Improving Immunization Rates Donna L. Weaver, RN, MN, Nurse Educator National Center for Immunization and Respiratory Diseases Brentwood, TN July 31, 2009 Disclosures The speaker is a federal government employee with no financial interest or conflict with the manufacturer of any product named in this presentation The speaker will not discuss the off-label use of any vaccine Th k ill di i The speaker will not discuss vaccines not currently licensed by the Food and Drug Administration (FDA) 1
Immunization Coverage Rates July 2007 June 2008 Vaccine United States Tennessee 4DTaP 84.6 86.7 3 Polio 93.0 95.4 1 MMR 92.4 96.9 3 Hib 92.0 95.2 3 HepB 93.3 93.2 1VAR 89.99 91.5 4 PCV 77.4 81.9 4:3:1:3:3:1:4 68.1 83.3 We Still Face Challenges Only 86.7% of TN children 19 to 35 months of age had received four doses of DTaP vaccine Economic and racial disparities exist Low-income and minority children are at greater risk for under immunization Pockets of need exist in inner cities Influenza coverage rates for children remain low 2
The AFIX Approach Assessment Feedback Incentives exchange Assessment Evaluation of medical records to ascertain the immunization rate for a defined group Diagnosis of potential service delivery problems Assessment increases awareness 3
Assess Your Rates! Comprehensive Clinic Assessment Software Application (CoCASA) Assesses immunization rates (immediate results) Diagnoses problem areas Improves patient care by identifying reasons for deficiencies Improves HEDIS Scores Health Plan Employer Data and Information Set Feedback Informing immunization providers about their performance Assessment with feedback creates the awareness necessary for behavior change 4
Incentives Something that incites to action Vary by provider and stage of progress Opportunities for partnership and collaboration exchange of Information Allows access to more experience than an individual can accumulate Motivates improvement Coordinates resources and efforts 5
Strategies for High Immunization Levels Recordkeeping Recommendations and reinforcement Reminder and recall to patients Reduction of missed opportunities Reduction of barriers to immunization Records Must be available at the time of the visit Must be easy to read Must be accurate reflect current patient population reflect all vaccines given 6
Immunization Registries Single data source for all providers Reliable immunization history Produce records for patient use Key to increasing immunization levels Tennessee Web Immunization System (TWIS) Recommendations and Reinforcement Recommend the vaccine powerful motivator patients likely to follow recommendation of the provider Reinforce the need to return verbal written 7
Providers Can Change Minds 2003-2004 NIS interviews suggest 28% of parents doubtful about benefits & safety of certain vaccines Doubtful parents delayed or refused their child's vaccination Oct. issue of Pediatrics Most parents who changed their minds about delaying or refusing vaccination cited information from their physician as the main reason for the change Recommend Vaccines & Communicate Risks Recommend vaccines and provide credible information about vaccine risks and benefits and risks of disease Build a relationship of trust and credibility Communicate appropriate information for informed decisions and increased compliance For those who refuse, document decision via the Refusal to Consent form 8
Use of Multifaceted Patient Education Strategies Display posters and brochures about childhood immunization in waiting rooms/ reception areas Post the schedule in waiting rooms in a simple, understandable format Provide shot record for parents Use of Multifaceted Patient Education Strategies Discuss changes in the schedule and the importance of keeping children up to date on their immunizations Encourage parents to know their child s immunization status, to keep the child's record up to date and in a safe place, and to bring it to every visit 9
Reminders and Recall to Patients Reminder notification that immunizations are due soon Recall notification that immunizations are past due Content of message and technique of delivery vary Reminders and recall have been found to be effective Reminder card (with incentive) 10
Recall card 11
Reminder card (with guilt) Missed Opportunity A healthcare encounter in which a person is eligible to receive vaccination but is not vaccinated completely 12
Reasons for Missed Opportunities Lack of simultaneous administration Unaware patient needs additional vaccines Invalid contraindications Inappropriate clinic policies Reimbursement deficiencies Lack of Simultaneous Administration Consider Combination Vaccines When the components of the vaccine are indicated When no component of the vaccine is contraindicated Use only as licensed Consider parent/patient preference Consider potential side effects 13
Lack of Simultaneous Administration Site Maps May Help Unaware Patient Needs Additional Vaccines Immunization Schedules All staff must use the same immunization schedule Three Schedules: Children 0-6 years Children 7-18 years Catch-Up schedule for children 4 months -18 years Be sure to review the Notes section very valuable information 14
Unaware Patient Needs Additional Vaccines Reminders and Recall for Providers Communication to healthcare providers that an individual client s immunizations are due soon or past due Examples computer-generated list stamped note in the chart Immunization Due clip on chart Valid Contraindications & Precautions Condition Live Inactivated Allergy to Component C C Encephalopathy Evaluate C Pregnancy C V Immunosuppression C V Moderate-severe illness P P Recent Blood Product P V C = contraindication P = precaution V = vaccinate if indicated 15
Invalid Contraindications to Vaccine Mild illness or injury Antibiotic therapy Disease exposure or convalescence Pregnant woman in household Family history of an adverse event to a vaccine Breastfeeding Allergies to products not in vaccine Need for TB skin testing Need for multiple vaccines Inappropriate Clinic Policies Physical required to receive vaccines Only administer vaccines at well-child visits Won t provide services if parent refuses vaccines Limited clinic hours Written physician s order required before vaccine Written physician s order required before vaccine can be administered 16
Can You Enhance Access Provide walk-in immunization services (no appointment required) Extend office hours Host special weekend or evening clinic hours (especially important for influenza) Provide info on transportation services Couple with other programs (e.g., WIC settings, school-based programs) Would Standing Orders Be Appropriate What: nonphysicians offer and administer vaccines without direct MD involvement How: established through policies and protocols Where: clinics, hospitals, nursing homes 17
Do You Have Systems for Follow-Up Check address and phone number at every visit Families should leave with an appointment For pts who cannot receive all the vaccines they need in a single visit (because of intervals) consider shot only follow-up visits Can You Reduce Costs Vaccines for Children (VFC) Eligible adolescents Medicaid eligible Uninsured American Indian or Alaska Native Underinsured (seen in Federally Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 18
It s a Team Effort! High Immunization rates begin with a team designed plan! What can your team do to improve rates Be a Vaccine Champion! Lead your immunization team! Initiate and assess immunization process improvements Implement staff education which reviews vaccine storage, handling, & administration. Educate staff on new recommendations 19
CDC Vaccines and Immunization Contact Information Telephone (for patients and parents) Email (for providers) Website 800.CDC.INFO nipinfo@cdc.gov www.cdc.gov/vaccines/ Vaccine Safety www.cdc.gov/od/science/iso/ 20