Improving Childhood Immunization Rates in Maine Amy Belisle, MD, - - PowerPoint PPT Presentation

Improving Childhood Immunization Rates in Maine

Amy Belisle, MD, Maine Quality Counts Cassandra Cote Grantham, MA, MaineHealth Caroline Zimmerman, MPP, Maine Primary Care Association/Maine Immunization Coalition

Agenda

• Setting the Stage – What does the data say?
• Landscape of Childhood Immunizations Efforts in

Maine

– Improving Health Outcomes for Children (IHOC) and First STEPS – MaineHealth and the Childhood Immunizations Taskforce – Maine Immunization Coalition

• Discussion and Questions

National Immunization Survey (NIS)

• Target Population: 19-35 month olds living in the U.S. (also

data for the adolescent population)

• Estimated rates of being up-to-date on all childhood

vaccinations recommended by Advisory Committee on Immunization Practices

• Up-to-date estimates based on two data sources

− Parents- random-digit-dialing telephone survey (year-round; does include cell #s) − Health Care Providers

• Parents of NIS-eligible children are asked for permission to

contact child’s medical provider

• If consent provided, provider sent questionnaire
• Rates reported are based on comparison of the two

sources

• NIS interviews a sample from each state; NOT the entire

population

• Every sample’s point estimate is likely different than the total

population’s true rate

− Therefore, a 95% confidence interval is calculated for each sample estimate − We can be 95% confident that the true rate for the entire population IS in the range (i.e. interval)

• Example: 2010 Up-to-Date (UTD) rate for the series 4:3:1:3:3:1:4

− Maine’s estimated UTD rate was 67.0 ± 7.5% (from NIS) − Maine’s true UTD rate for the entire population of 19-35 mth olds

• was NOT likely=67%, but
• WAS LIKELY to be between 59.5% and 74.5%
• If the confidence intervals for two estimates overlap, the observed

difference in the point estimates might be due to chance (Cannot say that there really a difference in the population rates.)

NIS: More About Estimates

69% 67% 67% 29% Best State: Rhode Island 82% 44% U.S. 70% 38% Maine 68% 2007 2008 2009 2010 2011 2012 2013

1: In response to a national shortage of Haemophilus Influenza B vaccine in 2009, clinicians were encouraged to delay booster shots. These delays reduced Up-to-Date rates for the series graphed above. 2:In 2009, the National Immunization Survey began reporting a measure that more accurately estimated the true Up- to-Date rate in each state. These more accurate estimates (lines from 2009-2013) are not directly comparable to the older measure’s rates in 2007-2009.

See notes below

2016 MaineHealth target: 82% or more

Percent of 19- to 35-Month-Olds Up-to-Date for a Series of Seven Immunizations

How Maine Compares to the U.S. (2013 NIS Data

released in 2014)

10 20 30 40 50 60 70 80 90 100

Rhode Island Nebraska Massachusetts Iowa Connecticut Alabama

• Dist. of…

Maryland Pennsylvania Utah New… Mississippi Minnesota South Dakota New Jersey Wisconsin Kentucky Texas New York North Carolina North Dakota Delaware Washington US National Idaho Florida Michigan Wyoming Georgia California Colorado Virginia Louisiana Kansas Indiana Tennessee Maine Missouri Vermont Illinois Oregon Hawaii South Carolina New Mexico West Virginia Montana Arizona Alaska Oklahoma Ohio

2013 National Immunization Survey: Estimated Percent of 19-35 Month Olds Up-to-date for Series of Seven Immunizations – All US States

Green band shows that Maine’s confidence interval overlaps with nearly all other states Blue Bars = 95% Confidence Intervals for State Estimates

10 20 30 40 50 60 70 80 90 100

Mississippi South Dakota South Carolina Alaska Arkansas West Virginia Iowa Oklahoma Hawaii Idaho Missouri Georgia Tennessee Maine Virginia Maryland Kansas Ohio Montana

