Sustaining Community Based Immunization Actions (SIA)

State: MI Type: Model Practice Year: 2019

OVERVIEW Description: The Michigan Association for Local Public Health (MALPH) was founded in 1985 as a private, non-profit, 501c (3) state association based in Lansing, Michigan. MALPH is organized to represent Michigan's 45 city, county, and district health departments (LHDs) before the state and federal legislative and executive branches of government. The 44-member Board of Directors, comprised of one representative from each local public health jurisdiction across the state, governs the association. Demographics: Michigan's population as of 2015 is estimated to be 9,922,576 ( with the majority of the population residing in southeast Michigan. Public Health Issue: The issue MALPH focused on is the episodic and fragmented nature of many community-based immunization efforts in recent years. Because of financial challenges, support for immunization campaigns has been reduced over time. MALPH, with funding provided by the Michigan Health Endowment Fund, implemented the Sustaining Community-Based Immunization Actions (SIA) and provided two Michigan Care Improvement Registry (MCIR) regions within the state (one urban; one rural) opportunities to develop new ways of sustaining high immunization rates and to disseminate the lessons learned. Goals and Objectives: The overarching goal of SIA was to improve the population health of Michigan's children (ages 0-18) and seniors (ages 65 and older) by developing and implementing both innovative and evidence-based strategies to achieve and sustain high levels of recommended vaccinations in the two populations of focus. In order to achieve the overall goal, the project objectives included: Increase the percentage of children aged 19 to 35 months who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, pneumococcal conjugate vaccine (PCV) and Hep A. (43133142) Increase the percentage of adolescents aged 13 through 17 years who receive the recommended doses of Tdap, Polio, MMR, Hep B, Varicella, MCV, and HPV. (1323213) Achieve and maintain an effective coverage level of a birth dose of hepatitis B vaccine. Increase the percentage of seniors receiving influenza, pneumococcal polysaccharide vaccine (PPSV23), and pneumococcal conjugate vaccine (PCV13). Creation of a reference model to specifically support the replication of successful activities completed within the project. Implementation Plan: The practice began in 2015 with the contracting of a senior project manager and external evaluation firm. A Request for Proposal process was developed and two MCIR regions were selected to serve as the project's pilot sites. MCIR Region 1 consists of eight local health departments representing seven counties and the City of Detroit. Within the project period, MCIR Region 1 adapted NACCHO's Mobilizing Action through Planning and Partnerships (MAPP Model) to conduct a regional community needs assessment focused on immunizations, recruited private pediatric practices and conducted immunization quality improvement projects, delivered provider trainings, and tested integrated WIC/Immunization clinics. MCIR Region 5 also consists of seven local health departments and represents 31 rural counties. The project was coordinated through District Health Department #10. Within the project period, MCIR Region 5 tested numerous evidence-based practices that included physician education, school-based clinics, centralized reminder recall systems, incentive-based and media campaigns. Both regions were fortunate to have consistent coordination and leadership throughout the project period which contributed greatly to the success of the project goal and objectives. Results and Outcomes: The process milestones and status: 1. Hire Senior Project Manager: February 2015 2. Appoint and assemble advisory committee members: Assembled August 2015; met quarterly through November 2018 3. Engagement with MDHHS leadership: Leadership on advisory committee 4. Recruit and select evaluator and consultant(s): Evaluator: March 2015; consultants contracted as applicable 5. Develop project work plan including outreach plan to providers: Developed within the two pilot regions March 2016 6. Select Urban and Rural MCIR Regions through RFP process: June 2015 7. Recruitment of new providers: September 2015- September 2018 8. Initiate evaluation process and data collection protocols; conduct interviews and field surveys: External evaluations conducted in 2016, 2017 and 2018 9. Identify evidence-based practices to be implemented: January -July 2016 10. Development of a Statewide Reference Model: October 2018 Although specific numerical goals were not originally defined or requested by the funder of the grant, both regions indicated in their proposals goals of improving immunization rates from 2- 25% depending on the antigens for the various vaccine series. The results and public health impact of their efforts exceeded our expectations: 5.6% increase in the 43133142-vaccination series in children 19-35 months 15.3% increase in the 1323213-vaccination series in adolescents 13-17 years old 11.1% increase in influenza rates 26.3% increase in PCV13 14.9% increase in PPSV23 MALPH Website:
RESPONSIVENESS AND INNOVATION Creative Use of Existing Tools and Practices and Evidence-Based Practices: The nature of the practice was to implement, in the two pilot regions, a combination of evidence-based practices, innovative process, and creatively use existing tools to improve immunization rates. Public Health Issue: According to the National Immunization Survey, when the practice began, Michigan had the 39th worst childhood immunization rate out of 54 states and territories. Only 49 percent of Michigan children, ages 19 to 35 months, have up-to-date immunizations (including Hepatitis A) and only 26 percent of girls, ages 13-17 years, have complete coverage for Human Papillomavirus (HPV). In Michigan, all children must be fully immunized to attend kindergarten unless parents sign a waiver. Concern on the part of the general public that vaccines could be harmful tends to be concentrated in specific communities which become vulnerable to