Adult Immunization in Michigan: Increasing Coverage using Standards

1. Adult Immunization in Michigan: Using the Standards to Increase CoverageP. Ann Ryan, D.O., Ph.D.August15th, 2016

2. Disclosure Statements • Presenter has no conflicts to disclose. • No commercial support was obtained for this activity. • The presenter will not discuss the use of vaccines in a manner not approved by the U.S. Food and Drug Administration (FDA) • Presenter may discuss off-label use of a product that is in accordance with Advisory Committee on Immunization Practices (ACIP) recommendations

3. Outline • Disease Burden and Impact of Vaccination • Adult Coverage Levels - U.S. and MI • Adult Immunization Standards • Immunization Disparities • Call to Action for Adult Providers

4. Disease Burden & Impact of Vaccination Vaccine-preventable diseases (VPDs) still exist

5. Vaccine-Preventable Diseases in the United States Newsworthy In the United States, approximately 42,000 adults die each year of vaccine-preventable diseases.1 Coverage Gaps Adult coverage is alarmingly low. For the majority of vaccines, coverage is well below 50percent.2 Navigation Adult clients may be recommended up to 13 vaccines.3 • Sources: • https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases#star • http://www.cdc.gov/mmwr/volumes/65/ss/ss6501a1.htm • http://www.cdc.gov/vaccines/schedules/hcp/adult.html

6. Burden of Disease Among U.S. Adults • Hepatitis B1 • 3,350 acute cases reported 2010 • Human Papillomavirus (HPV)2 • Estimated 79 million Americans currently infected • 14 million new infections/year in the US • Zoster (also known as shingles)3 • About 1 million cases of zoster annually U.S. • Sources: • CDC. Viral Hepatitis Surveillance United States, 2010. National Center for HIV/AIDS, Viral Hepatitis, STD& TB Prevention/Division of Viral Hepatitis. • CDC. Pink Book. http://www.cdc.gov/vaccines/pubs/pinkbook/hpv.html • CDC. Prevention of Herpes Zoster. MMWR 2008. 57(RR-5): 1-30.

7. Burden of Disease Among U.S. Adults (cont.) • Influenza disease burden varies year to year • Average of 226,000 hospitalizations annually with >75% among adults1 • 3,000-49,000 deaths annually, >90% among adults2 • Invasive pneumococcal disease (IPD)3 • 39,750 total cases and 4,000 total deaths in 2010 • Pertussis (also known as whooping cough)4 • ~28,000 cases per year for 2013 and 2014 • ~9,000 among adults • Sources: • Thompson WW, et al. Influenza-Associated Hospitalizations in the United States. JAMA 2004; 292: 1333-1340 • CDC. Estimates of deaths associated with seasonal influenza – United States, 1976-2007. MMWR. 2010;59(33):1057-1062. • CDC. Active Bacterial Core Surveillance. http://www.cdc.gov/abcs/reports-findings/survreports/spneu10.pdf. • CDC. Notifiable Diseases and Mortality Tables. MMWR 2013. 61(51&52): ND-719 – ND 732.

8. Whole-Person Care: High Risk Case Study 1 • Adults with diabetes (both type 1 and type 2) are at higher risk for serious problems from certain vaccine-preventable diseases: • Some illnesses, like influenza, can raise blood glucose to dangerously high levels • People with diabetes have higher rates of hepatitis B than the rest of the population • Outbreaks of hepatitis B associated with blood glucose monitoring procedures have happened among people with diabetes • People with diabetes are at increased risk for death from pneumonia (lung infection), bacteremia (blood infection) and meningitis (infection of the lining of the brain and spinal cord) http://www.cdc.gov/vaccines/hcp/adults/downloads/fs-diabetes-vaccines.pdf