• Dist. of Columbia

Delaware Florida Kentucky Louisiana Utah Arizona Oregon Michigan Nebraska US National New Mexico Nevada Illinois Texas Colorado New Jersey Alabama Washington California North Carolina Indiana Connecticut New York Pennsylvania Vermont Minnesota Wyoming Rhode Island Wisconsin North Dakota Massachusetts New Hampshire

2013 Estimates – NIS – All US States* Percent of children who received ≥1 dose Td/Tdap since age 10 yrs

(bars=95% Confidence Intervals for state estimates)

Maine

Band represents confidence interval for Maine up to date rate *States not listed did not report

10 20 30 40 50 60 70 80 90 100

Arkansas Mississippi Montana South Dakota Alaska Kansas Missouri Utah Wyoming Iowa Nevada Virginia Oregon Oklahoma Minnesota Tennessee South Carolina Ohio Alabama New Mexico Kentucky Maine Idaho Florida North Carolina Colorado Hawaii Georgia West Virginia Nebraska US National Maryland Illinois Washington Vermont California Wisconsin Delaware New York New Hampshire Arizona Texas Louisiana Massachusetts Pennsylvania Connecticut Michigan

• Dist. of Columbia

New Jersey Rhode Island Indiana North Dakota

2013 Estimates- National Immunization Survey Data Percent of children who received ≥1 dose of meningococcal conjugate vaccine – All US States*

(bars=95% Confidence Intervals for state estimates)

Maine

Band represents confidence interval for Maine up to date rate *States not listed did not report

10 20 30 40 50 60 70 80 90 100

Utah Kansas Arkansas Mississippi Kentucky Alaska Nevada Virginia Montana Missouri

• Dist. of Columbia

Idaho New Jersey North Carolina Georgia Maryland Illinois Florida Hawaii Michigan Indiana Ohio Oklahoma Tennessee Wisconsin Arizona US National Minnesota West Virginia Texas Colorado Massachusetts Oregon Alabama Connecticut South Carolina North Dakota Nebraska Iowa Louisiana Wyoming South Dakota Vermont New Hampshire New Mexico Washington New York California Maine Pennsylvania Delaware Rhode Island

2013 Estimates – NIS – All US States* Percent of 13-17 Year-Old Females Who Had Full HPV Series (≥3) –

(bars=95% Confidence Intervals for state estimates)

Maine

Band represents confidence interval for Maine up to date rate *States not listed did not report

10 20 30 40 50 60 70 80 90 100

Utah Michigan Mississippi Nevada North Carolina Arkansas Idaho Kansas Alaska Arizona

• Dist. of…

Kentucky Missouri Georgia Montana Wisconsin Oregon Virginia New Hampshire Nebraska Oklahoma Illinois Ohio New Mexico Minnesota Hawaii US National Colorado Indiana California Maryland South Carolina New Jersey Alabama Massachusetts Texas Louisiana Tennessee Connecticut North Dakota Rhode Island New York Florida Vermont South Dakota Washington Maine West Virginia Iowa Delaware Wyoming Pennsylvania

2013 Estimates- NIS Percent of 13-17 Year-Old Females Who Had Full HPV Series, among those who had at least 1 dose*

(bars=95% Confidence Intervals for state estimates)

Band represents confidence interval for Maine up to date rate

Maine

*States not listed did not report

5 10 15 20 25 30

Nevada Michigan Indiana South Dakota Wyoming Alaska Minnesota Montana Colorado Oregon North Carolina Washington Florida Louisiana Iowa Wisconsin US National New Jersey Ohio Texas Hawaii West Virginia Georgia Pennsylvania Illinois California Oklahoma Maine New Hampshire Delaware North Dakota New York New Mexico Arizona Nebraska Vermont Massachusetts Connecticut

• Dist. of Columbia

Rhode Island

2013 Estimates – NIS – All US States* Percent of 13-17 Year-Old Males Who Had Full HPV Series (≥3)

(bars=95% Confidence Intervals for state estimates)

