1. The Medical Home and Rural Childhood Immunization Delivery in Family Medicine STFM Practice Improvement Conference 7 November 2009 L.J. Fagnan, MD Oregon Health & Science University Oregon Rural Practice-based Research Network (ORPRN)

2. Learning Objectives
Review the findings of the Rural Oregon Immunization Initiative (ROII)
Describe the Eight “Best Practices” variables associated with high immunization rates
Reflect on the intersection of the Patient- Centered Medical Home Principles with early childhood immunization delivery

3. Background
Immunizations are one of the most effective disease prevention strategies
Increasing immunization rates is among 10 objectives of Healthy People 2010:
Increase the 4 DTP: 3 Polio: 1 MMR coverage to 90% among children mos.
Increase proportion of children in population-based immunization registries to 95% among children < 6 years of age.
62,512 Oregon children with 2+ shot records in ALERT. Total cohort (19 to 35 months) is 67,000 based on 45,000 births per year. [over 93% of Oregon children are in ALERT-at least one shot after birth]
41,895 (67%) up to date for 4:3:1 (DTaP, IPV, MMR) and 40,633 (65%) up to date for 4:3:1:3:3 (DTaP, IPV, MMR, Hib, Hep B)
83% of private providers and all county health departments use ALERT
*ALERT data as of Dec. 31, 2004 for children born between Jan through May 2003 (19-35 mos. Of age)
National health objectives for the year 2010 call for 95% of children to be listed in a population-based immunization registry and 90% of providers to conduct reviews of the immunization status of their patients

5. Background
Little is known about practice barriers to immunization among US clinicians serving children in large rural, Western areas including Oregon, e.g.,
Limited immunization services
Missed opportunities to vaccine
Inadequate health data system
Limited computerized registry, reminder/recall use
62,512 Oregon children with 2+ shot records in ALERT. Total cohort (19 to 35 months) is 67,000 based on 45,000 births per year. [over 93% of Oregon children are in ALERT-at least one shot after birth]
41,895 (67%) up to date for 4:3:1 (DTaP, IPV, MMR) and 40,633 (65%) up to date for 4:3:1:3:3 (DTaP, IPV, MMR, Hib, Hep B)
83% of private providers and all county health departments use ALERT
*ALERT data as of Dec. 31, 2004 for children born between Jan through May 2003 (19-35 mos. Of age)
National health objectives for the year 2010 call for 95% of children to be listed in a population-based immunization registry and 90% of providers to conduct reviews of the immunization status of their patients

6. Founded in 2002
All Rural
157 clinicians
49 practices
39 communities
Care for 235,000 patients

7. RURAL OREGON IMMUNIZATION INITIATIVE
Phase III
Site-specific practice reports of Phase I & II results prepared for each of the 11 Phase II practices. Report results presented and discussed face-to-face with 8 of these practices in August and September 2007.
Quality Improvement planning,
implementation, & evaluation with
Oregon Immunization Program (OIP).
RURAL OREGON IMMUNIZATION INITIATIVE
Phase I
Quantitative statewide survey sent to 1158 rural clinicians in December 2004 through early 2005.
670 completed survey.
413 qualified for analysis, of which 335 clinicians reported giving at least some immunizations.
Phase II
11 rural ORPRN practices participated in in-depth Phase II assessments during early Five clinicians not included in statewide Phase I sample later completed Phase I surveys.
Interviews/Focus Groups:
28 Clinicians
31 Clinic Staff
36 Parents
12 Health Dept Staff
Visits Observed 31
Chart Reviews 485

8. Childhood Immunization Delivery*, Rural Oregon Clinicians, 2005
60% of clinicians report that children receive some or all immunizations outside their clinic
17% of clinicians provide no childhood immunizations
89% of clinicians report that children in their communities receive immunizations at the county health department
* For children ages 0 –36 months

10. Immunization Practices
Immunization Practices*, Rural Oregon Clinicians, 2005 (N = 344 providing all or some vaccines)
Practice %
Offers vaccine-only visits 82
VFC participation 79
Will give # of shots indicated 68
Screen status all visits 56
Screen status chronic visits 38
Screen status acute visits 27
Have some way to identify under-immunized children 61
Population review of immunization status 34
Suggest replacing slide 23 with this one.

