Adult Immunization: Team Training Program

Adult Immunization: Team Training Program
Suggested talking points The program will cover the background and current state of immunization in the U.S., a basic overview of immunizations, best practices for immunization schedules and vaccine preparation and common supply maintenance guidelines. The training program is divided into 5 sessions: (1) vaccine fundamentals; (2) communicating benefits and risks of vaccination; (3) preparation, administration and adverse event reporting; (4) vaccine storage and handling and (5) billing, coding and documentation (including standing orders). Facilitator direction Throughout the course, encourage questions by handing out 3x5 cards to each participant at the beginning of each session and at the end (for the next session’s discussion). Ask participants to write down questions/concerns they have or they may have heard from patients regarding vaccines. Framing the question as having been a concern of a patient removes any embarrassment a participant may have about their own knowledge or hesitancy regarding vaccines. Do not have the participant write their name on the cards. Maintaining anonymity allows participants the freedom to ask questions at all levels. Use these questions to direct the level of detail provided throughout the training that is appropriate to the audience.

How to use this training program
Facilitators can use this program to provide immunization training for your practice or organization. This program curriculum contains five training sessions, each approximately 45 minutes in length, with facilitator notes. You can use this program as is or modify/adapt it for your team’s needs. It includes links to several engaging videos, articles and information that encourage staff participation and conversation. The training program is divided into 5 sessions: Vaccine fundamentals Communicating benefits and risks of vaccines Preparation, administration and adverse event reporting Vaccine storage and handling Billing, coding and documentation (including standing orders)

How to use this training program (cont.)
Each training session contains videos and materials to view to further articulate points. Some videos are quite long and viewing during the training session may not be possible. Also, some of the reading materials may take more time than the session allows. Depending on how much time is allotted for a training session, have team members review the videos or read materials either during or prior to the session. Prior viewing of videos and reading of materials will also facilitate class discussion. Talking points are available in the “Notes” section of most slides, along with direction for the facilitator on how to lead/frame the discussion. Encourage questions by handing out 3x5 cards to each participant at the beginning of each session and at the end (for the next session’s discussion) and have participants write down questions/concerns they have or they may have heard from patients regarding vaccines.

Course objectives Objective 1: Increase vaccine knowledge for your team and patients Objective 2: Improve administration of vaccines Objective 3: Improve immunization rates Objective 4: Increase guideline compliance Objective 5: Address work flow concerns and save time

Adult Immunizations: Team Training Program Session 1 Vaccine fundamentals
Facilitator direction Throughout the course, encourage questions by handing out 3x5 cards to each participant at the beginning of each session and at the end (for the next session’s discussion). Ask participants to write down questions/concerns they have or they may have heard from patients regarding vaccines. Framing the question as having been a concern of a patient removes any embarrassment an attendee may have about their own knowledge or hesitancy regarding vaccines. Maintaining anonymity allows participants the freedom to ask questions at all levels. Use these questions to direct the level of detail appropriate to the audience.

Adult immunization learning sessions Learning session 1
Vaccine fundamentals Communicating benefits and risks of vaccines Preparation, administration and adverse event reporting Vaccine storage and handling Billing, coding and documentation (including standing orders) Suggested talking points This session focuses on the foundations of vaccination and why it is important. The session takes approximately 30 minutes to complete, plus 15 minutes for questions – TOTAL TIME: 45 minutes

Session 1 objectives After this session, participants will be able to answer the following questions: What is the relationship between an antigen and an antibody? What is the difference between active and passive immunity? Which one is better and why? Which type of immunity is provided by the vaccination process? What is herd immunity? How can we know what vaccines are due for which patients and how often? Facilitator direction Ask participants to think about these questions while in this session. These questions will be asked again at the end of the session.

What is my role in disease prevention?
Providing vaccines is one of the best ways to prevent disease and save lives. The impact of vaccines on the health of the human population is comparable to the effect of having access to clean water. All team members play an important role in promoting vaccination. Team members who understand why vaccinations are important for saving lives are more likely to promote and provide vaccines. When health care professionals receive vaccines, we protect our patients, coworkers, families and ourselves. Suggested talking points Educating about and providing vaccines is one of the best ways to prevent disease and save lives. Health care team members play an important role in promoting vaccinations. Understanding vaccines and their importance is key. Getting vaccinations ourselves sets a good example. Facilitator direction Ask the audience: Do you know anyone who has ever had the flu, meningitis, polio, chicken pox or other vaccine-preventable illnesses? Encourage/probe further for stories about patients who have had uncommon diseases because of vaccines (e.g., polio). Attendees may state they know of people who had the ‘flu’ after getting the flu shot. This is a good opportunity to share the difference between the common cold (which erroneously is often called the ‘flu’ by clinicians) and influenza.

Get ready to learn and teach
Video: “Calling the Shots” - this video is an interesting introduction to vaccines Consider these questions while watching this video: What led to the return of diseases that were once eradicated? How can one vaccine affect a community? Why is the scene with the woman in the park significant? What can we learn from this movie about why health care professionals should be vaccinated and encourage vaccination? What stands out most for you as a viewer after watching this video? This video is 50 minutes in length and may be too long to view during the session. If needed, have team members review the video either during or prior to the session. Link to Calling the Shots video: Suggested talking points Where do we start? By learning and understanding adult immunizations we can teach our coworkers, patients, family members and the community about why vaccines are so important. We are going to watch a video called “Calling the Shots,” which is an introduction to vaccines, vaccinations and immunizations. Facilitator direction Introduce the questions prior to showing the video and use it to spark dialog after watching. Encourage staff to take notes. After the video, emphasize participants’ active role in vaccinating patients and how it can keep communities safe. Review the questions on the slide. Encourage all participants to engage in the conversation. Make sure to ask if anything was unclear or anyone has questions (to gauge clarity and understanding). Plan on this discussion leading to the understanding of herd immunity and how eradicated diseases have returned.

