Riding the Current: Upstream and Downstream

Approaches to Implement Adult Immunization

Strategies

Paul Nguyen Community Health Partnership

Connie Chung-BohlingCalifornia Department of Public Health

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

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

Vaccine Coverage in CA, by Year

4

0% 20% 40% 60% 80% 100%

Pneumococcal, age ≥65

Pneumococcal 18-64 yrs, high

risk

Tdap ≥18 yrs

Zoster

Coverage (%)

2013

2014

2015

Healthy People 2020 Goal

Data Source: Centers for Disease Control and Prevention (CDC) BRFSS 2013-2015 https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/data-reports/general-population/index.html

Vaccine Coverage, by race/ethnicity, California 2015

5

25%

59%

37%

36%

66%

31%

35%

76%

34%

39%

75%

46%

0% 20% 40% 60% 80% 100%

Pneumococcal 18-64 yrs

Pneumococcal, age ≥65

Tdap ≥18 yrs

Coverage (%)

White

Other/Multiple

Black

Hispanic

Healthy People 2020 Goal

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 2015 https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/data-reports/general-population/index.html

Project OverviewAdult Immunization Grant FQHCs

o Improve adult immunization standards in California

o Components

• FQHCs

• VFA Program

• Pharmacies

• Healthcare Systems

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

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

Survey MethodsHealthcare delivery sites Survey Details

• Gather data on current immunization practices within the consortium by administering a survey

• Distributed to 10 member health organizations – 9 respondentso 34 health care delivery

sites

• Respondents: Medical Directors, MD, RN, MA, Billing staff

8

Limitations• No validation

• Low sample size

• Respondents mostly Medical Directors

9

Clinic Workflow and Practices

Survey Results

10

Routine Immunizations Programs

Do your clinics routinely assess, recommend, and administer?

11

All

All

Some

Some

No

No

0

1

2

3

4

5

6

7

8

9

Pneumococcal and Hep B Tdap and Flu

Diabetes Pregnancy

# M

emb

er H

ealt

h O

rgan

izat

ion

s

N = 9

Standing Orders

Health Providers who Assess Health Providers who Administer

12

MD or

NP

PA

CNW

RN

MA

None

NP

PA

CNW

RN

MA

LVN

None

N = 9

Which healthcare providers within your clinics assess (and which administer) adult immunizations for patients under standardized procedures / protocols or standing orders, if any?

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

EHR and CAIR UseSurvey Results

14

EHR Use

15

0 2 4 6 8

Remind/Recall Patients

Run Coverage Reports

Decision Support

Provide Prompts

Print Records

Manage Inventory

# ResponsesN = 9

Clinics use NextGen or eClinicalWorks

CAIR Use

16

0 1 2 3 4 5 6 7 8 9

Shot history

Decision Support

Manage Inventory

List for Reminder/Recall

# Responses

N = 9

29 of 34 clinics use CAIR

CAIR UseMajor Barriers Major Needs

• Limited staffo Data entry into CAIR

o Double data entry into EHR and CAIR

o Check CAIR for immunization status

o Set up data exchange

• Usabilityo 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

ReimbursementSurvey Results

18

Adult Immunizations Offered in Health Centers

19

0 2 4 6 8

Influenza

Tdap/Td

Hepatitis B

PPSV23

PCV13

Zoster

HPV

Hepatitis A

MenACWY / MCV4

Varicella

Hib

MenB

MMR

# Member Health OrganizationsN = 9

ReimbursementDo payments meet the cost of vaccines and their

administration?

20

0 1 2 3 4 5 6 7 8 9

No Response

No

Yes

No Response

No

Yes

Ad

min

istr

atio

nV

acci

ne

# Member Health OrganizationsN = 9

Reimbursement

Have your clinics

decided not to offer

any vaccines due to

reimbursement

problems?

21

0 2 4 6 8

All are offered

PCV13

Zoster

HPV

MenACWY of MCV4

MenB

MMR

# Member Health OrganizationsN = 9

ReferralsIf 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?

22

0 2 4 6 8

No Response

No

Yes

0 2 4 6 8

No Response

No

Yes

Refer to: travel clinic, pharmacy, LHD Unsure of vaccine availability at other clinicsOnly if patient brings back documentationLoss to follow-upPatient may decline vaccineN = 9

Barriers Solutions

• Clinic Flow

• Patient Panels & Team Based Care

• Standing Orders

Staffing/Workflow

• Data exchange support and collaboration

• Data driven improvementEHR/CAIR Use

• VFA Program

• Policy Interventions Reimbursement

23

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.

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

Pilot Organization Demographics

4%

6%

11%

2%

5%

19%

17%

25%

10%

0% 5% 10% 15% 20% 25% 30%

Under 1 year

1 - 4 years

5 - 12 years

13 - 14 years

15 - 19 years

20 - 34 years

35 - 44 years

45 - 64 years

65 and over

AGE DISTRIBUTION

Male

37%

Female

63%

GENDER DISTRIBUTION

Pilot Organization Demographics

Medicare 3%

Medical 65%

Private insurance 2%

Other 1%

uninsured 29%

Coverage Data by Payer, SHC

Medicare

Medical

Privateinsurance

Other

uninsured

ApproachThe 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.

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 1991.

CHP uses PDSA methodology to drive

change in our member organizations,

to ensure that incremental

improvement initiatives are being

made.

Baseline 2016 Immunization Rates

Pilot Health Center

11%

17%14%

21%

13%

70% 70%

90%

30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Influenza 18+ Influenza 65+ Pneumococal Zoster Tdap

MayView Immunization Rates 2016 (January -September)

CY 2016 (January - September) HP 2020 Goal

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

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.

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.

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

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.