2017 AFIX TrainingSudha Setty, MPHAFIX and Quality Improvement Coordinator

MINNESOTA IMMUNIZATION INFORMATION CONNECTION 4/5/2017

Presenter CredentialsSudha Setty, MPH, has a Master of Public Health from the University of Minnesota School of Public Health. She has eight years of experience as an epidemiologist working with quality improvement activities and Immunization Information System data use. She iscurrently the AFIX/Quality Improvement Coordinator with the MIIC Operations Unit at the Minnesota Department of Health.

Objectives After participating in this webinar, you will be: Familiar with the components of an AFIX visit. Able to complete AFIX paperwork. Able to identify resources to use during site visits to help answer questions or address challenges that arise. Able to complete an enhanced adolescent AFIX visit.

Agenda 1. Introduction to CQI and AFIX 2. AFIX in Minnesota 3. Assessment 4. Feedback 5. Incentives 6. Information Exchange (X)7. Administrative Requirements and Resources 8. Enhanced Adolescent AFIX Visits

What is Continuous QualityImprovement (CQI)? Approach to quality management that builds upon traditional quality assurance methods Focuses on process of conducting business Emphasizes organization and systems Promotes need for objective data to analyze and improve processes

What does CQI involve? CQI commonly involves: A quality improvement team. Training. Methods for selecting improvement opportunities. A process for analysis and redesign.

What is Assessment, Feedback,Incentives, and eXchange (AFIX)? CDC CQI process informed by research Used to improve provider-level immunization rates and practices Quantitative and qualitative components

What does AFIX involve? Face-to-face interaction Sharing MIIC-based immunization rates Educating providers on using MIIC to improve immunization rates and practices Maintaining contact with immunization champions at clinic site and/or system level

AFIX in Minnesota AFIX visits originally part of MnVFC visits MIIC and AFIX components not always covered 2015 CDC site visit feedback: not enough emphasison MIIC MIIC regional coordinators took on AFIX Coordinators perform visits and/or work with county IPI advisors who perform visits

2016 AFIX Statistics 317 Grant objective: 130 complete visits Number of visits in Minnesota: Initial - 205 Complete - 147

2017 Goals 2017 CDC AFIX requirement: 25% of all VFC clinics must receive AFIX visit Total MN visits needed: 245 (195 AFIX, 50 Enhanced Adolescent AFIX)

Minnesota AFIX Visit Components Assessment MIIC Assessment Reports

Feedback Face-to-face site visit

Incentives Formal and informal

Information Exchange (X) Follow-up 3-6 months after face-to-face visit

AFIX Eligibility Recommendations Active or suspended MnVFC participant Serves >30 patients in assessment age ranges Low immunization coverage (MIIC-based rates) Requests AFIX visit Has new staff who need immunization-related training New MnVFC participant

Clinic Lists MDH priorities guiding clinic selection: Large population Low immunization coverage MnVFC status MIIC selection criteria: Primary Care Clinic provider type indicator Childhood and adolescent immunization coverage rates

Assessment

4/5/2017

Assessment Purpose: Quantify clinic’s vaccination coverage Evaluate clinic’s immunization practices Provides standardized method for immunization data collection and analysis Data reflect immunization practice patterns

Minnesota AFIX AssessmentRequirements MIIC Assessment Reports include all elements Childhood data elements: 4 DTaP, 3 IPV (Polio), 1 MMR, 3 Hib, 3 HepB, 1 VAR, 4 PCV13, 2-3 RV, 1 Hep A Childhood Immunization Series

Adolescent data elements: 1 Tdap, 1 MCV4, MCV Booster, 1 HPV, complete HPV

Reports must be run ≤5 business days before initialvisit

Additional Assessment Materials Childhood Not Up-To-Date Report Immunity Late up-to-date Refusal Medical contraindication

Feedback

4/5/2017

Feedback/Initial Site Visit In-person process of sharing Assessment information Two-way conversation focusing on: Putting clinic MIIC rates into practice context. Understanding any current problems with clinic’s MIIC use. Sharing resources to support clinic’s continued MIIC use.

