About the Presentation

 This

Immunization in the Medical Home

by David Wood, MD, MPH, FAAP AAP Council on Community Pediatrics & AAP Childhood Immunization Support Program

presentation will describe how the Medical Home concept can be applied to immunization practices for all children. will be placed on Medical Home principles such as the family-physician partnership and the pediatricians active application of knowledge, AAP policies, and best practice guidelines that apply to immunizations.

 Emphasis

Learning Objectives
medical home principles vis-avis immunization services  Understand the challenges facing pediatricians administering vaccines in the context of a medical home  Anticipate and overcome barriers and promote the optimal delivery of immunizations in the medical home  Learn how to access additional immunization and medical home resources and tools
 Understand

American Academy of Pediatrics Stance on Immunizations

The American Academy of Pediatrics (AAP) believes that immunizations are the safest and most cost-effective way of preventing disease, disability, and death, and that the benefits of immunizations far outweigh the risks incurred by childhood diseases, as well as any risks of the vaccine themselves. The AAP urges parents to immunize their children against dangerous childhood diseases.

Understanding the Pediatricians Role in Vaccine Administration

 Primary care

Comparison of Maximum and Current Reported Morbidity, VaccineVaccine-Preventable Diseases & Vaccine Adverse Events, US4
Disease Pre-vaccine Era* 31,054 390,852 21,342 117,998 4,953 9,941 19,177 1,314 24,856 566,706 0 2000 1 86 338 7,867 0 176 9 35 112 8,624 13,497 ^ % change -99 -99 -99 -93 -100 -98 -99 -97 -99 -98 +++

practices delivered 80% of vaccine administration1 prevent 10.5 million diseases per birth cohort in the US2

 Vaccines

Diphtheria Measles Mumps Pertussis Polio (wild) Rubella Cong. Rubella Synd. Tetanus Invasive Hib Disease** Total Vaccine Adverse Events
* + ^ **

 Administering seven

vaccines saves society over $40 billion a year3

Maximum cases reported in pre-vaccine era Estimated because no national reporting existed in the prevaccine era Adverse events after vaccines against diseases shown on Table = 5,296 Invasive type b and unknown serotype

References
1.

What Is A Medical Home?

A

2.

3.

4.

Santoli JM, Szilagyi PG, Rodewald LE. Barriers to immunization and missed opportunities. Pediatric Annals. 1998;27:366-374 Centers for Disease Control and Prevention. Ten great public health achievements United States, 1990-1999. MMWR Morb Mortal Wkly Rep. 1999;48:241-243 Zhou F, et al. Economic Evaluation of the 7-Vaccine Routine Childhood Immunization Schedule in the United States, 2001. Arch Pediatr Adolesc Med. 2005;159:1136-1144. Available at: http://archpedi.amaassn.org/cgi/content/short/159/12/1136 (Accessed: August 6, 2008) Atkinson W, Wolfe C, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases, 7th Ed. Department of Health and Human Services, Centers for Disease Control and Prevention; 2002

medical home is not a building, house, or hospital, but rather an approach to providing comprehensive primary care is a way to provide cost effective quality health care

 Medical Home

The AAP Medical Home*

Care is:
 Accessible  Coordinated  Continuous  Comprehensive  Family-Centered  Compassionate  Culturally Effective
* American Academy of Pediatrics, Medical Home Initiatives for Children
With Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002;110:184-186

Applying Medical Home Principles Can:

 Improve health

monitoring and delivery of preventive services Track needed immunizations Reduce missed opportunities Facilitate practice team efforts to educate families

Applying Medical Home Principles Can:

 Improve immunization delivery

Applying Medical Home Principles Can:

 Address problems of

with chronic conditions

for children

Monitor immunization for children needing special immunizations (Influenza, synagis, pneumococcal polysaccharide, etc.)
 Improve patient

compliance

vaccine delivery: Address vaccine controversies and increase parental confidence in vaccines Partially address vaccine financing and supply issues Decrease mortality/morbidity due to vaccine-preventable diseases by keeping immunization coverage levels high

Immunization: Accessible Care

Accessible: Physically and economically accessible to all patients
 Immunizations are

Immunization: Accessible Care

Scope of Problem: 12.8% of children with special needs1, some require physical accommodations 10.1% of children uninsured2 25% of children under 5 have no insurance or no immunization coverage3 Over 70% of poor children under 18 rely on SCHIP or Medicaid1

available and administered according to the harmonized immunization schedule

Patient Barriers to Accessible Care

Problems scheduling appointments Cant get off work, long office wait times Lack of transportation Costs of immunization/administration fees

Patient Barriers to Accessible Care

Uncertainty about how to access free vaccines Confusion about the vaccination schedule Vaccine safety concerns or misconceptions

Physician Barriers to Accessible Care

Increasingly complex immunization schedule Increased staff time for documentation and patient education Large uninsured and/or underinsured patient populations

Physician Barriers to Accessible Care

Low or delayed reimbursement Missing/lost patient immunization record Lack of centralized immunization registry Vaccine delays or shortages

Strategies to Provide Accessible Care

 Financially Accessible

Strategies to Provide Accessible Care

Changes in insurance are accommodated Clinicians/AAP chapters work with thirdparty payers (public and private) to ensure reimbursement and coverage of vaccine

All forms of insurance are accepted, including:  Medicaid  SCHIP Practice participates in Vaccines for Children (VFC) program

Strategies to Provide Accessible Care

 Physically Accessible to

Strategies to Provide Accessible Care

Vaccination-only visits available
The practice increases access during periods of peak demand (i.e., flu season, back to school, etc.) The practice is accessible by public transportation

Children with Special Health Care Needs (CSHCN) Practice strives to meet Americans With Disabilities Act requirements Hours Immunizations are available during all visits, sick or well, regular hours, or weekend clinics

 Accessible, Flexible Office

Strategies to Provide Accessible Care

 Health care

professionals review the vaccination and health status of patients at every encounter Staff can review records to determine if any vaccines were missed by the physician Staff can prepare immunizations while patients are with the physician  Maintain and prominently display vaccine storage and handling procedures and protocols

The following case study is designed to assist you to implement the Accessible Care component of the medical home concept during immunizationimmunizationrelated patient encounters. Strategies to address specific issues raised in the scenario are included.

