1. Excellence in Adolescent Immunizations at Western Michigan University Homer Stryker MD School of Medicine Conference on Practice Improvement December 4-7, 2014 Glenn V. Dregansky, DO, FAAFP Dorothy Bennett, RN, MBA Julius Ramirez, MD Susan Jevert, DO

2. WMed Clinic Setting WMed formerly known as MSU/KCMS: Residency program with three primary care clinics serving a low socioeconomic population Large pediatric population who are underinsured, uninsured, or Medicaid eligible 75,000 patient visits per year This year moved Family Medicine Residency clinic to nearby FQHC

3. WMed Patient Population

4. Background in Improving Pediatric Immunization Rates at WMed Clinic 2004- Kalamazoo Health & Community Services and the Michigan Care Improvement staff met with WMed Education was performed on the VFC and MCIR process The immunization status evaluated

5. JUNE 2004 Aged 19-35 months 4-DTP:3-IPV:3-HIB:1-MMR:3-Hep B:1- Varicella FM & MP 41% Peds 47%

6. Need for Change Different systems to assess immunization status Paper charts and EMR until August 2005 No QI initiatives- no direction New management in 2004 Staff Turnover

7. Barriers to Change Patients Financial, social, transportation, and educational issues Organization Lack of utilization of immunization history No defined roles for immunization administration Appropriate storage of immunization Financial- up front cost of immunizations & lack of understanding of the VFC process Community Lack of patient understanding of immunizations

8. Innovative Initiatives Management provided access and training for MCIR for all clinical staff Roles defined for all staff to streamline immunization reporting including printing of a MCIR report for all patients on the daily schedule QI initiative including monthly reporting to clinic personnel and quarterly reporting to QI committee Purchase of Sanyo pharmaceutical refrigerators to allow for proper storage and purchasing discounts In January, 2006 MSU/KCMS initiated “Immunize Now!” – nurse driven protocol using every encounter as an opportunity to vaccinate Continued staff training after showing initial improvements

9. Collaborative Coalition MSU/KCMS clinical teams to identify immunization processes Community collaboration with: Medicaid plans, GLHP & HPOM – Monthly meetings to discuss patient issues – Location of hard to find patients & families Pharmaceutical reps: GSK, Merck & Sanofi Educational opportunities for new immunizations Create roll out plans for new immunizations Immunization reference materials provided to clinic

10. JANUARY 2006 Aged 19-35 months 4-DTP:3-IPV:3-HIB:1-MMR:3-Hep B:1- Varicella June 2004 FM & MP 41% Peds 47% Jan 2006 FM & Peds 77% Peds 76% Goal 90%

11. Immunize Now Standing orders developed Reviewed by the Clinic Management Team against current immunization standards and practices Reviewed annually by the Clinic Management Team and renewed by the Medical Directors Nursing staff query the state data base (MCIR) at every patient visit. All immunizations are then expected to be given per protocol Contra-indications and refusals are communicated to the physician seeing the patient at that encounter The contra-indications are reviewed for accuracy and refusals lead to physician- patient discussion regarding the decision to refuse immunizations

12. Adolescent HPV immunization rates 2012 National Immunization Survey Association of vaccine with sexual activity Unaware of necessity Safety concerns Not recommended by provider

13. January 2010 Age 13-15 years 3-IPV:2-MMR:3-Hep B:2-Varicella:1- Meningococcal Jan 2010 91%

14. January 2011 Age 13-15 years 3-IPV:2-MMR:3-Hep B:2-Varicella:1- Meningococcal Jan 2010 91% Jan 2011 95%

15. January 2012 Age 13-15 years 3-IPV:2-MMR:3-Hep B:2-Varicella:1- Meningococcal Jan 2010 91% Jan 2011 95% Jan 2012 97%

16. June 2014 Age 13-15 years 3-IPV:2-MMR:3-Hep B:2-Varicella:1- Meningococcal Jan 2010 91% Jan 2011 95% Jan 2012 97% June 2014 99%

17. January 2010 Age 13-15 years 3-HPV Females Jan 2010 49%

18. Dec 2010 Age 13-15 years 3-HPV Females Jan 2010 49% Dec 2010 60%

19. June 2012 Age 13-15 years 3-HPV Females Jan 2010 49% Dec 2010 60% June 2012 91%

20. July 2012 Age 13-15 years 3-HPV Male and Females Jan 2010 49% Dec 2010 60% July 2012 40% June 2012 91%

21. July 2013 Age 13-15 years 3-HPV Male and Females Jan 2010 49% Dec 2010 60% July 2012 40% June 2012 91% July 2013 64%

22. July 2014 Age 13-15 years 3-HPV Male and Females Jan 2010 49% Dec 2010 60% July 2012 40% June 2012 91% July 2014 74% July 2013 64%

23. Proving Staff Competency In January of 2007, an immunization proficiency exam was initiated for all primary care nursing staff with a goal of 90% Baseline data averaged 74.04% 90 day data averaged 95.57% In April of 2008, an updated immunization proficiency exam was given to all primary care nursing staff Baseline data averaged 88.16% Annual data averaged 92.38% Annual immunization proficiency exam

24. Rewarding Success Monthly e-mails to clinic re: MCIR status Primary Care Clinics “friendly” competition of MCIR status Posting quarterly MCIR User Group awards in clinic Parties to celebrate successes Awarded the annual 2007 Site of Excellence Award through the Michigan Care Improvement Registry for Med Peds/Peds/FM Family Medicine was awarded the American Academy of Family Physicians/Wyeth “Best Practices” Award in recognition of process improvements in immunizations

25. Take Home Message Team Approach for Vaccinations Nurse driven protocols based on reviewed standing orders Use every encounter as an opportunity for immunization Be aware of guidelines, safety information, and have an effective vaccination system in place Have an outreach system in place to identify patients missing immunizations

26. Future endeavors Adapting Immunize Now initiative to current FQHC Achieve similar results in immunization rates in all pediatric age groups

27. Any Questions? Special Thanks to Clinical Staff at WMed Clinic and Dorothy Bennet RN, MBA Director of Nursing Services And Quality Improvement