Immunization in the Medical Home by David Wood, MD, MPH, FAAP AAP Council on Community Pediatrics & AAP Childhoo

1. Immunization in the Medical Homeby David Wood, MD, MPH, FAAP AAP Council on Community Pediatrics & AAP Childhood Immunization Support Program

2. About the Presentation • This presentation will describe how the Medical Home concept can be applied to immunization practices for all children. • Emphasis will be placed on Medical Home principles such as the family-physician partnership and the pediatrician’s active application of knowledge, AAP policies, and best practice guidelines that apply to immunizations.

3. Learning Objectives • Understand medical home principles vis-a-vis immunization services • Understand the challenges facing pediatricians administering vaccines in the context of a medical home • Anticipate and overcome barriers and promote the optimal delivery of immunizations in the medical home • Learn how to access additional immunization and medical home resources and tools

4. American Academy of Pediatrics Stance on Immunizations The American Academy of Pediatrics (AAP) believes that immunizations are the safest and most cost-effective way of preventing disease, disability, and death, and that the benefits of immunizations far outweigh the risks incurred by childhood diseases, as well as any risks of the vaccine themselves. The AAP urges parents to immunize their children against dangerous childhood diseases.

8. Understanding the Pediatricians’ Role in Vaccine Administration • Primary care practices delivered 80% of vaccine administration1 • Vaccines prevent 10.5 million diseases per birth cohort in the US2 • For every $1 spent on immunization, up to $29 can be saved3

9. Disease Pre-vaccine Era* 2000 % change Diphtheria 31,054 1 -99 Measles 390,852 86 -99 Mumps 21,342 338 -99 Pertussis 117,998 7,867 -93 Polio (wild) 4,953 0 -100 Rubella 9,941 176 -98 Cong. Rubella Synd. 19,177 9 -99 Tetanus 1,314 35 -97 Invasive Hib Disease** 24,856 112 -99 Total 566,706 8,624 -98 Vaccine Adverse Events 0 13,497 ^ +++ Comparison of Maximum and Current Reported Morbidity, Vaccine-Preventable Diseases & Vaccine Adverse Events, US4 * Maximum cases reported in pre-vaccine era + Estimated because no national reporting existed in the prevaccine era ^ Adverse events after vaccines against diseases shown on Table = 5,296 ** Invasive type b and unknown serotype

10. References • Santoli JM, Szilagyi PG, Rodewald LE. Barriers to immunization and missed opportunities. Pediatric Annals. 1998;27:366-374 • Centers for Disease Control and Prevention. Ten great public health achievements – United States, 1990-1999. MMWR Morb Mortal Wkly Rep. 1999;48:241-243 • Centers of Disease Control and Prevention, National Immunization Program Fact Sheet. Available at: http://cispimmunize.org/pro/pdf/ImpactofVaccinesCostSavings_CDC.pdf (Accessed: August 29, 2005) • Atkinson W, Wolfe C, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases, 7th Ed. Department of Health and Human Services, Centers for Disease Control and Prevention; 2002

11. What Is A Medical Home? • A medical home is not a building, house, or hospital, but rather an approach to providing comprehensive primary care • Medical Home is a way to provide cost effective quality health care

12. The AAP Medical Home* Care is: • Accessible • Coordinated • Continuous • Comprehensive • Family-Centered • Compassionate • Culturally Effective * American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002;110:184-186

13. Applying Medical Home Principles Can: • Improve health monitoring and delivery of preventive services • Track needed immunizations • Reduce missed opportunities • Facilitate practice team efforts to educate families

14. Applying Medical Home Principles Can: • Improve immunization delivery for children with chronic conditions • Monitor immunization for children needing special immunizations (Influenza, synagis, pneumococcal polysaccharide, etc.) • Improve patient compliance

15. Applying Medical Home Principles Can: • Address problems of vaccine delivery: • Address vaccine controversies and increase parental confidence in vaccines • Partially address vaccine financing and supply issues • Decrease mortality/morbidity due to vaccine-preventable diseases by keeping immunization coverage levels high

16. Immunization: Accessible Care Accessible: Physically and economically accessible to all patients • Immunizations are available and administered according to the harmonized immunization schedule