outbreaks. Influenza and pneumonia are the ninth most common cause of death. Yet, most years nearly 40 percent of seniors over age 65 do not get a flu shot. Half do not get a pneumococcal polysaccharide (PPSV23) vaccination to prevent pneumonia. The Advisory Committee on Immunization Practices (ACIP) recently recommended routine use of pneumococcal conjugate vaccine (PCV13) together with the PPS23. Target population: Overall Population: Region 1: 4.7 million Region 5: 833,226 Children 19-35 months Region 1 population 80580 Region 5 population 11596 Adolescents 13-17 years Region 1 population 354319 Region 5 population 53371 Seniors 65 and older Region 1 - 723,520 Region 5 - 185,051 Population Percentage Reached: Due to the nature of the practice and the multiple interventions implemented, it is difficult, if not impossible to predict the percentage of the population reached, but we do know a significant percentage of the target populations are now immunized and protecting not only themselves, but also their families and the general public from vaccine preventable diseases than prior to the interventions identified in the practice. Past Efforts: Past efforts to improve immunization rates have included statewide vaccination campaigns, LHD jurisdiction specific reminder recalls to the 19-35-month-olds and recently to the 13-17-year-old age groups. The interventions were delivered by each local health department with little, to no collaboration across jurisdictional lines. Because of financial challenges at the local level, support for immunization campaigns was virtually non-existent and many local health departments have limited staff with no capacity to try evidence-based or innovative interventions. TOOLS AND PRACTICES Creative Use of Existing Tools MAPP: Region 1 utilized NACCHO's MAPP process to assess the local health departments' capacity to provide essential public health services as they relate to immunization administration, education, and enforcement. Both Oakland County Health Division and the Livingston County Health Department provided their existing tools and a model of how MAPP was developed for county-wide regional health assessments as part of the accreditation process. Staff from both departments provided technical assistance throughout the needs assessment process. The steering committee completed the four MAPP assessments over a series of six months and identified and refined their top strategic issues. They used the CDC's evidence-based practices from the Community Guide to Preventative Services (Community Guide) to identify strategies. At the conclusion of the MAPP process, the steering committee continued to meet bi-monthly and three workgroups were formed to provide detailed efforts around key activities such as health system engagement, media, and local health department clinical transformation. Integrated WIC and Immunization Appointments: Within Region 1, the Oakland County Health Division piloted and implemented a policy to ensure that WIC appointments were scheduled on, or after the child's first birthday to ensure the child(ren) would be eligible to receive all of their one-year shots. Prior to the intervention, an estimated 40% of children were scheduled for WIC appointments at least one or more days before their first birthday and the immunization could not be given. Providing immunizations in WIC settings is an evidence-based strategy endorsed by CDC's Community Guide to increasing timely vaccinations. Patient Incentives: Five of the local health departments in Region 1 implemented the integrated WIC and Immunization appointments, and included a Diapers 4 DTaP” incentive program to provide diaper packs to families who opted to vaccinate their children at the WIC appointment. Despite the name, the program's intent is to increase timely vaccination of ALL routinely recommended vaccines. Providing patient incentives to increase immunization rates is also an evidence-based strategy supported by the CDC's Community Guide to increasing vaccination. Evidence-Based Practices: The implementation of evidence-based practices was guided by an analysis of the populations with lagging immunization rates. MCIR is a rich source of such data. The Michigan Department of Health and Human Services' (MDHHS) Immunization Program publishes detailed, monthly immunization report cards” that provide information on the vaccination rates of various populations, including children and youth, across the entire range of possible immunizations. Local health departments have access to raw data in MCIR to study immunizations in detail. The Community Guide calls out six evidence-based practices which it highly recommends: Client Reminder and Recall Systems Vaccination Programs in Schools and Organized Child Care Centers Provider Reminder Systems Providers Having Standing Orders for Vaccination Health Care System-Based Interventions Implemented in Combination (e.g. provider reminders, standing orders, provider feedback, and increased provider participation) Community-Based Interventions Implemented in Combination (e.g. Reminder and recall systems, client education, media campaigns, and increased access to vaccines) Source: The SIA project regions implemented adaptations of the client reminder/ recall systems, vaccination programs in schools, health care system-based and community-based interventions. (1,2,5, and 6) Client Reminder and Recall Systems: Region 5 developed a Centralized Recall system to decrease costs while simultaneously increasing response rates using alternative messaging. The intervention was based on research and discussion with Dr. Allison Kempe of Children's Hospital Colorado and her team. The research showed that centralized recall efforts were more impactful and recalls endorsed by provider offices carried more weight with patients. All seven local health departments in the region participated in the intervention and a postcard was developed and shared with a focus group of parents. For the participating private providers, the local health department identified the patients who were behind in their immunizations and the physicians provided customized letterhead and envelopes. A total of