Tribal Health Care Workers Knowledge, Attitudes, and Practices Tribal Health Immunization Workgroup Project Report February 2012 to March 2013

Transcription

1 2013 Tribal Health Care Workers Knowledge, Attitudes, and Practices Tribal Health Immunization Workgroup Project Report February 2012 to March 2013 Serving and supporting Tribal and Urban Indian Health AMERICAN INDIAN HEALTH COMMISSION FOR WASHINGTON STATE 3/31/2013 American Indian Health Commission Page 0

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3 The American Indian Health Commission (AIHC) for Washington State is a Tribally-driven non-profit organization with a mission of improving health outcomes for American Indians and Alaska Natives (AI/AN) through a health policy focus at the Washington State level. AIHC works on behalf of the 29 federally-recognized Indian Tribes and two Urban Indian Health Organizations (Urbans) in the state. The AI/AN population continues to experience the poorest health outcomes and highest overall mortality rates than any other population in Washington. AIHC serves as a forum where a collective Tribal government voice is shaped on shared health disparity priorities and Tribes and Urbans then work collaboratively with Washington State health leaders, the Governor s office and legislature to address these priorities. The Commission s policy-work improves individual Indian access to state-funded health services, enhances reimbursement mechanisms for Tribal health programs to deliver their own, culturally-appropriate care and creates an avenue for Tribes and Urbans to receive timely and relevant information for planning purposes on state health regulations, policies, funding opportunities, and health-specific topics. By bringing state and Tribal partners together, specific health disparity priorities can be addressed across multiple systems pooling resources and expertise for greater health outcomes. Tribal Health Immunization Workgroup Cynthia Gamble, MPH, CTG Coordinator, Chehalis Tribe Elizabeth Sachse, RN, PHN, Indian Health Services, Spokane Tribe Frank James, MD, Nooksack Tribe Jan Ward Olmstead, MPA, Public Health Consultant, American Indian Health Commission for Washington State Kim Zillyett, Health Director, Shoalwater Bay Tribe Marilyn Scott, Chairwoman, American Indian Health Commission for Washington State and Vice Chair of Upper Skagit Tribe Marsha Crane, Consultant, American Indian Health Commission for Washington State Mary M. Varco, RN, Lummi Tribe Sheryl Lowe, (former) Executive Director, American Indian Health Commission for Washington Thomas Weiser, MD, MPH, Indian Health Services Toni Lodge, Executive Director, Spokane NATIVE Project Wendy Stevens, MNPL, MSS, DOH Tribal Immunization Liaison Alan Harney, Tulalip Tribe American Indian Health Commission Page 2

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5 Table of Contents I. INTRODUCTION... 1 A. Project Description... 1 B. Project Timeline... 2 C. Development Team: Project Leads: Design/Project Team Tribal Health Immunization Workgroup... 3 II. DEVELOPMENT AND METHODOLOGY... 4 III. FINDINGS... 6 A. Part 1: Health Care Workers and Providers Individual Knowledge, Attitudes and Practices B. Part 2: Administrative Leadership Organizational Administrative Practices and Policies IV. REVIEW AND FEEDBACK A Tribal Leaders Health Summit B. Review of Final Report V. KEY FINDINGS A. Part 1: Health Care Workers and Providers Individual Knowledge, Attitudes and Practices B. Part 2: Administrative Leadership Organizational Administrative Practices and Policies C. Challenges/Lessons Learned VI. RECOMMENDATIONS VII. NEXT STEPS: VIII. ATTACHMENTS Attachment A - Graph 1: Project Timeline Attachment B Marilyn Scott, Chairwoman of AIHC, September 18, to participants Attachment C to extend the survey deadline Attachment D Survey Instrument Attachment E Model Tribal-State Collaboration: Address Immunizations as a Priority Health Disparity through Tribally-driven Processes: A Ten Year Continuum and Partnership Attachment F Tribal Health Care Worker Immunization Hesitancy-Initial Findings American Indian Health Commission Page 4

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7 I. INTRODUCTION The American Indian Health Commission of Washington State (AIHC) and the Washington State Department of Health (DOH) work jointly to address immunizations as a priority health disparity through Tribally-driven processes. Nationally health care worker vaccine hesitancy is a key factor impacting health care worker immunization rates. Specific to Washington State, the health care worker immunization hesitancy project direction was developed from the AIHC Tribal Health Immunization Workgroup (THIW) project of , the Healthy Communities: A Tribal Maternal-Infant Health Strategic Plan, the H1N1 pandemic influenza lessons learned and post-pandemic review, and Tribal health leadership discussions. AIHC identified health care worker immunization rates as a key project in The DOH Office of Immunization and Child Profile (OICP) identified competitive funding for this project and AIHC joined them through a letter of support. Subsequently, the Centers for Disease Control funded the project to improve immunizations for Tribal health care employees in Washington State. Funding was made available through the Affordable Care Act (ACA), All work has been accomplished in partnership between the AIHC and OICP staff and the THIW. A. Project Description Studies show that American Indians and Alaska Natives are impacted the most by illnesses that could have been prevented through proper immunizations. This has raised the issue of Vaccine Hesitancy for Health Care Workers and the following identified challenges: 1. Complacent providers, particularly during the H1N1 breakout, were a problem in some Tribal health clinics. At one Tribe, only one Tribal health provider said he would take the HIN1 immunization. What kind of message do complacent providers give to the Tribal patients? 2. Why aren t Tribal health care workers/providers getting immunizations? American Indian Health Commission Page 1