17. Immunization: Accessible Care Scope of Problem: • 12.8% of children with special needs1, some require physical accommodations • 10.1% of children uninsured2 • 25% of children under 5 have no insurance or no immunization coverage3 • Over 70% of poor children under 18 rely on SCHIP or Medicaid1

18. Patient Barriers to Accessible Care • Problems scheduling appointments • Can’t get off work, long office wait times • Lack of transportation • Costs of immunization/administration fees

19. Patient Barriers to Accessible Care • Uncertainty about how to access free vaccines • Confusion about the vaccination schedule • Vaccine safety concerns or misconceptions

20. Physician Barriers to Accessible Care • Increasingly complex immunization schedule • Increased staff time for documentation and patient education • Large uninsured and/or underinsured patient populations

21. Physician Barriers to Accessible Care • Low or delayed reimbursement • Missing/lost patient immunization record • Lack of centralized immunization registry • Vaccine delays or shortages

22. Strategies to Provide Accessible Care • Financially Accessible • All forms of insurance are accepted, including: • Medicaid • SCHIP • Practice participates in Vaccines for Children (VFC) program

23. Strategies to Provide Accessible Care • Changes in insurance are accommodated • Clinicians/AAP chapters work with third-party payers (public and private) to ensure reimbursement and coverage of vaccine

24. Strategies to Provide Accessible Care • Physically Accessible to Children with Special Health Care Needs (CSHCN) • Practice strives to meet Americans With Disabilities Act requirements • Accessible, Flexible Office Hours • Immunizations are available during all visits, sick or well, regular hours, or weekend clinics

25. Strategies to Provide Accessible Care • Vaccination-only visits available • The practice increases access during periods of peak demand (i.e., flu season, back to school, etc.) • The practice is accessible by public transportation

26. Strategies to Provide Accessible Care • Health care professionals review the vaccination and health status of patients at every encounter • Staff can review records to determine if any vaccines were missed by the physician • Staff can prepare immunizations while patients are with the physician • Maintain and prominently display vaccine storage and handling procedures and protocols

27. The following case study is designed to assist you to implement the Accessible Care component of the medical home concept during immunization-related patient encounters. Strategies to address specific issues raised in the scenario are included.

28. Case Study #1: Accessible Care • Flu season is just around the corner. Dr Weiss, a privately practicing pediatrician in an urban city, is concerned about the potential increase in children coming in for the flu vaccine due to the changes in the Recommended Childhood and Adolescent Immunization Schedule. Prior to the change in recommendations, Dr Weiss immunized <250 children against influenza. The practice already has pre-ordered vaccine on hand.

29. Case Study #1: Accessible Care • Question: How can Dr Weiss ensure that his at-risk and target patient population has adequate access to flu vaccine?

30. Case Study #1: Accessible Care Addressing the problem: • Dr Weiss decides to set up a flu clinic, which will be devoted to providing flu vaccine only. The flu clinic will run for 2 hours every Tuesday afternoon from October –March or until the virus is no longer circulating. • He ensures that all staff are vaccinated and develops vaccine standing orders so nursing staff can give vaccine without him having to see the patient.

31. Case Study #1: Accessible Care Addressing the problem: • He uses his computer-based patient information system to identify children needing flu vaccine. • The system will “flag” children that would need flu vaccine (e.g., those with asthma, etc.) and identify those currently 6-23 months old.

32. Case Study #1: Accessible Care • Dr Weiss assigns 1 staff person to serve as the office Immunization Champion, answering patient questions regarding the flu and flu vaccine(s). • In addition to the flu clinic, office staff will offer the flu vaccine at well child visits for all eligible children/siblings during flu season. • Patients are screened for and enrolled in the state’s VFC program.