Antigens and antibodies
What are antigens and antibodies? Antigens are on the surfaces of viruses and bacteria and trigger the body to make antibodies. Antibodies are part of the immune response. How do antigens and antibodies play a role in immunity and immunizations? Passive immunity – Occurs when we’re given antibodies to fight infections/antigens. Active immunity – Occurs when we create our own antibodies to fight infection, either after an infection or exposure to antigens or from a vaccine. Suggested talking points It’s time to take a deeper dive into vaccines by discussing immunity, antibodies, antigens, herd immunity and vaccine schedules. This will set the stage for the remainder of the presentation’s content. What are antigens? What are antibodies? How do they differ? How do they play a role in immunity and immunizations? What is passive immunity? What is active immunity? Facilitator direction Discuss examples of passive immunity (e.g., mother to baby transmission in utero, administration of IV immunoglobulin). Discuss why providing vaccine-induced immunity is preferable to immunity from an active infection. You may wish to ask participants to read the CDC webpage on this topic prior to this session:

How does a vaccine work? Video: “How a Vaccine Works”
Consider these questions while watching this video: How do vaccines work? Why do people need flu shots yearly? What is the difference between a vaccine, vaccination and immunization? How would you summarize these ideas for a patient? This video is 7 minutes in length and may be too long to view during the session. If needed, have team members review the video either during the session or prior to. Link to How a Vaccine Works video: Suggested talking points We are going to watch a video called “How a Vaccine Works,” which will build on the concepts we just discussed. Here are some questions I want you to be thinking about as you view the video and we can discuss them after watching. Feel free to take notes during the video. Facilitator direction Introduce the questions prior to showing the video and use them to spark dialog after watching. Encourage participants to take notes. After the video, encourage participants to put these concepts into their own words. For example, ask how participants would describe what a vaccine is in their own words. Possible response: A vaccine is used (like a medication) to vaccinate our patients, who then become immunized (and protected). Ask participants: Now that we know about antibodies, antigens and immunity, how can we explain that to coworkers? Sample language includes, “Vaccines expose us to antigens so we can make antibodies that increase our immunity.” Consider this exercise to help staff speak with patients about the importance of vaccines. Ask patients if they wear seatbelts. They are likely to agree that the need for a seatbelt is only “in case of an accident” but should be worn all the time – just like immunization prepares us to fight infection if faced with disease.

How do inactivated vaccines and live attenuated vaccines differ?
Inactivated vaccines are made from killed viruses or bacteria, so they cannot cause infections. But most inactivated vaccines cause a weaker antibody response than a live attenuated vaccine. Most people will need booster shots. Live attenuated vaccines are made from weakened viruses or bacteria so they shouldn’t cause infections. This is the closest thing to a natural infection, and causes a very strong antibody response. These often provide lifelong immunity with only one or two doses. Suggested talking points Live attenuated vaccines have a remote possibility of causing infections, so should not be given to people with weakened immune systems, such as due to HIV or chemotherapy. An example of a live attenuated vaccine is Zostavax, the shingles vaccine.

How might one person’s vaccine status effect me?
= Immunized and healthy = Not immunized but still healthy = Not immunized, sick and contagious No one is immunized Contagious disease spreads through the population

= Immunized and healthy = Not immunized but still healthy = Not immunized, sick and contagious Some of the population gets immunized Contagious disease spreads through some of the population

= Immunized and healthy = Not immunized but still healthy = Not immunized, sick and contagious Most of the population gets immunized Spread of contagious disease is contained

Herd immunity is like a protective force field around us!
What is herd immunity? Herd immunity is like a protective force field around us! Video: “Herd Immunity” Consider these questions while watching this video: Why is herd immunity important? If someone never gets vaccines because they say they’ve never been sick, how does this affect herd immunity? Does it affect their community? Does herd immunity affect only children, or also the elderly and those with impaired immunity? This video is 30 seconds in length. If needed, have team members review the video either during the session or prior to. Link to Herd Immunity video: Suggested talking points Herd immunity is how vaccines benefit all of us, not just people who are vaccinated, and how they protect people who cannot be vaccinated. Facilitator direction Introduce the questions on the slide to consider during the 30-second video and facilitate discussion of questions after. Include additional videos you feel would be educational.

How do we know who needs what vaccine and when?
There are only two science-based schedules from the Centers for Disease Control’s (CDC) Advisory Committee on Immunization Practices (ACIP) that are approved by the following specialty societies: Child vaccine schedule: Approved by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP) and the American College of Obstetrics and Gynecology (ACOG) Adult vaccine schedule: Approved by the American College of Physicians (ACP), the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse-Midwives (ACNM) Any other schedules can leave children or adults susceptible to vaccine-preventable diseases. Schedules are updated every year and are available on the CDC website. Link to CDC vaccine schedules: Suggested talking points There are only two science-based schedules from the CDC’s Advisory Committee on Immunization Practices (ACIP) that are approved by the specialty societies outlined on the slide. Other schedules are available but aren’t based on science and put children and adults at risk for infection – both the individual patient and those who are at risk due to decreased herd immunity. The vaccine schedules are updated yearly, but often it is quite similar from year to year. Some changes do occur, though, so it’s important to be familiar with current recommendations. Facilitator direction Consider handing out copies of the CDC/ACIP adult vaccine schedules and discussing how to read them. Point out that these are updated every year. Point out how easy it is to put the schedules on your website and the CDC will automatically update (link to information showing how to do so is in the module)

Where do I find the updated vaccine schedule?
The Adult Immunization Schedule is updated annually and can be found online on the CDC Adult Immunization Schedule webpage. Suggested talking points There are only two science-based schedules from the CDC’s Advisory Committee on Immunization Practices (ACIP) that are approved by the specialty societies outlined on the previous slide. Other schedules are available but aren’t based on science and put children and adults at risk for infection – both the individual patient and those who are at risk due to decreased herd immunity.

2017 Updated every year See next slide for contraindications
Facilitator direction Provide copies of the CDC/ACIP recommendations and ask attendees to review how the recommendations are provided based on age and risk. Encourage all attendees to participate in reasoning through the cases – they can do this in groups or individually. They should be encouraged to take these back to their offices and post them for easy reference and for the team to see. Stress that these recommendations may change every year so they need to stay updated and use the most recent recommendations and schedules. For further details and complete schedule see: Legend to explain chart: YELLOW: Recommended for all persons who meet the age requirement, lack documentation of vaccination or lack evidence of past infection; zoster vaccine is recommended regardless of past episode of zoster PURPLE: Recommended for persons with a risk factor (medical, occupational, lifestyle or other indication) WHITE: No recommendation Source: The 2017 Vaccine schedule published by Centers for Disease Control and Prevention. Accessed March 20, 2017. Adult vaccine schedule broken out by age group

2017 Updated every year Be sure to read the footnotes for
important information and considerations for certain populations Facilitator direction Provide copies of the CDC/ACIP recommendations and ask attendees to review how the recommendations are provided based on age and risk. Encourage all attendees to participate in reasoning through the cases – they can do this in groups or individually. They should be encouraged to take these back to their offices and post them for easy reference and for the team to see. Stress that these recommendations may change every year. For further details and complete schedule see: Legend to explain chart: YELLOW: Recommended for all persons who meet the age requirement, lack documentation of vaccination or lack evidence of past infection; zoster vaccine is recommended regardless of past episode of zoster PURPLE: Recommended for persons with a risk factor (medical, occupational, lifestyle or other indication) WHITE: No recommendation Source: The 2017 Vaccine schedule published by Centers for Disease Control and Prevention. Accessed March 20, 2017. Adult Immunization Schedule by Medical and Other Indications

How do we know who needs which vaccine and when?
Using the CDC/ACIP recommendation, what vaccines are recommended for: A 27-year-old man with asthma who has not had vaccines since high school? A 66-year-old woman with COPD/emphysema who has not had a vaccine in five years? Facilitator direction Provide copies of the CDC/ACIP recommendations and ask attendees to review how the recommendations are provided based on age and risk. Encourage all attendees to participate in reasoning through the cases. Tell participants to note if their electronic medical record (EMR) system offers prompts for which vaccine is due for which patient and when.

