Author: Sherly Abraham, MD FAAFP, Sylvester Sarfraz, MD, Seema Tayal, MD, Prabhjhot Manes, MD- The Brooklyn Hospital Center Department of Family Medicine
Older adults are at increased risk for many vaccine-preventable diseases. Older Hispanic and African-American adults are much less likely to be vaccinated against influenza and pneumococcal disease than their white counterparts.1,2,3Although great progress has been made in improving childhood immunization rates, disparities in overall immunization coverage rates among racial and ethnic groups still exist. This disparity is of great concern in large urban areas with underserved populations because of the potential for outbreaks of vaccine-preventable diseases.
The Brooklyn Hospital Family Medicine residency program serves a diverse minority, low socio-economic immigrant population, which tends to be underserved in all areas of health care, including immunizations. Our program is proud to see the fruits of our efforts over the last two years with improvements in immunization rates of our child and adolescent population. However, we fell short of our goals for adult vaccinations. While evaluating the practice using Healthcare Effectiveness Data and Information Set (HEDIS) indicator like influenza and pneumonia shots for patients aged 50+, we realized that our adult vaccination rate was significantly lower than the national benchmark. In strategizing to closing this gap, we initiated a quality project to improve the adult immunization rates in the Family Medicine Center at The Brooklyn Hospital Center.
The project incorporated simplifying the vaccination process, educating physicians and residents on the current adult vaccination schedule, creating physician teams to improve continuity of care, pre-visit adult chart reviews, identifying adult vaccine deficiencies, creating paper and electronic physician alerts and reminders and electronic vaccination order sets, as well as an electronic tracking mechanism, patient education, and increasing vaccine administration opportunities.
Study Design and Methodology:
We identified a 12 month study period from March 1, 2011 to February 29, 2012. Consistent with the study period, we selected a study population of 250 patients aged 19 -85 years. We reviewed the vaccination records of each study participant over the study period collecting baseline and interval vaccination data.
Our first task in improving adult immunization rates was identifying barriers, which were categorized in three groups:
- Nebulous process of immunization: adult vaccination practices differ from provider to provider.
- Few being very proactive in identifying the status while others more passive and needs chart reminders.
- Lack of knowledge on updated adult immunization schedule
- No show rate of 40% is a major obstacle in achieving improvement with the adults.
- Fragmented patient care with multiple providers /residents making it unlikely to complete the immunization status.
- Lack of patient and community awareness of the need for adult immunizations.
- Language and cultural barriers
- Limited availability of vaccine stock
- Non-availability of Zoster vaccine in the institution
- Missed opportunity to provide vaccine.
Programs & Processes Implemented to Overcome Barriers:
1) Proactive, pre-visit immunization review tools used to identify patients who are not up-to-date:
- Our motto is “Every Patient Every Time”.
- A day before the patient has a scheduled visit to the clinic, whether for an acute or a chronic visit, the immunization medical assistant coordinator goes through patients records and identifies missing immunizations and communicates the need to both the staff and the providers on the day of visit, hence completing the vaccination at that visit.
- The nurse is also responsible to review the adult patient’s immunization history during every visit. Moreover, for any patient who returns to the clinic for a “non face-to-face” MD visit (e.g. PPD placement, Depo-Provera shot, etc.) the nurse identifies the status of their immunization at the time of that visit. Order sets were developed in the EMR to help guide providers in choosing the appropriate vaccines at each well visit. These order sets remind providers that the patient may require additional vaccines. A new exit point person is assigned for every clinic session. The exit staff coordinates the referrals, sets the next appointment and assuring their return for their vaccines.
2) Education sessions provided to address lack of knowledge:
- All residents, attending physicians and nursing staff were coached to proactively determine the immunization status for each patient into our clinic. We also re-educated residents and attending physicians, while reminding them that the primary care provider is to be responsible and to use every opportunity to assess their immunization status.
- Using the AFMRD Comprehensive Curriculum For Family Medicine Residency, information was provided to the residents and attending physicians several times during the year, in several different formats (Power Point, quiz), to meet the needs of all types of learners, while increasing the knowledge of the immunization schedules.
3) Re-contacting and re-scheduling missed appointments by phone and by sending telegrams:
- Reminder calls made the night before through an automated calling system.
4) Tracking vaccine use and ordering vaccine more efficiently:
- Minimizing the missed opportunity to immunize.
5) Vaccine shortage strategy
- Physicians provide patients with an electronic script to come back only for vaccine administration when available without any appointment. A list is kept of these patients and when the vaccine is available these patients are called to come in for a nurse’s visit.
6) Availability of Language Line:
- Patients are offered the use of Language Line to ensure understanding, if the primary language spoken is not English.
7) Walk-In Appointments:
- We allow walk-ins to update vaccines.
8) Patient satisfaction surveys & monthly review of results
- Surveys were used to assess health care services, addressing all concerns about access and communication. We evaluated the survey scores on a monthly basis, which facilitated our delivery of better health care to our patients
9) Language appropriate educational materials
- Hand outs were provided to educate patients about the importance of vaccines, the hazards of the diseases they prevent, side effects and contraindications.
10) Introducing Zoster Vaccine in the Clinic
- Clinic has 40% of geriatric patient population. Therefore reintroduction and education of the adult Immunization Guidelines and reiterating the need for adult Zoster to prevent Shingles in the elderly were conducted.
11)Morning “Huddles” have been used with much success
- Prior to the start of patient sessions, the nurse, the physician and staff huddle to ensure that we are stocked and ready with educational material, vaccines, and review tools for the day. This collaborative management has significantly contributed to our increase in immunization rates.
The collected date was entered into a spreadsheet and analyzed. The baseline (pre-study period) and interval (post-study period) compliance rate per vaccine requirement was computed and compared.
Our baseline compliance rate was 17% which was improved to 59 % by the end of the study period.
- Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly Rep 2000;49:138.
- Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly Rep 1997;46:124. Centers for Disease Control and Prevention. Active bacterial core surveillance (ABCs) report, Emerging Infections Program Network, Streptococcus pneumoniae, 1998. Atlanta, Ga: Emerging Infections Program Network; 1998.
- Zimmerman RK, Silverman M, Janosky JE, Mieczkowski TA, Wilson SA, Bardella IJ, Medsger AR, Terry MA, Ball JA, Nowalk MP. A comprehensive investigation of barriers to adult immunization: a methods paper. J Fam Pract. 2001 Aug;50(8):703.