8 3. Health care workers in some Tribal clinics are not current and there is no policy for health care workers to be current on immunizations. 4. The challenge of assuring vaccine safety is increasing (e.g., live versus inactive). 5. Tribes can get caught up in debating why it is that immunizations are important. This project addresses health disparities issues by focusing on two objectives identified in recommendations made by the THIW convened in The objectives identified are: 1. Improve the immunization rates for Tribal health care employees in Washington State; and 2. Improve utilization of Tribal immunization information systems (i.e., RPMS or Child Profile) to support health care worker vaccination. Four key components have been identified as part of the project: 1. Identify health care work immunization best practices, policy development, and potential local solutions; 2. Conduct assessment on Tribal health care workers knowledge, attitudes, and practices; 3. Identify strategies, including how evidence-based strategies can be utilized, to address immunization barriers; and 4. Make strategic recommendations. B. Project Timeline The health care worker immunization hesitancy project began in February of 2012 and concluded March 31, See Attachment A - Project Timeline. The final report will be presented to the American Indian Health Commission delegates at the April 18, 2013 meeting. American Indian Health Commission Page 2

9 C. Development Team 1. Project Leads Jan Ward Olmstead, MPA, Public Health Consultant, AIHC Wendy Stevens, MNPL, MSS, DOH Tribal Immunization Liaison 2. Design/Project Team Jan Ward Olmstead, MPA, Public Health Consultant, AIHC Marsha Crane, Consultant, AIHC Sheryl Lowe, (former) Executive Director, AIHC Wendy Stevens, MNPL, MSS, DOH Tribal Immunization Liaison 3. Tribal Health Immunization Workgroup Cynthia Gamble, MPH, CTG Coordinator, Chehalis Tribe Elizabeth Sachse, RN, PHN, IHS, Spokane Tribe Frank James, MD, Nooksack Tribe Jan Ward Olmstead, MPA, Public Health Consultant, AIHC Kim Zillyett, Health Director, Shoalwater Bay Tribe Marilyn Scott, Chairwoman, AIHC and Vice Chair of Upper Skagit Tribe Marsha Crane, Consultant, AIHC Mary M. Varco, RN, Lummi Tribe Sheryl Lowe, (former) Executive Director, AIHC Thomas Weiser, MD, MPH, IHS Toni Lodge, Executive Director, Spokane NATIVE Project Wendy Stevens, MNPL, MSS, DOH Tribal Immunization Liaison Alan Harney, Tulalip Tribe American Indian Health Commission Page 3

10 II. DEVELOPMENT AND METHODOLOGY The AIHC conducted this project to learn about 1) the knowledge, attitudes, and practices of health care workers and 2) the organizational and administrative practices and policies regarding immunizations. The purpose of collecting this data was to identify barriers, opportunities and strategies to improve public heath practice and programs. The project is funded by CDC and is part of the ACA s Collaborative Agreement to improve health care employee immunization rates. The survey questions were drafted and designed through a Tribally-driven process. Issues that informed the development of the survey were first identified by the THIW in activities. The project/design team drafted the first set of questions based on history and research in best practices addressing health care workers immunization hesitancy. The draft questionnaire was presented to the THIW at its April 27, 2012 meeting for review and input. It was then presented to the AIHC delegates at their June 8, 2012 meeting for review and input by June 21, The CDC reviewed the draft questionnaire in July and provided feedback and suggestions. An update on the survey development and project were presented at the AIHC meeting on August 10, The THIW agreed at the April 27, 2012 THIW meeting to survey all Tribal and Urban Health Clinics in Washington State. In August, Indian Health Services (IHS) informed the project leads that they had developed a similar survey and it had been approved by the Portland Area IHS Institutional Review Board (IRB). This raised two issues 1) a revision of the targeted survey sites, and 2) clarification that appropriate protocol and methods were in place for the AIHC survey to be conducted. A number of discussions followed to determine the distinctions between the two surveys, the targeted participants, and to ensure appropriate methods were in place to conduct the survey. This project did not require IRB review as determined by CDC. The survey was administered for the purposes of informing the project and improving public health practice. The THIW met on September 7, 2012 to finalize the survey and the dissemination plan. It was determined that the AIHC survey would be distributed to Washington American Indian Health Commission Page 4