Case Study #1: Accessible Care



Case Study #1: Accessible Care



Flu season is just around the corner. Dr Weiss, a privately practicing pediatrician in an urban city, is concerned about the potential increase in children coming in for the flu vaccine due to the changes in the Recommended Childhood and Adolescent Immunization Schedules. Prior to the change in recommendations, Dr Weiss immunized <250 children against influenza. The practice already has preordered vaccine on hand.

Question: How can Dr Weiss ensure that his at-risk and target patient population has adequate access to flu vaccine?

Case Study #1: Accessible Care

Addressing the problem:  Dr Weiss decides to set up a flu clinic, which will be devoted to providing flu vaccine only. The flu clinic will run for 2 hours every Tuesday afternoon from October March or until the virus is no longer circulating.  He ensures that all staff are vaccinated and develops vaccine standing orders so nursing staff can give vaccine without him having to see the patient.

Case Study #1: Accessible Care

Addressing the problem:  He uses his computer-based patient information system to identify children needing flu vaccine. The system will flag children that would need flu vaccine (e.g., those with asthma, etc.) and identify those currently 6-23 months old.

Case Study #1: Accessible Care



References: Accessible Care

1.

Dr Weiss assigns 1 staff person to serve as the office Immunization Champion, answering patient questions regarding the flu and flu vaccine(s). In addition to the flu clinic, office staff will offer the flu vaccine at well child visits for all eligible children/siblings during flu season. Patients are screened for and enrolled in the states VFC program.

2.

3.

4.

Strickland B, McPherson M, Weissman G, Van Dyck P, Huang ZJ, and Newacheck P. Access to the Medical Home: Results of the National Survey of Children With Special Health Care Needs. Pediatrics. 2004;113:14851492 Cohen RA, Coriaty-Nelson Z. Health Insurance Coverage: Estimates from the National Health Interview Survey, 2003. Division of Health Interview Statistics, National Center for Health Statistics; 2004 Institute of Medicine. Vaccine Financing In the 21st Century. National Academies Press, Washington DC, 2004 National Vaccine Advisory Committee. Standards for Child and Adolescent Immunization Practices. Pediatrics. 2003;112:958-963

Immunization: Coordinated Care

Coordinated: All needed immunization services are facilitated through the medical home. Clinicians practice community-based approaches and work with community groups to develop appropriate vaccination services1
 Each

Immunization: Coordinated Care

Scope of Problem: 80% of vaccine administration takes place in a physician office2 43% of children <6 years have 2+ immunizations in a registry, 2002 (Healthy People 2010 Goal: 95%)3

visit is an opportunity for vaccination practice staff  Regularly review and update immunization procedures
 Continually educate

Immunization: Coordinated Care

22% of children receive early preschool vaccinations from more than one health care professional (leading to increased record scattering)4 45% of practices had 1 or more documented storage problems5

Who Is Part of a Medical Home for Immunizations?

AAP Chapter or State Educational Programs Health Departments

Community Organizations Vaccine Manufacturers

Barriers to Coordinated Care

 Parents/physicians may

Child Care Centers, Public & Private Schools

Medical Home Child Family Pediatrician

Immunization Coalition

Local, State, National Immunization Programs (i.e., VFC)

Registry/State Immunization Information System/EMR Third Party Insurers/ Authorizing Agents

lack knowledge of immunization-related community resources  Poor communication among public and private health care and child care professionals (relevant state/federal agencies, school nurses, child care centers, etc.)

Barriers to Coordinated Care

 Children receive  Lack

Strategies to Provide Coordinated Care

 When

immunizations in

multiple sites of state or local immunization registry  Complex and/or multiple vaccine supply sources  Delays and/or disruptions in vaccine supply

possible, the practice participates in local or state-level immunization registries  Clinicians work with local and state public health departments on quality improvement measures, such as Assessment, Feedback, Incentives, eXchange (AFIX) and Comprehensive Clinic Assessment Software Application (CoCASA), to increase immunization rates

Strategies to Provide Coordinated Care

 Cooperate with

Strategies to Provide Coordinated Care

 Designate Immunization Champions  The practice reports adverse events

local public health department to monitor disease outbreaks and educate parents  Develop and train staff on vaccine and office protocols  A central immunization record, including immunizations, is maintained at the practice

to the Vaccine Adverse Events Reporting System (VAERS), and is aware of the National Vaccine Injury Compensation Program (VICP)1

Strategies to Provide Coordinated Care

 Immunizations are

coordinated with routine well-visits, follow-up, and sick visits  Immunizations received outside of the medical home are communicated to the primary care clinician

The following case study is designed to assist you to implement the Coordinated Care component of the medical home concept during immunization-related patient encounters. Strategies to address specific issues raised in the scenario are included.

Case Study #2: Coordinated Care



Billy is a healthy 5 year-old Hispanic boy who is starting kindergarten this year. When Billys mom drops him off at school and shows the school nurse his immunization record, the nurse informs her that, according to their states immunization requirements, Billy is not current on all of his immunizations. His vaccination record indicates that he has received: 3 DTaP, 2 IPV, 1 Hib, 2 Hepatitis B, 3 Prevnar, 1 Varicella, and 1 MMR.

