I-Raise the Rates Tools for Improvement in Practice: Case ...

I-Raise the Rates Tools for Improvement in Practice: Case ...

I-Raise the Rates Tools for Improvement in Practice: Case Based Approach to Increasing Immunization in Your Practice Robert H Hopkins, Jr., MD, FACP, FAAP UAMS College of Medicine Director Division of General Internal Medicine i-RAISE Immunization Champion Training February 26-28, 2016 Key Largo, FL 1 Disclosures I have no financial conflicts of interest I have MAJOR nonfinancial conflicts I am a firm believer in adult immunization I am disturbed by our poor performance in this area I am confident that we can improve with better

Knowledge Skills Determination Tools 2 Outline Brief survey of current AI recommendations, rates Case based review of Adult Immunization Identify challenges associated with specific vaccines

Plant seeds in you: Because you are fertile soil to grow improved adult immunization practice!!! Provider Recommendation & Patient Communication Reminder Recall Chart/Provider Reminders Standing Orders Immunization Information Systems 3 4 5 Adult Vaccination Rates = POOR! Data: NHIS 2014

Vaccine [Population] Influenza 2013 2014 Influenza All Adults 39.7 % 43.2 % [All] 19 49 years 30.6 % 31.5 %

[All] 50 64 years 43.7 % 47.7 % > 65 years 61.3 % 71.5 % HCW [19 64 years] 65.4 % 65.4 %

2013 2014 High risk 19 49 years 21.2 % 20.3 % > 65 years 59.7 % 61.3 % Tetanus [19 49 years, received past 10 years]

62.9 % 62.6 % Tetanus/Pertussis [19+, received in past 8 yrs] 17.2 % 20.1 % Shingles [Zoster] age 60+ 24.2 % 27.9 % Hepatitis B Vaccine [High risk 19 49 years]

32.6 % 32.2 % PPS23 & PCV13 HPV Vaccine [women 19-26/men 19-26, >1 dose] MMWR Feb 5, 2016/ Vol 36.9 % 8.0 % 40.2 % 8.2 %

6 Disparities and Adult Vaccination Rates Data: NHIS 2014 Vaccine [Population] Pneumococcal [>65 years] All Adults Hispanic White Black Asian Rate 61.3 % 45.2 % 64.7 %

49.8 % 47.7 % and, unfortunately, there are similar disparities for most adult vaccines. This is absolutely unacceptable in the United States in 2015!! -RHH, MD 2/15/2015 MMWR Feb 5, 2016/ Vol 65(1). 7 Provider Recommendation: Standards for Adult Immunization Practice ALL providers should incorporate immunization needs assessment into every clinical encounter with strong recommendation. 1. ASSESS immunization status

2. RECOMMEND vaccines indicated, and strongly 3. ADMINISTER needed vaccines or REFER patients to a vaccine provider 4. DOCUMENT received vaccines http://www.cdc.gov/vaccines/hcp/patient-ed/adults/for-practice/standards/index.html 8 CASE 1: Jane Smith 42 year-old teacher at local high school with asthma since childhood presents for follow up. Is using her controller and needs reliever about once a month in fall, winter and spring. Nurse flagged chart because she refused recommended vaccines I dont need them, those are for sick people How do you respond to Janes comment?? What vaccines would you recommend?

9 Jane Smith: Answers STRONG recommendation to vaccinate Recommend: Influenza Asthma is high-risk condition PPSV23 Asthma is intermediate-risk Tdap Routine adult, once*, then resume Td *In pregnant women recommend Tdap every pregnancy for infant protection 10 Provider Recommendation NONCONFRONTATIONAL Recognize and turn motivations to positives Avoid pejorative/emotional reaction

SUPPORTIVE Data not highly effective in leading to behavior change Personal anecdotes, stories can be useful Conviction without judging is critical 11 Provider recommendation 1: Anti-Vaccine 5-Point Response RISK REDUCTION High risk patients may not understand this VALUE to INDIVIDUAL Cost of illness in work loss/effectiveness Cost of treatment of illness VALUE to FAMILY/Community

