1. Implementation of an Elementary School-located Influenza Vaccination Program with Billing of Third-Party Payers 44 th National Immunization Conference April 19 th, 2010 J. Shlay, C. Busch, A. Hammer, M. Riis, J. Lyons, S. Romero, J. Pyrzanowski, M. Daley, S. Hambidge, D. Rinehart, E. McCormick, S. Rodgers, T. Vogt, H. Fang, A. Kempe

2. Background Delivering annual influenza vaccination services to all children presents challenges –Most influenza vaccination for children occurs in public health or private settings –Traditional settings unlikely able to meet demand Schools recognized as potential sites to deliver influenza vaccines to school-age children –Offer platform to vaccinate large numbers of children efficiently –Provide vaccinations to children who are not seen for regular medical care –However, school-located programs have not traditionally billed insurance companies limiting programmatic sustainability

3. Objectives of Project To implement a school-located influenza vaccination program in selected elementary schools of Denver Public Schools (DPS) To develop a process for billing 3 rd party payers To evaluate the acceptability of this program To evaluate the feasibility of conducting this program To evaluate the costs of conducting this program To determine vaccine uptake and barriers to participation

4. Community Collaboration is Critical * Community Health * Denver Public Health * Health Services Research * Billing and Contracts * Data Warehouse SUCCESSFUL PROJECT!

5. Project Description Setting: Subset of elementary schools affiliated with DPS Services provided at 20 schools during 2009- 2010 school year –Two clinics per school conducted –Offered seasonal (intranasal and injectable) and H1N1 (injectable)(2 nd clinic only) influenza vaccinations –Second dose offered to children <9 years of age Insurance information collected with the consent Commercial and government insurances were billed

6. School Locations

7. Project Start-Up Description Start Up: Project team developed processes needed to establish, implement, and evaluate the program Implementation team established Paraprofessionals hired and trained by project staff Contracts negotiated with stakeholders and 3 rd party payers Consents, protocols, billing sheets developed Marketing tools developed including website and project logos Pilot clinic conducted to assess processes Implementation plan finalized

8. Process for Parental Consent Consents distributed to school by Project Staff Teacher/office sends consents home with students Consents returned to school and checked for completeness Immunization histories* entered into registry & vaccine eligibility determined Immunization history reviewed for every consent received Routing form completed for every consent received Consent, health info, and history reviewed for each student Eligibility verified & marked on administration form Entire packet reviewed by nurse prior to administering vaccine * Systems used for tracking immunization history include VaxTrax (Denver Health’s immunization registry system – exports directly into CIIS (Colorado Immunization Information System state registry)

9. Project Description Pre-Clinic  Consents distributed  Vaccine records obtained and updated  Insurance verified  Processes for clinic initiated  Staff oriented  Supplies including vaccines secured Clinic  Consents reviewed for completeness  Identity verified  Vaccines provided to consented patients  Evaluation information collected  VIS sheets provided to students/parents  Administered vaccines entered into registry Post Clinic  Students registered into hospital system  Rendered services billed  Evaluation information entered  Updated vaccine history provided to schools  Student records maintained for future clinics

10. Results: Summary Statistics Eligible for program: 9856 students –Student population demographics at baseline: Median age of students: 7.6 years Male – 51% %FRL – 77% Race: African-American 10.0%, Hispanic 64.0%, White 22.4%, Asian/Pacific Islander 2.3% 40 clinics conducted between 11/09 – 3/10 Students immunized: 3181(32.3%) Vaccines given: 4163 –Seasonal flu vaccines: 2530 1 st clinic:1997 2 nd clinic: 533 –H1N1 flu vaccine given 2 nd clinic: 1633 53.7% received both H1N1 and seasonal flu vaccine

11. H1N1 – Impact H1N1 vaccine (injectable only) offered only at 2 nd influenza clinics –H1N1 vaccine not available till after 1 st clinics completed –Separate H1N1 consent developed –Resulted in much larger participation in 2 nd clinics than had been anticipated Of 1633 H1N1 vaccines given, 756 students (46.3%) consented and vaccinated for H1N1 only (no seasonal flu participation)

12. Billing Information Upon completion of clinic, students were registered in hospital system, assigned a medical record number, and billed for services SIGNATURE® program used for billing Two billing codes used: one for the vaccine (seasonal only) and one for the administration ($12 charge) 17 third party payers currently identified that are being billed

13. Type of Insurance among Subset * of Students Immunized and Billed for Services Type of insurancePercent of students Commercial 25.8% Government 39.7% Uninsured 34.5% * N=1906 (91%) of 1st clinic students vaccinated

14. Lessons Learned Engaging partners early in the process is critical Important to choose schools that are invested in program Detailed training of staff is important Development of billing process is time consuming

15. Conclusions Developing strong collaborative partnerships with schools leads to successful implementation of school- located vaccination clinics Providing influenza vaccinations in school- located clinics is feasible Schools offer a suitable location to provide influenza vaccinations

16. Plans for the Future Conduct a third year of influenza clinics in the target schools without needing to provide H1N1 vaccine mid-program Conduct a cost-benefit analysis Conduct focus groups Conduct parent and provider survey to assess acceptance of program

17. Funding This project was funded by a grant from the Centers for Disease Control and Prevention (PI – Dr. Judith Shlay) entitled: Implementation of an Elementary School Located Influenza Vaccination Program with Billing of Third Party Payers.

18. Questions? Additional information: Judith Shlay, MD, MSPH jshlay@dhha.org 303-602-3714