11 State Tribal Clinics and Urban Indian Health Clinics, except for the three IHS direct care facility sites that would be included in the IHS survey. Following the decision regarding the survey distribution, there was a discussion about entering into a data sharing agreement between the NPAIHB and AIHC to have the ability to share data collected from the surveys; however, the timeframe did not allow for this to occur before the survey was conducted. The appropriate timing to enter into an agreement was at the inception of the project. The survey instrument was disseminated in an from Marilyn Scott, Chairwoman of the AIHC, on September 18, 2012 (Attachment B). It was distributed to Tribal and Urban Indian health clinic directors. The survey instrument (Attachment D) was designed and administered using Survey Monkey. The survey was open for response from September 18, 2012 to October 2, 2012 initially. The deadline was extended to October 19, 2012 in an dated October 2, 2012 (Attachment C). Additional follow up contacts were made from October 2 to October 12, 2012 through direct phone calls to clinic directors. This enabled questions regarding the purpose of the survey to be discussed with the clinic directors on an individual basis which raised the level of participation in the survey. There were a total of 89 participants in Part 1: Focus on Health Care Workers and Providers Individual Knowledge, Attitudes and Practices. Thirteen of the 89 participants also participated in Part 2: Focus on Administrative Leadership Organizational Administrative Practices and Policies. Note: The use of the word participants means total individuals that participated in the survey. The use of the word respondent means individuals that responded to a particular question. American Indian Health Commission Page 5

12 III. FINDINGS The findings in this report include two parts. Part 1: Health Care Workers and Providers Individual Knowledge, Attitudes, and Practices. All 89 survey participants were asked to respond to questions to learn the perspective of both health care workers and administrative leadership. Part 2: Administrative Leadership Organizational Administrative Practices and Policies. 13 of the 89 participants were asked to respond to the survey questions limited to administrative leadership to learn about implications of management and policies. A. Part 1 Health Care Workers and Providers Individual Knowledge, Attitudes, and Practices All 89 participants work in clinics in Washington State and identified their site as 67 Tribal Health Facilities, 11 Indian Health Facilities, 9 Urban Indian Health Facilities and 2 other. (Q1-3). Respondents indicated that most clinics serve all age groups as indicated in Graph participants answered and three skipped the question (Q4). 86 respondents said that vaccines are administered in their clinic. 2 participants skipped the question (Q5). Graph 2: Age Groups Served by Clinics 90 Age Groups Served by Clinics Early Children (birth to 6) Children and Adolescents (7-13) Teens (14-18) Pregnant Women Adults (19-64) Elders (65 plus) Yes No Unsure American Indian Health Commission Page 6

13 Respondents identified themselves as serving in the following roles by title as indicated below in Table A. 82 participants answered and 7 skipped the question (Q22): Table A: Titles of Respondents Title Number Survey Health Director 4 Parts 1&2 Social and Health Director 2 Parts 1&2 Medical Director 1 Parts 1&2 Clinic Director 8 Parts 1&2 Physician 4 Part 1 Nurse Practitioner 4 Part 1 Physician Assistant 1 Part 1 Nurse Case Manager 2 Part 1 Nurse (RN) 17 Part 1 Nurse (LPN) 9 Part 1 Certified Nurse Assistant (CNA) 1 Part 1 Medical Assistant (MA) 10 Part 1 Receptionist/Clerk 2 Part 1 Community Health Representative 4 Part 1 Other 18 Part 1 Over 71%of the respondents report they always get an annual flu shot indicated in Graph 3. The other 29% sometimes or never get an annual flu shot (Q6). Graph 3: Do You Get an Annual Flu Shot? Do You Get an Annual Flu Shot? I always get the annual flu shot 71.3% (62) I sometimes get a flu shot (skip to Question 8) 14.9% (13) 13.8% (12) I never get a flu shot (skip to Question 8) 0% 10% 20% 30% 40% 50% 60% 70% 80% American Indian Health Commission Page 7

14 The top reasons that 71.3% of the respondents that get an annual flu shot chose to do so are 1) to protect their families and friends, 2) to protect their patients, and 3) to protect themselves indicated in Graph 4 (Q7). Participants were asked to select all reasons that applied; therefore, totals are equal to more than 100%. 61 participants answered and 28 skipped the question. Graph 4: Reasons Respondents Always get an Annual Flu Shot Reasons Respondents Always get an Annual Flu Shot My employer requries me to be vaccinated To avoid missing work 16.4% (10) 41.0% (25) Vaccine was offered free of charge To protect patients To protect my family and friends To protect myself 32.8% (20) 82.0% (50) 90.2% (55) 80.3% (49) (Participants checked all reasons that applied) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100% About 15% of the respondents sometimes get an annual flu shot and 14% never get an annual flu shot; totally 29%. The 29% that reported the reasons that they do not get shots are indicated in Graph 5. Participants were asked to check all reasons that applied; therefore, totals equal more than 100%. Additional reasons given were: I don t like shots, I m healthy, personal reasons, and never had one why start now. (Q8). 21 respondents answered. Graph 5: Reasons Respondents Choose not to Get an Annual Flu Shot Reasons Respondents Choose not to Get an Annual Flu Shot It is not offered at my workplace Hard to get/not always available It makes me sick or gives me the flu I am concerned about the side affects I don't think it works I sometimes forget to get a flu shot It is not required for my job 4.8% (1) 4.8% (1) 9.5% (2) 9.5% (2) 19.0% (4) 23.8% (5) 38.1% (8) (Patricipants check all reasons that applied) 0% 10% 20% 30% 40% 50% American Indian Health Commission Page 8