11. Tracking Immunizations and ALERT Registry Use, Rural Oregon Clinicians, (N= 344 providing all or some vaccines)
Practice: %
Track immunizations using paper charts 85
Submit data to ALERT
Access ALERT to check immunizations
Access ALERT for every or most
child patients (among users only, N=240)
Use mail or telephone immunization 48
reminders

12. Practice Reports—What Did We Learn?

13. Figuring it Out: Immunization Responsibility
Phase 1 Provider Survey Findings:
“Receipt of immunizations is the main reason that parents come for well child care”
Majority (67%) agreed
Phase II Assessment
Different emphasis in parent focus groups: “right track”
“I think it’s nice to know that they’re growing properly, that you’re kind of on the right track.”
Implications for responsibility of tracking immunizations

14. Figuring it Out: Immunization Responsibility
Parents:
“Send a postcard that it’s time. I mean, just like when I take my animals to the vet, I always get a postcard from them telling me when my animals’ shots come due—not to compare my kids with animals, but you get them from the dentist when it’s time for your appointment, or it’s time for a check-up.”
“Probably remembering what the schedule is. I have to ask every time I come in, “Are we due for anything on this visit? Or what’s up next, and when?” It’s just not part of what I’m thinking about every day, since they are so far apart.”

15. Figuring it Out: Immunization Responsibility
Clinician:
“I think that if parents were more responsible for it, and if they were maybe well informed how important it is for them to get it, it might be a lot better. I think a lot of it is just a lack of knowledge that the parent has of knowing that the child needs shots at certain dates. There’s only so much we can do before the parents need to really step in and say, ‘Okay.’”

16. Figuring it Out: Immunization Responsibility
Patients:
Feel responsible, want reminders
Competing demands, complex immunization schedules affect adherence
Providers:
Perceive immunizations as principal reason for well child care
Also feel obligated to be responsible; want parents to be more aware of schedule
Limited capacity to produce reminders
Richer understandings of beliefs, perceptions of responsibility

17. Figuring it Out: Immunization Safety Responsibility
Phase 1 Survey Findings:
28% agreed that the “Safety of Immunizations Concerns Me”
Phase II Assessment
Parents: safety a consistent concern; relationship with provider cited as important
Providers: challenge of counseling and referral of “refusers”
How do we do this?
Education: who should provide it and how...?
Safety concerns among providers: need further exploration

18. Figuring it Out– Coordination (ALERT)
Phase 1 Survey Findings:
71% report submitting data to ALERT registry
66% report accessing ALERT registry
Phase II Assessment Questions/Findings:
Experience of ALERT in practice
Generally perceived as low to moderate burden
ALERT part of immunization safety net toolkit
Knowledge and usage of ALERT varies
Communication Issues—usage of ALERT
1. Clinics report that integrating ALERT into the practice setting is generally not resource intensive
2. Providers indicated that ALERT plays an important role in tracking immunizations but is part of a package
We now have children born from 1987 to the present. It is important to note that ALERT's immunization histories for school-aged children are not as complete or consolidated as they are for the younger children. Pre-school children have always been ALERT's priority, but we also have a growing volume of school-aged children.
3. We found wide variation with regard to how clinics are currently using ALERT and what they perceive its capabilities to be (example, using ALERT as a patient reminder system—clinics expressed a strong interest in wanting to do this, can ALERT be used in this way?)
4. We also came across an interesting communication issue between clinics and county health departments (lead in to next two slides)

19. Figuring it Out– Place Medical Home— relevance and feasibility
Differing models of immunization delivery in primary care practices:
Comprehensive—all immunizations
Mixed—Health department sets up immunization clinic within clinic
No immunization delivery
Patients report competence at navigating system:
Variations in insurance coverage, co-pay, access
County Health Departments provide many services such as WIC

20. PCMH Principle
Rural Childhood Immun.
Personal Physician
Provides immunizations in the office. Addresses vaccine availability, safety concerns, storage, and reimbursement
Shared Responsibility with the local health department and state immunization program
Physician directed practice
Delegate authority to an immunization “champion”—MA or nurse
Whole person orientation
Includes preventive services
Collaborate with community immunization resources
Care is coordinated and integrated
Universal use of immunization registries such as ALERT; check immunization status at all visits; develop enhanced well child visits; establish a reminder/recall system

21. PCMH Principle
Rural Childhood Immun.
Quality and Safety
ALERT; Quality Improvement—AFIX to look at missed opportunities and late starts; effective patient education materials; shared responsibility with parents; develop an approach to vaccine resistant parents
Enhanced Access
Vaccine only visits, reminder systems, participate in VFC, partner with the local health department and school-based clinics
Includes various methods of communication with patients and families
Payment
Participate in VFC and Medicaid
Partner with state health department regarding maintaining an cost-effective inventory of vaccine