Residency Programs Pinpoint Best Practices for Increasing Immunizations

It's a safe bet to assume that most family physicians encounter barriers to providing childhood immunizations all too often in everyday practice. Overcoming these obstacles demands perseverance and a spirit of innovation, something the winners of the 2007 AAFP Foundation Wyeth Immunization Awards have in plentiful supply. Check out some of the creative solutions these family medicine residency programs developed to increase the number of their young patients who are up-to-date on their vaccinations.

Just five years ago, only about 35 percent of kids seen at the Family Care Center operated by St. Joseph Family Medicine Residency in Milwaukee were up-to-date on their immunizations. Now, thanks in part to Tonka trucks and Little People play sets, the clinic has achieved childhood immunization rates of more than 95 percent.

The center gives the toys away during each toddler's one-year well-child visit to encourage compliance with immunization recommendations.

"We found through our studies that the one-year mark was a very common milestone of immunizations that our clinic missed," said residency director Beth Damitz, M.D.

To solve this problem, children receive a birthday card from the practice, reminding the family to schedule an appointment. Parents can swap the card for a toy during their visit. In addition to the birthday gifts, the practice gives away small gifts each time a child is vaccinated. The residency program is able to pay for these gifts through grants and by taking advantage of discounts at retailers.

It's not just a well-stocked goodie closet that keeps families coming back for more shots. It took a team effort to increase the practice's immunization rate by 60 percent in five years, Damitz said.

Nurses, who have standing orders for all immunizations, play a critical role in the program.

"With the standing orders, immunizations are on everyone's radar. If a child comes in with a cold, the nurses will automatically look up the immunization record and review it," Damitz said. Unless contraindications are identified, the child can receive missing immunizations immediately.

A nurse "champion" also is in charge of reviewing immunization records on a weekly basis. The nurse calls patients whose immunizations aren't up-to-date to schedule immunization appointments.

Pediatric vaccination rates at Pennsylvania State University/Good Samaritan Hospital Family and Community Medicine Residency Program in Lebanon increased almost 17 percent throughout 2006 before topping out at 94 percent in 2007.

Enlisting the help of the clinic's family support program has been critical to the clinic's success in raising immunization rates, said residency director Paul Aitken Jr., M.D. Physicians and nurses refer patients to the program for various reasons, including missed appointments and incomplete immunization profiles.

The family support team, in collaboration with the program's residents, reviews charts weekly and contacts families who have missed well-child appointments.

"That usually starts with a phone call, but most often will involve a home visit," Aitken said. "The social worker, nurse and resident will try to physically go to the home to get an understanding of what the barriers are that this particular family faces in coming in for a well-child visit. It's a bit more proactive than what we've been traditionally used to."

Once the support team understands the challenges the family faces, team members are able to work with other community organizations to help the family. Families who get support are more likely to honor well-child visits, increasing the practice's immunization rates, Aitken said.

Good Samaritan's residency program also operates a family medicine clinic in rural Pennsylvania, home to Mennonite and Amish communities. Several local Amish families object to immunizations, Aitken said, and a growing number of other families in the area are concerned about mercury in vaccines. Physicians have found that some extra time with these families can boost immunization rates, so they schedule special appointments to educate hesitant families on the benefits of immunizations and the risks of refusing them.

"We try to understand what the families' major concerns, fears and hesitations are," Aitken said. If patients agree to immunizations during this appointment, they are provided. If not, parents sign a waiver indicating that they refused immunizations.

The immunization program at Carilion Family Medicine Residency Program in Roanoke, Va., relies on the initiative of a well-trained nursing staff.

"We've empowered the nurses to immunize patients," said Roger Hofford, M.D., residency director at the Carilion Clinic.

Each time a patient presents in the program's clinic, a nurse pulls the patient's electronic medical record to review immunizations. Missing vaccinations usually can be dispensed immediately.

The clinic also participates in the state's vaccination supply program, and staff carefully monitor on-site vaccine supplies to prevent waste, Hofford said.

"If we have vaccines from the state health department that are close to expiring, we can look up any patients that are due and call them to tell them we have it available," he said. During the phone call, clinic staff members remind patients that vaccines are free to Medicaid beneficiaries and the self-insured.

Like health care professionals in other locales, staff at the E.A. Conway Medical Center Family Medicine Residency Program at Louisiana State University Health Science Center in Monroe have found that educating parents about the importance of immunizations helps ensure their kids stay up-to-date. But this program gets a real jump on improving parents' knowledge about vaccines; in fact, residents and faculty begin talking to parents about immunizations during prenatal visits.

All newborns are vaccinated before they're discharged, and residents and staff at the program continue to stress the importance of ongoing well-child visits.