Not there -or not at best- to care for family LOW COST ACA Mandated first dollar coverage [Not MCare, MCD] SAFETY of vaccines 12 Provider recommendation 2: SHARE More Information (If Needed) Share reasons why the recommended vaccines are right for the patient given age, health status, lifestyle, job, or other risk factors. Highlight your own experiences with vaccination to reinforce benefits

Address patient questions and any concerns about vaccines, include side effects, safety, effectiveness in plain, understandable language Remind patients many vaccine-preventable diseases are common in the U.S. and can be serious for them. Explain the potential costs of getting VPDs, including serious health effects, time lost (e.g. missing work or family obligations), and financial costs. 13

Provider Recommendation Translates Into Higher Vaccination Rates (Even for Patients With Negative Attitudes) Vaccination Rate (%) 100 80 No recommendation 85.1 82 60 40

27 15.8 20 0 Influenza PPV *High-risk patients were those ages 65 and older or those having heart disease, lung disease, diabetes, or other serious illness. Nichol KL, et al. J Gen Intern Med. 1996;11(11):673-677. 14 15

Provider recommendation 3: Patients Who Arent Ready to Decide Emphasize the benefits of getting vaccinated today Provide education Materials Trusted websites Community partners [Pharmacy, Health Department, AARP,] Document the conversation in the record Set a plan for deferred vaccines And send reminders about needed vaccines Continue the conversation at the next visit. For those who choose not to [be vaccinated] 16 Reminder Recall Strategy to remind patients that vaccines are due

(reminder) or late (recall) Can be delivered via various methods (telephone, letter, email, text) and include educational materials Usually targeted by patient demographics Disease: asthmatic, diabetes, cancer, HIV/AIDS, Risk Factors: smokers Age group: 18-19/College, 65+ Increase vaccination coverage ~ 12 20% Guide to Community Preventive Services http://www.thecommunityguide.org/vaccines/clientreminder.html 17 NO EMR: Sample Reminder Notice 18

Patient Reminder/Questionnaires: Assess Status, Patient Reminder In clinic or send out via patient portal. UAMS Adult immunization Clinic Screening Questionnaire NAME ____________________ Birthdate ___/___/19___ PCP _________________ Please complete this questionnaire to help our staff help better protect you and all of our patients from vaccine-preventable diseases! -UAMS Center for Primary Care Staff 1. Do you have an allergy to any vaccine, to eggs or to gelatin? O No O Yes 2. If you need additional vaccines, would you be willing to receive them today with your flu vaccination? O No O Yes If no, may we forward this questionnaire to your PCP? O No O Yes 3. Do you have any chronic health conditions, including any previous tissue or organ transplants? O No O Yes If yes, please list here:______________________________________________________________________________________ 4. Are you taking any medication [now or within the last month] which lowers the function of your immune system? O No O Yes Examples would include: Chemotherapy, prednisone, medications to treat lupus or rheumatoid arthritis, medications to prevent transplant

rejection, medications to treat colitis or Crohns. If yes, please list here:_______________________________________________ 5. Have you had [or are your doctors planning] surgery to remove your spleen? O No O Yes 6. Have you had any of the following: brain or spine surgery with placement of a shunt, brain or spine surgery which has resulted in a spinal fluid leak, or cochlear implant surgery? O No O Yes 7. Have you ever had an adult tetanus and whooping cough (pertussis) vaccination? O No O Yes 8. Was your last tetanus vaccination given within the last 10 years? O No O Yes If yes, what year was this given? __________ 9. Have you received a 'pneumonia [or Pneumococcal] vaccine in your adult life? O No O Yes If yes, what year was this given? __________ 10. Have you ever had any of the following diseases or vaccinations against these diseases? Chicken Pox: O No O Yes Measles: O No O Yes

Mumps: O No O Yes 11. Have you ever had a Shingles (Zoster) vaccine? O No O Yes 12. Have you ever had Hepatitis B or Hepatitis A vaccination [or both]? O No O Yes Hepatitis B O Yes Hepatitis A 13. Did you receive an influenza vaccine last year? O No O Yes If yes, where did you receive this immunization? ________________________ RHH, MD AI Screening Questionnaire 2014 NOTE: For this to be most useful, support with additional tools for patients, registration and vaccinating staff [e.g. guideline, standing order, access] 19 CASE 2: Bill Jones 54 year old man with diabetes and severe chronic kidney

disease [CKD5] here for follow up. He has been adherent to medications and has lost a few # since last visit. On kidney transplant list for severe CKD. He received influenza vaccine and Tdap from health department this past fall. Nurse flagged chart- he Zoster vaccine [and will consider others] but nurse concerned - he does not qualify based on standing order Resources used for improvement? What vaccines do you recommend? What about the Zoster question? 20 Bill Jones: Answers Resources: TOOLS TEAMWORK REMINDER STANDING ORDERS Recommend:

