1. Pennsylvania Immunization Education Program (IEP)
National Immunization Conference, 2006
Amy Wishner
Kathleen Marker
Sharon Shepherd
Harryl Allen
I would like to acknowledge my co-authors: Practice Manager Consultant Kathleen Marker, Senior Program Assistant Sharon Shepherd, and Pennsylvania Department of Health Immunization Program Manager Harryl Allen. We’re a team effort.

2. The PA IEP is a partnership between the PA Department of Health (DoH) Immunization Program, Philadelphia Department of Public Health, PA Chapter of the American Academy of Pediatrics (PA AAP), PA Academy of Family Physicians (PAFP), and the PA Osteopathic Medical Association (POMA). The IEP is carried out under contracts with the PA Department of Health and the Philadelphia Department of Public Health.
• University of Pittsburgh School of Medicine Center for Continuing Education in the Health Sciences provides CME/CEU credits for IEP activities.

3. PA Immunization Education Program On-site provider education
(presenter curriculum and updates)
“Let’s Talk” teleconferences
“Vaccine Tips” newsletter
Philadelphia Department
of Public Health
Philadelphia VFC
KIDS Registry
PA Department of Health
SIIS Registry
To give you the lay of the land - in Pennsylvania the PA Department of Health houses the SIIS immunization registry and subcontracts the PA VFC program. The Philadelphia Department of Public Health houses the Philadelphia VFC program and the KIDS registry. Both PA and Philadelphia health departments subcontract provider education to the PA IEP. The PA IEP carries out 3 activities: on site provider education, “Let’s Talk” teleconferences two to three times each year, and a page newsletter “Vaccine Tips” published twice each year. I am going to focus today on the on-site provider education and its evaluation, and the impact of the evaluation results on the IEP. Of the on-site provider education programs, approximately one fourth are referrals from VFC for CASAs below 75% or other problems.
PA VFC

4. The PA IEP Team (pulling together)
The on-site programs are a team of 3 presenters: physician or nurse practitioner, practice manager (may or may not be a nurse), and public health Immunization Nurse. The presenter team uses a set of 78 slides and speaker’s notes for the one and a half hour CME/CEU Immunization Update programs with the entire practice staff. This is not a canned lecture; I encourage presenters during their 2 hour telephone training to select material pertinent to site needs. We also stress the need for the presenter team to model an interactive team and give each presenter “air time” – we do not want the physician to go in and deliver an infectious disease lecture. We tailor on-site presentations with information from the site and the referral source – VFC, registry, managed care organization. IEP staff shares information with presenters and presenters contact the site ahead of time. Presenters feedback information to the IEP staff and in turn to the follow-up support Kathi Marker. Information from all these sources is continual feedback used to improve program content, activities, and presenter training.
Presenters for Immunization Education Program (IEP) – We try to have all three components represented at each presentation:
Physicians, nurse practitioners, physician’s assistants –lead scientific and infectious disease person
Practice manager – may or may not be a nurse – practice policies and procedures, documentation, vaccine ordering, storage and handling
PA Department of Health and Philadelphia Department of Public Health immunization nurses or VFC staff – VFC, registry, vaccine administration
Technical assistance
Practice manager follow-up to IEP – Kathi Marker RN telephones the practice’s Site Contact after each IEP to evaluate the IEP, ask for suggestions to improve future IEPs, and see if the practice has further questions or needs additional assistance. Kathi Marker RN asks about planned practice improvements noted on the Presentation Summary Form sent back to the PA AAP by the presenters.
PA AAP nurse – call with your questions! Call or the PA AAP IEP (Amy Wishner MSN, RN) with your questions at or (800)
Immunization Registries
IEPs include information about the immunization registry for each site, encourage participation, and help practices make full use of registry resources.

