Guide to Reaching and Engaging



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The following are case studies from the work completed by 14 participants of the IETA. Their plans, activities and lessons learned have been summarized following a template that reflects the technical assistance they received during their participation in the IETA. These are not intended, nor have they been vetted, as “best practices” but as examples that other programs can use and adapt in order to learn from the experience of their peers.


ATHOL BOARD OF HEALTH

Immunization Equity TA FY15 Case Study

Goal


  • Increase flu vaccination rates by at least 10% for under-immunized and hard-to-reach populations in Athol and surrounding small towns.

Objective/s


  • Develop and/or strengthen local partnerships.

  • Provide educational material and be available to answer questions.

  • Hold one or more flu clinics for our target population.

Target Population


  • Below poverty level, low income, and low literacy populations

  • Families with generational dependency on government aid

  • Focus on men and women 25 and older

Partners


  • Local churches and organizations (Valuing Our Children, Salvation Army, Athol Hospital, Family Pharmacy, Athol Housing Authority, RCAP Solutions)

Activities


  • Provided educational materials and answered questions for residents at: the Athol pre-school/kindergarten screening event, free community meals at St. Francis Church, American Legion and Salvation Army.
  • Held telephone meeting with owner of Family Pharmacy.


  • Met with Sanofi representative.

  • Held a meeting with church board members.

Outcomes/Outcome Measures

  • Developed and strengthened important partnerships with the local organizations that serve the target population. These partnerships are essential to reaching out and understanding underserved adults.

Progress


  • Provided education at three community events, gaining a better understanding of the target population and the organizations that serve them. By meeting people on their own turf, we began to gain trust from individuals.

Challenges


  • Low-literacy and undereducated individuals who have access to Internet often believe “if it’s on the internet, it’s true.”

  • Communication barriers and lack of interest.

Learning


  • Gaining the target population’s trust is important prior to holding a flu clinic. Initially met with resistance but learned that if you have a “value added” item, people are more likely to speak with you.

  • Some individuals needed basic information, such as why the flu vaccine is important and hand washing instructions.

  • After being at more than one function the target population became familiar with me and felt more comfortable.

Recommendations

  • Between now and flu vaccine season (fall 2015), spend more time at the free meals events, get to really know people so they are comfortable with me. Gain trust by answering questions (and a lot of the questions have nothing to do with vaccine).


Athol Board of Health FY15 Immunization Equity TA Report (cont.)

PLAN, DO, STUDY, ACT (PDSA)

PLAN (the idea, a specific thing to address a specific issue)

  • Get flu vaccine out to underserved populations and increase flu vaccination rates in the target population.

DO (list a specific activity "For 3 weeks we will…")


  • Spend time and provide education in organizations that cater to underserved populations. Target is to continue to be present at six community events.

STUDY (Analyze what happened as a result of the activity, the "do")


  • Initially underestimated the target population’s ability to communicate; face-to-face interaction was at first daunting and most didn’t have any desire to approach me even when free items were available. The more community events we attended, the more comfortable they became.

  • Learned that the flu vaccine was undervalued in the community. Many believed it was ineffective last year because that is what they saw as a ‘flash by’ on a TV or computer screen.

  • Speaking softly, avoiding touch (handshakes), and dressing down make us more approachable to the target population.

ACT (what you will adopt, adapt or abandon as a result of the “study”)



  • Limit and eventually stop pharmacy visits, as individuals there are in a hurry and few stop to ask questions.

  • Hold one ore more vaccination clinics in the Fall of 2015 at the free meal sites. (Free meal sites offered good opportunities for interaction. Recommend going early, setting up a table, offering “value added” items, and socializing before the meal is served. Most individuals come at least a half hour early for the meal.)

  • Build on the important partnerships and education work developed during the project period.

BERKSHIRE PUBLIC HEALTH ALLIANCE

Immunization Equity TA FY15 Case Study

Goal

  • Improve immunization rates for all children in Berkshire County.

Objective/s


  • Raise awareness of vaccination issues/needs among Boards of Health and the public.

  • Improve partnerships and relationships with providers.

  • Improve the Alliance Immunization Program.

Target Population


  • Under-vaccinated children, especially those who are homeless, uninsured, or without transportation; and children of undocumented, immigrant, seasonal, farm and hospitality workers.

Partners

  • Community Health Programs, Volunteers in Medicine, Fairview Hospital, Schools, Berkshire Community Organizations Active in Disasters, Berkshire Medical Reserve Corps, Berkshire Medical Center, Northern Berkshire Community Coalition, Latino Community Leaders, Western Mass Labor Action, Emergency Rooms, Head Start


Activities


  • Assess under-vaccination rates among children in Berkshire County.

