A Series in Support of the National Vaccine Advisory Committee Standards of Excellence for Child & Adolescent Immunization Practices Provider Training Jefferson County Public Health Service

Overview of Standards A Series in Support of the National Vaccine Advisory Committee Standards of Excellence for Child & Adolescent Immunization Practices (American Academy of Pediatrics, 10/17/13) –#1- Make vaccination services readily available. –#2- Coordinate vaccinations with other services and provide in “medical home.” –#3- Identify and remove barriers to vaccination. –#4- Minimize patient costs. –#5- Review vaccination and health status at every encounter. –#6- Assess for and follow only medically accepted contraindications. –#7- Educate parents/guardians in culturally appropriate and easy-to-understand language. –#8- Store and handle vaccines appropriately. –#9- Maintain written, up-to-date protocols for administering vaccines. –#10- Continually educate those who administer vaccines. –#11- Simultaneously administer as many indicated vaccine doses as possible. –#13- Report adverse events after vaccination accurately and appropriately.

#1- Vaccination Services are readily available. Create Vaccination-only Appointments or Dedicate Certain Office Hours to Vaccination –Timely available appointments Won’t wait until child is sick –Hold flexible hours at non-traditional times Weekends, evenings, early morning, lunch hours –Ensure immunizations are available at all visits Sick or well, traditional or non-traditional hours –Increase access (vaccination-only appointments) during peak times Back to school, flu season

#1- Vaccination Services are readily available. Provide a Vaccine-only Clinics –1x/wk- dedicated staff to vaccinate only, develop standing orders –Hire part-time staff to work clinic –Hold clinic after regular hours or on weekends –Integrate vaccinations with other appointments like SNAP or WIC Vaccinate Siblings Who Are Present at a Well- child Visit –Offer vaccination to siblings not up-to-date

#1- Vaccination Services are readily available. Maintain Proper Vaccine Storage and Handling Practices –Following proper procedures & proper protocols ensures a ready to access vaccine supply Refer to Public Health Service or Other PracticePublic Health Service –In the case of shortage, refer to another practice with adequate supply –Long-term shortage: partner with public health or other practice to create a referral process

Best Practices Dr McAuliffe says the following about her flu vaccine clinics: “I like doing this much better than having the kids get a vaccine at school where we are not provided with lot numbers or expirations dates. There is no physician available to ensure that kids with immune- compromised family members do not get live vaccine, and when they get vaccines elsewhere, and I get an after-hours call regarding vaccine site reaction, I don’t know who got what.”

Your turn What are you doing to make sure vaccines are readily available for your patients?

#2: Vaccinations are coordinated with other healthcare services and provided in a medical home when possible. Immunizations are coordinated with all visits (sick, well, weekend) Participate in the VFC program- avoids referring them elsewhereVFC Participate in NYS Immunization Information System (NYSIIS); keep information up-to-dateNYSIIS Communicate with other practices & public health; communicate with medical home

Your turn Do you participate with the VFC program? Have you done a spot check to make sure your EHR connects to NYSIIS? If it doesn’t, how are you getting the information into NYSIIS? How do you currently communicate with other providers?

#3: Barriers to vaccination are identified and minimized. Discuss Reasons for Delayed Immunization with Parents –Identify financial barriers & offer VFCfinancial barriers –Offer flyer for public transit near office –Offer block appointments to see all children in the family –Keep visual & written info to address vaccine hesitancy – at all literacy levels –Address any other barriers & provide resourcesother barriers Include All Recommended Vaccinations at Every Visit –Use sick & chronic care visits –Check on immunizations every visit –Always screen for contraindications

#3: Barriers to vaccination are identified and minimized. Review Standing Orders to Ensure that Vaccinations are Available During All Visits –Utilize standing ordersstanding orders Review Office Policy on Physical Exam Requirements for Immunization Administration –Discuss office policy, clarify physical exam not needed, rewrite policy if necessary Create Vaccination -only Appointments or Dedicate Certain Office Hours to Vaccination Provide Culturally-appropriate Educational Materials at the Necessary Literacy Level –Display culturally diverse pictures, posters, magazines, –Provide written material in family’s primary language, including VISprimary languageVIS –Make sure literacy level is appropriate, supplement w/pictures