PCV13 ESRD is highest-risk condition Followed by PPSV23 in 8+ weeks HBV DM < 60 yrs. is high-risk condition ESRD is high-risk condition [High Dose vax] [Likely NO] Zoster recommended by ACIP at 60+ FDA approved at 50+

Can give, one shot vax, likely this will require $$ out of pocket as not ACIP indicated.. 21 Chart/Provider Reminders Alert providers that patient(s) are due for vaccines Methods: EMR Alerts Pre-visit chart review Engage team in use of reminders in concert with SO Expect results! Shown to increase vaccination 12 16% overall EHR based: can result in up to 50% increase in flu and pneumococcal vaccinations http://archinte.jamanetwork.com/article.aspx?articleid=1105941 http://www.thecommunityguide.org/vaccines/providerreminder.html 22

Provider Reminder: Vax Indications Mr. Test has not received [none doc. in EMR] any immunizations!! He is deficient in many Health Maintenance elements, including no vaccinations 23 2 2 1 2

3 24 Select vaccines you wish to order [EMR associates with Preventive imm codes] Click sign button to activate 25

Standing Orders Protocol (SOPs) Strategy to avoid missed opportunities in vaccination by allowing non physician providers to administer vaccines without direct physician involvement Recommended by many groups, including: Advisory Committee on Immunization Practices (ACIP) U.S. Community Preventive Services Task Force Endorsed by CMS for vaccines since 2002 Resources: http://www.standingorders.org/ http ://www.immunize.org/standing-orders/ 26 SOP Procedure

Recommend vaccination Your doctor strongly recommends [flu] vaccine and wants you to have it may I give it to you? Screen for contraindications and precautions Provide appropriate Vaccine Information Statement (VIS) Vaccine administration procedure Vaccine documentation procedure 27 Standing Order Example: Influenza UAMS UAMS Standing Order: Tdap. AU: RHH, MD. 10/2014. Accessed 2/18/2015 28

Standing Orders Protocols Effectiveness Pharmacotherapy2007;27:729733 Journal of American Geriatric Society2005;53:1008-1010 American Journal of Kidney Diseases2009;54:6-9 American Journal of Preventive Medicine2000;18(1S):92-6 29 CASE 3: Johnny Boudreaux 76 year-old man transferred today from the regional trauma center to the rehab center for which you are the Medical Director following severe ortho injuries in MVA. On intake assessment you note Influenza vaccination documented in transfer summary but there is no record of any

other immunizations He does not know what vaccines he has received. How might you obtain this information? What vaccines would you recommend for Mr. B today? 30 Johnny Boudreaux: Answers Information: Family? PCP? Pharmacy? State Registry? Immunizations Today: PCV13 Single dose in all adults 65+ PPSV23 DELAY: Recommend IN 12 months [CMS]

Zoster Tdap Adults 60+ Would be surprising to not get this in trauma care but stranger things have happened.. 31 Immunization Information Systems (IIS): State Lifespan Registries IIS (registries) are confidential, population-based, computerized databases that record all immunization doses administered by participating providers in a given area IISs have robust vaccinations records for children, but remain underdeveloped or used for adults

Due to the mobility of the U.S. population, IISs will be critical to easily access complete vaccine histories Multiple vaccine providers and locations for adults Interoperability and data sharing between state IISs are needed http://www.cdc.gov/vaccines/programs/iis/contacts-registry-staff.html 32 State Registry Snapshots: AR WebIZ, Florida Shots, and NJIS 33 IIS and Meaningful Use Stage 2: Core Measure 16 Submit electronic data

to immunization registries Objective: Capability to submit electronic data to immunization registries or immunization information systems [] Measure: Successful ongoing submission of electronic immunization data from certified EMR to immunization registry or immunization information system for the entire EHR reporting period. Unidirectional feed is required from your EMR Bidirectional better but more problematic http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/ Stage2_EPCore_16_ImmunizationRegistriesDataSubmission.pdf