  • Develop strategies to improve overall vaccination rates

Outcomes/ Outcome Measures


  • Assessed 2014 Alliance flu immunization records for children: 148 total (26 uninsured; 48 on MassHealth); determined more than half were likely from lower income families potentially needing support.

  • Talked to 5 Providers over the course of 5 weeks: a hospital ER, pediatrician, school nurse, and 2 practice nurses

  • Improved relationships and connections between the Alliance and providers in the county.

  • Presented project and received feedback from 15 Board of Health representatives (3/12/15); increased awareness of vaccination barriers among Alliance Boards of Health and offered ideas on why children are not vaccinated.

  • Distributed survey to more than 10 pediatricians assessing the barriers to vaccinations: survey process was perhaps more valuable than the results as we made new connections, strengthened existing relationships and got some new ideas and perspectives on vaccination.

Progress


  • Survey is currently in progress.

  • Ordered flu vaccine for the fall (500 doses, 3 formulations, for individuals 2-18 years).
  • Survey results will be used to develop an immunization plan for Fall 2015.


Challenges


  • Lack of good data

  • Lack of funding for vaccines, including barriers for Boards of Health to access insurance reimbursements

  • Large number of undocumented workers in the hospitality business

  • School nurses are stressed and schools aren’t willing/able to take on new initiatives that are not mandated.

Berkshire Public Health Alliance FY15 Immunization Equity TA Case Study (cont.)

Learning


  • While many barriers to vaccination exist, many people are interested in improving vaccination rates.

  • Convenience may be one of the biggest contributors to vaccination delays.

Recommendations


  • Make it easier for Boards of Health (BOH) to bill for all vaccinations, including setting up a State system online to check insurance status and automatically bill the correct insurance.

  • Schools should provide all immunizations to children.

  • ERs should provide all immunizations during any visit. Insurance should pay for this.

  • Vaccination exemptions in public schools should be harder to obtain. Work with each school district to change local policies.

PLAN, DO, STUDY, ACT (PDSA): Immunization Data

PLAN (the idea, a specific thing to address a specific issue)


  • Looked at Alliance 2014 flu vaccination data to determine how many children were uninsured or underinsured.

DO (list a specific activity "For 3 weeks we will…")

  • Analyzed Alliance 2014 vaccination/insurance records.

STUDY (Analyze what happened as a result of the activity, the "do")

  • About half of the children were uninsured/underinsured.

ACT (what you will adopt, adapt or abandon as a result of the “study”)

  • Anticipate that many families with children will need additional resources to get vaccinations.

PLAN, DO, STUDY, ACT (PDSA): Immunization Survey

PLAN (the idea, a specific thing to address a specific issue)

  • Create and distribute a survey to learn why providers think children are not vaccinated. This will help us to decide how we can best reach and vaccinated children who have been missed.

DO (list a specific activity "For 3 weeks we will…")
  • Created a survey, received TA to improve the questions, beta tested it with 3 providers, updated again, loaded it into Survey Monkey and distributed.


STUDY (Analyze what happened as a result of the activity, the "do")

  • Berkshire Health Systems had initially agreed to distribute the survey to all their affiliated pediatricians, but later decided not to.

ACT (what you will adopt, adapt or abandon as a result of the “study”)


  • Identifying other channels to distribute the survey, including blind emails to practices with follow-up phone calls.

  • Continue with activities beyond the grant timeframe, including using the survey results to develop strategies to increase vaccinations for children during the Fall of 2015.

FENWAY HEALTH CENTER

Immunization Equity TA FY15 Case Study

Goal


  • Address immunization inequities by preparing and planning for the implementation of the Massachusetts Immunization Information system (MIIS).

  • Implementation will allow for more complete access to immunization records, which will increase vaccination rates, reduce missed opportunities for immunization, and provide a streamlined process for completing targeted outreach to our under immunized patients.

Objective/s

  • Update electronic health record (EHR) forms/software in order to make current system compatible with MIIS


  • Develop project plan for full implementation of MIIS

  • Plan staff training regarding use of new immunization forms

Target Population


  • Fenway Health patients (25,000 active patients, and 43,000 total patients who have vaccine records in our EHR system)

Partners


  • Collaborate with Qvera, a software company that has previously worked with Centricity Practice Solutions, our electronic health record provider, to create an interface that links the CPS system to the MIIS

Activities


  • Prepare EHR system to map to MIIS

  • Develop system to inform patients of MIIS data sharing

  • Review/develop training materials, and plan staff training on MIIS in advance of go-live date

Outcomes/Outcome Measures


  • Registered for MIIS; installed Qvera

  • Developed logic model for project planning and to track progress/outcomes

  • Converted 231,431 vaccine entries on 42,383 patients

Progress


  • Registered three Fenway Health practice sites with MIIS

  • Completed data conversions

  • Set testing date for linkage to MIIS (July 1)

Challenges


  • Technology: There were several technological hiccups that slowed progress slightly. Our system could not link directly to the MIIS, and many years of data had to be converted and tested for the new system

  • Due to many of the technological hiccups, dedicated staff time related to this project ended up being more extensive than anticipated

Learning


  • Learned that it is important to keep realistic timelines for projects that require in-depth IT solutions

Recommendations


  • Research how your particular system will link to the MIIS system as you prepare

  • Allow adequate time to address data challenges, including unstructured data fields, etc

Fenway Health Center FY15 Immunization Equity TA Case Study (cont.)