Your turn Do you utilize standing orders? What do you find are the most common barriers to immunization? Other than English, what 2 languages are the most common in Jefferson County? –Spanish & Vietnamese

#4- Patient costs are minimized Create Office Policies that Minimize Patient Costs –Consider accepting all forms of insurance, including Medicaid & CHIP –Accommodate insurance changes for established patients –Participate in VFC Screen Patients for Eligibility in State Vaccine Programs –ID children for VFC or refer to PH –Refer to Medicaid or CHIPMedicaid or CHIP Work with Third Party Payers to Ensure Payment and Coverage of Vaccine –AAP Hassel Factor FormAAP Hassel Factor Form

Your turn Do you accept Medicaid and/or CHIP? If you do not, where do you refer your patients?

#5 & #6- Review & Assess #5- Health care professionals review the vaccination and health status of patients at every encounter to determine which vaccines are indicated. #6- Health care professionals assess for and follow only medically accepted contraindications. –Assess Office-based Immunization Rates Annually AFIX (done every 3-4 years)AFIX CoCASA –Maintain a Centralized Vaccination Record at the Practice to Easily Assess the Vaccine Status of Every Child at Every Visit Designate Immunization Champions to remind others Obtain records of immunizations given elsewhere –Address How the Practice Can Minimize Missed Opportunities Create office procedures to assess & immunize at acute care visits Review valid contraindications Track children who didn’t receive immunization & remind parents Used recommended Catch-up ScheduleCatch-up Schedule

Your turn Do you have a system in place to track missed opportunities & a way to remind parents?

#7- Parent Education #7- Parents/guardians and patients are educated about the benefits and risks of vaccination in a culturally appropriate manner and in an easy-to-understand language. –Use Vaccine Information Statements (VIS) Required by law –Have Written Materials Available to Address Common Parental Concerns AAP-Common concerns, CDC- Provider Resources for Vaccine Conversations with ParentsCommon concernsProvider Resources for Vaccine Conversations with Parents Provide materials that are culturally & linguistically appropriate- use pictures, posters & handouts Help Parents Navigate the Internet to Find Reliable Information –Provide a list of valid sites or help them evaluate infothem evaluate info –CDC- Parents: Vaccines for Your Children (Great resource!)CDC- Parents: Vaccines for Your Children

#7- Parent Education Promote Shared Decision-Making Between the Pediatrician and Parent –Provide an immunization tracking record –Answer any questions before; discuss myths & misconceptions –Listen to parents concerns & be understanding –Have your Immunization Champion answer any questions after Document! –For school & daycare –The National Childhood Vaccine Injury Act requirements –Informed refusal document –Office policy for providing services for unvaccinated children

Your turn Do you have materials available to support the vaccine conversation with parents? –Use links on slide 17 What website can you refer parents to for more reliable information? –Use links on slide 17 What is the #1 influence on a parents decision to vaccinate? –You!

VIC Network Archived webinar: –Lessons Learned on Vaccine Hesitancy and Acceptance - Wed., Dec 18th - 12pm ET / 9am PT (9:00 am)Lessons Learned on Vaccine Hesitancy and Acceptance - Wed., Dec 18th - 12pm ET / 9am PT (9:00 am)

#8- Healthcare professionals follow appropriate procedures for vaccine storage and handling. Understand the importance of good vaccine storage and handling –Refrigerated vaccines that are exposed to frozen temps may be ineffective (no disease protection) –Spoiled vaccines may require re-administration (costs $) Store vaccine in the most appropriate equipment –stand-alone refrigerator and freezer units Maintain optimal storage conditions within the storage unit –Add water bottles (refrigerator) or gel packs for thermal mass & temperature stabilizations –Use wire shelves –Ensure that the storage units maintain proper temperature ranges Use a digital data logger to monitor vaccine in each storage unit –Digital data logger recommendationsDigital data logger recommendations Inspect vaccine stock weekly Remove expired vaccine Rotate stock