33. References: Accessible Care • Strickland B, McPherson M, Weissman G, Van Dyck P, Huang ZJ, and Newacheck P. Access to the Medical Home: Results of the National Survey of Children With Special Health Care Needs. Pediatrics. 2004;113:1485-1492 • Cohen RA, Coriaty-Nelson Z. Health Insurance Coverage: Estimates from the National Health Interview Survey, 2003. Division of Health Interview Statistics, National Center for Health Statistics; 2004 • Institute of Medicine. Vaccine Financing In the 21st Century. National Academies Press, Washington DC, 2004 • National Vaccine Advisory Committee. Standards for Child and Adolescent Immunization Practices. Pediatrics. 2003;112:958-963

34. Immunization: Coordinated Care Coordinated: All needed immunization services are facilitated through the medical home. Clinicians practice community-based approaches and work with community groups to develop appropriate vaccination services1 • Each visit is an opportunity for vaccination • Continually educate practice staff • Regularly review and update immunization procedures

35. Immunization: Coordinated Care Scope of Problem: • 80% of vaccine administration takes place in a physician office2 • 43% of children <6 years have 2+ immunizations in a registry, 2002 (Healthy People 2010 Goal: 95%)3

36. Immunization: Coordinated Care • 22% of children receive early preschool vaccinations from more than one health care professional (leading to increased record scattering)4 • 45% of practices had 1 or more documented storage problems5

37. Who Is Part of a Medical Home for Immunizations?

38. AAP Chapter or State Educational Programs Community Organizations Vaccine Manufacturers Health Departments Immunization Coalition Child Family Pediatrician Medical Home Child Care Centers, Public & Private Schools Registry/State Immunization Information System/EMR Local, State, National Immunization Programs (i.e., VFC) Third Party Insurers/ Authorizing Agents

39. Barriers to Coordinated Care • Parents/physicians may lack knowledge of immunization-related community resources • Poor communication among public and private health care and child care professionals (relevant state/federal agencies, school nurses, child care centers, etc.)

40. Barriers to Coordinated Care • Children receive immunizations in multiple sites • Lack of state or local immunization registry • Complex and/or multiple vaccine supply sources • Delays and/or disruptions in vaccine supply

41. Strategies to Provide Coordinated Care • When possible, the practice participates in local or state-level immunization registries • Clinicians work with local and state public health departments on quality improvement measures, such as Assessment, Feedback, Incentives, eXchange (AFIX) and Clinic Assessment Software Application (CASA), to increase immunization rates

42. Strategies to Provide Coordinated Care • Cooperate with local public health department to monitor disease outbreaks and educate parents • Develop and train staff on vaccine and office protocols • A central immunization record, including immunizations, is maintained at the practice

43. Strategies to ProvideCoordinated Care • Designate Immunization Champions • The practice reports adverse events to the Vaccine Adverse Events Reporting System (VAERS), and is aware of the National Vaccine Injury Compensation Program (VICP)1

44. Strategies to ProvideCoordinated Care • Immunizations are coordinated with routine well-visits, follow-up, and sick visits • Immunizations received outside of the medical home are communicated to the primary care clinician

45. The following case study is designed to assist you to implement the Coordinated Care component of the medical home concept during immunization-related patient encounters. Strategies to address specific issues raised in the scenario are included.

46. Case Study #2: Coordinated Care • Billy is a healthy 5 year-old Hispanic boy who is starting kindergarten this year. When Billy’s mom drops him off at school and shows the school nurse his immunization record, the nurse informs her that, according to their state’s immunization requirements, Billy is not current on all of his immunizations. His vaccination record indicates that he has received: 3 DTaP, 2 IPV, 1 Hib, 2 Hepatitis B, 3 Prevnar, 1 Varicella, and 1 MMR.

47. Case Study #2: Coordinated Care • Question: What should the school nurse do? What should Billy’s pediatrician do?

48. Case Study #2: Coordinated Care What should the school nurse do? • Document that Billy is behind and send a letter home to his parents. • Refer Billy to his pediatrician.

49. Case Study #2: Coordinated Care What should Billy’s pediatrician do? • Follow the written vaccination protocols, including the Catch-up Schedulefor children behind on immunizations. Billy needs: • DTaP #4, IPV #3—both final doses because given after age 4 • PCV #4—because the first 3 doses given before 24 months of age • Hep B # 3—last dose • MMR #2—he’s done

50. Case Study #2: Coordinated Care • Update the child’s immunization record to reflect which vaccinations were given, dates of administration, number of doses, intervals between doses, and the child’s age.