four (4) cycles were implemented. The first, third, and fourth cycles were Teleminder calls with postcards for those who did not have phone numbers listed in MCIR. The second cycle sent out postcards with magnets; a suggestion from the parent focus group. All four planned recall cycles were completed and over 18,500 recalls via phone and postcards were sent. 835 recalls were sent with local private provider information. Recall response rates increased for telephone recalls by an average of 57%. Consistent positive feedback was received by the private provider offices who participated in the recall intervention. School-Based Clinics: This intervention utilized school-based clinics in Region 5 in combination with a region-wide back to school media campaign that increased awareness of the need for immunizations in children and teens. The clinics were provided in 2016 (the first year of the project). In 2017, the team of immunization coordinators met to discuss lessons learned from the 2016 clinics, one of which was the need to create work plans and timelines. These were submitted to the project coordinator who monitored them and received reports on progress made. A key step was in making contact with the school staff to schedule the clinics, and staff in different counties worked together to establish the timing and number of clinics within each school. In addition to the students, many parents, teachers, and staff were also vaccinated. One local health department's success is the Central Michigan District Health Department. They provided 39 clinics and were able to increase the number of adolescent immunization rate above 35%. The most successful clinics were held in August when students were returning to school for orientation. Building new partnerships with schools and strengthening existing relationship was a major strength of this intervention. The media campaign portion of the intervention included a regional television ad promoting back to school immunization messaging and aired one month before the start of the school year. Healthcare System-Based Interventions Implemented in Combination: Both Regions implemented interventions with private providers for the purpose of increasing participation and improving immunization rates within their practices. Region 1 provided technical assistance and incentives to pediatric providers utilizing evidence-based practices and emerging models to develop long-term policies and procedures at the individual practice-level. The unique intervention developed used the Plan-Do-Study-Act (PDSA) model for healthcare quality improvement. As an incentive to participate, providers were given the opportunity to receive 25 Part IV Quality Improvement Maintenance of Certification (MOC) credits from the American Board of Pediatrics. Practices were informed of ways the PDSA project could improve their Health Effectiveness Data and Information Set (HEDIS) scores and potential bonuses from health plans, health systems, or physician organizations. Each practice established baseline data check followed by two data checks at the three- and six- month marks of the project. Each practice's PDSA project was tailored to the individual practice needs and where they wanted to improve their patients' immunization rates. The average time to complete the PDSA cycle was five to seven months depending on the complexity of the intervention. A total of 16 private practices have completed the intervention and 39 physicians have obtained MOC credits. A total of 15 out of 16 practices increased their hepatitis A completion rates; 6 of 16 had double-digit increases. A total of 14 of the 16 practices increased their HPV completion rates; 9 of the 16 by at least 7%. Region 1 also hosted a series of Immunization Provider Education trainings. While many immunization providers are aware of the ACIP-recommended schedule for children, they may be lacking awareness for the adult schedule. In addition, these providers understood what shots needed to be administered, but because of the success of vaccination in reducing or eradicating many serious illnesses in the U.S., providers may have a diminished understanding of the reason why vaccines are so crucial. Utilizing an innovative training program model developed by Kalamazoo County Health Department, the program coordinator adapted the materials for Region 1 and created a new module about vaccine communication. Twenty-eight LHD and MDHHS staff were provided a train-the-trainer opportunity and, in turn, provided the training modules to private providers. During the project period, four of the seven local health departments hosted a full-day training and three hosted a partial-day training in conjunction with their bi-annual Vaccine For Children (VFC) provider meetings. Training module topics include Vaccine Communication, Vaccine Preventable Diseases, and Breaking the Chain of Disease Transmission. The three modules presented will be made available by MALPH and the Southeast Michigan Health Alliance (SEMHA). Over 93 people were trained at the full-day trainings, including 76 immunization providers and 4 quality improvement specialists. Over 90% of attendees reported they will use the lessons learned in the training in their daily practice and they are more confident making a vaccine recommendation. Community-Based Interventions Implemented in Combination: Region 5 created the HPV Sweeps and Awareness Campaign” to increase adolescent immunization rates and to incentivize clients to become up-to-date on the HPV vaccination or to start the series. The intervention used was based on the successful Immunize Nevada campaign, and four of the seven local health departments, as well as 28 private provider offices, participated. The campaign included print materials, billboards, and radio ads. A total of 116 entries were received during the 10-month campaign. Region 1 also used the Nevada HPV campaign's videos on the seven local health departments' Facebook pages reaching over 65,000 people targeted to be likely parents/caregivers of preteens. They also produced seven radio ads that were aired across 29 metro Detroit stations reaching an estimated 2.1 million people.