34 CASE 4: Systems, QI Starter You have done a quick audit of 30 randomly selected patient charts in your clinic panel and see that only 40% of your patients received influenza vaccine and had it documented in the EMR in the 2014 15 season. What elements can you identify that might play into this low vaccination rate? What simple intervention could be implemented to address this issue? What other team members do you want to engage in this project to improve your likelihood of success? 35

QI Starter: Some Potential Answers Problems: Is there a systematic vaccination process in place? Is vaccination ad lib or actively encouraged? Process to document vaccines elsewhere, refusal? Are all vaccine doses being recorded? Is the team knowledgeable and engaged? Intervention: Education, Process, Outreach App, In-service, Post schedule/reminders Team: 1= Identify Champion Clinic admin/leaders, all providers must at least agree Registration, Nurses, MA, others? 36 QI: PDSA Cycling Plan

Design a process change: Identify gap in care, champions and stakeholders, process for change (with measurable outcome and timeframe) Do Put the process change into place Stu dy Review the data Act

Abandon, adapt, adopt, or repeat again 37 Where to start with Immunization QIP? Identify a champion Choose a specific focus/target: One vaccine One age group One disease state Assess the status of that target Rate in a sample population Impact on the practice Assess the knowledge and concerns of your team 38

Example QI Projects Strategy Utilized Patient Communication Vaccine Hepatitis B Reminder Recall Influenza Chart Reminder HPV Standing Orders Tdap

Immunization Information Systems Pneumo Population Diabetics Details Generate list of all diabetic patients and at next visit, recommend vaccination against Hepatitis B All adults At the start of flu season, send patient communication to remind patients to receive vaccine. After 2 months, identify patients not yet vaccinated and resend

reminder Female patients Query EHR to identify eligible patients 19 26 & Male who have not received HPV vaccine. patients 19 21 Program an alert in patient charts to discuss and administer vaccine at next visit Pregnant women, For each pregnant patient, have nursing 27 36 weeks staff offer and administer vaccine with gestation appropriate documentation Patients over 65 For each visit with elderly patients, transmit pneumo vaccination status to IIS 39

http://immunization.acponline.org/ 40 Pneumococcal Flow Sheet: ACIP Indications 41 Tdap QIP 1 1. Is there a problem? 2. Analyze the problem 3. Look for solutions a. Quick wins b. PDSA Candidates 4. Build a team 5. Start P-D-S-A 6. Assess results

7. Next cycle(s) a. Same problem b. Move to a new issue 42 Tdap QIP 2 43 Tdap QIP 3 And multiple other cycles could/should follow until rates are sustained at goal! Then we turn the teams attention to the next target! 44

Flu QIP: Starter Set 45 UAMS Vaccine Clinic QIP Goal: Raise Influenza rates in OPC patients to > 50% [from ~43%] Clinic admin variable despite SO, posters, Educ. Outreach, 100% Employee vax Plan: Flu Vax [+ Pneumo] clinic adjacent to OP Lab Oct 15-Jan 1. 1 REG, 1 LPN. SO + RN/MD backup

Do: Clinic, PR across OPC Study: 1307 doses Influenza, 270 doses PCV/PPS 14-15 4800 doses admin in OPC 15-16 ____ doses admin in OPC [4400 doses by 11/12] Some vaccinating clinics referred and did not vax Act: Planning for 2016-17 season 46 Additional Resources 1. ACP Guide to Adult Immunization http ://immunization.acponline.org/

2. CDC Patient Education Materials http://www.cdc.gov/vaccines/hcp/patient-ed/adults/index.html 3. Adult Vaccinations Resource Library http ://www.immunize.org/adult-vaccination/resources.asp 4. What Works to Increase Adult Vaccination Rates http://www2a.cdc.gov/vaccines/ed/whatworks/index.html 5. Quick Guide to Adult Vaccine Messaging http://www.izsummitpartners.org/wp-content/uploads/2014/05/ AdultVaccineMessaging.pdf 47

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