Case Study #2: Coordinated Care



Question: What should the school nurse do? What should Billys pediatrician do?

Case Study #2: Coordinated Care

What should the school nurse do?
 

Case Study #2: Coordinated Care

What should Billys pediatrician do?


Document that Billy is behind and send a letter home to his parents. Refer Billy to his pediatrician.

Follow the written vaccination protocols, including the Catch-up Schedule for children behind on immunizations. Billy needs: DTaP #4, IPV #3both final doses #3 because given after age 4 PCV #4because the first 3 doses #4 given before 24 months of age Hep B # 3last dose 3 MMR #2hes done #2

Case Study #2: Coordinated Care



Case Study #2: Coordinated Care



Update the childs immunization record to reflect which vaccinations were given, given, dates of administration, number of doses, intervals between doses, and the childs age.

If the physician participates in a immunization registry or child health information system (CHIS), enter data into the system. If necessary, provide parent education at next visit, and/or provide school with parent handouts.

Case Study #2: Coordinated Care



References: Coordinated Care

1.

Continuously monitor state requirements and the recommended schedule to ensure children are up-to-date. Consider implementing a reminder-recall system to identify and call in children that are behind.

2.

3.

National Vaccine Advisory Committee. Standards for Child and Adolescent Immunization Practices. Pediatrics. 2003;112:958-963 Santoli JM, Rodewald LE, Maes EF, Battaglia MP, Coronado VG. Vaccines for Children Program, United States, 1997. Pediatrics. 1999;104(2) Centers for Disease Control and Prevention. Immunization Registry Progress United States, January-December 2002. MMWR Morb Mortal Wkly Rep. 2004;53:431-433

References: Coordinated Care

4.

Immunization: Continuous Care

Continuous: The same primary pediatric clinician practice is available from infancy through adolescence and young adulthood care from birth through the second year of life greatly increases immunization levels3  Multiple clinicians leads to scattering of the immunization record1
 Continuity of

5.

Stokley S, Rodewald LE, Maes EF. The impact of record scattering on the measurement of immunization coverage. Pediatrics. 2001;107:91-96 Bell KN, Hogue CJR, Manning C, Kendal AP. Risk factors for improper vaccine storage and handling in private clinician offices. Pediatrics, 2001;107:100

Immunization: Continuous Care

Improper record keeping can lead to increased costs and extra immunizations  Greater continuity of care is associated with higher quality of care as reported by parents2  Review vaccination and health status of patients at every encounter to determine which vaccines are indicated


Strategies to Provide Continuous Care

 Regularly review

patient records and conduct practice-wide vaccination coverage assessments annually Identify children behind on immunizations Implement recall/reminder or other strategies to increase immunization rates

Strategies to Provide Continuous Care

1.

References: Continuous Care

Yusuf H, Adams M, Rodewald L, Lu P, Rosenthal J, Legum SE, Santoli J. Fragmentation of immunization history among clinicians and parents of children in selected underserved areas. Am J Prev Med. 2002 Aug;23(2):106-12 Christakis DA, Wright JA, Zimmerman FJ, Basset AL, Connell FA. Continuity of care is associated with high-quality care by parental report. Pediatrics. 2002;109:e54 Irigoyen M, Findley SE, Chen S, Vaughan R, Sternfels P, Caesar A, Metroka A. Early continuity of care and immunization coverage. Ambul Pediatr. 2004 MayJun;4(3):199-203

 Utilize standing

orders to allow staff to independently screen patients, identify opportunities for immunization, and administer vaccines under physician supervision (in accordance with local regulations)  Promote immunization at both well and sick visits

2.

3.

Immunization: Comprehensive Care

Comprehensive: Care is delivered or directed by a well-trained physician who is able to manage and facilitate all aspects of immunization and other preventive services Scope of Problem: Immunization coverage rates are higher for children receiving all or some vaccines within a medical home1

Immunization: Comprehensive Care

Promoting vaccination within the medical home improves both vaccination coverage and receipt of other preventive services1 Errors maintaining cold-chain (improper vaccine placement, inaccurate thermometers, improper temperature) can affect the access to vaccine quality4

10

Barriers to Comprehensive Care



Barriers to Comprehensive Care

 Missed opportunities (MOs)

 

Improperly deferring vaccination (i.e., not based on valid contraindications) Increasingly complex vaccination schedule Lack of reminder-recall system Improper storage and handling procedures resulting in spoilage of vaccine

to vaccinate (i.e., vaccine-eligible child does not receive needed vaccines) Eliminating MOs could increase immunization coverage by up to 30% or more2, 3

Barriers to Comprehensive Care

 MOs

Reasons for MOs

Deficits in clinician knowledge3,5  Vaccines delayed due to valid contraindication  Incorrect or overcautious interpretation of contraindications5  Failure to review the childs vaccination status6  Incomplete vaccine records7


are frequently associated with3,4 Inappropriate contraindications such as minor febrile illness Not giving vaccine at acute care visits Not giving all the shots needed at a visit

Reasons for MOs

Physician reluctance to give multiple vaccines simultaneously7  Vaccine delays/shortages8  Practice requirement to receive physical examination prior to vaccination


Differences Between Contraindications & Precautions

a recipient which greatly increases the chance of a serious adverse reaction  Precautions: Conditions in a recipient which may increase the chance or severity of an adverse reaction, or may compromise the ability of the vaccine to produce immunity
 Contraindications: Conditions in

11

Valid Contraindications vs Precautions

Condition Allergy to Component Encephalopathy Pregnancy Immunosuppression Severe illness Recent blood product
C=contraindication

Invalid Contraindications to Vaccination (not even precautions!)