PLAN, DO, STUDY, ACT (PDSA)

PLAN (the idea, a specific thing to address a specific issue)

  • Prepare for implementation of the MIIS in order to improve accuracy of immunization records and vaccination rates for all vaccines.

DO (list a specific activity "For 3 weeks we will…")

  • Identify data needs and researched options to link our system to the MIIS (2 months).


  • Perform tests and data conversions (3 months).

  • Identify staff training needs (ongoing).

  • Develop logic model for ongoing project planning (ongoing).

STUDY (Analyze what happened as a result of the activity, the "do")


  • As a result of these efforts, 231,431 vaccine entries on 42,383 patients were converted and will be sent to the MIIS when our go-live date arrives.

ACT (what you will adopt, adapt or abandon as a result of the “study”)


  • These project activities laid necessary groundwork for activities that will continue and be sustained. These organizational and systems changes will allow us to advance our immunization equity focus. Use of the MIIS is a significant system adoption that will permit us to target our under-immunized populations. Once we are fully using the MIIS outside partners can be pulled in to enhance our efforts.

  • Continue to use and adapt our logic model, which outlines the next steps, to document and monitor our progress as well as guide evaluation as we move forward with full MIIS implementation.

EDWARD M. KENNEDY COMMUNITY HEALTH CENTER

Immunization Equity TA FY15 Case Study

Goal

  • Address immunization disparities among substance users who are treated at our primary care site located at a nearby, outpatient substance abuse clinic operated by Spectrum Health Systems, Inc.


Objective/s


  • Determine the best method to increase vaccination rates of our high-risk Spectrum Health Patients.

Target Population

  • The 272 patients of the primary care site located at Spectrum Health Systems, Inc.

Partners

  • Spectrum Health Systems, Inc.

Activities


  • Evaluated supplies and equipment needed to provide vaccines at Spectrum site, reports designed for outreach to Spectrum Clinic patients, patients booked into EMK Tacoma Nursing schedule.

Outcomes/Outcome Measures


  • Initial report was run for patients seen in April at Spectrum; 33 patients were identified, and 15 patients had no vaccine history.

  • The medical assistant reviewed the chart for lab data for titers.

  • Booked appointments first and second week of June.

  • Analysis is pending for show rates for nursing appointments, lab results (titers), and patient self-booked appointments.

Progress


  • Medical Assistant now reviews vaccine needs as part of visit planning for upcoming appointments at Spectrum.

  • Scheduled meeting with partner organization in mid-June.
  • High-risk populations that were not receiving vaccinations as part of primary care will receive education and new appointment slots for needed vaccines. Will continue to work toward best method of scheduling.


Challenges


  • Still need to determine most effective method of scheduling and for having vaccines accessible at our Spectrum Health Clinic.

Learning


  • Data is still preliminary. Planning on several additional PDSAs to determine best practice to increase immunization rates.

  • Test having a monthly vaccine clinic on-site at Spectrum. Will discuss further with partners. Planning and work on developing educational/promotional fliers

Recommendations

  • Increase education to high-risk populations regarding adult vaccinations.

Edward M. Kennedy Community Health Center FY15 Immunization Equity Case Study (cont.)

PLAN, DO, STUDY, ACT (PDSA)

PLAN (the idea, a specific thing to address a specific issue)

  • Address immunization disparities among substance users who are treated at our primary care site located at a nearby, outpatient substance abuse clinic operated by Spectrum Health Systems, Inc.

DO (list a specific activity "For 3 weeks we will…")


  • January – March planning (equipment, staff resources)
  • March – April (Reports for outreach and staffing needed evaluation, Spectrum clinic staff providing vaccine education)


  • May (Outreach for Tacoma nursing appointments)

STUDY (Analyze what happened as a result of the activity, the "do")

  • High-risk populations that were not receiving vaccinations as part of primary care are provided education and appointment slots to receive needed vaccines.

ACT (what you will adopt, adapt or abandon as a result of the “study”)

  • Medical Assistant now reviews vaccine needs as part of visit planning for upcoming appointments at Spectrum.




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