Band represents confidence interval for Maine up to date rate *States not listed did not report

Maine

10 20 30 40 50 60 70 80 90 100

Michigan Nevada Tennessee California Colorado Maryland Georgia North Carolina Pennsylvania Oregon Oklahoma South Dakota Alaska

• Dist. of…

Hawaii Maine Texas US National Montana Minnesota Washington Connecticut New Jersey Iowa New Hampshire Arizona Illinois Louisiana Nebraska Florida New York Delaware New Mexico Wisconsin Massachusetts Vermont Ohio North Dakota West Virginia Rhode Island

2013 Estimates – NIS – All US States* Percent of 13-17 Year-Old Males Who Had Full HPV Series, among those who had at least 1 dose

(bars=95% Confidence Intervals for state estimates)

Band represents confidence interval for Maine up to date rate

Maine

*States not listed did not report

In 2014, we are monitoring population- based immunization rates from different sources, using different metrics – CONFUSING!

• NIS/America’s Health Rankings:

– Maine’s 2 year old immunization rate increased from 69% in 2011 to 72.6% in 2012, and decreased to 68% in 2013 – Adolescent immunizations (13-17 year old) rate increased from 59.5% to 65% in 2012 and to 66.7% in 2013 – Maine CDC (Sept. 2014) - 4 national CDC awards (2 adult; 2 kids) - increase in toddler rates by 35 months and childhood flu vaccine

• Maine Immunization Program – AFIX visits (2 yr olds UTD

at age 35 months; 4.3.1.3.3.1.4)

• Improving Health Outcomes for Children (IHOC)/CHIPRA

metrics – from ImmPact by practice; no national benchmarks; gold standard

IHOC/CHIPRA Measures

• Immunizations up-to-date at age 2 years (includes

Hep A, Rotavirus and Flu)

• Immunizations up-to-date at age 6 years (MMR, VAR,

DTaP and IPV)

• Immunizations up-to-date at age 13 years (HPV, MCV

and Tdap)

Align Efforts to Improve Immunization Rates

• Quality Gap in Care in Maine – rank 35th in nation for

childhood immunizations (America’s Health Rankings 2014)

• Maine Universal Childhood Immunization Program
• Aligning Metrics: In order to get buy-in from practices,

alignment was needed so practices would be held accountable for the same metrics:

− Accountable Care − Maine Patient Centered Medical Home − Pathways to Excellence at the Maine Health Management

Coalition

− CHIPRA − Meaningful Use

Improving Health Outcomes for Children (IHOC) Focus aka “The Catalyst”

Building a public-private framework and system for measuring and improving the quality of child healthcare services and

• utcomes. Collaborating with health systems, pediatric and

family medicine providers, associations, state programs and consumers to:

• Select and promote a set of child health quality measures
• Build a health information technology infrastructure to support the

reporting and use of quality measurement information

• Transform and standardize the delivery of healthcare services by

promoting a patient centered medical home model

• Create a Maine Child Health Improvement Partnership

IHOC Maine CHIPRA Quality Demonstration Grant

(Feb’10-Feb ‘15)

First STEPS is advised by the Maine Child Health Improvement Partnership (ME CHIP)

Mission To optimize the health of Maine children by initiating and supporting measurement-based efforts to enhance child health care by fostering public/private partnership. Vision All practices providing health care to children will have the skills, support, and opportunities for collaborative learning needed to deliver high quality health care.