Mild illness Antibiotic therapy  Disease exposure or convalescence  Pregnancy in the household  Breastfeeding  Premature birth  Allergies to products not in vaccine  Family history unrelated to immunosuppression  Need for TB skin testing  Need for multiple vaccines
 

Live C --C C P P

Inactivated C C V V P V

P=precaution V=vaccinate if indicated

Source: General Recommendations on Immunization, Epidemiology and Prevention of Vaccine-Preventable Diseases. National Immunization Program, Centers for Disease Control and Prevention. Revised December 2004.

Strategies to Improve Comprehensive Care

 Clinicians do

Strategies to Improve Comprehensive Care

recommended Catch-up Schedule for children who have missed or delayed immunization It makes it easier for staff to figure out who needs what Proven to get children up-to-date faster  Practice staff who administer vaccines and staff who manage or support vaccine administration are knowledgeable and receive on-going education
 Use the

not use false contraindications to prevent immunizations  Practices adopt and implement the Standards for Child and Adolescent Immunization Practices established by the National Vaccine Advisory Committee (NVAC)  Vaccines are administered according to the Recommended Childhood and Adolescent Immunization Schedules; physician stays upto-date about potential new vaccines

Strategies to Improve Comprehensive Care

 Educational resources

Strategies to Improve Comprehensive Care

should follow appropriate procedures for vaccine storage and handling  Staff should reduce vaccine liability and ensure proper coding/reimbursement  Health care professionals follow only medically accepted contraindications
 Staff

about all aspects of immunization are made available  Current Vaccine Information Statements (VISs) are provided and explained to patients/parents prior to vaccination

12

Strategies to Improve Comprehensive Care

 Combination vaccines

References: Comprehensive Care

1.

are utilized when appropriate  Practice staff should regularly conduct assessments to determine immunization coverage rates and incorporate quality improvement measures to raise rates  When possible, participate in a comprehensive state/local immunization registry or CHIS

2.

3.

4.

5.

Santoli JM, Rodewald LE, Maes EF, Battaglia MP, Coronado VG. Vaccines for Children Program, United States, 1997. Pediatrics. 1999;104(2) Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases: 8th Edition; January 2005 Szilagyi PG, Rodewald LE. Missed opportunities for immunizations: a review of the evidence. J Public Health Manage Pract. 1996;2:18-25 Sabnis SS, Pomeranz AJ, Lye PS, Amateau MM. Do missed opportunities stay missed? A 6-month follow-up of missed vaccine opportunities in inner city Milwaukee children. Pediatrics. 1998;101:1-4 Wood D, Halfon N, Pereyra M, et al. Knowledge of the childhood immunization schedule and of contraindications to vaccinate by private and public clinicians in Los Angeles. Pediatr Infect Dis J. 1996;15:140-145

References: Comprehensive Care

6.

Immunization: Family-Centered FamilyFamily-Centered: Care that is based on the understanding that the family is the childs primary source of strength and support and that the child/familys perspectives and information are important in clinical decision making1

7.

8.

9.

Ball TM, Serwint JR. Missed opportunities for vaccination and delivery of preventive care. Arch Pediatr Adolesc Med. 1996;150:858-861 Szilagyi PG, Rodewald LE, Humiston SG, et al. Immunization practices of pediatricians and family physicians in the United States. Pediatrics. 1994;94:517-523 Gindler JS, Cutts FT, Barnett-Antinori ME, et al. Successes and failures in vaccine delivery: evaluation of the immunization delivery system in Puerto Rico. Pediatrics. 1993;91:315-320 Rodewald L. Every medical home needs an immunization recall system. AAP News. February 2001:89

Immunization: Family-Centered FamilyScope of Problem: Family-centered care can improve patient/family outcomes, increase patient/family satisfaction, build on child/family strengths, increase professional satisfaction, decrease health care costs, and lead to more effective use of resources1

Barriers to FamilyFamily-Centered Care

 Parental

concerns about vaccine safety or refusal to vaccinate  Patient and physician have differing beliefs regarding vaccination 25% of parents believe immune systems are weakened by too many vaccines2 19% of parents do not think vaccines were proven safe prior to use in the US2

13

Barriers to FamilyFamily-Centered Care

 Patient

Common Parental Concerns About Vaccines

1. 2. 3. 4.

and physician have access to both accurate and inaccurate immunization resources  Poor communication (i.e., differing education/literacy levels, language barriers)

The use of Thimerosal (an organomercurial) as an additive in vaccines An unsubstantiated link between the MMR vaccine and autism The necessity of vaccinating children against hepatitis B Pneumococcal conjugate (new vaccine to protect against meningitis, blood infections, ear infections)

Common Parental Concerns About Vaccines

5.

The Facts About Thimerosal

a preservative that prevents bacterial and fungal contamination in some vaccines and contains a form of mercury (ethylmercury)  There is no evidence that the trace amounts of Thimerosal in vaccines has caused harm to infants, except for minor side effects like swelling and redness at the injection site
 Thimerosal is

6. 7.

