Immunization Training Tool

8/6/2019 Immunization Training Tool

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ImmunizationImmunizationin the Medical Homein the Medical Home

by David Wood, MD, MPH, FAAPAAP Council on Community Pediatrics &

AAP Childhood Immunization Support Program

This presentation will describe how theMedical Home concept can be applied toimmunization practices for all children.

Emphasis will be placed on Medical Homeprinciples such as the family-physicianpartnership and the pediatricians activeapplication of knowledge, AAP policies, andbest practice guidelines that apply toimmunizations.

About the PresentationAbout the Presentation

Learning ObjectivesLearning Objectives

Understand medical home principles vis-a-vis immunization services

Understand the challenges facingpediatricians administering vaccines in thecontext of a medical home

Anticipate and overcome barriers andpromote the optimal delivery ofimmunizations in the medical home

Learn how to access additional immunizationand medical home resources and tools

American Academy of PediatricsAmerican Academy of PediatricsStance on ImmunizationsStance on Immunizations

The American Academy of Pediatrics (AAP)believes that immunizations are the safestand most cost-effective way of preventingdisease, disability, and death, and that thebenefits of immunizations far outweigh the

risks incurred by childhood diseases, as wellas any risks of the vaccine themselves.

The AAP urges parents to immunize theirchildren against dangerous childhooddiseases.


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Applying Medical HomeApplying Medical HomePrinciples Can:Principles Can:

Improve immunization delivery for childrenwith chronic conditions

Monitor immunization for childrenneeding special immunizations(Influenza, synagis, pneumococcalpolysaccharide, etc.)

Improve patient compliance

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 keepingimmunization coverage levels high

Applying Medical HomeApplying Medical HomePrinciples Can:Principles Can:

Immunization: Accessible CareImmunization: Accessible Care

Accessible: Physically and economically

accessible to all patients

Immunizations are available andadministered according to the

harmonized immunization schedule

Immunization: Accessible CareImmunization: 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 immunizationcoverage3

Over70% of poor children under 18rely on SCHIP or Medicaid1

Patient Barriers toPatient Barriers toAccessible CareAccessible Care

Problems scheduling appointments Cant get off work, long office wait

times Lack of transportation Costs of immunization/administration

fees

Patient Barriers toPatient Barriers toAccessible CareAccessible Care

Uncertainty about how to access freevaccines

Confusion about the vaccinationschedule

Vaccine safety concerns ormisconceptions


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Physician Barriers toPhysician Barriers toAccessible CareAccessible Care

Increasingly complex immunizationschedule

Increased staff time for documentationand patient education

Large uninsured and/or underinsuredpatient populations

Physician Barriers toPhysician Barriers toAccessible CareAccessible Care

Low or delayed reimbursement

Missing/lost patient immunization record Lack of centralized immunization

registry Vaccine delays or shortages

Strategies to ProvideStrategies to ProvideAccessible CareAccessible Care

Financially Accessible All forms of insurance are accepted,

including:Medicaid

SCHIP Practice participates in Vaccines for

Children (VFC) program


Changes in insurance are accommodated

Clinicians/AAP chapters work with third-party payers (public and private) toensure reimbursement and coverage ofvaccine


Physically Accessible to Children withSpecial 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, orweekend clinics


Vaccination-only visits available The practice increases access during periods

of peak demand (i.e., flu season, back toschool, etc.)

The practice is accessible by publictransportation


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Health care professionals review thevaccination and health status of patientsat every encounter Staff can review records to determine

if any vaccines were missed by thephysician

Staff can prepare immunizations whilepatients are with the physician

Maintain and prominently display vaccinestorage and handling procedures andprotocols

The following case study isThe following case study isdesigned to assist you todesigned to assist you toimplement theimplement the AccessibleCareAccessibleCarecomponentofthemedicalhomecomponentofthemedicalhomeconceptduringimmunizationconceptduringimmunization--relatedpatientencounters.relatedpatientencounters.StrategiestoaddressspecificStrategiestoaddressspecificissuesraisedinthescenarioareissuesraisedinthescenarioareincluded.included.

CaseStudy #1:CaseStudy #1:AccessibleCareAccessibleCare

Flu season is just around the corner.Dr Weiss, a privately practicingpediatrician in an urban city, is concernedabout the potential increase in childrencoming in for the flu vaccine due to the

changes in the Recommended Childhoodand Adolescent Immunization Schedules.Prior to the change in recommendations,Dr Weiss immunized


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Case Study #1:Case Study #1:Accessible CareAccessible Care

Dr Weiss assigns 1 staff person to serve asthe office Immunization Champion,answering patient questions regarding theflu and flu vaccine(s).

