Riding the Current: Upstream and Downstream Approaches to Implement Adult Immunization Strategies

Transcription

1 Riding the Current: Upstream and Downstream Approaches to Implement Adult Immunization Strategies Paul Nguyen Community Health Partnership Connie Chung-Bohling California Department of Public Health

2 Session Agenda Overview of Adult Immunization Project Adult Immunization Practices Survey o Clinic Workflow, Practices, and Barriers o Electronic Health Records (EHR) and California Immunization Registry (CAIR) Use and Barriers o Reimbursement o Review of Barriers and Solutions Community Health Partnership o Implementation of Adult Immunization Program Vaccines for Adults (VFA) Program 2

3 Learning Objectives Identify specific health care settings where uninsured adults are more likely to seek services List at least two barriers and their solutions in adopting the standards for adult immunization practices into clinical workflows Describe current best practices to increase adult immunizations in a selection of FQHCs and community health centers 3

4 Vaccine Coverage in CA, by Year 2013 Zoster Tdap 18 yrs Pneumococcal yrs, high risk Pneumococcal, age 65 Healthy People 2020 Goal 0% 20% 40% 60% 80% 100% Coverage (%) Data Source: Centers for Disease Control and Prevention (CDC) BRFSS

5 Vaccine Coverage, by race/ethnicity, California 2015 Tdap 18 yrs 46% 34% 31% 37% White Other/Multiple Black Hispanic Pneumococcal, age 65 59% 66% 75% 76% Pneumococcal yrs 25% 39% 35% 36% Healthy People 2020 Goal 0% 20% 40% 60% 80% 100% Coverage (%) Vaccine Coverage % s among Hispanics and Blacks are consistently lower compared to that among Whites Data Source: Centers for Disease Control and Prevention (CDC) BRFSS

6 Project Overview Adult Immunization Grant o Improve adult immunization standards in California o Components FQHCs VFA Program Pharmacies Healthcare Systems FQHCs o Consortium of Community Health Centers and FQHCs in San Mateo and Santa Clara Counties o Pilot Health Centers (3) Implement strategies to increase adult immunizations Share lessons learned 6

7 Adult Immunization Standards ASSESS immunization status of all patients at every clinical encounter Strongly RECOMMEND vaccines that patients need ADMINISTER needed vaccines or REFER your patients to a vaccination provider DOCUMENT vaccines received by your patients 7

8 Survey Methods Healthcare delivery sites Survey Details Gather data on current immunization practices within the consortium by administering a survey Distributed to 10 member health organizations 9 respondents o 34 health care delivery sites Respondents: Medical Directors, MD, RN, MA, Billing staff 8

9 Limitations No validation Low sample size Respondents mostly Medical Directors 9

10 Clinic Workflow and Practices Survey Results 10

11 # Member Health Organizations Routine Immunizations Programs All All Some Some No No Pneumococcal and Hep B Tdap and Flu Diabetes Pregnancy Do your clinics routinely assess, recommend, and administer? N = 9 11

12 Standing Orders Which healthcare providers within your clinics assess (and which administer) adult immunizations for patients under standardized procedures / protocols or standing orders, if any? Health Providers who Assess None Health Providers who Administer None MA RN LVN NP PA CNW MD or NP CNW MA RN N = 9 PA 12

13 Staff and Clinic Workflow Strategies Barriers Patient registry or panel management EHR guidelines/protocols Routine screening at every appointment Clinician and staff education Standing orders Huddle sheet, chart scrubs or reviews Vaccine purchase and administration cost Implement standing order protocols Continued education to providers 13

14 EHR and CAIR Use Survey Results 14

15 EHR Use Manage Inventory Print Records Provide Prompts Decision Support Run Coverage Reports Remind/Recall Patients Clinics use NextGen or eclinicalworks N = # Responses 15

16 CAIR Use 29 of 34 clinics use CAIR List for Reminder/Recall Manage Inventory Decision Support Shot history # Responses N = 9 16

17 CAIR Use Major Barriers Major Needs Limited staff o Data entry into CAIR o Double data entry into EHR and CAIR o Check CAIR for immunization status o Set up data exchange Usability o Concerns about incomplete immunization histories o Unsure about usability o Clinic uses EHR immunization record module Data exchange support o Support to transfer records from EHR to CAIR o Set up EHR to interface with CAIR o Interpreting and resolving error messages to improve data quality Additional Staff o Help with data entry CAIR Staff Training 17

18 Reimbursement Survey Results 18

19 Adult Immunizations Offered in Health Centers MMR MenB Hib Varicella MenACWY / MCV4 Hepatitis A HPV Zoster PCV13 PPSV23 Hepatitis B Tdap/Td Influenza N = # Member Health Organizations 19

20 Administration Vaccine Reimbursement Do payments meet the cost of vaccines and their administration? Yes No No Response Yes No No Response N = # Member Health Organizations 20

