Immunization Strategies for Healthcare Practices and Providers AFIX,when used successfully,is a unique blend of advanced technology and personal interaction.Much of the AFIX proces sing speed and al skills of reamlining that peron's ability to establish rapport with and motivate a provider are critical to achieving lasting results. Assessment Assessment rate for a patientsas al studie have documented that most healthcare providers,while tial service supportive of immunizations,do not have an accurate stu ammzafinh nt vider pra provider staff. CDC has developed a soft enouh to accommodate whatever assessment parameters are desired,and provides results that can be printed is the p ess of informi ing im Feedback ide e defined cie assessment is of no use unless the results are fed back to Asstes the with feedback persons who can make a change.Assessmer havior necessary for behavior change change. e How to Provide Feedback e at as take place th me day Th or it With feeling and precision Without judgme toprc If CoCASA beed the summary report that is generated can identify specific subsets of patients (e.g.,those who have not completed the s t
3 32 Immunization Strategies for Healthcare Practices and Providers attempt to persuade clients to be vaccinated, but instead focuses on changing healthcare provider behavior. Third, AFIX, when used successfully, is a unique blend of advanced technology and personal interaction. Much of the AFIX process can be done electronically, increasing speed and accuracy of assessment and feedback and streamlining reporting. However, the personal skills of the assessor and that person’s ability to establish rapport with and motivate a provider are critical to achieving lasting results. Assessment Assessment refers to the evaluation of medical records to ascertain the immunization rate for a defined group of patients as well as to provide targeted diagnosis for improvement. This step is essential because several studies have documented that most healthcare providers, while supportive of immunizations, do not have an accurate perception of their own practice’s immunization rates. Pediatricians in these studies greatly overestimated the proportion of fully immunized children in their practices. Assessment increases awareness of a provider’s actual situation and provides a basis for subsequent actions by provider staff. CDC has developed a software program, CoCASA, that enables assessment to be done electronically, is flexible enough to accommodate whatever assessment parameters are desired, and provides results that can be printed immediately. This program will be described further in the section, “AFIX Tools and Training.” Feedback Feedback is the process of informing immunization providers about their performance in delivering one or more vaccines to a defined client population. The work of assessment is of no use unless the results are fed back to persons who can make a change. Assessment together with feedback creates the awareness necessary for behavior change. Feedback generally consists of the immunization program representative meeting with appropriate provider staff and discussing the results of the assessment in order to determine the next steps to be taken. This may be done at a second visit following the assessment of the provider’s records, or it may take place the same day. There are advantages and disadvantages to each approach. If CoCASA has been used, the summary report that is generated can identify specific subsets of patients (e.g., those who have not completed the series because of a missed opportunity for immunization) that, if found in substantial numbers, can provide clues to
Immunization Strategies for Healthcare Practices and Providers which changes in the provider's practice would be most effective.This can save time and make the feedback session 3 more focused. The personal element of feedback,as mentioned,is also critical to its success A reviewer who is involved and committed to the AFIX process,who addresses deficiencies the gata and thent,and who respects the comtdentality ot efforts of the provid er w ll be likely to gain them to increase action or forare bu An incenti e is defined as something that incite ess Incentives m Something that incites to actior to do so if motivated components are no T9R8otesagPatnenhNp recognize high immunization coverage as a desirable goal and be motivated to achieve it. one rh nd a eed Things like small tokens of appreciation and providing resource materials at meeti es ha ave helped providers approach their task positivel Since the fr an increase in duties for staff,offering assistance in reviewing c心股adn s needs.Incentives pose a challe als o try nev Finally,incentives are opportunities for partnerships and organizations or bus esses have nization en orts in a ta Many ther also have the benefit of increasing awareness of immunization among diverse groups. eXchange of Information eXchange of Information The final AFIX component,eXchange of information,goes Motivates improvement ut th n0mmimcov. 'Segodoatesresources 33
3 33 Immunization Strategies for Healthcare Practices and Providers which changes in the provider’s practice would be most effective. This can save time and make the feedback session more focused. The personal element of feedback, as mentioned, is also critical to its success. A reviewer who is involved and committed to the AFIX process, who addresses deficiencies without judgment, and who respects the confidentiality of the data and the efforts of the provider will be likely to gain the trust of providers and motivate them to increase immunization rates in the practice. Incentives An incentive is defined as something that incites one to action or effort. Incentives are built into the AFIX process, recognizing that immunization providers, like everyone else, will accomplish a desired task more successfully if motivated to do so. The assessment and feedback components are not intended to be done in isolation; providers may have sufficient data about their practice’s immunization rates, but they must recognize high immunization coverage as a desirable goal and be motivated to achieve it. Incentives are extremely variable. No one thing will be effective for every provider, and a single provider may need different types of motivation at different stages of progress. Things like small tokens