5. PA IEP On-site provider education
2005: Presenters did 87 IEPs:
31 physicians
4 nurse practitioners
20 public health nurses or registry staff
15 practice managers
: 198 IEP Sites
Private practice sites: 144 (73%)
Professional conferences: 34 (17%)
Medical or nursing students: 7 (4%)
Medical assistant training programs: 2 (1%)
Hospitals including Grand Rounds: 5 (3%)
Family practice residency training programs: 5 (3%)
Other: 1
: 979 IEPs to 16,276 participants
We do roughly 100 IEPs to 1200 people per year. From , we did 979 IEPs to 16,276 participants. In 2005, we had 31 physicians, 4 nurse practitioners, 20 public health nurses or registry staff, and 15 practice managers carrying out the programs. Over the past two years ( ), of the 198 IEPs, 144 or 73% of IEPs were to private practices, 34 or 17% were to professional conferences, 7 or 4% were to medical or nursing student groups, an additional 2 or 1% were to medical assistant training programs, and 5 or 3% were each to hospital conferences including Grand Rounds and family practice residency training programs. Not all of these sites can be evaluated with a phone call to a site contact.

6. One part of the IEP is the curriculum for the on-site programs
One part of the IEP is the curriculum for the on-site programs. The curriculum has a major revision each year with updates as needed to presenters. We are fortunate to have a terrific group of contributors to this curriculum. The 2006 curriculum has 78 slides with 161 pages of speaker’s notes. I do a major revision annually and update presenters as needed throughout the year.

7. IEP team pulling together - Giving sites what they need -
VFC, self, MCO referral – identify problems
Scheduling an IEP– Program Assistant:
Probes for issues
Informs presenters – CASA results and site concerns
Presenter – contacts site ahead of IEP
BEFORE an on-site program, the IEP team finds out what the site identifies as their issues or concerns, and communicates this to presenters via , telephone, and with confirming paperwork.
Coordinator Sharon Shepherd. Sharon finds out from VFC and the site contact what they want, and the name of the site’s physician the IEP physician should contact. A VFC referral is triggered by a CASA less than 75% UTD or any other issues. Sharon communicates this to presenters so they know what VFC and the site say they need, and who our physician should contact. In her contact with presenters while scheduling, Sharon also communicates program changes and updates.
Presenters consult with each other and tailor the IEP accordingly.

8. AT THE TIME OF THE IEP, When the IEP presenter team of the physician, practice manager, and public health nurse start an on-site program, they ask, “How can we help?”
This slide is used early in an IEP and includes things which are probably on the practice’s radar screen such as reimbursement and coding issues and understand a complex immunization schedule. It also includes things that may not be the practice’s immediate concerns but are things we know practices need to know about such as storage and handling, and joining and utilizing immunization registries.

9. IEP provides materials for site and individual participants, enrolls site to receive teleconference invitations and Vaccine Tips newsletter.

10. We want the IEPs to result in practices identifying a few specific, doable changes they will make. We use this slide near the start and near the end of the IEP. You will notice that it has our new Immunization Champion and I will be talking more about the Immunization Champion.

11. IEP team pulling together - Giving sites what they need -
Presenters: inform IEP staff about site plans and Immunization Champion
IEP staff – follow-up as needed
Follow-up Practice Manager Consultant
Evaluation questionnaire
Additional assistance
AFTER the IEP, at least one but often each of the 3 presenters completes a summary form. They identify specific site plans for change and if the site identified an Immunization Champion.
IEP staff follow up on requests as needed and forward all information to the Practice Manager Consultant Kathi Marker.
Kathi now has a wealth of information when she does her follow-up with the site: VFC or other referral information, all previous CASA results, presenter feedback, list of practice plans for change, and hopefully the name of the Immunization Champion at the site.
Kathi calls the site and asks how the IEP went, was it interactive, etc., and goes over site plans for change. She completes a structured questionnaire. She offers additional help and suggestions as needed. Her assistance may extend beyond this one phone call.

12. Practice Changes What do we encourage?
Use the same immunization schedule
Use the CDC/AAP/AAFP immunization schedule
Immunize at the earliest opportunity
Check immunizations and immunize at all visits
Immunize when patient has mild illness
Identify an Immunization Champion
Improve vaccine storage and handling
Initiate or improve reminder/recall
The structured questionnaire used by Kathi Marker is aimed at detecting whether or not the practice has made headway on the achievable changes that make a difference to immunization rates or practices. We are looking for changes that are easiest to implement and do not incur additional out of pocket expenses. Having all providers on the same schedule may seem like a small change but in a large practice can help avoid missed opportunities. Particularly with vaccines for which the schedule gives an age range, if one provider uses one end of a range and another uses the other end of the range, missed vaccines can result. We promote immunizing at the earliest opportunity (the Timely Immunization Schedule), especially important in clinic settings. Checking and immunizing at all visits is important, easy to implement, and particularly important for healthy adolescents who may be in only every year or two.