ME CHIP is part of the National Improvement Partnership Network

First STEPS Learning Initiative

First STEPS (Strengthening Together Early Preventive Services): First STEPS is a

four year Quality Improvement Initiative funded by a CHIPRA grant focused on improving children’s health care & improving preventive health (EPSDT*) screenings:

• Phase 1: Introduce Bright Futures 3rd Ed and Improve Childhood Immunizations:

24 practices

• Phase 2: Developmental, Autism, and Lead Screening: 12 practices
• Phase 3: Healthy Weight and Oral Health: 19 practices
• First STEPS 2014: Spread lessons learned on developmental/autism screening: 44

practices trained in 2014 with 5 regional trainings and 9 are doing MOC project

• Each 8 month MOC Project/Phase: 2 Learning Sessions; Monthly Practice Calls, Data

Submission and PDSA Cycles

• First STEPS Learning Initiative (1-3) targeted to practices serving high volume of

children (>1000) covered by Maine’s Medicaid program; 28 practices collectively serving 37,630 kids enrolled in MaineCare (32% of 118,861 kids)*(based on December 2012

MaineCare data)

First STEPS Phase I Goals and Final Evaluation Results

Sept 2012: 12 months after beginning of learning collaborative, an avg increase of:

5.1 Percentage Points

in overall immunization rates above baseline, across FS practices Dec 2012: 15 months after beginning of learning collaborative, an avg increase of:

7.1 Percentage Points

in overall immunization rates above baseline, across all FS practices

Within 12 months of beginning of learning collaborative, achieve an average increase of

4 Percentage Points

in overall immunization rates above baseline, across all First STEPS practices.

GOAL ACHIEVED ACHIEVED

Source: Improving Health Outcomes for Children (IHOC) First STEPS Phase I Initiative: Improving Immunizations for Children and Adolescents Final Evaluation Report, Muskie School of Public Service, University of Southern Maine, March 2013.

And, 26 months after the start of the project, the average increase in overall immunization rates above baseline across FS practices was 11.1%.

Muskie School of Public Service

First STEPS Phase 1 Evaluation Highlights: Increase in Overall Immunization Rates

Immunization Rates in First STEPS Phase I Practices from Aug 2011 to Nov 2013: Immunization Rates in First STEPS practices increased 7.1% in 15 months and 11.1% at 26 months

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ImmPact Rate Reports – Data for Improvement

• The “IHOC Quick Picks” generate reports for four IHOC

Immunization Measures

– At age 2, 6, and 13 years (Tdap and MCV) – All reports can be generated by gender

• The IHOC Quick Picks were designed to run practice-level

immunization reports in support of quality improvement efforts at practices and health systems. Practices need to submit per client dose information to run reports.

• Practices can use these reports to submit data to the

Pathways to Excellence (PTE) program.

IHOC Quick Picks

Pathways to Excellence Childhood Immunization Metrics – Data for Accountability

• Reflects the core set of federal childhood immunizations metrics

(CHIPRA); comprehensive and stringent

– Immunizations up-to-date at age 2 yrs (includes Hep A, Rotavirus and Flu) – Immunizations up-to-date at age 13 yrs (HPV, MCV and Tdap) – Use IHOC reports from ImmPact

• ME CHIP and PTE

– 2011: ME CHIP has been an advisor to the PTE Physicians Steering Committee on Child Health metrics since 2011 – 2012: New PTE metrics for immunizations were approved in Sept 2012 to align with federal CHIPRA measures – 2013-2014: Update to immunizations metrics implemented in 2014 after August 2013 ME CHIP recommendations to October 2013 PTE Steering Meeting – 2014-2015: ME CHIP recommending updates to current PTE metrics- increasing benchmarks for good-better-best by 5 points; updating targets based on 2013 NIS and ImmPact data

Current PTE Immunization Chart

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Lessons Learned

• Aligning measures across state initiatives is key for provider buy-in

and to sustain quality improvement (QI) work after grant funding

• Child health measures need to be actionable and easily available

at the practice-level to improve performance

• Data source matters - Measures cannot be operationalized

without reliable methods for capturing, collecting, calculating, and reporting the data

• Integrating data system improvements as part of child QI efforts

helps increase visibility and accuracy of data and demonstrates how data can be ‘meaningfully used’ to sustain quality improvement over time

• Measures helped drive our QI efforts; we hope in the future that

HIT solutions to report measures will help drive and sustain quality improvement at the state and practice level

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Significant Changes in Immunization-related Office Systems

• Training all staff in how to discuss importance of vaccinations

with hesitant patients/parents

• Using recall and reminder systems for children due or past

due for vaccinations

• Routinely reviewing practice vaccination rates
• Reviewing and updating immunization registry dose data
• Reviewing immunization registry to identify vaccinations

received at alternate sites

• Establishing shared goals and a standardized immunization

schedule for all providers in the practice

Source: IHOC First STEPS Phase I Initiative: Improving Immunizations for Children and Adolescents Final Evaluation Report, Muskie School of Public Service, University of Southern Maine, March 2013.

