Guide to Reaching and Engaging


MATTAPAN COMMUNITY HEALTH CENTER



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MATTAPAN COMMUNITY HEALTH CENTER

Immunization Equity TA FY15 Case Study

Goal


  • Increase rates of HBV and pneumococcal vaccination in under-immunized patients.

Objective/s


  • Use evidence-based strategies to increase adult vaccination rates.

  • Partner with a community organization.

Target Population


  • HBV vaccination: Patients 50 years and old with diabetes.

  • Pneumococcal vaccination: Patients 60 years and older with chronic health conditions.

  • For both groups, there is a focus on the Haitian Creole population.

Partners


  • CVS pharmacy: located on group level of health center

  • Haitian Adult Day Care: a community-based organization

  • Behavioral Health: a new department within the health center

Activities


  • Used EMR system to run reports, conduct a record review, and determine number of 50+ diabetic patients that started but didn’t finish, or didn’t start, the HBV vaccine series.
  • Identified more than 500 patients.


  • Reminder/recall letters were sent to all patients.

  • Purchased HBV vaccine.

  • Running reports for patients who need pneumococcal vaccine and in the process purchasing PCV13 vaccine.

  • Setting up a meeting with DPH MIIS staff to move forward the process of on boarding with the registry.

  • Holding a health fair for adult vaccination education at a local church.

Progress / Outcomes


  • There was a large, receptive response to the reminder/recall letters. We strategized to make the letter simple with easy-to-understand information, which we believe contributed to the positive response.

  • Increased understanding of the importance of vaccines among patients.

  • Increase in the understanding of the importance of adult vaccination among medical staff (particularly medical assistants) as part of overall wellness, the adult vaccination schedule, and risk groups for HBV and pneumococcal vaccine. We now plan to review all adults for recommended vaccines as they come in for visits.

  • Vaccinated 100 patients with HBV vaccine; 75 more are scheduled for visits.

  • Strengthened partnership with CVS (health center refers patients to CVS for adult vaccines not stocked).

  • Increased communication with behavioral health department regarding diabetic patients.

Mattapan Community Health Center FY15 Immunization Equity Case Study (cont.)

Challenges


  • Grant work progressed without major challenges or barriers.

  • New patients that come to the health center without previous vaccination records always present a challenge.

  • Understaffing of nurses in the health center staff often resulted in delays in reaching out to community partners and moving forward on the pneumococcal vaccination component of the project.

Learning


  • It is important to continually monitor adult patients for vaccination status and to ensure patients are up-to-date with all recommended adult vaccines. Providers need to be diligent. Adult vaccination needs to be prioritized in the same way as childhood vaccination, and incorporated as part of overall wellness.

  • Our internal organizational systems that were in place were important to identifying our target groups. We are moving our EMR to the EPIC system in December 2015, which should provide more consistent reports, better capturing of information and more accurate data.

  • We did not see much vaccine hesitancy with the Haitian Creole patients. There was more resistance with Muslim patients, with their religious beliefs being a barrier to vaccination.

Recommendations


  • The health center could utilize more staff workshops or in-services on adult immunizations, with a focus on understanding cultural implications and communicating with people from other countries.

PLAN, DO, STUDY, ACT (PDSA)

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


  • Use our EMR system to identify under-immunized patients for HBV and pneumococcal vaccination.

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

  • Send out reminder/recall letters in easy-to-read language targeting patients 50+ in need of HBV vaccine.

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


  • The letters resulted in a positive response with many return phone calls made to the health center to schedule vaccination visits. During an approximate 8-week period (end of March to end of May), we vaccinated 100 patients with HBV vaccine, and approximately 75 more have scheduled visits or are in the process of scheduling visits.

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


  • We adapted our organizational practice to include increased record review for high-risk and under-immunized patients for HBV vaccination.

  • Beyond the grant time frame, we will continue with HBV vaccination and will start pneumococcal vaccination. The project overall encouraged our providers to recommended adult vaccines, and adult vaccination will be incorporated into our overall wellness plan.

NATICK BOARD OF HEALTH

Immunization Equity TA FY15 Case Study

Goal


  • Provide increased access to Shingles vaccination for all Natick residents age 60+; in particular, to provide access for homebound Natick residents age 60+.

Objectives


  • Increase the average monthly number of Shingles shots given among all Natick adults age 60+ by 50% by June 30.

  • Establish vaccination coverage against Shingles among homebound/isolated Natick elders age 60+ by completing 3 home immunization visits by June 30.