9. Whole-Person Care: High Risk Case Study 2 • Adults with asthma or COPD are at higher risk for serious problems from certain vaccine-preventable diseases: • Adults with COPD or asthma are more likely to get complications from the flu • COPD and asthma cause your airways to swell and become blocked with mucus, which can make it hard to breathe. • Certain vaccine-preventable diseases can also increase swelling of your airways and lungs. The combination of the two can lead to pneumonia and other serious respiratory illnesses • Cigarette smoking also places adults at high risk for pneumococcal disease http://www.cdc.gov/vaccines/hcp/adults/downloads/fs-asthma-vaccines.pdf

10. Vaccination Coverage Rates Among Adults United States and Michigan

11. Adult Influenza Vaccination Coverage, by Age, United States (Influenza Season) 2011-12 Data Source: 2011, 2012, 2013 and 2014 NHIS = Healthy People 2020 target

12. Adult Immunization Coverage, Selected Vaccines by Age and High-risk Status, United States 2013 2012 2013 2012 2013 2012 Data Source: 2012, 2013 and 2014 NHIS = Healthy People 2020 target

13. Adult Immunization Coverage, Selected Vaccines by Age, Sex, and High-risk Status, United States 2014 2014 2013 2014 2013 2012 2013 2012 2012 Coverage rate (%) Data Source: 2012, 2013 and 2014 NHIS = Healthy People 2020 target

14. Adult Tdap Vaccination Coverage by Age and High-risk Status, United States 2014 2014 2014 Data Source: 2014 NHIS

15. HEDIS Quality Measures for Vaccination • HEDIS includes three quality measures for two vaccines in the adult populations • Remember to incorporate all ACIP recommended vaccines for adults in your routine assessments of adults • Vaccine-preventable diseases are disruptive to the operations of your health centers and the wellbeing of your underserved populations http://www.ncqa.org/hedis-quality-measurement/hedis-measures

16. Why we need the Standards • Adult vaccination rates are extremely low • Most adults are not aware that they need vaccines • Immunization disparities exist • Health Care Personnel (HCP) recommendation is the strongest predictor of whether patients get vaccinated

17. Adult Immunization Standards Make immunizations a standard of adult patient care in your practice

18. Adult Standards:1. Assess2. Recommend3. Administer or 4. Refer5. Document www.cdc.gov/vaccines/hcp/patient-ed/adults/for-practice/standards/

19. Step 1: Vaccine Needs Assessment Assess immunization status of all patients at every clinical encounter Implement protocols and policies Ensure patients’ vaccine needs are routinely reviewed Ensure patients get reminders about vaccines they need

20. Routine Health Care Visits, U.S. Source: 1. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2012, http://www.cdc.gov/nchs/data/series/sr_10/sr10_260.pdf 2. National Ambulatory Medical Care Survey: 2010 Summary Tables, http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf • 82.1% of U.S. adults had contact with a HCP in the past year1 • 1.0 billion physician office visits2 • 332.2 visits per 100 persons2 • 55.5% of visits made to primary care physicians2 • Cough most frequent principal illness-related reason for visit2 • Essential hypertension most commonly diagnosed condition2 • We know that patients are coming in; use this as an opportunity to assess for needed vaccines.

21. Implementing Routine Vaccine Assessment www.immunize.org/handouts/screening-vaccines.asp • Utilize vaccine questionnaires • Helps identify vaccine need • Grabs patient’s attention regarding immunization history • Screening for vaccines • Contraindications & precautions • Screening forms can be found at www.immunize.org

22. Implementing Routine Vaccine Assessment • Source: www.thecommunityguide.org/vaccines/standingorders.html http://www.immunize.org/standing-orders/ • Implement standing orders and protocols • Incorporate assessment and administration of vaccines as you would routine vitals • The Community Preventive Services Task Force recommends standing orders for vaccinations based on strong evidence of effectiveness in improving vaccination rates: • In adults and children • When used alone or when combined with additional interventions • Across a range of settings and populations

23. More Tools to Help with Assessment • Source: www.thecommunityguide.org/vaccines/standingorders.html • The Task Force recommends client reminder and recall interventions based on strong evidence of effectiveness in improving vaccination rates • Send patient reminders • Utilize Electronic Health Records (EHRs) to distribute patient reminders via postcards, letters, text message or automated phone calls • MCIR can be used to send letters to overdue patients • Utilize HCP prompts • Next dose reminders may be generated by an EHR