The Culmination

First STEPS Change Package Toolkit

– System index – Checklist of improvement ideas – Action planning and full change package as needed

Aim:

To improve preventive services for Maine's children. Aim/Outcome: Between September 2011 & September 2012, improve immunization rates (2010) by > 4% in practices that serve a high volume of MaineCare. Team based and evidence based system of care with informed, engaged and competent staff. Leaders as champions for change. Access to care. Immunization information and tracking systems (HIT) that support improving immunizations.

Immunization Rates for:

2-Year Olds 6 Year Olds 13 Year Olds

D R I V E R S M E A S U R E S

P R O C E S S

Improving Immunization Rates Change Package

Engage partners in improving immunization rates.

Standing Orders for All Routine Immunizations

Tasks and Specific Tests of Change Review existing example standing orders from evidence based resources. Customize standard order set based on individual practice and provider needs. Review standing orders with clinical support staff to identify potential challenges, including processes related to where standing orders will be available for staff to use (EMR, binder, etc.)- revise orders as necessary. Seek any necessary approvals and test standing orders using PDSA cycles. Implement standing orders to allow staff to independently screen patients, identify

• pportunities for immunization, and administer vaccines under physician supervision (or in

accordance with local regulations).

System Index: Assessing Your System

MaineHealth’s Childhood Immunizations Program

• Program began in June 2010
• One of seven MaineHealth (MH) Health Index priorities,

included in MaineHealth Systems Measures list

• Employs a multi-sector approach to improvement: clinical,

community and policy initiatives; utilizes a comprehensive logic model as its foundation

• Overseen by the Childhood Immunizations Taskforce
• Collaborates extensively with IHOC/First STEPS, Maine

Immunization Program, Maine Immunization Coalition, District Coordinating Councils

Childhood Immunizations Logic Model

Goal of MaineHealth Childhood Immunizations Program

• Increase Maine’s 7-series immunization rate of children 19-35

months from 67% (2010) to 82% or higher in 2016

• All member-owned family and pediatric practices achieve at

least a “GOOD” rating for their performance related to the childhood immunizations metrics from Maine Health Management Coalition’s (MHMC) Pathways to Excellence (PTE) Program

Sustaining Improvements: MaineHealth’s Story

How do you maintain momentum for an immunizations quality improvement project after grant funding ends? INVOLVE YOUR PARTNERS – HEALTH SYSTEMS How did MaineHealth build off of First STEPS?

Why Create a Clinical Improvement Plan for Childhood Immunizations?

• Establish common standards for measurement and

reporting to support increasing childhood immunization rates within member-owned practices

• Align MH efforts with state and national quality program

requirements

• Embed the program within existing work
• Establish baseline data and compare results across the

health system to identify opportunities for improvement

• Create common supports and ways of recognizing member-
• wned practices for their excellent work

Reporting

• Maine Health Management Coalition’s (MHMC)

Pathways to Excellence (PTE) Childhood Immunization Metrics

• Use of ImmPact registry-based reporting
• MH staff has access to download practice-level reports

from ImmPact for member-owned practices monthly

• Compare to PTE scoring matrix; determine achievement

level

• Results of the measures to be reported transparently to

all member-owned primary care practices; overarching results to be posted on the MH Health Index website

Implementation

• Foundation: First STEPS Change Package Toolkit (system

index, checklist of improvement ideas, action planning and full change package as needed)