Results in development of QI activities

Pre-Visit Outreach Schedule initial visit Offer several days and times Tell clinic that visit should take ≤1.5 hours Welcome all staff involved in clinic’s immunization work flow

Educate clinic staff on what to expect Discussion of clinic rates AFIX questionnaire QI plan with two activities Follow up contact in 3-6 months

Pre-Visit Mailing Documents to send before visit: AFIX Questionnaire Clinic staff may complete questionnaire before or during visit Guidance on questionnaire available on MIIC website

Immunization Assessment Reports Run reports as of sending date Instruct clinic to see if rates reflect internal clinic data

Instructions on how to inactivate non-active patients Clinics may have different definitions of “active patient”

Multiple Clinics at One Visit Minnesota has many health care systems of varying sizes 1-2 staff members in charge of QI and data tracking for 2+ sites AFIX site visitor may discuss multiple clinics in1 visit

Preparing for Multiple Clinics atOne Visit Contact Sudha before planning a meeting on multiple sites Approach may not be appropriate in all cases Sudha will work with interested site visitors on case-by-case basis

Feedback Process: Assessment Reports Review Assessment Reports: Childhood Adolescent Not Up-To-Date Detail Report

Start with positive Above state average/met Healthy People 2020 goal Highest rates among vaccines

Transition into areas for improvement Lowest rates among vaccines

Share anecdotes from other clinic encounters

Feedback Process: DevelopingQI Objectives Review questionnaire line by line Each question should have “Yes” or “No” checked Help clinic complete questionnaire if not complete

Help clinic select 2 QI objectives Can be childhood and/or adolescent Can be “custom objectives” based on current improvement activities and/or organization goals QI Project column should have two checked boxes by end of visit

Use Guide to Site Visit Strategies to prepare for staff questions and provide resources

Examples of QI Activities Improve HPV rates 5 percent within 6 months Ensure front desk staff remind patients to schedule next appointment Use MIIC to see if vaccines are due at current patient visit Schedule next vaccination visit before patient leaves Ensure immunization champion has active MIIC login Regularly document vaccine refusals and reasons in EMR and/or MIIC Inactivate patients in MIIC no longer seen by clinic Contact no-show patients/parents to reschedule visit 3-5 days after no-show

Feedback Process: Tips Clinic staff sometimes reluctant to believe MIIC rates reflect true coverage Clinic may have inactive patients associated with assessment denominator – run Client Follow-Up list Clinic data may not be getting into MIIC accurately– contact MIIC Help Desk Clinic may be in line for real-time data exchange and onboarding – contact MIIC Help Desk

Feedback Process: Tips Clinic staff may question MIIC report relevance and accuracy if EMR reports show higher coverage Emphasize MIIC measures as statewide source ofimmunization data MDH and LPH use MIIC to identify immunization gaps

Feedback Process: Tips Clinic may already have excellent immunization coverage If childhood immunization rates are high, discuss adolescent immunization Statewide HPV coverage is still below HP 2020 goals Tdap and MCV4 are required for school entry

If childhood and adolescent immunization rates are high, and clinic sees adults, run Adult Assessment Report Can help clinic ensure excellent practices across all ages Not AFIX-required

If all ages are high, your work is done!

Feedback Process: Follow-Up Planand Resources Follow-up plan: Notify clinic about follow-up contact in 3-6 months Will check progress on QI plan and implementation Will review new immunization rates and compare to site visitrates

Resources to leave with clinic: Be creative! CDC MDH Region-specific materials

Feedback Process: Documentation Submit to MDH: Childhood and/or Adolescent Assessment Reports Completed Immunization Assessment Questionnaire: Must indicate clinic’s chosen immunization improvement activities (using yes/no checkboxes) Must indicate clinic’s chosen improvement objectives (using QI plan column)

Incentives

4/5/2017

Incentives Used to motivate clinic staff to: Develop more effective immunization delivery systems. Improve immunization coverage rates.