In addition to the flu clinic, office staffwill offer the flu vaccine at well child visitsfor all eligible children/siblings during fluseason.

Patients are screened for and enrolled inthe states VFC program.

References: Accessible CareReferences: Accessible Care1. Strickland B, McPherson M, Weissman G, Van Dyck P,

Huang ZJ, and Newacheck P. Access to the MedicalHome: Results of the National Survey of Children WithSpecial Health Care Needs. Pediatrics. 2004;113:1485-1492

2. Cohen RA, Coriaty-Nelson Z. Health Insurance Coverage:Estimates from the National Health Interview Survey,2003. Division of Health Interview Statistics, NationalCenter for Health Statistics; 2004

3. Institute of Medicine. Vaccine Financing In the 21stCentury. National Academies Press, Washington DC,2004

4. National Vaccine Advisory Committee. Standards forChild and Adolescent Immunization Practices. Pediatrics.2003;112:958-963

Immunization: Coordinated CareImmunization: Coordinated Care

Coordinated:All needed immunization servicesare facilitated through the medical home.Clinicians practice community-basedapproaches and work with community groupsto develop appropriate vaccination services1

Each visit is an opportunity for vaccinationContinually educate practice staffRegularly review and update immunization

procedures

Immunization: Coordinated CareImmunization: Coordinated Care

Scope of Problem: 80% of vaccine administration takes

place in a physician office2

43% of children


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Immunization

CoalitionChild

Family

Pediatrician

Registry/State

Immunization

Information

System/EMRLocal, State,

National Immunization

Programs (i.e., VFC)

Third Party Insurers/

Authorizing Agents

Community

Organizations

AAP Chapter or

State Educational

ProgramsVaccine

Manufacturers

Child Care Centers,

Public & Private

Schools

Medical Home

Health

Departments

Barriers to Coordinated CareBarriers to Coordinated Care

Parents/physicians may lack knowledgeof immunization-related communityresources

Poor communication among public andprivate health care and child careprofessionals (relevant state/federalagencies, school nurses, child carecenters, etc.)

Barriers to Coordinated CareBarriers to Coordinated Care

Children receive immunizations inmultiple sites

Lack of state or local immunizationregistry

Complex and/or multiple vaccinesupply sourcesDelays and/or disruptions in

vaccine supply

When possible, the practice participates inlocal or state-level immunization registries

Clinicians work with local and state publichealth departments on quality improvementmeasures, such as Assessment, Feedback,

Incentives, eXchange (AFIX) andComprehensive Clinic AssessmentSoftware Application (CoCASA), toincrease immunization rates

Strategies to ProvideStrategies to ProvideCoordinated CareCoordinated Care

Cooperate with local public healthdepartment to monitor disease outbreaksand educate parents

Develop and train staff on vaccine andoffice protocols

A central immunization record, includingimmunizations, is maintained at thepractice

Strategies to ProvideStrategies to ProvideCoordinated CareCoordinated Care Strategies to ProvideStrategies to ProvideCoordinated CareCoordinated Care

Designate Immunization Champions

The practice reports adverse events tothe Vaccine Adverse Events ReportingSystem (VAERS), and is aware of theNational Vaccine Injury CompensationProgram(VICP)1


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Immunizations are coordinated with routinewell-visits, follow-up, and sick visits

Immunizations received outside of themedical home are communicated to theprimary care clinician

Strategies to ProvideStrategies to ProvideCoordinated CareCoordinated Care

ThefollowingcasestudyisdesignedtoassistyoutoimplementtheCoordinated Care componentofthemedicalhomeconceptduringimmunization-relatedpatientencounters. Strategiestoaddressspecificissuesraisedinthescenarioareincluded.

Case Study #2:Case Study #2:Coordinated CareCoordinated Care

Billy is a healthy 5 year-old Hispanic boywho is starting kindergarten this year.When Billys mom drops him off at schooland shows the school nurse his immunizationrecord, the nurse informs her that,according to their states immunization

requirements, Billy is not current on all ofhis immunizations. His vaccination recordindicates that he has received: 3 DTaP, 2IPV, 1 Hib, 2 Hepatitis B, 3 Prevnar, 1Varicella, and 1 MMR.


Question: What should the school nurse do?Question: What should the school nurse do?What should Billys pediatrician do?What should Billys pediatrician do?


What should the school nurse do?

Document that Billy is behind and sendDocument that Billy is behind and senda letter home to his parents.a letter home to his parents.

Refer Billy to his pediatrician.Refer Billy to his pediatrician.

Case Study #2:Case Study #2:

Coordinated CareCoordinated CareWhat should Billys pediatrician do?