  • Increase knowledge about Shingles disease and the Homebound Shingles Program among homebound/isolated Natick elders age 60+ by:

    • Utilizing at least 2 suggested partner strategies to distribute information by April 30, 2015

    • Mailing information to all town residents aged 60+ who have been listed disabled in the Town Census by June 30.

  • Increase community awareness of the Shingles Immunization Program for Natick adults age 60+ by:

    • Advertising in at least 3 media by March 31.

    • Distributing info to at least 3 community sites by June 30.

Target Population


  • Natick adult residents age 60+

  • Homebound and/or isolated Natick adults age 60+

Partners



  • Natick Housing Authority, Natick Service Council, Natick Clergy Association, Natick Council on Aging (COA), Meals on Wheels, Town Clerk

Activities


  • Presentation of Homebound Vaccination Program to partners, enlisting assistance in targeting homebound/isolated adults age 60+

  • Targeted mailing to 62 addresses of disabled residents, and to 371 addresses of seniors age 60+ living in senior/handicapped housing.

  • Informational displays and brochures at library, Community Senior Center, Town Hall

  • Submissions in COA, Housing Authority newsletter publications, public access cable channel, town website, and online news sites

  • Administration of Shingles vaccine to Natick adults age 60+

Outcomes/Outcome Measures


  • Number of vaccinations for total population in 5 months of 2015 matched the total for all of 2014.

  • Average number of shots given/month increased 229% from 2014-May 2015

  • Number of homebound vaccination visits unchanged 2013-May 2015

Natick Board of Health FY15 Immunization Equity Case Study (cont.)

Progress


  • Established new partnership with Natick Clergy Association

    • New identification strategies suggested which target caregivers of homebound

  • Strengthened existing partnerships with Natick Service Council, Natick Housing Authority

    • Goal to meet 2x/year to evaluate the Homebound Program

Challenges


  • Determining where homebound/isolated adults are located

  • Continuing cooperative commitment of partners necessary

  • Multiple meetings with new and established partners

Learning


  • Need to use social media to get the word out

  • Use this model to include other vaccinations (e.g., Tdap, PCV13)

Recommendations


  • Continue to explore additional identification strategies by:

    • Establishing partnerships with other stakeholders: Sherwood Village (federal senior/handicapped housing), Natick Veterans’ Services

    • Using social media to get the word out (e.g. Facebook)

PLAN, DO, STUDY, ACT (PDSA)

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

  • Set up an expansion of our current Adult Immunization Program to provide immunization access to homebound/isolated adults 60+ by offering Shingles vaccination in their homes.


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

  • Establish visits to offer Shingles immunization among homebound/isolated Natick elders age 60+ by June 30.

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


  • Ongoing challenge to determine where homebound/isolated adults are located.

    • Isolated due to non-physical reasons, e.g., don’t know their neighbors and are unable to drive.

    • Isolated due to mental health issues, e.g. phobias, afraid or unwilling to enlist help.

  • Ongoing and evolving effort to find and enlist partners.

    • Explore other community groups with interest in serving the homebound/isolated.

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


  • Need to establish and use social media accounts to get the word out more efficiently.

  • Continuous system of advertising, checking with participating partners to find new clients.

  • Sustaining the program through continuing participation with the Commonwealth Medicine Reimbursement Program.

    • Reimbursement monies placed in town Vaccine Revolving account for purchase/administration of vaccine, other activities.

WHITTIER STREET HEALTH CENTER

Immunization Equity TA FY15 Case Study


Goal


  • Create a viable clinical model for achieving immunization equity for vulnerable (immuno-compromised, uninsured, or under-insured) patient populations in the community.

  • Vaccinate 30-45 patients over a 3-month period.

Objective/s


  • Devise a successful method for connecting with, establishing consistent follow-ups, and immunizing high-risk patients with vaccines unlikely to be covered, such as the Pneumococcal Conjugate Vaccine (Prevnar: PCV-13).

Target Population


  • Patients who are immuno-compromised (HIV+) and /or uninsured or under-insured.

Partners


  • Lead HIV physician: Dr. Mothusi Chilume; HIV Nurse: Elizabeth Oliva; Lead Medical Assistant: Ronisha McElroy-Brown; BMC Infectious Disease Specialist: Dr. Cassandra Pierre; WSHC I.T. Department.

Activities


  • Discussed, evaluated need for immunization with PCV-13 amongst HIV-infected patients; determined, defined qualifying criteria for immunization; reached out to target population to begin the vaccination process.