Your turn Have you & your staff completed the CDC Module: Vaccine Storage & Handling?Vaccine Storage & Handling –There are continuing education credits available. Do you have the Vaccine Storage & Handling toolkit?Vaccine Storage & Handling toolkit

#9- Up-to-date, written vaccination protocols are accessible at all locations where vaccines are administered. Develop a Routine Vaccine Storage and Handling Plan –Refer to the CDC’s Vaccine Storage & Handling ToolkitCDC’s Vaccine Storage & Handling Toolkit Develop an Emergency Vaccine Retrieval and Storage Plan –Refer to AAP Immunization Resources Storage and Handling Series Disaster PlanningAAP Immunization Resources Storage and Handling Series Disaster Planning Post up-to-date protocols on all vaccine storage units and locations where vaccines are administered. –Post routine & emergency plans –Post recommended vaccination schedule, vaccine contraindications, & administration techniquesrecommended vaccination schedule Provide protocols on treatment & reporting of adverse events, vaccine benefit & risk communication, & vaccination record maintenance & accessibility where parents can easily see them.

#10- Persons who administer vaccines & staff who manage or support vaccine administration are knowledgeable & receive ongoing education. Partner with your local AAP chapter and Department of Health to provide your office with immunization education and quality improvement –Visit the AAP Immunization Continuing Education page to find AAP-sponsored CME.AAP Immunization Continuing Education Participate in CDC-sponsored continuing education events.CDC-sponsored continuing education events Provide practice staff with continual updates about the immunization schedule – Update staff when new vaccines enter the market- – Childhood Immunization Support Program or CDC National Immunization Program Childhood Immunization Support Program CDC National Immunization Program Provide in-office training to using AAP Tools –AAP Risk Communication VideosAAP Risk Communication Videos –AAP Training GuideAAP Training Guide –The AAP Education in Quality Improvement for Pediatric Practices (EQIPP): ImmunizationsEQIPP

Your Turn How does your staff currently receive continuing education?

#11- Healthcare professionals simultaneously administer as many indicated vaccine doses as possible Use standing orders for all vaccines due –office policies, procedures, and orders to provide recommended immunizations to patients –all vaccines due, unless contraindications Use provider prompts –EHR or NYSISS prompts, notes in chart, to-do task –Follow-up prompts at visit –Screen for contraindications Prepare your practice to provide appropriate parent education –VIS, encourage parents to visit reliable websites

Your Turn Do you use EHR or NYSIIS prompts to remind you of necessary vaccinations? If not, what technique do you use to prevent missed opportunities?

#13 #13- Health care professionals report adverse events after vaccination promptly and accurately to the Vaccine Adverse Events Reporting System (VAERS) and are aware of a separate program, the National Vaccine Injury Compensation Program (VICP) Create a protocol for responding to vaccine adverse events. –Include protocol with all other vaccine protocols –Review protocol often & update as needed Be prepared to handle rare cases of anaphylaxis after vaccination. –Report all clinically significant adverse events witnessed in the office after vaccination. The National Childhood Vaccine Injury Act (NCVIA) requires health care providers to report: –Any event listed by the vaccine manufacturer as a contraindication to subsequent doses of the vaccine. –Any event listed in the Reportable Events Table that occurs within the specified time period after vaccination. A copy of the Reportable Events Table can be obtained by calling VAERS at 800/ or by downloading it.Reportable Events Table

Your turn Is your protocol for responding to vaccine adverse events included with your other vaccine protocols? Are all clinical staff aware of what to do if an adverse event occurs?

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Sources “A Series in Support of the National Vaccine Advisory Committee Standards for Child and Adolescent Immunization Practices,” American Academy of Pediatrics (10/7/13).A Series in Support of the National Vaccine Advisory Committee Standards for Child and Adolescent Immunization Practices