Enter the LHD and Community Collaboration related to your practice LHD AND COMMUNITY COLLABORATION Goals and Objectives: The overarching goal of SIA was to improve the population health of Michigan's children (ages 0-18) and seniors (ages 65 and older) by developing and implementing both innovative and evidence-based strategies to achieve and sustain high levels of recommended vaccinations in the two populations of focus. In order to achieve the overall goal, the project objectives included: Increase the percentage of children ages 19 to 35 months who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, pneumococcal conjugate vaccine (PCV) and Hep A. (43133142) Increase the percentage of adolescents aged 13 through 17 years who receive the recommended doses of Tdap, Polio, MMR, Hep B, Varicella, MCV, and HPV. (1323213) Achieve and maintain an effective coverage level of a birth dose of hepatitis B vaccine. Increase the percentage of seniors receiving influenza, pneumococcal polysaccharide vaccine (PPSV23), and pneumococcal conjugate vaccine (PCV13). Creation of a reference model to specifically support the replication of successful activities completed within the project. Steps Taken to Achieve Goal and Objectives: The first step taken after the contract with the Michigan Health Endowment Fund was signed, was to hire Mary Kushion as the Senior Project Manager for the project. Ms. Kushion has 30 years of governmental public health experience in Michigan, is respected within the public health community, and possessed the necessary skills and experience as an implementation strategist to launch and oversee the project. Simultaneously, a contract for the external evaluation was established with Public Sector Consultants (PSC), a well-established and credible firm both in-state and nationally. A Request for Proposal was developed and disseminated to Michigan's 45 local health departments. A review team comprised of MDHHS' Immunization staff and the senior project manager reviewed the applications and came to consensus as to which MCIR Regions were most qualified to carry out the functions outlined for the project. Katie VanDorn of PSC consulted with MDHHS staff to gather baseline data for the populations of focus in the two regions. Additional details regarding the evaluation process are included in the Evaluation Section of the application. The contracts for the two regions were executed and each region successfully recruited a project coordinator. REGION 1 The actionable items for Region 1 include: Completion of a Mobilizing for Action through Planning and Partnerships (MAPP) assessment process on or before March 2016 Recruitment of immunization providers to reduce the percentage of non-VFC providers within the region by at least 2% Increase the percentage of children ages 19 to 35 months in the region who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, pneumococcal conjugate vaccine (PCV) and Hep A by at least 2% Increase the percentage of adolescents ages 13 through 17 years who received the recommended doses of Tdap, Polio, MMR, Hep B, Varicella, MCV, and HPV by at least 2% Achieve and maintain an effective coverage level of a birth dose of hepatitis B vaccine Increase the percentage of seniors (65+) receiving influenza, pneumococcal polysaccharide vaccine (PPSV23), and pneumococcal conjugate vaccine (PCV13) by at least 2% Demonstrate development and implementation of enhanced billing strategies by assuring all health departments in the region are billing private insurance for immunizations Share insights and progress with the local health departments in Michigan through the provision of written materials and presentations Demonstrate implementation of evidence-based strategies Demonstrate development and implementation of enhanced billing strategies Participation in the SIA Advisory Board meetings Completion of quarterly performance reports Completion of a final project report In Region 1, they elected to begin their project with an innovative adaptation of the NACCHO MAPP process. The MAPP process allowed a diverse mix of public and private stakeholders to evaluate the assets and challenges that exist around immunizations, as well as the opportunities to intervene on key issues. Those key issues were addressed through the steering committee and three workgroups: Health Systems Engagement Workgroup Media/Communications Workgroup Local Health Department Clinical Transformation Workgroup While the final results are still pending (final data-pull from MDHHS is occurring in December 2018), at the time of this application, Region 1 had more than surpassed the 2% goal for the childhood and adolescent series as well as the four adult antigens of focus. The specific steps Region 1 took to achieve these results are: Improve rates of newborn (Hep B) and children 19-36 months for 43133142 series: The region distributed educational materials to preschools, daycares, and health fairs. They engaged with birthing hospitals to improved the birth dose coverage by promoting standing orders and developing patient education materials for new parents. They developed materials for OB-GYN providers on childhood/adolescent vaccination promotion and adult vaccination during/after pregnancy. The region's local health departments engaged pediatric and family practice providers by creating jurisdiction-specific report cards with provider rank highlighting local health department resources and quick-win opportunities. They created a social media campaign for parents Complete Vaccination Just 1 Hep A Dose Away”. Increase timely vaccination of adolescents 13-17 years for 1322313 series: The region is working to provide adolescent vaccines in the local health departments as well as in non-traditional settings such as schools and health fairs in high-impact zip codes. They also developed a media campaign titled Complete Vaccination Just 1...2... HPV Dose Away” as well as co-branded with the American Cancer Society to develop a media campaign highlighting HPV as cancer prevention. Increase timely vaccination of adults 65 and older for flu, pneumonia and shingles (60+): The region developed proposed vaccination policies for patients and staff in long-term care facilities and they trained the staff on MCIR use and its benefits. They also engaged workforce and retiree groups to encourage them to publicize adult vaccine recommendations and resources in retiree bulletins, newsletters, etc. The region distributed adult vaccine information through the Meals on Wheels program and developed a media campaign promoting vaccinations for self and grandchildren. REGION 5 The actionable items for Region 5 include: Increase the percentage of children ages 19 to 35 months who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, pneumococcal conjugate vaccine (PCV) and Hep A from baseline of 49% for the Region 5 MCIR service area to 75% Increase the percentage of adolescents ages 13 through 17 years who receive the recommended doses of Tdap, Polio, MMR, Hep B, Varicella, MCV, and HPV from baseline of 26% for the Region 5 MCIR service area to 50% Achieve and maintain an effective coverage level of a birth dose of hepatitis B vaccine from baseline of 82% in 2014 for the Region 5 MCIR service area to the Healthy People 2020 goal of 85% Increase the percentage of seniors (65+) receiving influenza vaccine from baseline of 52.2% for the Region 5 MCIR service area to 80% Increase the percentage of seniors (65+) receiving pneumococcal polysaccharide vaccine (PPSV23), and pneumococcal conjugate vaccine (PCV130) from baseline of 8.4% for the Region 5 MCIR service area to 45% Recruitment of immunization providers to increase the number of VFC providers within the region by at least 2% Share insights and progress with the local health departments in Michigan through the provision of written materials and presentations Demonstrate implementation of evidence-based strategies Demonstrate development and implementation of enhanced billing strategies by assuring all health departments in the region are billing private insurance for immunizations. Participation in the SIA Advisory Board meetings Completion of quarterly performance reports Completion of a final project report In Region 5, in the first full year of the grant, they conducted a series of region-wide efforts that included enhancing reminder and recall efforts across the region, implementing school-based clinics, targeting non-compliant families, and strengthening provider engagement. In subsequent years of the project, the strategies were split between regional and local efforts. A portion of the funding went directly to partner local health departments to perform tailored pilot projects for their jurisdictions. Regional funding went to the areas of need and evidence-based strategies that all local health department partners identified as needs. While the final results are still pending, the last data collection point indicates that the Region 5 goals, while lofty, were within a few percentage points of meeting the goals set. As of June 2018, they had increased the 19-35-month old's compliance rate from 49% to 60%, the teen (13-17) series rates from 26% to 43%, and the pneumococcal vaccine rates for person 65 and older from 8.4% to 34%. The specific steps Region 5 took to achieve these results were: Provider Outreach and Education: The region conducted an assessment of provider practices for all age groups. Responses indicated that many providers were not practicing immunization best practices; free educational webinars were promoted to increase education on immunization strategies. Hospital OB staff were educated on the importance of the birth dose of Hepatitis B. The Assessment Feedback Incentives ExChange (AFIX) Provider Incentive Program was an effort to improve provider training and had success in reaching more providers than in previous visits. School-Based Clinics: Local health departments weighed a variety of factors against highest need in selecting their schools including: past success with partnerships, experience with school staff, and a background in performing school-based clinics. A list of best practice recommendations for school-based clinics was created and disseminated. Reminder Recall: A new centralized recall process was successfully developed and piloted. The centralized recall process showed positive impacts. Technology was integrated including use of Televox for automated phone recalls. Third-Party Billing: Assessment was conducted both locally and throughout the grant process. Results identified that the fee for the administration of vaccines is paid at a different rate, depending on the health plan. Medicaid and Medicaid Managed Care Plan pay $7.00, while all other commercial plans pay between $10.00-$30.00. Other commercial health plans pay the full amount for the first vaccine, but only reimburse at 50% for any additional vaccines. Another issue identified with a few of the smaller health plans was the rejection of claims if the patient was enrolled in a patient-center medical home. Practice Selection Criteria: The Michigan Health Endowment Fund grant stipulated that MALPH needed to provided funding to two MCIR regions within the state. A Request for Proposal process was implemented. The proposals received were reviewed and scored as follows: Organization Description (5%) Does the applicant state its agency's mission? Did the applicant provide agency's history and experience relevant to the provisions of proposed service and to the target populations outlined in the RFP? Did the applicant provide evidence of collaboration with other relevant service providers or organizations as it relates to improving immunization rates for the target populations? Data and Demographics (5%) Does the applicant define the geographic service area? Did they indicate the specific geographical service area(s) which will be served, and why was/were the area(s) chosen? Did the applicant list what percent of services will be conducted in each community, city or county if the proposed activities do not encompass the entire region? Objectives and Timeframes (25%) Did the applicant describe how service providers will be recruited? Did they include venue-based or electronic outreach, internal or external referrals or other program promotion strategies? Did they describe the role of community providers and partners that will be instrumental in reaching the target population? Did the applicant provide measurable objectives with targeted timeframes? Did the applicant state measurable process objectives related to providing the proposed services and the operational structure of the project for each of the three years of the project period? Is the budget submitted adequate, realistic and within the budget parameters set in the RFP? Expected Outcomes (25%) Did the applicant provide relevant and realistic outcomes for the project? Did they include short-mid and long-term outcomes? Performance Monitoring (20%) Did the applicant provide a description of how they would monitor and report their performance? Sustainability Plan (10%) Did the applicant describe their post-project sustainability plan? Is it realistic? Replication Plan (10%) Did the applicant provide a description of their plans to replicate the project in other areas of the state and/or MCIR region(s)? Once all of the proposals were independently reviewed by the team of MDHHS staff, a conference call facilitated by the Sr. Project Manager was held and the decision to fund Region 1 and Region 5 was unanimous. Time Frame and Stakeholder Involvement: The time frame for the project was initially designed to begin in mid-2015 and conclude by December of 2017, but due to sound fiscal stewardship of the funds by both pilot regions and the overall project costs, a no-cost extension was requested and accepted by the funder. The grant activities within the regions have concluded, and the final report and project evaluation will be submitted to the funding organization in January 2019. Early in the project, the SIA Advisory Committee was established. Members of the SIA Advisory Committee were comprised of local health department leaders, both from the pilot regions and non-funded agencies, state health department immunization staff, private providers and academia. The regional pilot coordinators and evaluation consultants also were active members on the committee. Stakeholder Roles in Planning and Implementation Process: The primary role of the SIA Advisory Committee is to monitor and review the project status, as well as provide oversight for the initiative's implementation of objectives and