24. Step 2: Give a Strong Recommendation http://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/recommend.html Your recommendation is a critical factor in whether your patients get the vaccines they need Using SHARE Tool: Share tailored reasons why vaccination is right for the patient Highlight positive experiences Address questions & concerns Remind patients that vaccines protect them and their loved ones Explain the costs of getting sick

25. Provider Side of Messaging Source: Adult Immunization: The Consumer Perspective and CDC Communication Efforts, Presentation at the 2014 National Adult and Influenza Immunization Summit http://www.izsummitpartners.org/wp-content/uploads/2014/05/1e-3_Ramakrishnan_Adult-Immunization-CDC-Communications.pdf • HCP commonly discuss with their patients: • Consequences of not being vaccinated • Safety and efficacy • Possible side effects • Benefits • HCP believe that vaccination is the adult’s choice and are reluctant to be “pushy” • Unless they perceive the VPD to be potentially very serious

26. Patient Side of Messaging Source: Adult Immunization: The Consumer Perspective and CDC Communication Efforts, Presentation at the 2014 National Adult and Influenza Immunization Summit http://www.izsummitpartners.org/wp-content/uploads/2014/05/1e-3_Ramakrishnan_Adult-Immunization-CDC-Communications.pdf • Adults: • Favor simple and to-the-point messages • React positively to messages that stress prevention or encourage vaccination as a way have control over their health (proactive) • Prefer empowering messages - ones that provide information that can help them make an informed decision • Value references to HCP - messages that urge them to talk to their HCP to determine which vaccines are right for them • Remember that a strong recommendation prompts most patients to get immunized.

27. Examples of Targeted Messages: CDC What You Need to Know About Heart Disease and Adult Vaccines “I have too much to do to risk getting sick, so I’m getting vaccinated” Source: www.cdc.gov/vaccines/hcp/adults/for-patients/adults-all.html

28. Addressing Common Questions • Patients vary in their level of knowledge • Questions may include: • What vaccines do I need? • Is vaccination necessary? • Am I at risk for contracting these diseases? • Do vaccines work? • Are there any risks in receiving vaccines? • Fact sheets are available to help address common questions at: • www.cdc.gov/vaccines/hcp/adults/for-practice/standards/recommend.html • Apply resources when addressing common questions and give a strong provider recommendation

29. Step 3: Vaccine Administration • Have all vaccines available at clinic site • Preferred practice • Stock and offer all vaccines recommended by the ACIP

30. Visits Based on Provider Specialty Source: National Ambulatory Medical Care Survey: 2010 Summary Tables, www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf • Adults are being seen in a variety of settings. • Opportunity for vaccine administration: • General/Family Medicine • 70.4 visits/100 persons • OB/GYN • 63.7 visits/100 persons • Internal Medicine • 46.1 visits/100 persons

31. Recommendation & Offer Do Make a Difference = Received Influenza Vaccine Reported a provider recommendation and offer Reported a provider recommendation but no offer Reported neitherprovider recommendation nor offer Source: Ding H, et al. Influenza Vaccination Coverage Among Pregnant Women — United States, 2014–15 Influenza Season. MMWR. 2015;64(36):1000-1005.

32. Adult Immunization Schedules www.cdc.gov/vaccines/schedules/hcp/adult.html

33. Recommended Adult Vaccines www.cdc.gov/vaccines/schedules/hcp/adult.html

34. Resources for Vaccine Administration • Quick Looks HCP offer: • Vaccine types/brands available • Indications for use • Recommended schedule and minimum intervals • Recommendations for persons at high risk • Revaccination guidelines • Vaccine administration, including needle length • Storage and handling • Special situations • Contraindications and Precautions • Documentation • Vaccine Information Statement (VIS) www.michigan.gov/immunize  health care professionals  quick looks and other resources