of appreciation and providing resource materials at meetings have helped providers approach their task positively and create an atmosphere of teamwork, but longer-term goals must be considered as well. Since the effort to raise immunization rates may involve an increase in duties for staff, offering assistance in reviewing records or sending reminder notices might more directly address a provider’s needs. Incentives pose a challenge to the creativity of the program representative but also offer the opportunity to try new ideas. Finally, incentives are opportunities for partnerships and collaboration. Professional organizations or businesses have been solicited to publicize the immunization efforts in a newsletter or provide funding for other rewards for provider staff. Many other types of collaboration are possible; these also have the benefit of increasing awareness of immunization among diverse groups. eXchange of Information The final AFIX component, eXchange of information, goes hand in hand with incentives. The more information providers have about their own practice’s immunization coverage status, how it compares with state norms and with other providers in their community, and what strategies
Immunization Strategies for Healthcare Practices and Providers have beer cessful with other the mor immunization rates.It is up to the AFIX representative to educational information Staff members at all levels can benefit from the exchange of ideas about immunization practices and increasing rates of tor suc the local nsored by government or professional organizations.Immunization training sessions can be combined with sharing of ideas regardin g actual recommendations,such as those from With the increased use of electronic communication,this method should not be neglected in the information exchange component of AFIX.Although different from muni on e-mail ex minating info VFC-AFIX Initiative In the last several years,responsibility for immunization has VFC/AFIX hCooyeeafXaetviies shifed from public health deparments VFCIAFIX site visits e prov rs pal .Reduces number of visits ided fo d er i ·Extends reach of AFIX programs to purchase vaccines and make them available at ee的wm e period he quality e site teATXacimisdriagTcat and site visits. VFC program staff are encouraged to pror ote the AFIX approach and,if possi ble,to combine VFC and AFIX site visit This ces th id un er of visits to a single ps av d effort as th requirements of a single program. VFC serves mor s in th screening requirements and to evaluate vacci 34
3 34 Immunization Strategies for Healthcare Practices and Providers have been successful with other providers, the more knowledgeable and motivated they will be to increase their immunization rates. It is up to the AFIX representative to provide appropriate statistical and educational information and create forums for exchange of information among providers. Staff members at all levels can benefit from the exchange of ideas about immunization practices and increasing rates of coverage—what has worked or not worked with another provider, streamlining office procedures, or where to obtain educational or other resources. The forums for such exchanges vary widely from informal meetings on the local level to more structured meetings sponsored by government or professional organizations. Immunization training sessions can be combined with sharing of ideas regarding actual situations in which recommendations, such as those from ACIP, are applied. With the increased use of electronic communication, this method should not be neglected in the information exchange component of AFIX. Although different from face-to-face communication, e-mail exchanges or newsletters sent electronically can be cost-saving and fast means of disseminating information. VFC–AFIX Initiative In the last several years, responsibility for immunization has largely shifted from public health departments to private providers, who now vaccinate nearly 80% of children in the United States. Many of these providers participate in the Vaccines for Children (VFC) program, a federal program whereby funding is provided for state and other immunization programs to purchase vaccines and make them available at no cost to children who meet income eligibility requirements. Because immunization program staff make periodic quality assurance site visits to VFC providers, NIP launched an initiative in 2000 to link some AFIX and VFC activities and incorporate AFIX activities during VFC provider site visits. VFC program staff are encouraged to promote the AFIX approach and, if possible, to combine VFC and AFIX site visits. This reduces the number of visits to a single provider and helps avoid duplication of staff time and effort. In addition, it increases the emphasis on overall quality improvement for a provider rather than meeting the requirements of a single program. VFC serves more than 30,000 private provider sites, and every state participates in the program. VFC provider site visits are conducted to review compliance with VFC eligibility screening requirements and to evaluate vaccine storage and handling procedures. Linking VFC with AFIX enables AFIX to reach a large number of providers in the private
Immunization Strategies for Healthcare Practices and Providers sector and to reinforce the goals of both programs. oe皮 3 AFIX Tools And Training e National Immu gram has entry of AFLX and VFC site visit data.CoCASA,first released in December 2005,is an update of previous versions ·VFC and AFIX results ment result CoCAS erage Reports on patient subsets rde Th visit oucomes and VFCsite visit information. CoCASA n provide immediate results of the assessment. mm various analysis options.CoCASA reports provide estimates swhodidortanti al reasons for the coverage lev r to finish the specific sets of patients.such as those mentioned.Dta from an immunization registry or patient management ,and data collected further analysis Cocasa is available on the website of the national Immunization Program (http://www.cdc.gov/nip/casa/). Comprehensive training modules on AFIX and on how to are built into the CASA N.ma on ab eon the hpAnwmtedcg8owhp/hWichhnicgTan AFIX Endorsements AFIX is widely supported as an effective strategy to improve vaccination rates.Many states have shown gradual and stent improvement in their cover ragelevels in the private pe ns nave a and private provider sites are rec mmended by the National Standards of ices as well as by the Advisory Committee on Im eon Practices (AC and private providers. 35