strategies. To carry out these functions, the Advisory Committee was tasked with: Monitoring and review of the project at quarterly meetings; Providing assistance to the project when required; Controlling project scope as emerging issues force changes to be considered, ensuring that scope aligns with the agreed to business requirements of project sponsor, regional projects, and MALPH Board of Directors; Resolving project conflicts and disputes, reconciling differences of opinion and approach; Formal review and acceptance of project deliverables most notably the statewide reference model and development of a comprehensive vaccine waiver toolkit. It is intended that the Advisory Committee leverage the experiences, expertise, and insight of key individuals at organizations committed to building professionalism in project management. Advisory Committee members are not directly responsible for managing project activities, but provide support and guidance for those who do. Thus, individually, Advisory Committee members should: Understand the strategic implications and outcomes of initiatives pursued through project outputs Appreciate the significance of the project for some or all major stakeholders and represent their interests Be genuinely interested in the initiative and be an advocate for broad support of the outcomes being pursued in the project Have a broad understanding of project management issues and approach being adopted Consider ideas and issues raised Foster positive communication outside of the team regarding the project's progress and outcomes Report on project progress to those responsible at a high level, such as agency executive management groups, heads of agencies, or the Michigan Health Endowment Fund In addition to the SIA Advisory Board, each region also has advisory committees to guide their work. Region 1 created a MAPP Steering Committee which is comprised of members representing MDHHS, local health departments, health care systems, health plans, physicians, and academia. The seven health officers with jurisdictions in Region 1 make up the MAPP Advisory Committee. Region 1 also has a cadre of contributing advisors, again from MDHHS, local health departments, private providers and health care systems. The Northern Michigan Health Alliance, a non-profit organization whose members are the health officers for MCIR Region 5, served in an advisory capacity for the regional SIA projects. The Region 5 SIA Coordinator also sought out the opinions and feedback from the Northern Michigan Vaccine Preventable Disease Coalition. The Coalition's backbone organization is Munson Healthcare Systems, the major and primary healthcare system in Northern Michigan. Its members include physicians, nurses, and local health department representation. Start-Up, In-Kind and Funding for Practice: MALPH was provided $1.9 million to implement the Sustaining Community-Based Immunization Action for the three-year project and one-year no-cost extension. Of that total, $984,000.00 was provided to the two pilot regions to implement the program and remaining funding was utilized to support the contracts for the senior project manager, the evaluation and project-specific consultants, MALPH staff time dedicated to the project, production and dissemination of the Strategies to Improve and Sustain Immunization Rates in Your Clinic and Community” (reference model) and an educational webinar on its use. MALPH also provided one-year mini-grants to three additional MCIR regions to implement enhanced reminder recalls and media campaigns. In-kind support was provided by the advisory committee members who served without compensation or travel reimbursement.
EVALUATION ??????? Goals and Objectives: The overarching goal of SIA was to improve the population health of Michigan's children (ages 0-18) and seniors (ages 65 and older) by developing and implementing both innovative and evidence-based strategies to achieve and sustain high levels of recommended vaccinations in the two populations of focus. In order to achieve the overall goal, the project objectives included: Increase the percentage of children ages 19 to 35 months who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, pneumococcal conjugate vaccine (PCV) and Hep A. (43133142) Increase the percentage of adolescents ages 13 through 17 years who receive the recommended doses of Tdap, Polio, MMR, Hep B, Varicella, MCV, and HPV. (1323213) Achieve and maintain an effective coverage level of a birth dose of hepatitis B vaccine. Increase the percentage of seniors receiving influenza, pneumococcal polysaccharide vaccine (PPSV23), and pneumococcal conjugate vaccine (PCV13). Creation of a reference model to specifically support the replication of successful activities completed within the project. MALPH is awaiting the final data pull from the MDHHS MCIR staff for the rates of each of the objectives as of September 30, 2018 the official end date of the pilot regions' activities. However, based on the results provided by the external evaluator, PSC in June of 2018, for the grant period of December 2015 through June 2018, there was an overall 5.6% increase for Objective 1 (19-35 months 43133142 series) with Region 1 seeing a 5.5% increase and Region 5 rates increasing by 6.8%. In comparison, the Michigan rate for the same series increased by 5.1% during the same time period. The non-pilot MCIR regions experienced a 4.2% increase; almost 1.5% lower than those of the pilot regions. The pilot regions experienced similar success in increasing the percentage of adolescents, ages 13-17, for the 1323213 series. Overall, the pilot regions experienced a 15.3% increase with Region 1 increasing 15.4% and Region 5 increasing 13.3%. The Michigan and non-pilot regions rates rose as well 14.5% and 14% respectively. Both regions were able to achieve and maintain an effective coverage level for the birth dose of the hepatitis B vaccine and improved the rate by 1% during the project period. Michigan and the non-pilot regions also saw a 1% improvement. Objective #4 Increasing the percentage of seniors receiving influenza, and the pneumococcal vaccines, had the most impressive increases with pilot regions improving by11 % for influenza, 26.3% for PCV13, and 14.9% for PPSV23. Michigan and the non-pilot regions had similar successes and increased the influenza rates by 10.6% and 10.3% respectively. They were also slightly higher than the pilot regions for PCV13, with the non-pilot regions increasing the rates by 30.2% and PPSV23 by 15.5% and the overall Michigan rates increased for PCV13 by 28.3% and PPSV23 by 15.2% which is commendable for the state as a whole. The creation of the reference model Strategies to Improve and Sustain Immunization Rates in Your Clinic and Community” was published and disseminated at the Michigan Premier Public Health Conference in October 2018. It was also shared with the MALPH Nurse Administrator Forum in November 2018 in conjunction with an informational webinar about the process used to develop it and its contents. The publication has three sections (1) Partner Engagement and Coordination, (2) Evidence-Based Practices, and (3) Resources and Materials to Support Evidence-Based Interventions to Increase Vaccinations. Each section provides resources for the reader, but more importantly, it contains