Promote change and reward achievement Two types: informal and formal No requirements or paperwork for thiscomponent

Informal Incentives MDH, CDC, and other QI resources Free immunization materials Educational in-services for staff Ongoing immunization updates Assistance with developing an immunization quality improvement plan Letters of recommendation

Informal Incentive Examples Inter-Clinic Competition Clinics that share a building keep penny jars for number of vaccines given Count pennies donated Winning clinic gets prize from other participating clinics

Letters of recommendation from local publichealth jurisdiction Published in local papers

Formal Incentives Certificates of participation, improvement, and collaboration Promotion of clinic as “Immunization Champion” or role model Recognition of clinic with significant improvement or high coverage levels at localor state conferences, educational seminars, and/or professional meetings

Formal Incentive Examples National awards CDC Childhood Immunization Champion Award MN awards Coverage awards G. Scott Giebink Award for Excellence inImmunization Regions may develop awards

Information Exchange (X)

4/5/2017

Information Exchange (X) Follow-up with clinic to monitor and support progress on QI strategies from site visit Helps maintain continuous quality improvement Supports clinic to improve immunization services

Follow-Up Contact Every clinic gets follow-up ≤6 months post-site visit Discuss and document clinic’s progress on QIstrategies Provide clarifications and technical assistance

Preparing for Information Exchange (X) Schedule contact Face-to-face Conference call/webinar Template slides available

Email correspondence Run new rates

Requirements for Follow-Up: Rates Re-run Childhood/Adolescent Assessment Reports for same birthdate range from site visit Same vaccines for childhood and adolescent Use custom reports to adjust age range Assessment date: “today” Compare new rates and site visit rates with clinic staff

Requirements for Follow-Up:QI Activities Check on progress made on QI activities since initial visit Progress should be documented on AFIX follow-up form Fully implemented Some implementation No implementation

Send follow-up form to MDH once follow-up contact is complete For progress less than 100% complete, request estimated date for 100% completion Further follow-up via email, conference call, or in-person Once clinic has reported 100% implementation, resubmit follow-up form to MDH

One Information Exchange (X) forMultiple Clinics Covering multiple clinics with one follow-up contact may be allowed after consulting with Sudha

Administrative Requiand Resourcesrements

4/5/2017

Visit Tracking and Timeline Track progress with your regionalcoordinator/list of visits for your jurisdiction All initial visits to occur 4/1/17-6/30/18 Follow-up contact may continue until 9/30/18

AFIX Paperwork Send initial visit and follow-up paperwork to MDH AFIX mailbox within 10 business days ofcontact Email: Health.AFIX.Mailbox@state.mn.us. Mailbox monitored by Sudha and data entry staff Can also send AFIX questions there

Enhanced Adolescent AFIX Visits Goal: educate providers on how to give strong HPV recommendation Format: Face to face visit with an AFIX site visitor Teleconference w/family physician Continuing education for participating physicians and other primary care providers Available summer 2017

Teleconference Preparation Offer teleconference to eligible providers See Enhanced AFIX Eligible column on your AFIX list An interested provider may contact you Contact MDH Give MDH staff times when physician will be ableto participate MDH will coordinate schedules with physicianeducator

Site Visit with Teleconference Go through visit as normal Discuss rates, QI plan, etc. 15-20 minute session with physician during visit via WebEx or Skype Time for questions

Peer-to-Peer Education Content Importance of HPV vaccination Strategies to increase vaccination Scripts Strong recommendation

Additional Documentation None! Indicate on Questionnaire that this was enhanced AFIX visit Can do enhanced AFIX visits for multiple clinics in one

AFIX Resources CDC: AFIX: http://www.cdc.gov/vaccines/programs/afix/index.html

MDH: AFIX:http://www.health.state.mn.us/divs/idepc/immunize/registry/afix.html QI Toolbox: http://www.health.state.mn.us/divs/opi/qi/toolbox/ Office of Performance Improvement:http://www.health.state.mn.us/divs/opi/

QI Resources: Community Guide, Vaccinations section:http://www.thecommunityguide.org/vaccines/index.html

Questions? Sudha Setty, AFIX/QI CoordinatorSudha.setty@state.mn.us651-201-5551