Follow the written vaccination protocols,Follow the written vaccination protocols,including theincluding the Catch-up Schedule for childrenfor childrenbehind on immunizations.behind on immunizations.

Billy needs:Billy needs:DTaP #4, IPV #3DTaP #4, IPV #3both final dosesboth final dosesbecause given after age 4because given after age 4PCV #4PCV #4because the first 3 dosesbecause the first 3 dosesgiven before 24 months of agegiven before 24 months of ageHep B # 3Hep B # 3last doselast doseMMR #2MMR #2hes donehes done


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Update the childs immunization recordUpdate the childs immunization recordto reflect which vaccinations were givento reflect which vaccinations were given,,dates of administration, number ofdates of administration, number ofdoses, intervals between doses, and thedoses, intervals between doses, and thechilds age.childs age.

If the physician participates in aimmunization registry or child healthinformation system (CHIS), enter datainto the system.

If necessary, provide parent education atnext visit, and/or provide school withparent handouts.


Continuously monitor state requirementsand the recommended schedule to ensurechildren are up-to-date.

Consider implementing a reminder-recall

system to identify and call in children thatare behind.


References: Coordinated CareReferences: Coordinated Care

1. National Vaccine Advisory Committee. Standards forChild and Adolescent Immunization Practices. Pediatrics.2003;112:958-963

2. Santoli JM, Rodewald LE, Maes EF, Battaglia MP,Coronado VG. Vaccines for Children Program, UnitedStates, 1997. Pediatrics. 1999;104(2)

3. Centers for Disease Control and Prevention.Immunization Registry Progress United States,January-December 2002. MMWR Morb MortalWklyRep. 2004;53:431-433

References: Coordinated CareReferences: Coordinated Care

4. StokleyS, Rodewald LE, Maes EF. The impact ofrecord scattering on the measurement of immunizationcoverage. Pediatrics. 2001;107:91-96

5. Bell KN, Hogue CJR, Manning C, Kendal AP. Riskfactors for improper vaccine storage and handling inprivate clinician offices. Pediatrics, 2001;107:100

Immunization: Continuous CareImmunization: Continuous CareContinuous:The same primary pediatric

clinician practice is available from infancythrough adolescence and young adulthood

Continuity of care from birth throughthe second year of life greatly increasesimmunization levels3

Multiple clinicians leads to scattering ofthe immunization record1


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Immunization: Continuous CareImmunization: Continuous Care

Improper record keeping can lead toincreased costs and extra immunizations

Greater continuity of care is associatedwith higher quality of care as reportedby parents2

Review vaccination and health status ofpatients at every encounter to determinewhich vaccines are indicated

Strategies to ProvideStrategies to ProvideContinuous CareContinuous Care

Regularly review patient records andconduct practice-wide vaccinationcoverage assessments annually Identify children behind on

immunizations Implement recall/reminder or other

strategies to increase immunizationrates

Utilize standing orders to allow staff toindependently screen patients, identifyopportunities for immunization, andadminister vaccines under physiciansupervision (in accordance with localregulations)

Promote immunization at both well andsick visits

Strategies to ProvideStrategies to ProvideContinuous CareContinuous Care

References: Continuous CareReferences: Continuous Care

1. Yusuf H, Adams M, Rodewald L, Lu P, Rosenthal J,LegumSE, Santoli J. Fragmentation of immunizationhistory among clinicians and parents of children inselected underserved areas. Am J Prev Med. 2002Aug;23(2):106-12

2. Christakis DA,Wright JA, Zimmerman FJ, BassetAL, Connell FA. Continuity of care is associated with

high-quality care by parental report. Pediatrics.2002;109:e543. Irigoyen M, Findley SE, Chen S, Vaughan R, Sternfels

P, Caesar A, Metroka A. Early continuity of care andimmunization coverage. Ambul Pediatr. 2004 May-Jun;4(3):199-203

Immunization:Immunization:Comprehensive CareComprehensive Care

Comprehensive: Care is delivered ordirected by a well-trained physician whois able to manage and facilitate allaspects of immunization and otherpreventive services

Scope of Problem:Immunization coverage rates are higherfor children receiving all or somevaccines within a medicalhome1

Immunization:Immunization:Comprehensive CareComprehensive Care

Promoting vaccination within themedical home improves both vaccinationcoverage and receipt of otherpreventiveservices1

Errors maintaining cold-chain (impropervaccine placement, inaccuratethermometers, improper temperature)can affect the access to vaccinequality4


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Barriers toBarriers toComprehensive CareComprehensive Care

