1. Adult Program Stakeholder Engagement Framework Development Discussion VAC January 21, 2016

2. OICP Charge Develop structure for making decisions about vaccine selection Determine promotion activity priorities Explore data quality questions: accuracy, completeness, provider participation in IIS Define how barriers are different for adults and what the best approach should be

3. Developing an Adult Program Use national Vaccine Advisory Committee adults standards as framework – Assess – Recommend – Administer or refer – Document Examine barriers to meeting the standards Explore process for prioritizing use of vaccine funds – Input via provider survey – Discuss at IACW and VAC

4. Assumptions Awareness among providers and public about importance of immunization for adults, especially for under age 65 Adult hesitancy/lack of accurate information Level of awareness and concern among public about VPDs Barriers to access – Un- and under-insured – Medicare – No medical home How to find & reach this population Is IIS understood as a lifespan registry?

5. Process Stakeholder engagement – Provider survey – IACW – VAC Apply adult standards as framework

6. Provider Survey To gather stakeholder input from providers, November 2015 Are they providing vaccine to adults? Are they making referrals? What vaccines do they provide? If they don’t, do they want to? What are the barriers to immunizing adults? Use of IIS and barriers to use Adult standards: familiarity and use Priority vaccines for un-under-insured

7. Select Survey Results n=303 LHJ = 57 Community/migrant health = 52 Private = 42 Hospitals = 34 Family Practice = 26 General medical/dental = 12 Primary care = 7 Free Clinics = 5 Pharmacy = 3 Tribal = 2 Others including naturopathic, pediatric, private, school-based

8. Survey Results 80% provide adult vaccines 117/224 have adult coordinator Which vaccines do you provide? Most common: Flu and Tdap = 93% HepB (173) and PPSV23 (172) = 77% HepA (166) = 74% PCV13 (157), HPV (155), and MMR (154) =70% Td (148) = 66% Varicella (132) = 59% Zoster (129) and meningococcal (128) = 57% Combo/twinrix (96) = 42%

9. Survey Results If you refer, to where? Local Pharmacy (68%) Local Health Provider (58%) Other (16%): Primary care, mobile clinics, free clinics, MRC clinics, worksite clinics Barriers to immunizing adults? 57% said yes. Most common: Investment/cost: vaccine, equipment Reimbursement: – visit and/or admin fee not covered, uninsured – 30-40% in some clinics uninsured and underinsured, out of pocket cost to patient – Medicare doesn’t cover some vaccines (Tdap) Limited community awareness of importance of adult immunization Patient hesitancy Maintain inventory, using before they expire, waste from unused package Perception that pharmacies leave low profit and risky vaccines to providers Have to be established patient to get this service

10. Survey Results Familiar with Adult Standards? Yes (57%) Somewhat (26%) No (17%) Implemented in clinic? Yes (61%) No (12%) Unsure (27%)

11. Survey Results No-cost vaccine priorities? 1.Tdap (168 prioritized this vaccine) 2.Flu (146) 3.PCV13, PPSV23, zoster (122/118/118) 4.HPV (93) 5.HepB (74) 6.Combo (66) 7.Hep A, Meningococcal, Varicella, (59/58/53) Training topics of interest: 1.Adult vaccine schedule = 82% 2.IIS = 58% 3.Storage and handling = 35%

12. Survey Results Do you share adult data in the IIS? EHR connects with IIS = 43% Manual = 23% Send data file = 3% Don’t know = 17% No = 14% Barriers? 53% said no. Of those that said yes, most common: Didn’t know they could enter adult records into the IIS Not familiar with the IIS Need training to use the IIS for adults Not sure how the IIS would help their adult immunization practice Don’t have interface Don’t have time; too difficult to navigate; inaccurate; inconsistent data EHR/IIS don’t talk Adults don’t have a file in IIS, hard to add new patients

13. Where and who are the un- and under- insured adult population? NYT 10/30/2015 Washington State Latino/Hispanic Assessment Report 2013-2014

14. SES and Insurance Status Office of the Insurance Commissioner, 2014

15. Adult Data Increasing in the IIS

16. ACA Adult Grant Lessons learned inform priorities and address barriers What we did: Education materials for providers and patients Provider training in immunizations and IIS Pharmacy schools training in use of IIS Training for health care workers

17. Lessons learned: what is needed Incorporate immunization measures into processes Establish assessment in regular work flow Performance measures Leadership support Immunization champion at clinic Provider professional organizations to raise profile of immunizations

18. Discussion Questions What have we missed? What are other barriers to adult immunization? How can we raise profile of immunizations for adults? What do you think adult immunization priorities should be? How do we select vaccines? What should be our focus: disease, vaccine, population (un- or under-insured), other?