15 Approximately 75% of the respondents indicated that they got a flu shot last flu season; 24% chose not to get a shot as indicated in Graph participants answered and 2 skipped the question (Q9). Graph 6: Did You Got a Flu Shot Last Flu Season? Did You Get a Flu Shot Last Flu Season? (September 2011 to March 2012)? Don't remember (skip to Question 11) 1.1% (1) No (skip to Question 11) 24.1% (21) Yes 74.7% (65) 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% The 74.7%, who indicated they got a flu shot last season, were asked what the single most important reason was. The top reasons were: 1) to protect me from getting the flu and 2) it helps me from giving the flu to patients indicated in Graph participants answered and 33 skipped the question (Q10). Graph 7: Single Most Important Reason for Getting the Flu Shot Single Most Important Reason for Getting the Flu Shot It helps prevent me from giving the flu to patients 30.4% (17) It helps protect me from getting the flu 48.2% (27) It is highly recommended for my role in the clinic 17.9% (10) It is required for my job 3.6% (2) 0% 10% 20% 30% 40% 50% 60% American Indian Health Commission Page 9

16 79% of the respondents reported what they tell patients about flu shots as indicated in Graph 8. None of the respondents indicated that they discourage patients from getting flu shots. 70 participants answered and 19 skipped the question (Q11). Graph 8: What Health Care Workers tell Patients about getting Flu Shots What Health Care Workers tell Patients about Getting Flu Shots I discourage patients from getting flu shots I offer it but don't push it I offer it to those who need it most I recommend that all my patients receive an annual flu shot I insist they get a flu shot 4.3% (3) 14.3% (10) 27.1% (19) 78.6% (55) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Additionally, 29 respondents answered a question about whether they recommend or do not recommend flu vaccines and why. The question required a narrative response. Of the 29 that answered the question: 26 recommended that patients get an annual flu shot mostly for protection of patients, community, and children and elders. Three did not recommend either way, but believe it is important to inform patients so they can make their own decision. Sixty participants skipped the question (Q12). American Indian Health Commission Page 10

17 Table B describes who chooses to get an annual flu shot by their role in the clinic. (Crosstab Q6 and Q22). Table B: Who chooses to get an Annual Flu Shot by Title Answer Options Who Chooses to get an Annual Flu Shot by Title I never get a flu shot I sometimes get a flu I always get the annual flu shot Percent Count Health Director % 4 Social and Health % 2 Director Medical Director % 1 Clinic Director % 8 Physician % 4 Nurse % 4 Physician Assistant % 1 Nurse Case Manager % 2 Nurse (RN) % 17 Nurse (LPN) % 9 Certified Nurse Assistant % 1 (CAN) Medical Assistant (MA) % 10 Receptionist/Clerk % 2 Community Health % 4 Representative Other % 16 TOTAL %* 85 *Rounded percentage American Indian Health Commission Page 11

18 77% of the respondents look to CDC for information on immunizations against the flu and 64% look to the DOH as indicated in Graph 9. Participants were asked to select all that applied; therefore, the total equals more than 100%. 78 participants answered and 11 skipped the question. Graph 9: Sources used for Information about Flu Immunizations 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Sources used for Information about Flu Immunizations 76.9% (60) 64.1% (50) Center for Disease Control State Health Department 32.1% (25) Indian Health Services 16.7% (13) Local Tribal/Urban Indian Health Clinic 32.1% (25) Local Health County or City Department 10.3% (8) I do not look 88% of the respondents believe that the CDC/ACIP Immunization schedule should be followed for children, as indicated in Graph participants answered and 8 skipped the question (Q14). Graph 10: Recommend Immunizations according to CDC/ACIP Schedule Practices that see Children Indicate whether they Recommend Immunizations according to the CDC/ACIP Immunization Schedule Unsure 8.6% (7) Children are not served in practice 1.2% (1) No 2.5% (2) Yes 87.7% (71) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% American Indian Health Commission Page 12

19 Slightly over 24% of health care workers provide parents with one or more alternative schedules for their child as indicated in Graph 11. Participants were asked to select all that applied; therefore, the total is equal to more than 100%. 66 participants answered and 23 skipped the question (Q15). Graph 11: When a Parent Requests an Alternative Immunization Schedule When a Parent Requests an Alternative Immunization Schedule for their Child, which Describes your Response? I encourage parents who do not follow the recommended immunization schedule to find another provider 0.0% (0) I provide them with one or more alternative schedules that I believe are effective and safe 24.2% (16) I encourage following the recommended immunization schedule I try to inform the parent about the risks of not following the recommended immunization schedule 60.6% (40) 77.3% (51) I always follow the parent's wishes 12.1% (8) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% American Indian Health Commission Page 13