How do we know who needs which vaccine?
Use the CDC Immunization Questionnaire Link to CDC Immunization questionnaire: Suggested talking points This questionnaire from the CDC is for use by patients to determine what vaccines they may need. Let’s all try looking at this questionnaire on our phones now and try to determine which vaccines are recommended for each of us. Facilitator direction Ask your team to use their smartphones to pull up this website and to answer the questionnaire for themselves to see what vaccines are recommended for patients like them. Source: The Adolescent and Adult Vaccine Quiz published by the Centers for Disease Control and Prevention. Accessed March 20, 2017.

What are some diseases prevented by vaccines?
Child with a severely deformed leg due to polio Photo courtesy of World Health Organization Woman suffering from liver cancer caused by hepatitis B Photo courtesy of Patricia Walker, MD, Ramsey Clinic Associates, St. Paul, MN Infant with pertussis (“whooping cough”) Photo courtesy of Centers for Disease Control and Prevention Adult with influenza (“flu”) on life support Suggested talking points This slide shows a number of diseases that are preventable through vaccines. The first picture shows us a child with polio. Vaccinating against polio has been one of the most successful medical interventions in history. Polio causes paralysis, and until the vaccine was introduced widely, entire buildings would be filled with patients who could not breathe due to paralysis. The last polio case reported in the U.S. was in 1979. The second picture shows someone with liver cancer caused by hepatitis B, which can be prevented through a vaccine. The third picture shows an infant with whooping cough. When adults are vaccinated against pertussis (“whooping cough”), it also helps protect children who can’t get vaccinated against it because they are too young. The last picture shows an adult with the flu who had to be put on a ventilator. Vaccinating the community with flu shots has been shown to save lives and prevent these kinds of situations.

Are there different types of exemptions from vaccinations
Are there different types of exemptions from vaccinations? What responses are available? Religious Medical Personal Visit the Immunization Action Coalition website for more information on vaccination exemptions. Look to the Immunization Action Coalition website for more information on vaccination exemptions - Suggested talking points Some patients request exemptions from indicated vaccinations. All exemptions can risk undermining herd immunity. Facilitator direction Discuss exemptions and how we balance respect for religion, culture and personal beliefs with the need to preserve and protect herd immunity. Read a handout from the following link and think about how exemptions can affect herd immunity and why organizations may require a signed document from a religious leader for a workplace exemption. Consider distributing copies ahead of time:

Key takeaways Vaccines save lives by preventing diseases.
Healthy people should be vaccinated as they can get infections and spread disease. There is only one valid schedule for getting adult vaccines! No matter what their age or size, don’t forget to immunize! Suggested talking points Vaccines save lives. Herd immunity protects everyone. There’s only one valid schedule for getting adult vaccines. Facilitator direction Facilitate discussion around what participants learned from this session. Offer prompts to ensure participants understand that vaccines save lives by preventing the diseases, that it’s important that healthy people are vaccinated so that herd immunity protects everyone and that there is only one scientific schedule for getting adult vaccines – and that adopting other schedules puts everyone at risk. Consider additional discussion questions: How does vaccinating the community affect the healthy and the vulnerable? Who are some vulnerable populations?

Next steps Get your own vaccines first!
Discuss with your team how you can stay motivated and engaged! I got vaccinated! Suggested talking points We set a standard for our patients, families and communities when we get our own vaccines. We can stay motivated with our own ideas about promoting vaccines. What ideas do you have? I got vaccinated!

Session 1 quiz What is the relationship between an antigen and an antibody? How is this related to active and passive immunity? Which type of immunity do vaccinations provide? What is herd immunity and why is it important? How can we know what vaccines are due for which patients and how often? Suggested talking points Q1 ANSWER: An antigen is a foreign substance (e.g., part of a bacteria or virus) that triggers the production of antibodies by the body’s immune system. An antibody made by the body will recognize and attack a specific antigen as part of the immune response. Q2 ANSWER: Active immunity is produced when the body reacts to an antigen, either from an infection or from a vaccine, by producing antibodies. Passive immunity is produced by giving antibodies directly into the bloodstream (without necessarily being exposed to an antigen first), instead of letting the body make its own. Q3 ANSWER: Active immunity Q4 ANSWER: Herd immunity, or community immunity, is seen when a community is protected from an outbreak because enough members of the community have been vaccinated. This means that even those individual members of the community who were not vaccinated will be protected by the fact that others in the community were vaccinated; it only works when a critical majority of people are vaccinated. This is an important way of providing immunity to individuals who cannot get certain vaccines (e.g., infants, pregnant women, immunocompromised individuals). Q5 ANSWER: The CDC/ACIP publishes an updated vaccination schedule based on patient age and risk for disease. This schedule is endorsed by various medical specialty societies and is the only schedule health care professionals should follow. When patients get their vaccines on a different schedule than the CDC/ACIP schedule, they are at risk for missing vaccines, personally becoming ill and jeopardizing herd immunity.

Questions?

For additional resources, tools and other practice transformation modules, visit Facilitator direction Steps Forward is a free, online resource, available to all. Please visit our website to view other tools, resources, frequently asked questions and implementation support. In addition to the Immunizing adults: a team-based approach module, the Steps Forward website also offers modules on many other topics that focus on patient care, workflow and process, leading change, professional well-being and technology and finance.

Adult Immunizations: Team Training Program Session 2 Communicating benefits and risks of vaccines

Vaccine fundamentals Communicating benefits and risks of vaccines Preparation, administration and adverse event reporting Vaccine storage and handling Billing, coding and documentation (including standing orders) Suggested talking points This second session of the training program focuses on communicating the benefits and risks of vaccines The session takes approximately 30 minutes to complete, plus 15 minutes for questions – TOTAL TIME: 45 minutes Facilitator direction Show the video of patient interviews by Drs. Brown and Sinsky on slide 47

Session 2 objectives After this session, participants will be able to answer the following questions: What is the most common side effect of vaccination? Can a flu shot give you the flu? Why do healthy people need to be vaccinated? Facilitator direction Ask participants to think about these questions while in this session. These questions will be asked again at the end of the session. Refer to "Ask the Expert" ( for answers to common questions you may be asked. Refer your audience to this site as well. Most questions that a patient might ask are answered here.

Benefits and risk Our patients and family members look to us to inform them about vaccines, so it’s important we know how to speak about benefits and risk.

