Improving Adolescent Immunization Rates with a Phone Call-Based Reminder/Recall System Northeast Valley Health Corporation Allison E. Campos, BS Debra Rosen, RN, MPH

Northeast Valley Health Corporation (NEVHC) NEVHC is a Joint Commission-accredited, Federally Qualified Health Center (FQHC) whose mission is to provide comprehensive, high quality and safe health care services to residents of Los Angeles County, particularly in the San Fernando and Santa Clarita Valleys with special concern for low income and medically underserved populations.

Northeast Valley Health Corporation Across 12 licensed clinics (including a Mobile Clinic for “hard-to-reach” homeless), NEVHC provided 47,923 patients with more than 170,000 primary health care visits in Over 97% of these patients have incomes below 200% FPL, 72% are below 100% FPL, 47% are uninsured and more than 83% are Latino.

Northeast Valley Health Corporation The new Sun Valley Health Center, a community health center, will serve the entire community, adults, adolescents and children, but with the added advantage of being located on a school campus (Sun Valley Middle School).

Northeast Valley Health Corporation NEVHC administers the fifth largest Women's, Infant's, and Children's Nutrition Program (WIC) in California, providing 68,000 monthly visits across 14 WIC sites in the San Fernando and Santa Clarita Valleys.

NEVHC Immunization Visits In 2007, NEVHC had a total of 33,970 childhood immunization visits, including 15,789 given to 0 – 2 year-olds and 6,505 given to 10 – 18 years-olds. There are currently 6,743 active 13 – 15 year old NEVHC patients in the Los Angeles Orange Immunization Network (LINK).

2002 Childhood Baseline UTD Rates Despite significant efforts to improve immunization UTD rates for 24 – 35 month old children, the average UTD rate for the 5 NEVHC Primary Care Health Centers only increased to 49% in 2002.

Previous Interventions Utilized successful interventions identified in the literature Implementation of a computerized immunization tracking system Reminder/recall postcards Tools to prompt providers Practice assessments and feedback Education on immunization standards of care including missed opportunities

Revised Plan NEVHC received funding through the State Department of Health Services Immunization Branch for the period of July 2002 – June 2005 to implement a Case Management Project. Funding continues from July 2005 – June 2008.

Implementation The Case Management Project was implemented at four NEVHC Primary Care Centers in Pacoima Health Center was chosen as the control site.

Implementation Baseline UTD rates were recorded for 24 – 35 month old children Monthly not-UTD reports and UTD reports were generated at 3, 5, 7, 13, 20, and 24 month intervals. Based on the reports each month, children found to be not-UTD were enrolled in the Case Management Program All enrolled children were then followed and tracked until they completed the primary series, or turned 3 years of age.

Intervention The Parents/Guardians were contacted by phone by the case manager and informed of their child’s not-UTD status. Approximately 250 phone calls are made each month The Case Manager also scheduled immunization appointments and provided information on insurance for those in need.

Intervention After 3 unsuccessful phone call attempts, reminder postcards were sent. If the postcards were returned, or if the parent/guardian stated they had a new provider, the patients were changed to MOGE status (Moved or Gone Elsewhere) and eliminated from future reports. Patients were identified as LTFU (Lost to Follow Up) after 3 unsuccessful phone call attempts and no postcard returned.

Phone Log

Case Management Log

2003 Results UTD rates for our 24 – 35 month old children increased to 80% at the 4 NEVHC Primary Care Centers (Pacoima 62%– Control Site). Intervention was successful, results were statistically significant. No intervention implemented at NEVHC had demonstrated as much success at increasing immunization UTD rates as Case Management.

Results (continued) As a result, the Case Management Project was implemented at all 5 primary care centers in the second year. Average UTD rates for our 24 – 35 month old children in 2004 increased to 93%. Average UTD rates for our 24 – 35 month old children in 2005 increased to 95%.

UTD Rates for Case Management Sites

2006 Adolescent Immunization Rates Successful improvement for childhood immunization rates did not transfer to our adolescent population. No funding to focus on this high-risk population. No reminder/recall activities were occurring at NEVHC for the high risk adolescent population

Improving Adolescent Immunization Rates Despite lack of funding, we were committed to improving adolescent immunization rates. Assessed baseline rates for 13 year old adolescents. (see vaccine criteria) In 2006, implemented postcards only for those not UTD for Td. Theory – if the adolescent came in, he/she would be immunized with all shots due. Postcards were sent each month to adolescents who turned 13 years of age during the last month.

Assessing Adolescent UTD Rates: Vaccine Criteria DTaP/Td/Tdap: 5 doses plus Booster Polio: 4 doses Hepatitis B: 3 doses Hepatitis A: 2 doses MMR: 2 doses VZV: 1 dose Assessed baseline rate for Td/Tdap booster

NEVHC 13 year old UTD Rate: All Vaccines

NEVHC 13 year old UTD Rate: Td/Tdap Only

2006 Recall Postcards Results No improvement – in fact, the UTD rate decreased at some sites. It was clear that recall postcards were not effective in improving immunization rates of this population.

Phone Call Based Reminder/Recall Intervention Phone call based reminder/recall system began in January NEVHC also decided to target our intervention at 12 year olds to provide adolescents an opportunity to access immunizations. Approximately 175 phone calls are made each month

Phone Call Based Reminder/Recall Intervention Each month, NEVHC targets adolescents who turned 12 years of age during the last month and who are not UTD for Td/Tdap booster. Make 3 phone call attempts and then send postcard. Update patient status in LINK: Active, MOGE, or Lost to Follow Up. Continue to assess UTD rates for 13 year olds based on same vaccine criteria.

NEVHC 13 yr. old UTD Rate: All Vaccines

NEVHC 13 year old UTD Rate: Td/Tdap Only

UTD Rates for 12 year olds Although we expected the phone call intervention to improve UTD rates, we knew we would not see improvement until the 12 year olds turned 13. In order to ensure the intervention was effective, the 12 year old UTD rates were assessed in August UTD rates for 12 year olds based on the same vaccine criteria.

August 2007: 12 and 13 year old UTD Rates

Future Directions Assess UTD rates based on Healthy People 2010 goal.  Td/Tdap: 1 Booster dose  Hepatitis B: 3 doses  MMR: 2 doses  VZV: 1 dose Assess for single antigens MCV4, HPV, VZV 2 nd dose

NEVHC Conclusions Recall postcards alone do not increase immunization rates for children or adolescents. Calling patients helps to identify active patients and facilitates the inactivation of patients who are MOGE or LTFU. Most parents contacted were unaware that their adolescent needed immunizations. Gives us the opportunity to encourage a preventive visit.

Contact Information Northeast Valley Health Corporation