20 91% of the respondents reported that were not likely to skip any of the early childhood as indicated in Table C (birth-6 years). 9 respondents that recommended skipping gave the following explanations: don t have direct contact with patients, skipped because son was in chemo, don t usually see infants within the scheduled time period or see enough infants to keep the vaccine, patient immune system not fully developed enough to fight off live viruses, and skips when parent will only approve a certain amount of vaccines at a time.* 72 participants answered and 17 skipped this question (Q16). Table C: Early Childhood Immunization (birth-6 years old) Respondents indicated which of the following early childhood (birth-6 years) immunizations they were most likely to actively skip or discourage and why? Answer Options Response Percent DTaP (Diphtheria, Tetanus, acellular Pertussis) 0.0% 0 HIB (Hemophilus influenza, type B) 0.0% 0 Hep B (Hepatitis B 0.0% 0 Hep A (Hepatitis A 1.4% 1 Influenza 2.8% 2 MMR (Measles, Mumps and Rubella) 1.4% 1 Rotavirus 5.6% 4 Varicella (Chickenpox) 1.4% 1 None 91.7% 66 Please identify and explain why you would skip or discourage immunizations checked above? Response Count 9* American Indian Health Commission Page 14

21 95% of the respondents reported that they were not likely to skip any of the childhood immunizations as indicated in Table D (7-18 years old). 6 respondents that indicated that they recommended skipping childhood immunizations gave the following explanations: only skipped at a parents request, the Human Papillomavirus hasn t been around long enough, never discourage or actively skip but some vaccines may not be indicated, and depends on supply and don t have contact with patients.* 72 participants answered and 17 chose to skip this question (Q17). Table D: Childhood Immunizations (7-18 years old) Respondents indicated which of the following childhood (7-18 years old) immunizations they were most likely to actively skip or discourage and why? Answer Options Response Percent DTaP (Diphtheria, Tetanus, acellular Pertussis) 0.0% 0 Human Papillomavirus 2.8% 2 Meningococcal 0.0% 0 Influenza 1.4% 1 Hepatitis A 0.0% 0 Hepatitis B 0.0% 0 Inactivated poliovirus 0.0% 0 MMR (Measles, Mumps and Rubella) 0.0% 0 Varicella (Chickenpox) 1.4% 1 None 95.8% 69 Please identify and explain why you would skip or discourage immunizations checked above? Response Count 6* American Indian Health Commission Page 15

22 Over 84% of the respondents reported that they were not likely to skip any of the adult vaccinations indicated in Table E (adults 19 years and older). 14 respondents that recommended skipping adult immunizations gave the following explanations: allergies, reactions, do not have adequate supply, costs make prohibitive, and don t stock (Zoster). 17 participants chose not to respond to this question (Q18). Table E: Adult Immunizations (19 years and over) Which, if any, of the following adult (19 years and over) immunizations are you most likely to actively skip or discourage and why? (Check all that apply.) Answer Options Response Percent Response Count Influenza (Flu) 4.2% 3 Tetanus, diphtheria, pertussis 0.0% 0 (Td/Tdap) Varicella (Chickenpox) 5.6% 4 Human papillomavirus (HPV) Female 1.4% 1 Human papillomavirus (HPV) Male 5.6% 4 Zoster (Shingles) 9.7% 7 Measles, mumps, rubella (MMR) 1.4% 1 Pneumococcal (pneumonia) 0.0% 0 Meningococcal 4.2% 3 Hepatitis A 0.0% 0 Hepatitis B 0.0% 0 None 84.7% 61 Please identify and explain why you would skip or discourage immunizations checked above? 14* American Indian Health Commission Page 16

23 Well over 90% of the respondents indicated that either nurses or medical assistants have responsibility to maintain up-to-date patient immunizations records in their clinics in Graph answered and 15 skipped the question (Q19). Chart 12: Responsible for Maintaining Patient Immunization Records Responsible for Maintaining Patient Immunizations Records Physicians Assistants Nurse Practioners Physicians 1.4% (1) 2.7% (2) 1.4% (1) Medical Assistants 37% (27) Immunizations Nurse 6.8% (5) Nurses 51.4% (38) 0% 10% 20% 30% 40% 50% 60% 72.8% of the respondents indicate that there is an employee immunizations program at their clinic indicated in Graph participants answered and 8 skipped the question (Q20). They report that at most clinics, nurses and medical assistants have primary responsibility to maintain up-to-date employee immunization records (Q21). Graph 13: Employee Immunization Program Employee Immunization Program Unsure 12.3% (10) No 14.8% (12) Yes 72.8% (59) 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% American Indian Health Commission Page 17