21 MMR MenB MenACWY of MCV4 HPV Zoster PCV13 Reimbursement Have your clinics decided not to offer any vaccines due to reimbursement problems? All are offered N = # Member Health Organizations 21

22 Referrals If unable to provide immunizations on-site, do your clinics: Refer patients to another provider for immunization? Find out if the referral was successful and patient was immunized? Yes Yes No No No Response No Response Refer to: travel clinic, pharmacy, LHD N = Unsure of vaccine availability at other clinics Only if patient brings back documentation Loss to follow-up Patient may decline vaccine 22

23 Barriers Solutions Staffing/Workflo w Clinic Flow Patient Panels & Team Based Care Standing Orders EHR/CAIR Use Data exchange support and collaboration Data driven improvement Reimbursement VFA Program Policy Interventions 23

24 Introduction to CHP Community Health Partnership, Inc. (also known as "CHP") was founded in 1993 in response to community concern for the viability of community-based, primary care health centers. CHP is 1 of 19 Community Health Center Associations in California. CHP represents 9 Community Health Center (CHC) organizations with 39 clinical sites in Santa Clara and San Mateo Counties. Our member CHC serve 176,348 patients in 2015, 2/3 or which are below 200% of the federal poverty level.

25 Criteria for Selecting Pilot Organization Has Electronic Medical Record system that is uploading data to California Immunization Registry (CAIR) Has a significant number of prenatal patients annually Has a significant number of uninsured patients annually Is a participant of the Vaccine For Adult (VFA) Program Has an active vaccination program

26 Pilot Organization Demographics AGE DISTRIBUTION GENDER DISTRIBUTION 65 and over 10% years 25% Female 63% Male 37% years 17% years 19% years 5% years 2% 5-12 years 11% 1-4 years 6% Under 1 year 4% 0% 5% 10% 15% 20% 25% 30%

27 Pilot Organization Demographics Coverage Data by Payer, SHC uninsured 29% Medicare 3% Medicare Medical Private insurance Other Other 1% uninsured Medical 65% Private insurance 2%

28 Approach The 10 Building Blocks of High Performing Primary Care - Tom Bodenheimer, MD The Bodenheimer model has been adopted by Community Health Partnership as a framework for helping our member Health Centers transform to becoming a High Performing Primary Care Practice. To improve immunization rates CHP focused on the 4 foundational building blocks of engaged leadership, data-driven improvement, empanelment, and team-based care.

29 Approach (Continued) Quality Improvement Principles The PDSA Cycle (Plan-Do-Study-Act) is a process to conduct small test of change to identify if the intervention was successful or not, that was created by the Deming Institute in CHP uses PDSA methodology to drive change in our member organizations, to ensure that incremental improvement initiatives are being made.

30 Baseline 2016 Immunization Rates Pilot Health Center 100% MayView Immunization Rates 2016 (January -September) 90% 90% 80% 70% 70% 70% 60% 50% 40% 30% 30% 20% 10% 11% 17% 14% 21% 13% 0% Influenza 18+ Influenza 65+ Pneumococal Zoster Tdap CY 2016 (January - September) HP 2020 Goal

31 Barriers Identified From Pilot Lack of inventory management process Lack of standard clinical workflows Understanding of Immunization Coverage No Culture of Data Sharing Access to complete immunization records Patient Panels are not in place for proper care management

32 Engaging Leadership Barriers & Strategy: Lack of inventory management process Review job descriptions and redefined roles for Lab Technicians to lead handling of vaccine inventory. Lack of standard clinical workflows Developed standing orders for medical assistants to conduct initial assessment of patient immunization gaps and report to Provider for approval. PDSA Pilot standing order with selected Provider/Medical Assistant dyad. Understanding of Immunization Coverage Coordinated CDPH VFA Program training for clinical staff to understand vaccine coverage.

33 Data Driven Improvement Barriers & Strategy: No Culture of Data Sharing Developed data wall to post immunization rates data for staff and patient Data for project is shared with staff at monthly all staff meeting Staff not comfortable with identifying Immunization Gaps Implement Care Guidelines to provide Medical Assistance with clinical decision support to identify patient immunization gaps. Access to Incomplete Immunization Records No record, No shot If patients are not able to provide proof of immunizations or if immunization records can not be read or translated then staff are trained to proceed as if the immunization did not occur and proceed to immunize and document in patients chart.

34 Empanelment Barriers & Strategy: Patient Panels are not in place for proper care management CHP provided training to Pilot Health Center Staff: Develop Provider Panels Review Patient Health Registries Training to conduct Care Team Huddles to identify immunization gaps prior to shift

35 Team-Based Care Barriers & Strategy: Lack of standard clinical workflows Using standing orders and implementation of care guidelines to help Support Staff identify patient immunization gaps during office visits and report to Provider for approval.