How we speak about benefits and risk is important
Many people have heard confusing information about the benefits and risks of vaccination. Even though there are some risks from getting vaccines, these are far outweighed by the benefits. Stories are more meaningful than numbers.

Who does the public believe?
Most credible Least credible Local citizens perceived as neutral, respected, informed about the issue Health/safety professionals (MAs, nurses, physicians, firefighters) Professors/educators (especially from respected local institutions) Clergy Non-profit organizations Media Environmental/advocacy groups Federal government State/local government Industry “For profit” consultants Suggested talking points How we speak about benefits and risk is very important because health and safety professionals (including physicians and nurses) are highly trusted by the public. Our words carry extra weight.

As experts, how we speak about benefits and risks is important
Patients are more likely to get vaccinated when they are recommended by their physician or health care team member. Suggested talking points Since health care professionals are trusted, it’s very important for us to communicate accurate information. 55% of patients would not get a vaccine unless recommended by a physician.

Communication matters
As health care professionals with years of training and experience, it can be difficult to understand patients’ fears about vaccines. We often consider an unemotional scientist in a dark suit or lab coat as an expert. But that may not be the case for our patients! Don’t worry Suggested talking points It may be hard for us to understand our patient’s fears about vaccines. It may be tempting to shake our heads, sigh deeply or complain about uninformed patients. We need to always be respectful of our patients’ views, as they do not have the same medical training as we do. It is our job to help them understand, in a safe and non-judgmental way, the benefits of vaccines. Patients may get their information from non-credible sources. For example, an attractive or famous person who speaks passionately about the risks of vaccines without talking about benefits can spread misinformation and increase their fears. We as medical professionals need to guide our patients to where they can get credible information.

What happens when non-credible sources exaggerate the risk of vaccines?
It is difficult for science to compete with an emotional appeal – even if it’s inaccurate. It is very easy to scare people, it takes patience to un-scare them. Suggested talking points As a result of several famous people and other non-credible sources incorrectly blaming vaccines for causing medical conditions such as autism, many people have become suspicious of immunizations and have avoided vaccines. This has led to declines in herd immunity and recurrences of diseases that were previously rare. In some cases, this has led to catastrophic outcomes, including children’s deaths. Facilitator direction Discuss the Lancet article by Andrew Wakefield that claimed to identify a link between vaccines and autism. In addition to the article being retracted and the study disproven multiple times, Mr. Wakefield lost his license to practice medicine in the U.K. and was found to be unethical. Link to original Lancet article:

How we communicate matters
Recent outbreaks have shown us that we need to do a better job of helping patients understand the risks and benefits of vaccines. Our patients want their families and communities to be healthy, but need reassurance from us, the experts. We can help correct misperceptions about the benefits and risks of vaccines.

Address Patient Barriers
“How much does it cost to miss three days of work?” “Healthy people often get the flu and they can pass it onto young and elderly family members” “Here is the information in your language” “There are after-hours clinics at…” “The CDC guidelines have changed and are clear. Everyone benefits!” “The flu shot cannot give you the flu. It doesn’t protect you from the common cold and sometimes we incorrectly call a bad cold “the flu”. Influenza is very different from a cold.” “I can’t afford them.” “I always get the flu when I get the flu shot.” “I’m fine. I’m cancer-free now.” “My other doctor never told me about it.” “I work every day and can’t come in.” “No hablo inglés.” Suggested talking points Now that we know our role is important, we should practice good communication skills. Facilitator direction Ask your team: In your experience, what is the most often heard reason patients give for not getting vaccinated? Some common answers include: I’ll get sick from them Not aware of need Not recommended by their physician Financial reasons Forgot Ineffective/”they don’t work” Don’t have time to get one Any others?

How would you answer a patient who said…
“I’m worried about side effects from vaccines.” You could say… “Side effects are extremely rare. In my xx years of practice, I have never seen any serious reaction.” “I have received my Tdap and my arm was a little sore for a few days but I was so excited to see my new little nephew it didn’t matter. I wouldn’t want to go near him without having had my shots - he looked so small and helpless. I would do anything to protect him from the whooping cough!” Facilitator direction Ask your team to practice explaining how you would counsel a patient with this concern. Add your own story for how you counseled a patient. Your team wants to learn from you!

“I always get the flu when I get the flu shot.” You could say… “You said you got the flu after you got the flu shot last year… Aren’t winter colds the worst? The flu shot doesn’t protect against the common cold and sometimes people mistake a bad cold for the flu. The flu often causes days of very high fevers with coughing, shortness of breath, body aches and sometimes hospitalization…it is very different from a cold.” Suggested talking points The flu shot cannot cause the flu, although people often mistake colds for the flu. We health care professionals often erroneously call a severe cold “the flu.” A severe cold is not the same as influenza. The flu is actually much worse, and getting a flu shot is the best way to reduce your risk for getting the flu. Facilitator direction Describe influenza symptoms and how they differ from a cold. Ask your team to practice explaining how you would counsel a patient with this concern. Add your own story for how you counseled a patient. Your team wants to learn from you!

“I never get sick so I don’t need the flu shot.” You could say… “The most common side effect is a sore arm. Healthy people can get diseases and spread infection when unvaccinated.” “The vaccine is just like a seatbelt – you don’t normally get in accidents, but if you do, you want to make sure you are as protected as you can be!” The vaccine is just like having a fire extinguisher in your house – the chances of you having a fire is rare, but you sure don’t want to be unprepared if one does break out! Suggested talking points When healthy patients get vaccines, they provide herd immunity to people who can’t get vaccinated or in whom vaccines may be less effective due to chronic illnesses. Facilitator direction Ask your team to practice explaining how you would counsel a patient with this concern. Add your own story for how you counseled a patient. Your team wants to learn from you!

“I can’t afford vaccines.” You could say… “Most insurance plans and Medicaid cover vaccines because it’s cheaper to prevent disease than treat them after they happen. Let’s check your insurance plan to see.” “Your employer may offer free yearly flu shots as part of the Employee Health Program.” “The health department may provide vaccines inexpensively.” Facilitator direction Ask your team to practice explaining how you would counsel a patient with this concern. Add your own story for how you counseled a patient. Your team wants to learn from you!

What other reasons might patients mention for not getting vaccinated?
Fear? Suggested talking points What are some other examples for why patients say they can’t get vaccines? What can we say to patients to help overcome those barriers? Some potential reasons could be: REASON: Language barriers. ANSWER: Offer interpreters, or print the vaccine information statement (VIS) in their native language. REASON: Too busy! ANSWER: Remind patients that infections don’t discriminate based on how busy we are - busy people get sick, too! Provide information about evening and weekend availability of vaccine administration in your area. Facilitator direction Encourage participants to role play, emphasizing that their patients want to hear from them and that their stories matter! Mistrust?