24 B. Part 2 focused on Administrative Leadership Organizational Administrative Practices and Policies In Graph 14, administrative leadership indicates the following regarding immunization policy and practice. 13 of the 13 participants answered (Q26). Graph 14: Importance of the following in their Practice Importance of the following in their Practice Providing culturally appropriate handouts to encourage prevention through immunizations Keeping healthcare workers current on recommended vaccines Keeping patients current on recommended vaccines Having employees support immunization policy Having providers support immunization policy Providing immunizations to prevent the spread of communicable diseases Rate 1.00 level of importance 1 lowest to 4 highest 13 respondents indicated the following systems are used by their clinics. (Q27) Table F RPMS CHILD RPMS/CHILD EMR&CP NEXTGEN GE CPS N/A PROFILE PROFILE Centricity American Indian Health Commission Page 18

25 Summary of narrative responses for questions All but one respondent indicated that there is some level of process for notifying health care workers when they are due to be vaccinated. (Q28) All respondents indicated that there was a process to notify parents and patients when they are due for vaccinations either by , US mail, phone, or by informing them at appointments. (Q29) All respondents indicated a process to prevent missed opportunities to update immunizations by varying methods, such as, review of charts, screening at all appointments, electronic medical records, and audit reports. (Q30) Respondents indicated that clinic staff communicate the importance of immunizations by using a variety of methods, such as, prevention campaigns, VIS sheets, using educational skills verbally at appointments and check-ups, and by providing education materials in newspaper articles, pow wow events, and early education programs. (Q31) Respondents indicated that various methods to build trust, such as, providing culturally appropriate practices, longevity of staff, open communication, ensuring quality care, providing accurate information, listening, and providing longer appointments.(q32) Three respondents have established regular training for immunizations. Others indicated various ways of getting information, such as , reviewing recommendations, established protocols, and updates from local health departments. (Q33) American Indian Health Commission Page 19

26 13 respondents indicated the following regarding their clinic s practice and policy in Table G (Q34) Table G: Vaccination Practice and Policy Respondents indicated Clinic's practice and policy on vaccinations. Answer Options Yes No Unsure Count The Clinic provides health care staff education on vaccinations The Clinic has an employee immunization program The Clinic offers recommended vaccines to Tribal health care staff The Clinic offers required vaccines to health care staff The Clinic requires health care workers to meet TB testing requirements The Clinic health care workers are required to receive CDC/Advisory Committee on Immunizations' (ACIP) recommended vaccinations The Clinic has had some health care staff decline recommended vaccinations The Clinic requires health care staff to have signed proof of declined vaccination The Clinic requires health care staff to wear a mask during flu season if not vaccinated The Clinic requires Tribal health care staff have proof of flu vaccine annually The Clinic requires proof of declined vaccines other than seasonal flu The Clinic maintains a system to track health care worker vaccinations The Clinic has written policies of health care worker immunization procedure or practice American Indian Health Commission Page 20

27 Is RPMS used for documenting immunizations? Is CHILD PROFILE (WSIIS) used for documenting immunizations? Is NextGen used for documenting immunizations? Is the CHILD PROFILE(WSIIS)/RPMS bridge In place? Is the CHILD PROFILE(WSIIS)/RPMS operating Is there a specific person responsible for handling immunization data? Tribal Health Care Workers Knowledge, Attitudes, and Practices Summaries of narrative responses for questions of 11 Respondents indicated that standing orders are used in their clinics for immunizations and two indicated they are in development. (Q35) 6 respondents indicated that they were willing to share their policy or find out from Tribal management if their policy could be shared. (Q 36) Several respondents suggested that an immunization policy should include requirements for health care worker immunizations, CDC recommendations, and tracking.(q37) Respondents indicated what their clinics use to track immunizations in Graph 15 (Q38). Graph 15: Tracking Systems Used for Immunizations Tracking Systems Used for Immunizations Children Adolescents Adults Employees Not Used None American Indian Health Commission Page 21

28 Respondents indicated methods for tracking immunizations in Table G (Q39). 12 of 13 participants answered the question. Table G: Resources and Access for Training for Immunizations Tracking Systems Resources and Access to Training for immunization Tracking Systems Answer Options Yes No Unsure total Does your clinic use paper charts? Does your clinic use electronic charts? Does your clinic have a dedicated health informatics person? Does your clinic have a clinic applications coordinator? Does your clinic have a site specific RPMS coordinator? Does your clinic have a dedicated IT person? answered question 12 Respondents indicated who has primarily responsible for maintaining up-to-date immunization records for patients in Graph 16 (Q40). 12 of 13 participants answered the question. Graph 16: Responsible for Maintaining Patient Immunization Records Physicians Assistants Nurse Practioners Responsible for Maintaining Patient Immunizations Records No One Physicians Medical Assistants Immunizations Nurse Nurses 8.3%(1) 41.7% (5) 50.0% (6) 0% 10% 20% 30% 40% 50% 60% American Indian Health Commission Page 22