3 35 Immunization Strategies for Healthcare Practices and Providers sector and to reinforce the goals of both programs. Information about VFC is on the NIP website at http://www.cdc.gov/nip/vfc/Default.htm. AFIX Tools And Training The National Immunization Program has developed a software program titled Comprehensive Clinic Assessment Software Application (CoCASA) to enable electronic entry of AFIX and VFC site visit data. CoCASA, first released in December 2005, is an update of previous versions of CASA and supersedes previous versions. Using CoCASA, a reviewer enters appropriate basic information about an individual provider and conducts an assessment of patient records. The user also has the option to record AFIX visit outcomes and VFC site visit information. CoCASA can provide immediate results of the assessment, supplying the reviewer with the information needed for use in the feedback session and noting areas that need further follow-up. CoCASA saves the reviewer time and provides various analysis options. CoCASA reports provide estimates of immunization coverage levels and potential reasons for the coverage level, such as missed opportunities for immunization and patients who did not return to finish the immunization series. The program can generate reports on specific sets of patients, such as those mentioned. Data from an immunization registry or patient management system can be imported into CoCASA, and data collected during the visit can be exported for further analysis. CoCASA is available on the website of the National Immunization Program (http://www.cdc.gov/nip/casa/). Comprehensive training modules on AFIX and on how to use CoCASA are built into the CoCASA program. Additional information about AFIX is available on the website of the National Immunization Program (http://www.cdc.gov/nip/afix/default.htm). AFIX Endorsements AFIX is widely supported as an effective strategy to improve vaccination rates. Many states have shown gradual and consistent improvement in their coverage levels in the public sector, and studies of private pediatricians have also documented substantial improvements in median up-to-date coverage at 24 months. Assessment and feedback of public and private provider sites are recommended by the National Vaccine Advisory Committee (NVAC) in the Standards of Pediatric Immunization Practices as well as by the Advisory Committee on Immunization Practices (ACIP) in a statement endorsing the AFIX process and recommending its use by all public and private providers. Healthy People 2010 also
Immunization Strategies for Healthcare Practices and Providers oviders who have measured vaccination levels among children in their practice within the past 2 years. One of the recently vised Standards for Adult Im PractieeNVAC call spread as among Other Essential stratedies Although a substantial er is devoted to AFlX.certain other strategies for improvement of immu- nization levels deserve emphasis.These are complementary ns and Is,an Reminder and recall to patients cilitate th Reminder and recall to providers sure a favorable outcome o duction of missed mmlteon8ghamiersto is critical to pro requirements as w Records uld wh ailable at thtm AFIX or VFC representative and should be easy to interpret by anyone examining the record. Must be easy to read Must be accurate The popecionTentpatient -reflect all vaccines given Records should be kept up-to-date as new immunizations are complete Because patients often receive vaccines at more than one provider office,communication between sites is necessary records. lic health,and ommunity-based relephone.fax.or e-mail.This will become incre important as new vaccines for adolescents are added to the 36
3 36 Immunization Strategies for Healthcare Practices and Providers supports the AFIX concept with a recommendation for increasing the proportion of immunization providers who have measured vaccination levels among children in their practice within the past 2 years. One of the recently revised Standards for Adult Immunization Practices issued by NVAC calls upon providers of adult immunization to do annual assessments of coverage levels. Although the use of AFIX among providers who serve adults is still in its infancy and is not as widespread as among childhood immunization providers, this strategy can be a powerful tool to improve rates in the adult population. Other Essential Strategies Although a substantial portion of this chapter is devoted to AFIX, certain other strategies for improvement of immunization levels deserve emphasis. These are complementary to AFIX; their adoption will support the goals of AFIX, i.e., raising immunization coverage levels, and will facilitate the AFIX process and ensure a favorable outcome of an assessment. Recordkeeping Patient records are of vital importance in a medical practice, and maintaining these records, whether paper or electronic, is critical to providing optimal healthcare. Immunization records, specifically, should meet all applicable legal requirements as well as requirements of any specific program, such as VFC, in which the provider participates. These records should be available for inspection by an AFIX or VFC representative and should be easy to interpret by anyone examining the record. Immunization records must be accurate. The active medical records must reflect which patients are actually in the practice; charts of persons who have moved or are obtaining services elsewhere should be clearly marked accordingly or removed. Records should be kept up-to-date as new immunizations are administered, and all information regarding the vaccine and its administration should be complete. Because patients often receive vaccines at more than one provider office, communication between sites is necessary for maintaining complete and accurate immunization records. School-based, public health, and community-based immunization sites should communicate with primary care personnel through quick and reliable methods such as, telephone, fax, or e-mail. This will become increasingly important as new vaccines for adolescents are added to the immunization schedule and more alternative sites are available for receiving immunizations