Wakefield’s article and the Tuskegee syphilis study
Andrew Wakefield’s article in was retracted in 2010. Wakefield lost his license to practice medicine in the U.K. Research found that MMR vaccines do not cause autism. U.S. Public Health Service syphilis study at Tuskegee Men with syphilis were denied treatment with penicillin Facilitator direction Encourage participants to read about Andrew Wakefield’s article that influenced, and still influences, the anti-vaccine movement. Link to the Immunization Action Coalition, The Fraud Behind the MMR Scare: Encourage participants to read about the Tuskegee experiment to understand why some patients may be hesitant or mistrustful of the health care system. Link to the Tuskegee University website explanation of the syphilis study:

We can learn from and teach our patients
Video: INSERT LINK While watching this brief video, think about the language you will use when recommending vaccines. Facilitator direction (***Staff looking into how to link to these videos***) Staff can also ask patients if their home is free from clutter that could cause a fire. They are likely to respond that their home is very tidy. Follow up with “Do you have a fire extinguisher in your home?” Most patients will say yes. Then, point out that it is wise to be ready just in case a fire occurred, the same way our bodies (if immunized) are ready to fight infection if faced with the disease. Staff could also ask patients if they wear seatbelts. They are apt to agree that the need for a seatbelt is only “in case of an accident” – just like immunization prepares us to fight infection if faced with disease. Staff can also share the CDC “bailing out the boat” metaphor: In a boat with a slow leak, bailing out the boat starts fast and hard. When the boat is dry, we don’t sit back and relax – we stop the leak. Just like that boat with a leak, we should continue to immunize until the disease is eradicated.

Key takeaways Misconceptions and lack of physician recommendation are important factors in not being immunized. As respected experts, we should engage in conversations about risks and benefits of vaccines. Make a clear recommendation to vaccinate!

Session 2 quiz What is the most common side effect of vaccinations?
Can a flu shot give you the flu? Why do healthy people need to be vaccinated? Suggested talking points Q1 ANSWER: A sore arm Q2 ANSWER: No. It is impossible for the vaccine to cause the flu. However, it does not protect against the common cold, which some people can mistake for the flu, and as a result mistakenly believe getting sick was related to getting the flu shot. Q3 ANSWER: There are multiple reasons for this. One is that while being healthy decreases your chance of becoming seriously ill from a vaccine-preventable disease, it certainly does not guarantee that you are safe! Another major reason for healthy people to be vaccinated is for herd immunity, or community immunity. This refers to when a community is protected from an outbreak because enough members of the community have been vaccinated. As a result, even those individual members of the community who were not vaccinated will be protected by the fact that others in the community were vaccinated. This is an important way of providing immunity to individuals who cannot get certain vaccines (e.g., infants, pregnant women, immunocompromised individuals.)

Questions?

For additional resources, tools and other practice transformation modules, visit Facilitator direction is a free, online resource, available to all. Please visit our website to view other tools, resources, frequently asked questions and implementation support. In addition to the Immunizing adults: a team-based approach module, the Steps Forward website also offers modules on many other topics that focus on patient care, workflow and process, leading change, professional well-being and technology and finance.

Adult Immunizations: Team Training Program Session 3 Preparation, administration and adverse event reporting Facilitator direction Throughout the course, encourage questions by handing out 3x5 cards to each participant at the beginning of each session and at the end (for the next session’s discussion). Ask participants to write down questions/concerns they have or they may have heard from patients regarding vaccines. Framing the question as having been a concern of a patient removes any embarrassment an attendee may have about their own knowledge or hesitancy regarding vaccines. Maintaining anonymity allows participants the freedom to ask questions at all levels. Use these questions to direct the level of detail appropriate to the audience.

Vaccine fundamentals Communicating benefits and risks of vaccines Preparation, administration and adverse event reporting Vaccine storage and handling Billing, coding and documentation (including standing orders) Suggested talking points This third session of the training program focuses on preparing and administering vaccines and adverse event reporting. The session takes approximately 30 minutes to complete, plus 15 minutes for questions – TOTAL TIME: 45 minutes

Session 3 objectives After this session, participants will be able to answer the following questions: Can you give a vaccine to a patient who has a cold? Are we required by law to provide patients with a Vaccine Information Statement (VIS) prior to vaccination? How do we report adverse events? Facilitator direction Ask participants to think about these questions while in this session. These questions will be asked again at the end of the session.

Preparing to give vaccines
The easiest way to think about which adult needs which vaccine is by thinking about H-A-L-O H – Health conditions A – Age L – Lifestyle O – Occupation Facilitator direction Download the H-A-L-O document ahead of time and distribute to all participants. Handouts can be found on the Immunization Action Coalition website: Suggested talking points Health conditions - Includes factors such as pregnancy, certain chronic illnesses, transplant status, asplenia, alcoholism, etc. Age is generally through 26 years of age, then if 60 or 65 years of age (depending on the vaccine) Lifestyle factors - Includes factors such as if your patient is born outside the U.S., is a man who has sex with men, uses injecting or non-injecting drugs, travels internationally, smokes, etc. Occupation - Includes factors such as if your patient is a college student, in the military, is a health care worker, etc. Some H-A-L-O factors can be quickly determined but others require more research. Review the chart or ask your patients about the presence or absence of other factors such as immunosuppression, transplant patient, etc. Refer to the health condition, age, lifestyle and occupation statuses listed to quickly see which vaccines may be due.

Which patient gets what vaccine?
Using the H-A-L-O checklist, determine which vaccines are indicated for the following patients: A pregnant 32-year-old woman who had chickenpox (varicella) as a child A 26-year-old male smoker who works as a respiratory therapist A 32-year-old gay man in a mutually monogamous relationship who was born outside the U.S. A 66-year-old woman with diabetes Suggesting talking points Some H-A-L-O factors can be quickly determined but others require more research. Review the chart or ask your patients about the presence or absence of other factors such as immunosuppression, transplant patient, international travel, etc. Refer to the health condition, age, lifestyle and occupation statuses listed to quickly see which vaccines may be due. Facilitator direction Hand out the current recommendations and work in small groups to identify which vaccines are indicated by looking at the graph. This is how they will determine what vaccines a patient might require when they are back in their office.

Vaccine Information Statement (VIS)
All patients should be provided a Vaccine Information Statement (VIS) whenever they are due for a vaccine. A VIS is a document created by the Centers for Diseases Control (CDC) that informs patients about the benefits and risks of a vaccine. These are updated periodically – be sure you use the most recent one! For more information on VISs, visit the CDC VIS homepage. Facilitator direction You may wish to preprint several VIS examples for viewing by participants. VISs can be accessed at:

All patients must be provided a Vaccine Information Statement (VIS) prior to vaccination. The appropriate VIS must be given prior to each dose of a multi-dose series. It must be given regardless of the patient’s age. VISs have been translated into more than 40 languages. Suggested talking points VISs must be provided to all patients (or their guardians), regardless of their age, and are available in many languages. Reference:

Photos from Accessed March 16, 2017. We thank the Immunization Action Coalition. Suggested talking points VISs are available on the CDC website for every vaccine. They are double-sided and written in plain language. These are examples of the VIS for the flu vaccine and pneumococcal vaccination.