Improperly deferring vaccination (i.e.,not based on valid contraindications)

Increasingly complex vaccinationschedule

Lack of reminder-recall system Improper storage and handling

procedures resulting in spoilage ofvaccine

Missed opportunities (MOs) tovaccinate (i.e., vaccine-eligible childdoes not receive needed vaccines)

Eliminating MOs could increaseimmunization coverage by up to30% or more2, 3


MOs are frequently associated with3,4

Inappropriate contraindications suchas minor febrile illness

Not giving vaccine at acute care

visits Not giving all the shots needed at a

visit


Reasons for MOsReasons for MOs

Deficits in clinician knowledge3,5

Vaccines delayed due to validcontraindication

Incorrect or overcautious interpretationof contraindications5

Failure to review the childs vaccinationstatus6

Incomplete vaccine records7

Reasons for MOsReasons for MOs Physician reluctance to give

multiple vaccinessimultaneously7

Vaccine delays/shortages8

Practice requirement toreceive physical examinationprior to vaccination

Differences BetweenDifferences BetweenContraindications & PrecautionsContraindications & Precautions

Contraindications: Conditions in a recipientwhich greatly increases the chance of aserious adverse reaction

Precautions: Conditions in a recipient whichmay increase the chance or severity of anadverse reaction, or may compromise theability of the vaccine to produce immunity


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Valid Contraindications vsValid Contraindications vsPrecautionsPrecautions

ConditionAllergy to ComponentEncephalopathyPregnancyImmunosuppressionSevere illnessRecent blood product

LiveC

---CCPP

InactivatedCCVVPV

C=contraindication P=precaution V=vaccinate if indicated

Source: General Recommendations on I mmunization, Epidemiology andPrevention of Vaccine-Preventable Diseases. National I mmunization Program,Centers for Disease Control and Prevention. Revised December2004.

Mild illnessAntibiotic therapyDisease exposure or convalescence Pregnancy in the household Breastfeeding Premature birthAllergies to products not in vaccine Family history unrelated to immunosuppressionNeed for TB skin testingNeed for multiple vaccines

InvalidInvalid Contraindications toContraindications toVaccination (not even precautions!)Vaccination (not even precautions!)

Strategies to ImproveStrategies to ImproveComprehensive CareComprehensive Care

Clinicians do not use falseClinicians do not use false contraindicationscontraindicationsto prevent immunizationsto prevent immunizations

Practices adopt and implement the Standardsfor Child and Adolescent ImmunizationPracticesestablished by the National VaccineAdvisory Committee (NVAC)

Vaccines are administered according to theRecommended Childhood and AdolescentImmunization Schedules; physician stays up-to-date about potential new vaccines


Use the recommended Catch-upSchedule forchildren who have missed or delayedimmunization It makes it easier for staff to figure out

who needs what

Proven to get children up-to-date fasterPractice staff who administer vaccines and

staff who manage or support vaccineadministration are knowledgeable and receiveon-going education

Strategies to ImproveStrategies to Improve

Comprehensive CareComprehensive Care

Educational resources about all aspectsof immunization are made available

Current Vaccine InformationStatements (VISs) are provided andexplained to patients/parents prior tovaccination


Staff should follow appropriateprocedures for vaccine storage andhandling

Staff should reduce vaccine liability andensure proper coding/reimbursement

Health care professionals follow onlymedically accepted contraindications


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Barriers toBarriers toFamilyFamily--Centered CareCentered Care

Patient and physician have access to bothaccurate and inaccurate immunizationresources

Poor communication (i.e., differingeducation/literacy levels, languagebarriers)

Common Parental ConcernsCommon Parental ConcernsAbout VaccinesAbout Vaccines

1. The use of Thimerosal (anorganomercurial) as an additive in vaccines

2. An unsubstantiated link between the MMRvaccine and autism

3. The necessity of vaccinating childrenagainst hepatitis B

4. Pneumococcal conjugate (new vaccine toprotect against meningitis, bloodinfections, ear infections)

Common Parental ConcernsCommon Parental ConcernsAbout VaccinesAbout Vaccines

5. Meningococcal vaccine (new meningococcalconjugate vaccine to protect againstmeningococcal disease)

6. The relative danger of influenza and theneed for a yearly vaccination

7. The relative danger of varicella(chickenpox)

The Facts About ThimerosalThe Facts About Thimerosal

Thimerosal is a preservative that preventsbacterial and fungal contamination in somevaccines and contains a form of mercury(ethylmercury)

There is no evidence that the trace amounts

of Thimerosal in vaccines has caused harmto infants, except for minor side effectslike swelling and redness at the injectionsite