29 Respondents reported who has primary responsible for maintaining up-to-date immunization records for health care workers in Graph 17 (Q41). 4 of 13 participants answered the question. Participants were asked to select all that applied; therefore, the total equals more than 100%. Graph 17: Responsible for collecting Health Care Worker Immunization Records No One Responsible for collecting Health Care Worker Immunization Records 0.0% Physicians 0.0% Medical Assistants 0.0% Immunizations Nurse 40.0% (2) Nurses 80.0% (4) 0.0% 50.0% 100.0% Nurses Immunizations Nurse Medical Assistants Physicians No One In Table H below respondents indicated how vaccines are obtained or purchased (Q42). Participants were asked to select all that applied; therefore, total equals more than 100%. 12 of 13 answered the question. Table H: Sources for Obtaining Vaccines Type WA State County Vendor/ IHS Unknown Health Private Children Adolescents Adults Employees TOTALS American Indian Health Commission Page 23

30 12 Respondents indicated in a narrative response that the following methods are used to ensure accurate recording of all aspects of vaccine administration (Q43): Inventory, Charts and logs, Electronic medical records, RPMS, Child Profile, and Working with the local health department on compliance checks. Respondents indicated their clinic s payment source for immunizations in Graph 18 (Q44). Participants were asked to select all that applied; therefore, the total equals more than 100%. 12 participants answered the question and 1 did not. Graph 18: Payment Source for Immunizations Payment Source for Immunizations Other (please specify) 25.0% (3) Private Insurance 100.0% (12) Healthy Options 50.0% (6) Medicaid 100.0% (12) 0% 20% 40% 60% 80% 100% 120% 8 respondents reported that their clinic has conducted recent work on the following types of immunization improvement projects (Q45): Flu Clinics Implementing EMR/RPMS Positive rewards and competition resulted in improvement from 40% to 80% in three years New policy Well checks for children, adolescents, and adults TDAP American Indian Health Commission Page 24

31 6 respondents suggested the following immunizations issues for AIHC to address (Q46). Reinforce GPRA requirements of IHS TDAP Educational campaign about safety of immunizations Patient education about value of being immunized vs. negative perceptions Cost of adult immunizations 75% of the clinics are not accredited in Graph 19 (Q47). 12 participants answered this question. Graph 19: Is the Medical Clinic accredited by an Accrediting Organization? Is the Medical Clinic accredited by an Accrediting Organization? Unsure 8.3% (1) No 75.0% (9) Yes 16.7% (2) 0% 10% 20% 30% 40% 50% 60% 70% 80% American Indian Health Commission Page 25

32 IV. REVIEW AND FEEDBACK A Tribal Leaders Health Summit The THIW s work was presented at the 2012 Tribal Leaders Health Summit on December 11, 2012 at the Kiana Lodge at the Suquamish Tribe. In the Immunization breakout session, two topics were covered 1) Model Tribal-State Collaboration: Addressing Immunizations as a Priority Health Disparity through Tribally-driven Processes-A Ten Year Continuum (see Attachment E) and Tribal Health Care Worker Immunization Hesitancy Project (see Attachment F). The 10+ year continuum was presented to demonstrate the connection to work done in preceding years based on five strategies to address disease outbreak and the collaborative values identified by the Tribes (see Attachment E). This was the basis for the focus on the health care worker hesitancy project and the work to justify funding from CDC through the DOH. The feedback from the breakout session was very positive about the long-term approach illustrated by the continuum. Attendees thought the continuum helped them to understand the relationships, progress, and accomplishments made based upon past work. The initial findings of the survey on Tribal Health Care Worker s knowledge, attitudes and practices were presented and discussed. There were primarily questions and observations. Questions/Observations: Interest in reasons why respondents choose to get vaccinated First, to protect family and friends Second, to protect patients Third, to protect self 10 of 13 clinics have had staff decline recommended vaccinations. 6 of 13 clinics required proof of declined vaccinations. Why don t health care workers have proof of flu vaccination (only 5 of 13 indicated that proof is required)? Why are TB tests required (12 indicated TB is required; 1 unsure) and not require other vaccines? American Indian Health Commission Page 26

33 High interest in EMR. There was a discussion about who keeps records and the different needs for employees vs. patients. Group also discussed policies that guide responsibility for the records. A need for more information about what is out there and who has policies. Questions: What is the status of the work identified in the five top strategies to address disease outbreak, where are they on the timeline? What is PHEPR doing on rapid and timely responses? Will the collaborative values be continued, are they still relevant? 1. Address immunizations as a priority health disparity through a Tribal/Urban Indian process that is community driven and culturally appropriate; Identify strategies for 2. Seasonal flu, 3. Pandemic flu, and 4. Routine adolescent immunizations; and 5. Focus on why health care workers are hesitant to be vaccinated Overall, attendees expressed the importance of the project in the connection to increasing immunization rates and looked forward to the full report and data. The questions and comments went to the design team and THIW to incorporate in the final report. B. Review of Final Report The project leads and the design/project team worked closely to produce the draft report to be reviewed by the THIW. The THIW met on March 4 and March 25 to review the final report and provide their input. The final report will go to the AIHC s April 18, 2013 for presentation to the full commission. American Indian Health Commission Page 27