Photos from Accessed March 16, 2017. We thank the Immunization Action Coalition. Suggested talking points VIS sheets are available in many languages but always state in English the particular vaccine and the language. These are VIS sheets for pneumococcal vaccine in simplified Chinese on the left and in Somali on the right. VIS sheets always state when they were written so you know if you have the most updated version.

Using a VIS How can you save time while also using a VIS?
How and when will you use a VIS in your office, considering your workflow? Suggested talking points We all agree it’s important that patients receive a VIS before getting their vaccines – it’s good medicine and the law. But we should take a few minutes to consider how to fit this into the current office workflow. Facilitator direction Consider asking participants to discuss practical considerations. When do you hand the VIS to the patient? How can we save time? Will preprinting VISs for commonly administered vaccines be helpful? Is pre-visit planning possible, such as printing a VIS and writing the patient’s name on it for vaccines that are due when reviewing the chart the day before?

Precautions and contraindications
Do we need to check vitals before giving vaccines? Does a patient having a cold or other mild or moderate infection mean I shouldn’t offer a vaccine? Does having a fever mean someone should not get their vaccine? Suggested talking points As health care professionals, we want to be ready to address questions that will arise about giving vaccines. Here are some common ones. The answers to all of these commonly asked questions is NO. Answers to other commonly asked questions can be found on the Immunization Action Coalition website: Facilitator direction Consider printing copies of the handout “Precautions and Contradictions” from the Immunization Action Coalition to provide to participants: Encourage participants to read these questions and reason through their answers aloud. Assign attendees questions that they need to find the answers to and report back at the next session.

Should pregnant and breastfeeding women put off getting their Tdap and influenza vaccines? Do people who received chemotherapy need their vaccines repeated? Should people who have an egg allergy avoid ALL vaccines? Should patients on antibiotics not get vaccines? Should patients on chronic steroids avoid getting ALL vaccines? Suggested talking points Here are some more common questions about vaccines. The answers to all of these commonly asked questions is NO. Answers to other commonly asked questions can be found on the Immunization Action Coalition website: Facilitator direction Consider printing copies of the handout “Precautions and Contradictions” from the Immunization Action Coalition to provide to participants: Encourage participants to read these questions and reason through their answers aloud.

Suggested talking points For practices that have a lot of vaccinations available, having a screening checklist for contraindications can be helpful. This two-page handout can help. It has one page of questions and one page that provides answers. Facilitator direction If your practice gives a lot different vaccines, talk about how a screening checklist can be helpful. Consider printing copies of a screening checklist provided on the Immunization Action Coalition website, giving it to participants and having a discussion about it: If providing copies of this handout, consider asking participants: Does someone being sick mean they cannot get their vaccines? Which food allergies affect if someone can get their vaccine? Does having a latex allergy affect if someone can get vaccines? Can someone with a stable seizure disorder get vaccines? Photo from Accessed March 16, We thank the Immunization Action Coalition.

Most patients will have no difficulties with most vaccines, but every clinic should be aware of contraindications and potential adverse events. Know how to manage medical emergencies. Know where your clinic keeps emergency supplies. Suggested talking points Vaccines are generally safe, but do have some risks. Just like with medications, we should be familiar with precautions and contraindications. Facilitator direction Consider adopting the standing orders for managing medical emergencies from vaccines such as those provided by the Immunization Action Coalition. Consider printing copies and having them available for session participants: Engage session participants in discussing: Where are the guidelines for managing medical emergencies kept? Where are supplies for managing emergencies kept? Are they easy to get to in an emergency? Will we be scrambling to find what we need? What’s in the emergency supply? Do we have what we need?

Precautions and Contraindications
Suggested talking points Common reactions to some vaccines include soreness, redness, swelling at injection site, slight bleeding and fright. It is more worrisome is if a patient loses consciousness and falls, and the most concerning reaction is anaphylaxis. Facilitator direction If your practice does not have a medical management of vaccine reactions policy, consider adopting the standing orders for managing medical emergencies from vaccines from those provided by the Immunization Action Coalition: Consider printing copies of your policy for managing vaccine reactions on hand, and reviewing the policy aloud by asking participants to answer how they would manage different situations: How would you manage a swollen arm after giving a shot? What would you do for a patient who is fearful of getting a vaccine (but still wants it)? How would you manage itching at the site of injection? What would you do if after receiving a shot your patient became pale and dizzy? And then fell? What is it called when a patient has swelling of the lips, face or throat with hives? What would you do if this developed after a vaccine? Photo from Accessed March 16, 2017. We thank the Immunization Action Coalition.

Administration Review the patient’s chart for indicated vaccines
Check the physician’s orders Provide the VIS for all vaccines you are administering Provide patient education, answer questions and confirm verbal consent Use site maps to ensure consistent language and practice, and select the right needle Suggested talking points Each step, including patient education, is essential to the work flow of the office and to quality patient care. Appropriate site and needle length depends on age and body mass. Think through multiple injections and sites. Most vaccines can be given on the same day! Most injected vaccines are administered by the intramuscular route. Review site maps and decide which vaccine will be administered where. Pneumococcal vaccines and flu vaccines can never be combined in the same syringe. Facilitator direction Consider reviewing an immunization site map with your team so everyone understands the process and is consistent. An example is available from the California Vaccines for Children Program:

Administration Confirm:
Right patient Right vaccine Right dose Right route Prep the skin with an alcohol wipe Position the patient Inject with steady pressure Use needle safety, including following OSHA standards Suggested talking points Each step, including patient education, is essential to the workflow of the office and to quality patient care. Facilitator direction Consider conducting a skills check list as a competency sign-off, hands-on activity. There is a skills check-off list available on the Immunization Action Coalition website to use as an example:

Administration challenges
Can multiple vaccines be given on the same day? Does the alcohol skin prep need to dry before giving the vaccine? Can a vaccine be given before it warms to room temperature? Is it safe to give a vaccine where there is a tattoo? Should I give vaccines without aspirating first? Suggested talking points As health care professionals, we want to be ready to address questions that will arise about giving vaccines. Here are some common ones. The answers to all of these commonly asked questions is YES. Facilitator direction Aspirating while giving a vaccine causes more pain.

Adverse event reporting
We are required to report adverse events from vaccines to the Vaccine Adverse Event Reporting System (VAERS). VAERS provides a nationwide mechanism to report immunization adverse events—its findings are available to the public. Events can be reported online, via fax or through the mail. Facilitator direction Consider reviewing this process via a computer with internet access, including those on the team who will assume this role.