The Facts About ThimerosalThe Facts About Thimerosal

In 1999, the Public Health Service and theAAP recommended that Thimerosal betaken out of vaccines as a precautionarymeasure. By the end of 2001, all routinepediatric vaccines contained no Thimerosalor only trace amounts (some Influenza andTd vaccines)

The Facts About MMRThe Facts About MMR

Autism spectrum disorder is a commonAutism spectrum disorder is a commondevelopmental disability, affecting 1 in 166developmental disability, affecting 1 in 166childrenchildren33

Concerns have been raised about a possibleConcerns have been raised about a possiblelink between the proximity of the MMRlink between the proximity of the MMRvaccination administration and thevaccination administration and thedevelopment of signs of autismdevelopment of signs of autism


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The Facts About MMRThe Facts About MMR

StudiesStudies and independent panels in the USand independent panels in the USand in Europe, including experts from theand in Europe, including experts from theInstitute of MedicineInstitute of Medicine and the AAP, haveand the AAP, havefound no association between the MMRfound no association between the MMRvaccination and autismvaccination and autism

The Importance ofThe Importance ofthe Hepatitis B Vaccinethe Hepatitis B Vaccine

The hepatitis B vaccine is the bestprotection a child can have against adangerous disease with lifelong serioushealth problems

Vaccinating early against hepatitis B assureschildrens immunity when they are the mostvulnerable to the worst complications ofhepatitis B and before they enter the highrisk adolescent years

The Importance ofThe Importance ofthe Hepatitis B Vaccinethe Hepatitis B Vaccine

Before the vaccine was introduced, 20,000children under age 10 became infected eachyear

The Importance of thePneumococcal Conjugate Vaccine

Pneumococcus bacteria can causemeningitis and other blood infections.Meningitis is an inflammation of the brainand spinal cord, which can lead to braindamage, mental retardation, and even

death Pneumococcal conjugate vaccine providessuperior protection against this serious anddeadly infection

The Importance of thePneumococcal Conjugate Vaccine

Meningitis symptoms in children are lessobvious than in adults. The disease can goundetected and untreated. Vaccination canprotect children from this uncertainty

The Importance of theMeningococcal Vaccine

Meningococcal disease is caused bybacteria that infect the bloodstream,lining of the brain, and spinal cord, oftencausing serious illness.

Ten to 14% of people with meningococcaldisease die, and 11-19% of survivors havepermanent disabilities


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CISP ResourcesCISP Resources

Key Contact Network:A key contact network

of immunization clinicians who are instrumentalin promoting immunization delivery has beendeveloped.

The AAP Immunization Initiatives Newsletteris disseminated electronically to members ofthe network. To receive a copy of this monthlypublication, e-mail [email protected]


Vaccine Safety Reports:The Measles -

Mumps-Rubella Vaccine and AutisticSpectrum Disorder:Report From the NewChallenges in Childhood ImmunizationsConference, based on the conferenceconvened in June 2000 was published in theMay 2001 issue of Pediatrics.

*A variety of AAP Policy Statements, ClinicalPractice Guidelines, and Technical Reportsonimmunizations and related topics are alsoavailable.


Technical Assistance: Technical assistanceon immunization issues is provided topediatricians, other health careprofessionals, and others in an effort tosupport their efforts to communicate withparents around vaccine safety issues and

immunize children within a medical home.

CISP ResourcesCISP ResourcesResource Publications: Fact sheets, brochures,educational posters, AAP policy statementsand technical reports, and strategies on avariety of immunization related topics areprovided for pediatric office practices.


CISPWeb siteCISPWeb site: For fast, helpful and: For fast, helpful andaccurate information on immunizations foraccurate information on immunizations forparents, the public, and all health careparents, the public, and all health careprofessionals visit:professionals visit: www.cispimmunize.orgwww.cispimmunize.org ororwww.aap.orgwww.aap.organd click the Immunizationand click the ImmunizationInformation button on the homepage.Information button on the homepage.


The AAPCompendiumof Immunization Resourcesand Organizations is an organizedlisting of national and state-basedorganizations and initiatives, including AAPchapter immunization activities. In addition,the resource provides a compilation ofimmunization educational resources forparents and pediatricians. An on-line version ofthe Compendium is available on the CISPWebsite.


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Contact UsContact Us

For more information about the CISP, to receive copiesof our materials, or to be added to the CISP keycontact network, please contact:

American Academy of Pediatrics

Department of Practice

141 Northwest Point Blvd.

Elk Grove Village, IL 60007

Tel: 800/433-9016 ext 4271 Fax: 847/228-9651

E-mail: [email protected]

Documents

Immunization Training Tool