Meningococcal vaccine (new meningococcal conjugate vaccine to protect against meningococcal disease) The relative danger of influenza and the need for a yearly vaccination The relative danger of varicella (chickenpox)

The Facts About Thimerosal



The Facts About MMR

 Autism

In 1999, the Public Health Service and the AAP recommended that Thimerosal be taken out of vaccines as a precautionary measure. By the end of 2001, all routine pediatric vaccines contained no Thimerosal or only trace amounts (some Influenza and Td vaccines)

spectrum disorder is a common developmental disability, affecting 1 in 166 children3  Concerns have been raised about a possible link between the proximity of the MMR vaccination administration and the development of signs of autism

14

The Facts About MMR

 Studies

The Importance of the Hepatitis B Vaccine

 The hepatitis

and independent panels in the US and in Europe, including experts from the Institute of Medicine and the AAP, have found no association between the MMR vaccination and autism

B vaccine is the best protection a child can have against a dangerous disease with lifelong serious health problems  Vaccinating early against hepatitis B assures childrens immunity when they are the most vulnerable to the worst complications of hepatitis B and before they enter the high risk adolescent years

The Importance of the Hepatitis B Vaccine

 Before the

The Importance of the Pneumococcal Conjugate Vaccine

 Pneumococcus bacteria can cause meningitis and other blood infections. Meningitis is an inflammation of the brain and spinal cord, which can lead to brain damage, mental retardation, and even death  Pneumococcal conjugate vaccine provides superior protection against this serious and deadly infection

vaccine was introduced, 20,000 children under age 10 became infected each year

The Importance of the Pneumococcal Conjugate Vaccine

 Meningitis symptoms in children are less obvious than in adults. The disease can go undetected and untreated. Vaccination can protect children from this uncertainty

The Importance of the Meningococcal Vaccine

 Meningococcal disease is caused by bacteria that infect the bloodstream, lining of the brain, and spinal cord, often causing serious illness.  Ten to 14% of people with meningococcal disease die, and 11-19% of survivors have permanent disabilities

15

The Importance of the Meningococcal Vaccine

 In 2005, a new quadrivalent conjugate vaccine (MCV4) was licensed and recommended for children 11-12 and teens entering high school, as well as college freshman living in dormitories  A quadrivalent polysaccharide vaccine is available in the U.S.; however, it is not recommended for routine vaccination use


The Importance of the Influenza Vaccine

In an average year, the flu causes 36,000 deaths and more than 226,000 hospitalizations in the US. An annual flu vaccine is the best way to reduce circulation of the flu

The Importance of the Influenza Vaccine

 

The Importance of the Varicella Vaccine

Many people believe that the chickenpox is a harmless illness In 1999, an average of 1 child a week died in the US from complications of chickenpox These complications include encephalitis, a brain infection; severe staph and strep secondary infections (flesh-eating strep and toxic shock syndrome); hepatitis; and pneumonia

Annual shots are necessary because flu viruses change from year to year. A vaccine made against flu viruses circulating last year may not protect against the newer viruses Immunity to the disease declines over time and may be too low to provide protection after 1 year

Helping Families Locate Reliable Information on the Internet

The Internet can be a confusing place to navigate! To help parents locate factual vaccine information on the Web, practice staff should provide information and resources about how to locate and evaluate Web sites Additional Reading: Content and Design Attributes of Antivaccination Web Sites.
 As

State Exemptions: Information and Definitions

of 2004, all 50 states allow vaccination exemptions for medical reasons, as determined by a physician  48 states (all except Mississippi & West Virginia) allow exemptions for religious reasonsreasons- when immunizations contradict the parents sincere religious beliefs

Wolfe RM, Sharp LK, Lipsky MS. JAMA 2002;287:3245-3248 2002;287:3245-

16

State Exemptions: Information and Definitions

 20

Strategies to Provide FamilyFamily-Centered Care

 Treat the

states (AZ, AR, ID, LA, ME, MI, MN, MO, NE, NM, ND, CA, CO, OH, OK, TX, UT, VT, WA, and WI) allow exemptions for philosophical reasons- other non-religious reasonsnonbeliefs held by the parents who do not believe their child should be immunized  Additional information on state exemptions is available at: http://www.cispimmunize.org/pro/StateRequ irements.html

family as a partner in their childs care and promote shared decisiondecisionmaking  Provide the parent with an immunization record book to track their childs vaccination history and gain better understanding of which vaccines are needed and when

Strategies to Provide FamilyFamily-Centered Care

 When

Strategies to Provide FamilyFamily-Centered Care



necessary, clinicians should document parents refusal to vaccinate in the patients record. Providers may utilize the AAP Refusal to Vaccinate Form.  Provider should be aware of local school and childcare immunization requirements

Be available to answer questions or concerns Educate parents about risks versus benefits of vaccination Warn them about inaccurate information on the Web

Strategies to Provide FamilyFamily-Centered Care



Use Vaccine Information Statements (available in simple wording, multiple languages) Provide culturally-appropriate educational culturallymaterials at the necessary literacy level
Resource: American Academy of Pediatrics and National Perinatal Association. Transcultural Aspects of Perinatal Health Care: A Resource Guide. Shah MA, ed. National Perinatal Association; 2004

The following case study is designed to assist you to implement the Family-Centered Care component of Familythe medical home concept during immunizationimmunization-related patient encounters. Strategies to address specific issues raised in the scenario are included.

17

Case Study #3: FamilyFamily-Centered Care

 Jane

Smith is a new mom who is bringing her baby girl in for her first visit with the pediatrician. Jane has done some research on the Internet regarding vaccine safety. From this research, Jane has many questions and concerns regarding vaccination, including the risks vs benefits of vaccines and possible side effects of vaccination. She is confused about the complexity of the vaccination schedule and is concerned about the pain her baby might feel when the vaccine is injected.

Case Study #3: FamilyFamily-Centered Care

 Question: How

can Janes pediatrician create a partnership with her and provide familyfamily-centered care?