• Access to a Pediatric Practice Support Specialist
• Meetings with member-owned practices serving high

volumes of children and reporting immunization rates below those that would qualify for PTE’s Good Rating – complete First STEPS survey and identify areas of change

• Member-owned practices that achieve the PTE Good Rating

will receive: Plaque, Recognition in MaineHealth Publications, Notification/press releases to local newspapers and organization’s senior leadership

Supports and Resources

• ImmPact-Epic Interface
• Childhood Immunizations Education and Training

Program for clinical support staff

• Patient education materials
• Reminder/recall systems
• Vax Maine Kids
• Other (projects as defined by the Childhood

Immunizations Task Force, e.g. Standing Orders, Common Pediatric Immunization Schedule for MaineHealth)

Maine Immunization Coalition (MIC) Priority Areas (2014)

• Raising awareness of the importance of vaccination

– Immunization Awards – Recognizing Champions in Maine and nationally – Support policies to improve vaccination rates in children and adults – Engage the media in vaccine stories through education

• Become a trusted, reliable resource for information

– Be a resource for new and emerging information for practices

• Example: Changes in ACIP recommendations and payment for

pneumococcal vaccine for 65+

MIC Priority Areas (2014)

• Facilitate Statewide Collaboration

– HPV: alignment with MIP to work towards goals set in SHIP for Immunization – School-Located Vaccine Clinics: Education and building connections with the state program – Public Health: Discuss access to immunizations in a public health setting

Maine Immunization Coalition Bills of Interest

• Rep. Sanborn - LR 840: An Act to improve childhood vaccination rates in Maine

The legislation would amend the philosophical exemption part of the state's vaccination law by having a physician or other health care practitioner sign a form along with the parent indicating that the parent has been informed of the risks and benefits of vaccination.

• Rep. Farnsworth - LR 1098: An Act to require childhood immunization

counseling

This bill has a similar goal to LR 840, in requiring a physician or other health care provider sign a form indicating that they have received education and counseling on the risks and benefits of vaccination.

• Rep. Tucker - LR 1123: An Act to Eliminate the Exemption Based on Philosophical

Reasons from the Immunization Requirements for Children Enrolling in School.

This legislation seeks to eliminate the philosophical exemption.

• Sen. Mason - LR 1494: An Act to Establish the Maine Vaccine Consumer Protection

Act

This bill seeks to create a state vaccine injury office that would provide more transparent data on vaccine injuries. Developed with the Maine Center for Vaccine Choice.

Contact Information

• Amy Belisle, MD, Director of Child Health Quality

Improvement, Maine Quality Counts, abelisle@mainequalitycounts.org

• Sue Butts-Dion, First STEPS Program Manager,

sbutts@maine.rr.com

• Cassandra Cote Grantham, MA, Director, Child Health,

Community Health Improvement, MaineHealth, cotec1@mainehealth.org

• Caroline Zimmerman, MPP, Director, Health Initiatives, Maine

Primary Care Association; Representative, Maine Immunization Coalition

Funding Statements

CHIPRA/IHOC Quality Demonstration Grant February 2010 to February 2015: The Improving Health Outcomes for Children (IHOC) work is conducted under a Cooperative Agreement between the Maine Department of Health and Human Services and the Muskie School of Public Service at the University of Southern Maine and is funded by a grant from the Centers for Medicare and Medicaid Services (CMS) through Section 401(d) of the Child Health Insurance Program Reauthorization Act (CHIPRA). This document was developed under grant CFDA 93.767 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. However, these contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the Federal Government. For more information, please contact the IHOC Project Director, Joanie Klayman at jklayman@usm.maine.edu or 207-780-4202. Developmental Systems Integration (DSI) Supported by the Maine DHHS through funding from the US CDC Preventive Health and Health Services Block Grant 3B01DP009026-13 and the US DHHS Health Resources and Services Administration Maternal and Child Health Bureau Grant 2D89MC23149-02-00.

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