Key takeaways When preparing to update vaccines, we should think about H-A-L-O. All patients need a VIS, available for every vaccine and in many languages. Adverse events are rare, but we should be ready for them. Adverse events should be reported to the VAERS. H – Health conditions A - Age L - Lifestyle O –Occupation Facilitator direction HALO: Health conditions, Age, Lifestyle, Occupation VAERS: Vaccine Adverse Event Reporting System

Session 3 quiz Can you give a vaccine to a patient who has a cold?
Are we required by law to provide patients with a Vaccine Information Statement (VIS) prior to vaccination? How do we report adverse events? Facilitator direction Q1 ANSWER: Yes. Q2 ANSWER: Yes. Q3 ANSWER: Adverse events can be reported online, via fax or through the mail. We are required to report adverse events from vaccines to the Vaccine Adverse Event Reporting System (VAERS). The website is:

Questions?

Adult Immunizations: Team Training Program Session 4 Vaccine storage and handling

Disclaimer Please note that the content provided in this training program changes frequently and is meant to be used as examples and reference only. The information provided can be modified so you can update it based on your patient population, current clinical guidelines and practice workflow. This content is provided for informational purposes only and is not intended as medical advice, or as a substitute for the medical advice of a physician. This content does not constitute a recommendation or endorsement of any specific tests, products, procedures, practices or medical opinions.

Vaccine fundamentals Communicating benefits and risks of vaccines Preparation, administration and adverse event reporting Vaccine storage and handling Billing, coding and documentation (including standing orders) Suggested talking points: This fourth session of the curriculum focuses on vaccine storage and handling and why it is important. The session takes approximately 30 minutes to complete, plus 15 minutes for questions – TOTAL TIME: 45 minutes

Session 4 objectives After this session, participants will be able to answer the following questions: Can we administer vaccines that have been exposed to the wrong temperatures during storage? Are all vaccines kept in the refrigerator? Is it okay to use the same refrigerator for vaccines and food? Facilitator direction Ask participants to think about these questions while in this session. These questions will be asked again at the end of the session.

When vaccines are exposed to improper conditions, they are less effective
Vaccines need a climate-controlled environment. Storage and handling conditions must be maintained at every step because incorrect exposure to heat, cold or light can cause decreased vaccine effectiveness. Suggested talking points Mistakes in storage and handling can make vaccines less effective, and patients may not be protected if they receive vaccines that aren’t as effective. Ineffective vaccines need to be discarded, which is expensive to a practice. But if a less effective vaccine reaches a patient, they will need revaccination and this decreases patient confidence in vaccines and in health care professional teams.

When vaccines are exposed to improper conditions, they are less effective
Storage and handling starts at the manufacturer, continues through transport to the provider and ends with administration to the patient. Suggested talking points Mistakes in storage and handling can make vaccines less effective, and patients may not be protected if they receive vaccines that aren’t as effective. Ineffective vaccines need to be discarded, which is expensive to a practice. But if a less effective vaccine reaches a patient, they will need revaccination and this decreases patient confidence in vaccines and in health care professional teams.

Storage and handling One staff member should be selected as the Chief Vaccination Officer. The vaccine officer should champion maintaining vaccine storage and handling and staff trainings. The Center for Disease Control (CDC) has a comprehensive Vaccine Storage and Handling toolkit that is easy to use. Suggested talking points The duties of the Chief Vaccination Officer can also include: Tracking the number of vaccines given each day Pulling vaccines from their central storage location in a small, set number of vaccine doses per day Returning unused doses to the central location at end of day Reconciling administration record with the number checked out from storage Billing at the end of each day Facilitator direction Consider implementing a storage and handling checklist, such as one from the Immunization Action Coalition: Image source: The Centers for Disease Control and Prevention.

Things we all need to know
Never keep food in the same refrigerator as vaccines. Use a checklist to ensure all steps of vaccine storage are followed. Facilitator direction Consider printing a copy of your practice’s storage and handling checklist to have on hand. If your practice doesn’t have one, consider using this one from the Immunization Action Coalition:

Tracking vaccine storage temperature is critically important! This must be done twice daily via a temperature log. Suggested talking points Mistakes in storage and handling can make vaccines less effective, and patients may not be protected if they receive vaccines that aren’t as effective. Ineffective vaccines need to be discarded, which is expensive to a practice. But if a less effective vaccine reaches a patient, they will need revaccination and this decreases patient confidence in vaccines and in health care professional teams. Facilitator direction Examples of temperature logs can be found through the Immunization Action Coalition: Temperature Log for Freezer: Temperature Log for Refrigerator: Photo acquired from on March 16, 2017. We thank the Immunization Action Coalition.

Some vaccines should be stored in the refrigerator
Maintain fridge temp between 2oC and 8oC (36oF and 46oF) Aim for 5oC (40oF) Suggested talking points Never ignore a temperature reading out of range! For specific, detailed storage and handling protocols for individual vaccines, always refer to the manufacturers’ product information and package inserts *, or contact the manufacturer directly. What is the asterisk indicating?

Some vaccines should be stored in the freezer
Maintain freezer temp between -50oC and -15oC (-58oF and 5oF) Suggested talking points Never ignore a temperature reading out of range! For specific, detailed storage and handling protocols for individual vaccines, always refer to the manufacturers’ product information and package inserts *, or contact the manufacturer directly. What is the asterisk indicating?

Refrigerated vaccines should be kept at 2°C to 8°C Frozen vaccines should be kept at -50°C to -15°C Never ignore a temperature recording out of range! Image source: The Centers for Disease Control and Prevention. Suggested talking points Never ignore a temperature reading out of range! If you find a vaccine exposed to an inappropriate temperature, determine the reason for the incorrect temperature, mark the vaccine "Do Not Use," and contact the manufacturer or the health department to see if the vaccine can still be used.

Tips we all need to know Never give an expired vaccine.
Rotate your vaccine supply so that expensive vaccines don’t expire and go to waste. Suggested talking points Rotate your vaccine supply so expensive vaccines do not expire. If you find an expired vaccine, remove it from the refrigerator or freezer so that it is not given to a patient - even if it is only one day past the expiration date. Contact your vaccine coordinator or Chief Vaccination Officer for specific guidance on disposing of expired vaccines.

Storage and handling Storage and handling training should be done:
As part of new employee orientation Annually as a refresher for all team members involved in vaccination When new vaccines are added to inventory When CDC recommendations are changed Facilitator direction Consider asking team members about the commonly seen mistakes and challenges in vaccine storage and handling that they see, and encourage peer-to-peer education.

Key takeaways Proper vaccine storage and handling is important to prevent vaccine-preventable diseases. Mistakes in storing and handling vaccines can reduce vaccine effectiveness. Storage and handling mistakes result in revaccination of patients and wasted vaccines. Suggested talking points Mistakes in storage and handling can make vaccines less effective, and patients may not be protected if they receive vaccines that aren’t as effective. Ineffective vaccines need to be discarded, which is expensive to a practice. But if a less effective vaccine reaches a patient, they will need revaccination and this decreases patient confidence in vaccines and in health care professional teams.

