check list of eligible study members with MIIC database MIIC sends data back to health plans to enhance admin. claims data Care System/County lead divides and distributes lists to appropriate care coordinator Member Reached? Yes No Care Coordinator continues efforts until member is contacted Member does not recall whether or not they received pnuemococcal vaccine. Declines Member interviewed, has not had pnuemococcal vaccination. Declines Member interviewed and recalls having pneumococcal vaccination, Declines Member does not recall whether or not they received pnuemococcal vaccine. Accepts Member interviewed. Has not had pnuemococcal vaccination. Accepts Health Plan Expansion Counties Medica (11) UCare (28) Medica & MHP (1) UCare & Medica (2) UCare & MHP (1) Medica, MHP, UCare (4) Member refuses Remains in study denominator Care coordinator refers member for PPV Yes No Document why not and forward to HP for tracking Home health agency sets up home visit Home health agency is contacted with lists of those consenting to Member referred for home care visit Member referred to community clinic Member referred to primary care Member home? Yes Is member vaccinated? No Document why not and forward to HP for tracking No Yes Member placed in queue for another attempt Health plan is billed 64 Second attempt, member not home, is considered refusal for Completed s counted in measurement year and data sent to MIIC Action List Mock up 65 11

12 Reporting Cycle Questions? Care Coordinator send to the health plan Health Plan send to the Care Coordinator 67 May 1 May 15 July 1 July 15 September 1 September 15 November 1 November 15 January 1 January 15 March 1 March 15 May 1 May 15 Etc. 68 Internet Resources VIS (vaccine information statement) PPV administration guideline look for the adult preventive guideline CDC s National Immunization Program CMS Bibliography [1] Texas Department of Health. Accent on Health. Vaccinations Can Prevent Unnecessary Illness or Death. August 17, 1998; online at [2] U.S. Department of Health and Human Services. Research Activities. Researchers Examine Accuracy of Patient Reports of Vaccination as well as Vaccination Barriers and Facilitators Among Seniors. August 23. [3] National Center for Chronic Disease Prevention & Health Promotion Behavioral Risk Factor Surveillance System online at Immunization Action Coalition MN Dept of Health