Case Study #3: FamilyFamily-Centered Care

Janes pediatrician should provide:  An immunization record book so that she can take partnership in her childs care  Educational resources regarding the safety of vaccines (Resource: Compare the Risks).  Additional Resources:
Evaluating

Case Study #3: FamilyFamily-Centered Care

Janes pediatrician should also: Review the Recommended Childhood and Adolescent Immunization Schedules to address confusion Update the patients record and remind Jane which immunizations will be due at the next visit Identify practice staff to serve as an Immunization Champion to be readily available to answer questions after shots are given

Information on the Web fact sheet Be There for Your Child During Shots Shots fact sheet

References: FamilyFamily-Centered Care

1.

Immunization: Compassionate Care

Compassionate: Concern for the well-being of wellthe child and family is expressed and demonstrated in verbal and nonverbal interactions. Efforts are made to understand and empathize with the feelings and perspectives of the family and child

2.

3.

American Academy of Pediatrics, Committee on Hospital Care. Family-centered care and the Familypediatricians role. Pediatrics. 2003;112:691-696 2003;112:691Gellin BG, Maibach EW, Marcuse EK. Do parents understand immunizations? A national telephone survey. Pediatrics. 2000;106:1097-1102 Pediatrics. 2000;106:1097American Academy of Pediatrics, Autism Expert Panel, Committee on Children with Disabilities. Autism A.L.A.R.M. Website: www.medicalhomeinfo.org (Accessed October 11, 2007).

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Immunization: Compassionate Care



Barriers to Compassionate Care

 

A patient that feels understood is more likely to adhere to the physicians recommendations1 Patients tend to judge the quality of treatment on the basis of physicians affective behavior towards them2

Limited time during patient visit Cultural or racial/ethnic differences between patients and physicians Ignoring or misinterpreting parents or patients nonverbal cues Operating from a medical model Us versus them, paternalistic

Strategies to Provide Compassionate Care

 Listen

Strategies to Provide Compassionate Care

 Address specific

unhurriedly to family concerns and respond to them appropriately  Honor or validate family experiences, beliefs, questions and perspectives

concerns directly: Discuss myths or misconceptions openly and dispassionately Offer them the pamphlet Be There for Be Your Child During Shots  Ensure privacy/confidentiality for families

The following case study is designed to assist you to implement the Compassionate Care component of the medical home concept during immunizationimmunization-related patient encounters. Strategies to address specific issues raised in the scenario are included.

Case Study #4: Compassionate Care



As Kristen enters the pediatricians office with her baby girl, the pediatrician, Dr Susan, notices a worried look on Kristens face. Dr Susan asks Kristen if something is bothering her. Kristen explains that she is worried about the number of vaccines her daughter will receive in one visit, specifically the effect on her immune system, as well as about the pain that her daughter may experience.

19

Case Study #4: Compassionate Care

 Dr 

Case Study #4: Compassionate Care

Susan tells Kristen that she understands her concerns. She provides Kristen with verbal and written explanation about babys immune systems capability of handling multiple vaccines. She also leads Kristen toward additional resources.  Dr Susan explains to Kristen the ways to comfort a baby before, during, and after vaccination and provides her with a fact sheet, Be There for Your Child During Be Shots, Shots, which describes methods of comfort.

Question: What should Dr Susan do?

Case Study #4: Compassionate Care

 Dr

References: Compassionate Care

1.

Susan encourages Kristen to ask her about any additional concerns or questions.

2. 3.

4.

Bellett PS, Maloney MJ. The importance of empathy as an interviewing skill in medicine. JAMA. 1991;266:1831-1832 1991;266:1831BenBen-Sira Z. Stress, Disease and Primary Medical Care. Gower, England, 1986 Offit PA, et al. Addressing parents concerns: do multiple vaccines overwhelm or weaken the infants immune system? Pediatrics. 2002;109:124-129. 2002;109:124Available at: http://www.cispimmunize.org/fam/infant.html (Accessed: October 12, 2007) Offit PA, Jew RK. Addressing parents concerns: do vaccines contain harmful preservatives, adjuvants, additives, or residuals? Pediatrics. 2003;112:13942003;112:13941401

Immunization: CulturallyCulturally-Effective
CulturallyCulturally-Effective: The delivery of care within the context of appropriate physician knowledge, understanding, and an appreciation of all cultural distinctions Familys cultural background, including beliefs, rituals, and customs, are recognized, valued, and respected and incorporated into the care plan 3

Immunization: CulturallyCulturally-Effective
Scope of Problem: Immunization coverage rates are lower among children living in poverty1 and among black and Hispanic children2 By 2020, approximately 40% of schoolschool-age children will be of nonnonwhite racial or ethnic backgrounds3

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Important Definitions
Cultural Competence: the awareness of cultural/religious practices, beliefs, and differences, enabling clinicians to adapt health care in accordance with the ethnocultural/religious heritage of the individual, family, and community4 Linguistic Competence: the provision of bilingual staff or interpretation services for all clients without English language proficiency4 Spiritual Competence: the ability to identify and understand one's own values and spiritual beliefs in the context of a pluralistic society, recognizing how interactions with patients and families may be affected by religious differences4

Barriers to CulturallyCulturally-Effective Care

 Differences in

cultural backgrounds including differing perceptions and beliefs  Language and communication barriers  Lack of skilled staff or resources  Lack of appropriate services (i.e., patients that require interpretation vs translation services)

Strategies to Provide CulturallyCulturally-Effective Care

 Immunization clinicians

Strategies to Provide CulturallyCulturally-Effective Care

 Provide safe

should be aware of any differences between their own cultural/religious values and those of the patient/family4  Foster mutual respect and understanding4  Determine the most effective way of adapting professional interpretations and recommendations to the value system of each family4

and realistic choices to patients/families within the least restrictive environment4  Promote equity for all cultural/religious backgrounds4