Session 4 quiz Can we administer vaccines that have been exposed to the wrong temperatures during storage? Are all vaccines kept in the refrigerator? Is it okay to use the same refrigerator for vaccines and food? Facilitator direction Q1 ANSWER: No. Q2 ANSWER: No, some require storage in a freezer. Always check with the manufacturer and package insert. In addition, some vaccines can be frozen and then kept in refrigerator for a short period of time. It is very important to follow storage and handling instructions for each vaccine as they may differ. Q3 ANSWER: No.

Questions?

Adult Immunizations: Team Training Program Session 5 Billing, coding and documentation
Facilitator direction Throughout the course, encourage questions by handing out 3x5 cards to each participant at the beginning of each session and at the end (for the next session’s discussion). Ask participants to write down questions/concerns they have or they may have heard from patients. Framing the question as having been a concern of a patient removes any embarrassment an attendee may have about their own knowledge or hesitancy regarding vaccines. Maintaining anonymity allows participants the freedom to ask questions at all levels. Use these questions to direct the level of detail appropriate to the audience.

Disclaimer Please note that the content provided in this training program changes frequently and is meant to be used as examples and reference only. The information provided can be modified so you can update it based on your patient population, current clinical guidelines and practice workflow. This content is provided for informational purposes only and is not intended as medical advice, or as a substitute for the medical advice of a physician. This content does not constitute a recommendation or endorsement of any specific tests, products, procedures, practices or medical opinions.

Vaccine fundamentals Communicating benefits and risks of vaccines Preparation, administration and adverse event reporting Vaccine storage and handling Billing, coding and documentation (including standing orders) Suggested talking points This fifth session of the curriculum focuses on documentation, billing and coding, as well as standing orders. The session takes approximately 30 minutes to complete, plus 15 minutes for questions – TOTAL TIME: 45 minutes

Session 5 objectives After this session, participants will be able to answer the following questions: What is necessary to document when giving a vaccine? Why is it important to bill for the vaccines we administer? What are standing orders? Facilitator direction Ask participants to think about these questions while in this session. These questions will be asked again at the end of the session.

Documentation requirements
There are federal requirements for vaccine administration documentation that must be included in the patient’s medical record or a permanent office log: Vaccine name Vaccine manufacturer Vaccine lot number Vaccine administration date Name, office address and title of health care provider administering the vaccine Vaccine Information Statement (VIS) edition date Visit the Centers for Disease Control website to obtain free downloadable copies of VISs Date the VIS is given to the patient or guardian Suggested talking points We are required to document this information in the patient's paper or electronic medical record (EMR) or in a permanent office log. The only vaccines not included in this law are pneumococcal polysaccharide, zoster and certain infrequently used vaccines, such as rabies and Japanese encephalitis. The VIS edition date is located on the lower right corner on the back of the VIS. Federal law requires that health care staff provide a VIS to a patient, parent or legal representative before each dose of certain vaccines.

Documentation requirements
All practices must use either a paper-based or electronic medical record (EMR)-based vaccine log to capture this required information Facilitator direction Consider distributing copies of your practice’s vaccine log. Photo acquired from on March 16, 2017. We thank the Immunization Action Coalition.

Provide all patients with documentation
An immunization card is easily recognized and portable - wallet size. An immunization record from your EMR is acceptable, too. Photo from Accessed March 16, 2017. We thank the Immunization Action Coalition.

Many states have an immunization registry
If your state has an immunization registry (or Immunization Information System - IIS), then all vaccines administered must be reported to it. Many EMRs can automatically report your vaccines. Facilitator direction Inform your staff if your state has an IIS. More information on IIS is available on the CDC website:

Documentation FAQs Question: What do we do when a patient says they’ve had a vaccine but we don’t have records? Answer: For all vaccines except influenza and PCV23, obtain records, check serological tests for immunity or re- vaccinate. Suggested talking points Site maps help us use consistent language in documentation.

Coding and billing Accurate coding and billing are important so that the practice can be reimbursed for vaccines. Recognize that reimbursement depends on correct procedure and diagnostic coding.

Coding and billing Ensure your practice is:
Tracking the number of vaccines given each day Reconciling the vaccine administration log with the number of vaccines checked out Using correct procedure and diagnosis codes Periodically reviewing with your coder that the medical record is supporting the codes submitted

Simplify documentation with standing orders
Standing orders empower staff with the ability to administer indicated and stocked vaccines without obtaining a new physician’s order every time. Standing orders increase autonomy and staff satisfaction. Standing orders can increase patient satisfaction. Suggested talking points Standing orders can be customized for the practice’s needs and can include decision support including indications for vaccination, contraindications, precautions and information on administering and documenting vaccines. Facilitator direction Consider preprinting standing orders that your practice uses. If you don’t have any, then consider printing examples from the Immunization Action Coalition:

Standing orders - example
Suggested talking points If your EMR includes age- and disease-specific vaccination reminders and provides billing and coding support, standing orders can still be helpful to streamline care, provide guidance on contraindications and precautions, provide education on administration and increase teamwork. This example standing order is for the pneumococcal vaccines (PCV13 and PPSV23). Facilitator direction Consider having standing orders on hand from the Immunization Action Coalition: Ask your team to read through the orders and to discuss the potential advantages and answer any question, including the following: Is it helpful to have indications? Is it helpful to have contraindications? Does it save time to have information on the standing orders about needle size? Photo from Accessed March 16, We thank the Immunization Action Coalition.

Key takeaways There are federal documentation requirements when vaccines are given, and this must be kept on a vaccine log or in the patient’s EMR. Billing and coding are critical to being reimbursed for vaccines provided. Using standing orders can streamline your practice, improve care and improve patient and staff satisfaction.

Session 5 quiz What are necessary things to document when giving a vaccine? Why is it important to bill for the vaccines we administer? What are standing orders? Facilitator direction Q1 ANSWER: Vaccine manufacturer Vaccine lot number Vaccine administration date Name, office address and title of health care provider administering the vaccine VIS edition date (vaccine information statement) Date the VIS is given to the patient or guardian Q2 ANSWER: Accurate coding and billing are important so that the practice can be reimbursed for the vaccines. Q3 ANSWER: Standing orders are a set of orders related to vaccinations that can be customized for a practice’s specific needs. They can include information about indications and contraindications for vaccinations as well as information on vaccine administration and documentation. Standing orders empower staff with the ability to administer indicated and stocked vaccines without obtaining an order from a physician every time.

Questions?

Congratulations on completing all five adult immunization learning sessions!
Together, we can improve vaccination rates among adults and improve the overall health of our nation.

Adult Immunization: Team Training Program

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