35. Helping Adult Clients Pay for Vaccines • Healthy Michigan Plan – no co-payments or cost-sharing for all ACIP-recommended vaccines • Adult Medicaid (ages 19 through 64 years) – all ACIP-recommended vaccines • Coverage extended to all ACIP-recommended vaccines given in pharmacies to individuals 19 years and older • Adult Medicare (beginning at age 65 years) • Part B – annual flu, pcv13, ppsv23, and hepatitis B (for high-risk) • Part D – Zoster, MMR, Tdap; coverage varies by plan • Example of update in coverage policy • Blue Cross Blue Shield & Blue Care Network cover HPV, MMR, Tdap in pharmacies

36. Step 4: Vaccine Referral Refer patients to providers in the area that offer vaccines not stocked at your clinical site Be prepared to give an informed referral for vaccines not stocked Follow up Confirm vaccines were received

37. The Immunization Neighborhood: Partners in Health Health Systems Private Providers Health Professional Groups College Health Community Health Centers Occupational Health Pharmacies Hospitals Government Agencies Local Health Departments Community Groups Faith-Based Groups Goal: To Promote and Increase Adult Immunization Rates

40. Michigan Vaccine Replacement Program (MI-VRP) • Public vaccines (purchased by MDHHS) administered through: • Federally Qualified Health Centers (FQHCs) • Tribal Health Centers • Migrant Health Centers • Local Health Department (LHD) clinics • Available to adults ages 19 years and older who have no insurance or who have insurance that doesn’t cover any of the cost of the vaccine • Very specific eligibility criteria • Limited vaccines offered: • Tdap, Td, MMR, Hep A, Hep B, and Zoster • Added July 2016: HPV9, PCV13, and PPS23

41. Step 5: Vaccine Documentation Document all administered & historical vaccine doses into the MCIR Help your office, patients, and patients’ other providers know which vaccines your patients have received

42. MCIR is for adults, too! www.aimtoolkit.org/docs/mcir-adults.pdf *Data current as of February, 2016 • Expanded to include adults in 2006 • Strongly recommend reporting for adult vaccinations • Some private health plans and Medicaid require documentation of adult vaccines in MCIR • 6.6 million adults have a MCIR record* • 54.8 million individual vaccines have been recorded in MCIR for adult patients*

43. Working Toward a Better MCIR for Adults Enter adult immunization data in a timely manner Direct, transfer, HL7 (2-way messaging) Review every adult’s MCIR record at each encounter Update system to comply to HL7 specifications Enhance vaccine forecasting for adult vaccines Priority: PCV13 and PPSV23 Provide staff training on use of MCIR Move toward 2-way HL7 interface Provider Side MDHHS Side

44. Immunization Disparities Decrease barriers and missed opportunities in Community Health Centers

45. Racial/Ethnic Vaccination Disparities (influenza coverage) Data Source: 2014 NHIS • When compared with non-Hispanic, white adults:

46. Racial/Ethnic Vaccination Disparities (non-influenza coverage) Data Source: 2014 NHIS • When compared with non-Hispanic, white adults:

47. Disparities In U.S. Adult Immunization Rates Source: Lu, P-J, et al. Racial and Ethnic Disparities in Vaccination Coverage Among Adult Populations in the U.S. Am J Prev Med 2015; 49(6):S412–S425 • Lower vaccine coverage among: • Hispanics and African Americans compared to non-Hispanic Caucasians • Uninsured • Lower incomes • Improved frequency of provider vaccine assessment and recommendations may help reduce disparities • For newly insured adults • ACA requires non-grandfathered private plans to include coverage for ACIP-recommended vaccines • Especially important to conduct assessment among newly insured

48. Call to Action All adult providers

49. Call to Action: Implement the Standards for Adult Immunization Practice Today! • Turn missed opportunities for vaccination into vaccination successes • Routinely assess adult immunization status at every visit • Implement office protocols and policies to enhance vaccination • Be a good neighbor in the immunization community • Document all vaccines administered in MCIR • Know your referral partners and neighbors

50. The Standards (Booster Shot) Make immunizations a standard of adult patient care in your practice to ensure your adults and communities are fully protected!