Strategies to Provide CulturallyCulturally-Effective Care

 Openly

Strategies to Provide CulturallyCulturally-Effective Care

 Listen

address cultural barriers with respect and demonstrate sensitivity to conflicts with child/familys cultural patterns  Recognize, value, respect, and incorporate the child/familys cultural background into care; including beliefs, rituals, and customs

to verbal and nonverbal cues, using translation or interpretation resources if necessary  Ensure the child/family understands the results of the medical encounter  Consider medical, religious, and philosophical exemptions to immunization (understanding state law and requirements) requirements)

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Strategies to Provide CulturallyCulturally-Effective Care

 If

Strategies to Provide CulturallyCulturally-Effective Care

 Provide written materials, including

possible, have bilingual staff/volunteers on hand  Display culturally diverse pictures, posters, magazines, etc  Learn key words/phrases in the patients language

VISs, in the familys primary language and at the appropriate literacy level; supplement with additional resources (i.e., visual aids, videos) if necessary  Educate and train immunization clinicians at all levels (medical school, residency programs, and continuing medical education)

The following case study is designed to assist you to implement the CulturallyCulturallyEffective Care component of the medical home concept during immunization-related immunizationpatient encounters. Strategies to address specific issues raised in the scenario are included.

Case Study #5: Culturally-Effective Culturally Derek,

a practicing Catholic, has a 5 year old son, Jack, who will be attending kindergarten in 3 months. Derek and his son recently relocated from Texas to Illinois. Derek takes his son to their new pediatrician, Dr Bob.  Dr Bob reviews Jacks immunization history and notices that Jack has not received a varicella vaccine, which is required by law before school entry.

Case Study #5: CulturallyCulturally-Effective

 Dr

Case Study #5: CulturallyCulturally-Effective

 Dr.

Bob asks Derek the reason for this and Derek explains that in Texas, he received a philosophical exemption for varicella vaccine because the vaccination was developed using aborted fetuses. Dereks religious beliefs do not permit abortion of any kind.  Dr Bob tries to address Dereks concern by explaining what the vaccine is and does and that its production does not involve aborted fetuses.

Bob also explains that Illinois law only allows religious exemptions. Therefore, unless he has a religious objection, Jack will need to be vaccinated with varicella vaccine prior to entering kindergarten.  Derek is unhappy with this option and refuses to vaccinate Jack.

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Case Study #5: CulturallyCulturally-Effective

 Question: What

Case Study #5: CulturallyCulturally-Effective

Dr Bob should:  Explain to Derek that there is a religious exemption in Illinois, and given that he is Catholic, perhaps he could talk to his priest about it.  Listen to and respect Dereks concerns; let Derek know that he is respected and his beliefs are understood.

should Dr Bob do to address this cultural difference?

Case Study #5: CulturallyCulturally-Effective

 Explain the

Case Study #5: CulturallyCulturallyEffective

Dr Bob should:  If, after discussion about the importance of vaccination and the risks of not vaccinating, Derek still refuses, Dr Bob should document the discussion and consider having Derek sign a statement affirming his decision not to vaccinate (i.e., AAP Refusal to Vaccinate Form).  Continue to make himself available to answer additional questions from Derek as he gains new information.

state immunization laws to Derek; if Jack is not vaccinated, he cannot attend school.  Explain to Derek the importance of vaccination, including the benefits and risks of varicella vaccine.

Case Study #5: CulturallyCulturallyEffective

 Provide educational materials

References: CulturallyCulturally-Effective
1. 2.

regarding the varicella vaccine for Derek to review at home.  Provide parent-focused fact sheets and Web-based resources that explain the importance of vaccines and provide detailed answers to common vaccine concerns.

3.

4.

Klevens RM, Luman ET. US children living in and near poverty. Risk of vaccine-preventable diseases. Am J Prev vaccineMed. 2001;20:41-46 2001;20:41Wood D, Donald-Sherbourne C, Halfon N, et al. Factors Donaldrelated to immunization status among inner-city Latino innerand African American preschoolers. Pediatrics. 1995;96:295-301 1995;96:295American Academy of Pediatrics, Committee on Pediatric Workforce. Culturally effective pediatric care: education and training issues. Pediatrics. 1999;103:1671999;103:167170 American Academy of Pediatrics. Preface. In: Shah MA, ed. Transcultural Aspects of Perinatal Health Care: A Resource Guide. Elk Grove Village, IL: American Academy of Pediatrics; 2004, xv-xxix xv-

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Implementing Immunization in a Medical Home Concepts at the Practice-Level Practice Pediatricians and

Implementing Immunization in a Medical Home Concepts at the Practice-Level Practice Choices among

practice staff should work together to remove perceived vaccination barriers of parents  Pediatricians and practice staff should use multiple strategies to improve delivery of vaccines

strategies should be tailored to the individual child/family  Practice staff, should regularly review office protocols and procedures to ensure efficiency & accuracy

Acronyms
AAP AFIX CASA CDC CHIS CSHCN EMR MO NVAC SCHIP VFC VAERS VICP VIS American Academy of Pediatrics Assessment, Feedback, Incentives, eXchange Clinical Assessment Software Application Centers for Disease Control and Prevention Child Health Information System Children with Special Health Care Needs Electronic Medical Record Missed Opportunity National Vaccine Advisory Committee State Child Health Insurance Program Vaccines for Children program Vaccine Adverse Event Reporting System Vaccine Injury Compensation Program Vaccine Information Statement