case studies of the work conducted as a part of the grant project. For example, it includes a case study on Region 1's experience using the NACCHO MAPP process to assess immunizations as well as Region 5's case study on building hospital partnerships. A total of 11 case studies are provided in the model. It is available in electronic and hard copy form through the MALPH office. External Evaluation of Practice: MALPH engaged the services of PSC to serve as the external project evaluator. During the grant project period, PSC provided annual interim reports of progress made. In order to produce each report, PSC reviewed and analyzed quantitative county-level and regional immunization data, immunization waiver rates, and provider rates drawn from the state's MCIR database. PSC also conducted interviews with key stakeholders about the project's status, successes, challenges and policy recommendations to collect the qualitative data necessary to produce the evaluation findings. PSC interviewed key project staff from MALPH; project coordinators for each pilot site; and select advisory committee members including representatives from the two pilot regions and the MDHHS Division of Immunization. All interviewees were asked a similar set of questions. The purpose of the interviews was to gather qualitative data to be able to understand how the SIA project activities were unfolding in the different MCIR regions and to identify any significant challenges that needed to be addressed. Interviewees were asked about the project status and lessons learned, the accomplishments and challenges of the SIA pilot project to date, and recommendations for state or local policy changes that could support improvements in vaccination rates. As stated previously, MALPH is awaiting the final evaluation report, but the findings of the interim 2017 report include: Recommendations to improve the reference module; inclusion of the case studies Acknowledgement of the exceptional importance of advisory committee members Recommendations based on lessons learned during the pilot regions' implementation of school-based clinics, media campaigns, provider incentives and sustained engagement Acknowledgement of the relationship cultivation and partner engagement as significant accomplishments Identification of challenges such as organizational barriers and in a few cases lack of expertise in creating media campaigns and effective promotion and distribution of materials. Vaccine-resistant residents also proved to be a challenge as they appear to be a well-organized and vocal group throughout the state Recommendations on policies they believe need to be changed to assist with improving immunization rates, specifically a No Wrong Door policy which provides reimbursement by all health plans regardless of their status in a patient-centered medical home and a policy requiring all providers to report adult immunizations in the MCIR. The MALPH Executive Director and Senior Project Manager discussed these findings as well as shared them with the members of the SIA Advisory Committee for their input and recommendations. As a result of the discussion, the recommended improvements were made to the current version of the reference module. The lessons learned in both of the pilot regions were shared among and between the regions during quarterly conference calls with the SIA coordinators and within their regional working groups and committees. MALPH engaged the services of the former MDHHS Immunizations Bureau Chief, Gillian Stoltman, PhD, to produce a 12-part series of informational factsheets to be utilized with policy makers at the local and state level to counteract the opposition to vaccine rules and laws within the state. The MALPH Executive Director will be seeking sponsors for legislation in the 2019/2020 session to support the No Wrong Door Policy as well as to mandate the reporting in MCIR.
SUSTAINABILITY Lessons Learned in Relation to Practice: The Michigan Health Endowment Fund grant was the largest grant received in MALPH's history. Meghan Swain and the MALPH Executive Committee recognized that to receive a grant award of $1.9 million would require the development and implementation of multiple strategies to address and improve child, teen, and adult immunization rates within the state. The lesson learned, based on evaluation feedback received is that the scope of the project, even with the generous funding was a tremendous undertaking for some health departments involved if they did not have the infrastructure and capacity to engage in this work. Internal organizational barriers were a challenge for some of the smaller health departments when they lacked the infrastructure and capacity to take on the large interventions designed at the regional level. Staff did not always have the expertise needed to be successful in increasing vaccinations in general, and this made it difficult for them to create a clear message to the community about why local health departments should be their vaccine provider. Local health departments were further hampered in increasing their own rates due to billing issues and out-of-network challenges. In reflection, it may have been advantageous for MALPH to offer a series of trainings on community engagement and how to develop effective media campaigns in the initial phase of the practice. A second lesson learned is in regards to data collection and analysis. MDHHS has a robust immunization registry (MCIR) and can produce much data for monitoring rates and identifying those who are not up-to-date with their immunizations. However, since it is not a requirement to enter adult immunizations into MCIR, it is difficult to determine exact progress made, but the MDHHS Immunization Bureau and their epidemiologists have confidence in the data provided to PSC for evaluation purposes. The practice taught the regions and MALPH to be flexible. In 2017 in the middle of the project cycle, Michigan experienced, and still is to a lesser extent today, a Hepatitis A outbreak. The outbreak started in southeast Michigan (Region 1) and spread throughout the state. This resulted in many of the staff, who were working on the project, to have to turn their attention to providing Hepatitis A vaccine clinics and delay or cancel other types of immunization clinics. However, the outbreak was used as a teachable moment, and both regions altered some messaging to promote Hep A vaccinations for all ages. The practice experience alerted MALPH to policy needs and clarifications. As previously mentioned, the No Wrong Door billing policy needs legislative support as does the mandating of entering adult immunizations into MCIR. It was learned during the practice experience that schools and local health departments were interpreting and implementing the school exclusion policies in various ways, and guidance on the correct interpretation is needed for both schools and local health departments. Lastly, during the MAPP process in Region 1, it was discovered that the local health departments in the region were paying varying prices for vaccines from the same manufacturer. This discovery led to a heightened sense of awareness when purchasing vaccines amongst the local health departments. Unfortunately, there is a statewide vaccine purchasing contract, but the local health