Roles & Time Frames:
  • Project leaders set meetings, led discussions, directed partners to particular tasks, developed overall plan, including list of criteria for immunization of 30-40 patients (12 weeks).


  • Medical Assistant to Dr. Chilume was directed to call patients, schedule appointments, and review set provider schedules to make changes as appropriate (2-3 weeks).

  • Lead medical assistant will play an active role in purchasing vaccines.

  • HIV Nurse called and met with patients (immunization-related teaching), served as liaison (6 weeks), and is set to administer vaccines both during nursing visits and follow-ups with MD.

  • The HIV nurse continues to update list of potential patients (currently about 30), based on list of criteria developed by the team.

Outcome Measures


Measures

  • Number of HIV-infected patients seen at WSHC (N=72)

  • Not receiving Anti-Retroviral Therapy

  • Diagnosis / History of chronic pulmonary disease

  • Diagnosis / History of diabetes

  • Diagnosis / History asplenia

  • Diagnosis / History of chronic cardiac disease

  • Diagnosis / History of asthma

  • Diagnosis / History of sickle cell

  • Diagnosis / History tobacco dependence

  • Diagnosis / History chronic renal disease

  • Without health insurance coverage

  • With limited health insurance coverage

  • Number of HIV-infected patients 50 and older

  • Living in poor, underserved Roxbury/Dorchester

  • Vaccinated with PPSV-23

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


Outcomes

  • The number of HIV- infected patients aged 50 and older became our main guiding figure, as the patients within this subset had all received PPSV-23 at least 1 year ago (qualify for PCV-13, per CDC recommendations), reside in underserved areas, and include those with a history of chronic lung disease and other co-morbidities.

  • Telephone calls proved not as effective as in-person talks, which allowed greater opportunity for building trust (per the HIV Nurse).

Progress


  • We continue working on further refining our immunization criteria, in view of limited funding. The list of qualifying criteria has become more extensive over the past 2 weeks (see above).

  • Lead Medical Assistant has been directed to assist in the purchase of 30 doses of PCV-13 through contracted vendor.

Challenges


  • Certain patients on our high-risk list could not be reached by phone or mail.

  • Some patients have a pattern of no-shows on schedule and happen to be on our list of potentials for vaccination

  • Appointments could not be set as regularly as we had hoped.

Learning

  • Our patients are far more willing to participate in new activities / initiatives when treated as equal partners: they demanded to be fully informed of all aspects of the PCV-13 vaccine administration project (benefits, risks, financial considerations, etc.).


  • Humans are our greatest resource. Methods and plans make for a focused, disciplined achievement of set goals, but the value of the human touch cannot be overstated (e.g., many patients were convinced to be vaccinated, not by cold hard data, but by the empathic, compassionate, and welcoming attitude of our HIV nurse).

  • In-person conversations allow greater opportunity for building trust between healthcare provider and patient than phone conversations.

  • Seizing the moment is the way to go, when dealing with an immunization-hesitant patient population: vaccinate them while they are on site; do not schedule a later appointment just for the better aesthetics found in the checking of set project boxes.

Recommendations


  • We must strive for even greater flexibility in our scheduling practices, which at times entails not scheduling at all, allowing patients to walk in for all vaccines: this is already commonplace at our practice. We need only establish vaccine-specific parameters geared toward widening our standing order list, to include vaccines not regularly administered to our adult patient population in the recent past (e.g.: PCV-13).

  • Become more methodical: gather accurate sets of data, pre- and post- implementation; devise a sound action plan, guided by measurable outcomes; re-evaluate fearlessly and make corrections accordingly.

  • Do not let the adopted method become a stumbling block: allow people’s creativity and compassion to flourish.

Whittier Street 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)

  • Immunization equity for high-risk patients, specifically patients who are HIV+, with co-morbidities.

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

  • See Activities and Learning above.




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

  • See Progress and Challenges above.




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


  • The I.D. Specialist, who has championed this project from the beginning, continues to actively collaborate with project leaders, Medical Assistants, and the HIV Nurse, meeting on a bi-weekly basis to seek a more efficient and more fluid immunization model: we will immunize during nurse visits and provider follow-ups.

  • We will bring other team members on board (mainly nurses) in order to provide greater scheduling flexibility to patients on the high-risk list (evening and Saturday walk-ins).

  • As a result of this project, we have laid the necessary groundwork for activities that will continue beyond the grant time frame (i.e., the purchase and implementation of pneumococcal vaccination).
  • We are making organizational changes that will allow us to advance our immunization equity focus. Our new method may be a model that we can continue to sustain.



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