13. What changes do practices report?
2005 Practice Changes. N=73
What changes do practices report?
Make some change: 69 sites or 95%
Use the CDC immunization schedule: 11%
Check immunization status at each visit: 32%
These are the results from the follow-up questionnaire administered by telephone by Kathi Marker about two weeks after each IEP. Of the 87 IEPs in 2005, we were able to complete questionnaires on 73 sites. Note that these results do not include practices that were already doing these things – these are what practices report they have done as a result of the IEP. “Make some change” was 69 or 95%. So almost everyone found something in the IEP that they could improve. Other percents are the percent of 69. Despite structural, time, and financial obstacles to making changes, some practices do make changes.
Make any change: 69 or 95%
Use the CDC/AAP/AAFP schedule: 8 or 11%. Sixty-one other sites said they already use this schedule. Use same immunization schedule: not asked previously – we are asking this starting in 2006
Check immunization status at each visit: 22 or 32%

14. What changes do practices report?
Immunize when patient has mild illness: 7%
Identify an Immunization Champion: 10%
Improve vaccine storage and handling: 10%
Initiate or improve reminder/recall: 17%
Results of follow-up:
Immunize when patient has mild illness: 5 or 7%
Identify an Immunization Champion: 7 or 10%
Improve vaccine storage and handling: 7 or 10%
Initiate or improve reminder/recall: 12 or 17%

15. What changes do practices report?
Develop an emergency power failure plan: 7%
Improve documentation: 19%
Provide training on immunization techniques: 9%
Improve staff skills: 77%
Other changes reported by practices:
Develop an emergency power failure plan: 5 or 7%
Improve documentation: 13 or 19%
Provide training on immunization techniques: 6 or 9%
Improve staff skills: 53 or 77%

16. Impact of presenter and practice feedback:
Improved collaboration with VFC
Vaccine Tips topics
Teleconference topics and speakers
Practice and presenter feedback is used to improve collaboration with VFC, suggest topics and speakers for the “Let’s Talk” teleconferences, and topics and emphasis for newsletter articles.

17. Impact of presenter and practice feedback:
Presenter Updates –
; Teleconference; Regional in-person conferences
Posters for practices
Presenter and site feedback is used to suggest needed materials – such as this poster on vaccine promotion and content and format for keeping presenters up-to-date.
Presenter updates offered in a variety of formats – reinforced by Sharon Shepherd when she is in touch with presenters for scheduling and Kathi Marker when she is in touch with presenters getting feedback after an IEP.

18. Impact of presenter and practice feedback:
Changes to IEP curriculum:
All ages
Vaccine safety
Storage and handling
New vaccines
Immunization Champion
Coding and reimbursement
Registries
Changes resulting from presenter and site feedback.
Went from pediatric to all ages.
Included information on vaccine safety – not an issue during the 1996 planning year.
Storage and handling.
Have added new vaccines, recommendations, combinations.
Coding and reimbursement
Registries
Immunization Champion

19. Immunization Champion
How the Immunization Champion is being used – resulting from presenter and family practice site feedback. Here are three slides in the 2006 curriculum that include the Immunization Champion tag line on the bottom.

20. Immunization – it’s a team effort.
The IEP team does a variety of activities to promote practice quality improvement regarding immunization. We think that this process is applicable to a variety of health issues. We do on-site education, teleconferences, a newsletter, and provide technical assistance. We tailor on-site presentations with information from the site and the referral source – VFC, registry, managed care organization. IEP staff shares information with presenters and presenters contact the site ahead of time. Presenters feed back information to the IEP staff and in turn to the follow-up support Kathi Marker. Information from all these sources is continual feedback used to improve program content, activities, and presenter training.