VaccineVaccine-Preventable Diseases
Diphtheria, Tetanus toxoids, acellular Pertussis (DTaP/Tdap) Haemophilus Influenzae type b (Hib) Inactivated Poliovirus Vaccine (IPV) Measles, Mumps, Rubella (MMR) Meningococcal (Menactra/MCV4) Influenza (LAIV, FluMist) Varicella (chicken pox) Hepatitis B Pneumococcal Disease (PCV7/Prevnar) Hepatitis A (given in selected areas of the US)

Additional Web-based Resources Web

Additional Web-based Resources Web

Childhood Immunization Support Program (CISP) is a joint program of the AAP and CDC. The CISP provides extensive information on immunizations for health care professionals and families. Web site: www.cispimmunize.org (Accessed: August 6, 2008) Teaching Immunization Delivery and Evaluation (TIDE) is an internet-based continuing education program in internetchildhood immunizations. Web site: www.musc.edu/tide (Accessed: August 6, 2008) Centers for Disease Control and Prevention National Center for Immunization and Respiratory Diseases (NCIRD) provides leadership for the planning, coordination, and conduct of immunization activities nationwide. Web site: www.cdc.gov/vaccines (Accessed: August 6, 2008)

Immunization Action Coalition (IAC) creates and distributes educational materials for health professionals and the public that enhance the delivery of safe and effective immunization services. Web site: www.immunize.org (Accessed: August 6, 2008) National Network for Immunization Information (NNII) provides the public, health professionals, policy makers, and the media with up-to-date, scientifically valid up-toinformation related to immunization. Web site: www.immunizationinfo.org (Accessed: August 6, 2008)

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Other Resources
 Recommended

Other Resources
 

Childhood, Adolescent Childhood, Immunization Schedule & Catch-up Schedule Catch Guide to Contraindications  Summary of Rules for Childhood and Adolescent Immunization  VISs in over 30 languages  AAP Refusal to Vaccinate Form  Vaccine Management: Recommendations for Handling and Storage of Selected Biologicals  Vaccines for Children Program

Immunization Registry Clearinghouse Vaccine-Preventable Diseases: Improving Vaccination Coverage in Children, Adolescents, and Adults Report on Recommendations from the Task Force on Community Prevention Services National Childhood Vaccine Injury Act Vaccine Injury Table Immunization Coverage in the US, National Immunization Survey Data

About the Training Tool

Lead Author: David Wood, MD, MPH, FAAP, Council on Community Pediatrics (COCP) and Childhood Immunization Support Program (CISP) Project Advisory Committee AAP Reviewers: Charles Onufer, MD, FAAP, Medical Home Project Advisory Committee Gilbert Handal, MD, FAAP, COCP and CISP Project Advisory Committee Edgar Marcuse, MD, MPH, FAAP, AAP Immunization Advisory Team AAP Board of Directors Reviewer: Alan Kohrt, MD, FAAP

Acknowledgments
Jill Ackermann, Manager, Medical Home Surveillance and Screening, Department of Community and Specialty Pediatrics Carmen Mejia, Manager, Immunization Initiatives, Department of Practice Elizabeth Sobczyk, Program Coordinator, Immunization Initiatives, Department of Practice *The development of this training tool was supported by a grant from the CDC (Childhood Immunization Support Program, Cooperative Agreement No. U66/CCU524285)

About AAP Immunization Initiatives

In an effort to help pediatricians address the barriers to increasing and maintaining national immunization coverage levels, the AAP, in collaboration with the CDC, established the Childhood Immunization Support Program (CISP). Since 1999, the Academys CISP grant has been working to improve the immunization delivery system for children across the nation.

CISP Goals
Goal 1: Promote quality improvement and best immunization practices in community- and office-based primary care settings and other identified medical homes. Goal 2: Enable pediatricians and pediatric health care professionals to communicate effectively with parents about vaccine benefits. Goal 3: Promote system-wide improvements in the national immunization delivery system.

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CISP Resources
Key Contact Network: A key contact network of immunization clinicians who are instrumental in promoting immunization delivery has been developed. The AAP Immunization Initiatives Newsletter is disseminated electronically to members of the network. To receive a copy of this monthly publication, e-mail cispimmunize@aap.org

CISP Resources
Vaccine Safety Reports: The Measles Mumps-Rubella Vaccine and Autistic Spectrum Disorder: Report From the New Challenges in Childhood Immunizations Conference, based on the conference convened in June 2000 was published in the May 2001 issue of Pediatrics. *A variety of AAP Policy Statements, Clinical Practice Guidelines, and Technical Reports on immunizations and related topics are also available.

CISP Resources
Technical Assistance: Technical assistance on immunization issues is provided to pediatricians, other health care professionals, and others in an effort to support their efforts to communicate with parents around vaccine safety issues and immunize children within a medical home.

CISP Resources
Resource Publications: Fact sheets, brochures, educational posters, AAP policy statements and technical reports, and strategies on a variety of immunization related topics are provided for pediatric office practices.

CISP Resources
CISP Web site: For fast, helpful and site: accurate information on immunizations for parents, the public, and all health care professionals visit: www.cispimmunize.org or www.aap.org and click the Immunization Information button on the homepage.

CISP Resources
The AAP Compendium of Immunization Resources and Organizations is an organized listing of national and state-based organizations and initiatives, including AAP chapter immunization activities. In addition, the resource provides a compilation of immunization educational resources for parents and pediatricians. An on-line version of the Compendium is available on the CISP Web site.

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Contact Us
For more information about the CISP, to receive copies of our materials, or to be added to the CISP key contact network, please contact:

American Academy of Pediatrics Department of Practice 141 Northwest Point Blvd. Elk Grove Village, IL 60007 Tel: 800/433-9016 ext 4271 Fax: 847/228-9651 E-mail: cispimmunize@aap.org

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