departments indicated it is cumbersome, and in some cases, the prices are higher that what they are currently paying. Although MALPH offered to attempt to broker prices within the region, those who were purchasing the vaccines at lower rates did not want any interventions that might cause the prices they were paying to go up. Lessons Learned in Relation to Partner Collaboration: MALPH found MDHHS to be an engaging and participatory partner in the practice. They provided the data needed to monitor the practice's progress and they also reviewed materials and offered timely recommendations with updated information available through their networks. They were also active participants on the SIA Advisory Council and followed through with all requests and updates as applicable. The lesson learned was to rely on MDHHS for the most up-to-date information when developing materials and accept their offer to review materials prior to production. In terms of sustainability, MALPH is confident MDHHS will continue its I Vaccinate” campaign on a statewide basis now that the project period has closed. During the project period, the state provided minimal media materials as it was aware of the media campaigns being developed in the pilot regions, and in order to measure the effectiveness of the regional campaigns, the state wisely opted to scale back its media markets away from the pilot regions. MDHHS has a clearinghouse with an abundance of educational materials and can be obtained at no cost. In Region 5, the partner collaboration with the K-12 schools will certainly continue after the grant funding cycle is complete. The region's local health departments would like to be able to continue to offer incentives to providers to attend the AFIX visits, but those who were offered the incentive one time may now come back for future AFIX visits, even without the incentive as they now recognize the value and importance of it. They are also now, as a result of the practice, more aware that they can direct their patients to local health departments if they are not carrying certain vaccines. The birthing hospitals in Region 5 will continue to promote the birth dose of Hepatitis B, and efforts to promote immunizations to a variety of sectors will continue through the partnership with the Northern Michigan Vaccine Preventable Disease Coalition. The Region 1 coordinator incorporated into her work the production of best-practice guides, templates, and samples for private provider partners to use, should they wish to embark in quality improvement activities. These materials are available upon request from MALPH for anyone who desires to implement an immunization quality improvement project. Walgreens has been a contributing partner, and work will continue with them after the practice period. The organization worked with the SIA coordinator on everything from sponsoring immunization clinics at voter polling locations to donating thousands of diapers for the Diapers for DTaP program. The Michigan Peer Review Organization (MPRO) is another partner committed to sustaining the work dedicated to adult immunizations. MPRO is a nonprofit organization and national leader in healthcare quality improvement and medical review. MPRO provides medical consulting and review, as well as data analysis to federal agencies, state Medicaid and public health organizations, healthcare facilities, private health plans and other third-party payers. In addition, MPRO represents Michigan in Lake Superior Quality Innovation Network (QIN), which also serves Minnesota and Wisconsin under the Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization (QIO) Program. ( MPRO assisted in securing contracts with five Sav-Mor pharmacies in Southeast Michigan (St. Clair County) that were willing to do an immunization assessment pilot. In exchange for MCIR training, educational resources about vaccine assessments/the ACIP schedule, and a small stipend of $750.00, the pharmacies agreed to stock and administer flu, PPSV23, PCV13, and zoster vaccines. They also agreed to routinely assess all adults ages 60+ coming in to fill or pick up prescriptions for vaccines, based on an assessment guide provided to them. Region 5 coordinator and MPRO connected the pharmacies to vaccine manufacturer resources such as prepaid postage postcards, encouraging vaccination to clients in their databases. As a result, several hundred postcards were sent out. Cost-Benefit Analysis: MALPH did not conduct a cost-benefit analysis as an element of the practice, but it is widely recognized that immunizations do have an enormous return on investment. Applying the Centers for Disease Control and Prevention (CDC) estimates to Michigan, one can calculate that among children and youth born between 1994-2013, vaccination will prevent approximately 10 million illnesses, 650,000 hospitalizations, and 23,000 deaths over the course of their lifetimes, at a net savings of $9 billion in direct costs and $43 billion in total societal costs. Immunization saves $22 for each dollar invested. (The Benefits of Immunization During the Vaccines for Children Program Era. Morbidity and Mortality Weekly Report. CDC. 2014) Stakeholder Commitment to Sustain the Practice: The stakeholder commitment to sustain the practice will undoubtedly vary by region, county, and community. The SIA Coordinator for Region 1 has since left SEMHA and moved to Germany, but the SEMHA board, comprised of the health officers from the region are committed to not having the rates drop simply because the funding ended. Much of the funding utilized in Region 1 was to conduct the MAPP process and materials development. With both of these complete, activities and strategies initiated should be self-sustaining as long as the SEMHA Board continues to support them. The integrated WIC/Immunization clinic protocols are now in place. The Sav-Mor pharmacy model can be replicated with other small pharmacies and the materials and modules are produced and readily available for provider training and quality improvement projects. Region 5 will continue to sustain the school-based clinics, some provider education on an as-needed basis, and the media campaign and educational materials will continue to be utilize to sustain and continue to improve the rates for all three populations of focus. The Northern Michigan Health Alliance and the Northern Michigan Vaccine Preventable Disease Coalition will both continue to address immunizations as a priority. The Alliance has been highly successful in securing additional funding for immunization projects, and much of the practice work continues today due to the continued funding. MALPH will continue to provide consultative services, educational sessions, media campaign materials, and seek new funding opportunities to sustain and replicate the success of the practice. All of the materials developed during the project will be made available to LHD's on the MALPH website. Meghan Swain, Executive Director will work on behalf of all local health departments in the state and seek legislative support for policy change in the areas of billing, immunization waivers, MCIR data entry requirements, and school exclusions for non-vaccinated children during vaccine preventable disease outbreaks in the classroom.
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