34 V. KEY FINDINGS A. Part 1: Health Care Workers and Providers Individual Knowledge, Attitudes and Practices Most clinics provide services to all ages. 29% of the health care workers (respondents) never or sometimes do not get an annual flu shot. Respondents reported reasons they did not get vaccinated are: 38% Concerned about side affects 23% Employer did not require them to get vaccinated 22 health care workers of 87 did not get a flu shot last year. Of the 71% that reported that they always get a flu vaccination, their reasons for doing so were: 90.2% or 55 health care workers said to protect their family and friends 82% or 50 health care workers said to protect their patients 80.3% or 49 health care workers said to protect myself Most health care workers recommend flu shot to all patients. 27.1% or 19 don t push it 14.3% or 10 offer it to those that need it most Over 24% provide parents with alternative schedules Adult vaccines may be skipped due to availability of vaccines 60 participants did not respond to the narrative question about whether they recommend or do not recommend flu vaccines and why. However, the narrative question may not have been effective in getting an adequate level of response because it was placed among a series of multiple choice questions. American Indian Health Commission Page 28

35 When looking for information and resources regarding immunizations against the flu: 76.9% or 60 indicated they look to CDC 64.1% or 50 look to DOH 32.1% or 24 look to IHS and Local County/City Health Departments 16.7% or 13 look locally to the Tribe to Urban Indian Health Clinic B. Part 2: Administrative Leadership Organizational Administrative Practices and Policies Administrative leadership did not indicate a high importance of culturally appropriate handouts and materials; however, it was raised that providing a culturally appropriate practice is important to build trust with patients and community. 12 of 13 indicated that their clinic has a health care worker immunization policy. 10 clinics have had staff decline recommended vaccines. 6 require signed proof of declined vaccine. 5 require health care staff to have proof of flu vaccine. 12 have a system to track health care worker vaccinations. 8 of 13 have a written policy of health care workers immunizations procedure or practice. C. Challenges/Lessons Learned Including definitions in future work will ensure consistent understanding. Q23-Q25 did not provide useful information. CDC determined that the immunization project, being solely for the purpose of public health improvement, need not go through an IRB process. However, AIHC should consider developing data collection protocols for future work. AIHC explored entering into an agreement with the Northwest Portland Area Indian Health Board, but the timing to enter into an agreement should have been at the inception of the project. AIHC should consider developing a data sharing agreement for future work. American Indian Health Commission Page 29

36 VI. RECOMMENDATIONS 1. Research the implications of the 29% of the health care workers (respondents) choosing not to be immunized against the flu on patients immunization rates, employee absenteeism, and the relationship to other health care workers immunization rates. 2. Perform a comprehensive review and analysis focused on long term solutions for sustainable health care worker immunizations policies, including: a. Heath care worker incentives b. What works and what does not c. Standards of care/practice d. What is in the Tribes H1N1 (or other novel flu virus or outbreak) emergency plan related to employee immunizations e. Recruitment/screening requirements for hiring providers to include immunization attitudes/beliefs f. Tracking of health care worker immunizations records and systems g. Follow up with clinics willing to share policies h. Follow up on requests for examples of employee immunization policies to be shared via AIHC s website 3. Review data to identify connection to other immunization issues. For example, health care worker flu vaccine hesitancy to other specific individual immunizations, such as MMR, (re: rubella) due to its implication for pregnant women and babies (birth defects). 4. Perform a review and assessment of tribal access to data and tracking systems for employee immunization programs, whether it is mandatory or not. 5. Develop communication plan to share the Immunizations Report and data, including: a. How to reach targeted audience, may be multiple audiences (providers, Tribal Leaders, staff, Tribal/Urban Community) b. Messaging needs to be specifically framed to the target audience c. Presentation to Tribes, Urbans, AIHC, NPAIHB, ATNI, etc. American Indian Health Commission Page 30

37 6. Develop educational materials regarding health care worker hesitancy. a. Ensure all materials are culturally appropriate and community driven b. Address the myths c. Develop a primer for ongoing learning for health care providers d. Develop a template for immunization information that can be customized by Tribes and Urbans. e. Emphasize the positive aspect of immunizations protecting patients and families 7. Inform Tribes and Urbans of opportunities for quality improvement projects to improve immunization rates. 8. Develop a collaborative approach for planning and partnerships to convene an immunization summit to review, identify goals, and develop strategies regarding: a. Ten Year Continuum and carry work forward b. Top 5 strategies to address disease outbreak identified by Tribes c. Continue Tribally-driven approach and collaborative values d. Identify technology needs 9. Develop AIHC process and protocol for data gathering for Tribal surveys addressing Tribal IRB processes, data sharing agreements, and a comprehensive review of Tribal needs to ensure quality surveillance and to insure value is added for Tribes. VII. NEXT STEPS: 1. Identify funding to support the above recommendations. 2. Continue to convene THIW to ensure communication and engagement with 29 Tribes and two Urbans. 3. Establish a long-term work plan from the recommendations. 4. Develop a communication plan as part of the work plan. 5. Develop partnerships to support, plan and convene immunization summit. American Indian Health Commission Page 31