It's back-to-school time. In any other year, our clinics would be gearing up for the school and sports physical season. It is always a joy to see all the kids, teens and young adults. Hearing about what they have been up to and ensuring they are up to date on their routine preventive care is one of the most rewarding aspects of my practice.
Although my office is open (with proper COVID-19 protections in place) this year, we are not seeing the usual volume of wellness visits. Unfortunately, office visits to primary care offices are down across the country. This trend is even more worrisome when you consider the steep drop in immunization rates during the spring and early summer. What can we do to make sure we are protecting our kids regardless of whether they are doing in-person or virtual school this fall?
Although 48 of the 50 states require mandatory vaccination for attendance at public schools, some states allow home-schooled children to remain unvaccinated. It is unclear whether temporary virtual schooling due to a pandemic is considered homeschooling, but we will continue to advocate for all children and teens to be immunized on schedule.
It's unclear when schools will be able to consistently bring everyone back safely in person, but it is still important for us to be proactive and to encourage families to stay on schedule. We all know that one reason for the typical August rush for physicals is because many families wait until the last moment to get the necessary paperwork (and requirements) met. This year, the unclear start date for schools and frequently changing plans may take the pressure off and tempt parents to postpone or forego routine well-child visits (subsequently delaying vaccination).
Late fall and winter are prime time for other viral illnesses, such as influenza. Often clinics are busy then, and the risk of being exposed to an ill person will likely be higher. Encourage patients to beat the rush we may experience later by taking advantage of the lower foot traffic in our offices right now.
Vaccine-preventable diseases can be caught outside of school settings. Children, teens and young adults who are not attending school may still be out in public, participating in recreational sports, attending camps or clubs, in daycare or spending time with friends. Each of these interactions provides an opportunity for infection. Delaying vaccines can create pockets of unprotected people within the community, leading to outbreaks of infection. In 2019, we saw the highest rates of measles in the United States since 2000 (the year measles was declared eliminated in this country) due to multiple outbreaks, including a large cluster in New York City traced to an unvaccinated child who had traveled abroad.
The AAFP recommends using the CDC Advisory Committee on Immunization Practices immunization schedule. This year you may find yourself referencing Table 2 (the catch-up vaccine schedule) much more often, as patients begin returning after delays in face-to-face care. Fortunately, the CDC has recently published resources to assist clinicians when trying to interpret Table 2 in the child and adolescent schedule. On that same page you will find the most recent updates to the immunization schedule, including recent tweaks to the recommendations for hepatitis A and B; meningitis; polio; and tetanus, diphtheria and pertussis vaccines. The CDC has also provided recommendations for how to optimize your practice during this pandemic.
Family physicians are increasingly using telemedicine to offer wellness visits in the comfort of patients' homes and then bringing the family in for exams and immunizations later. This approach shortens the time needed in the office, which could mean getting all the kids in a family examined and vaccinated in a single face-to-face visit, saving the family time, limiting exposure and keeping everyone on track for wellness. Another way to potentially streamline visits could be providing drive-up immunizations, similar to COVID-19 testing clinics.
As you redesign your practice to incorporate more telemedicine opportunities, consider if your team can be redeployed in new ways. For example, perhaps your medical assistant can use the EHR to identify kids who are overdue for wellness visits and immunizations, and put them on your telemedicine schedule for the initial part of the visit. Your nurse could have drive-up clinic times, using either standing orders or following the orders you placed during the remote visit. The Immunization Action Coalition has useful resources for practices looking to implement standing orders.
No one wants to get sick during an office visit intended to prevent another infection. You likely have already done the work to make your visits as safe as possible -- requiring face coverings, limiting waiting room use, reducing contacts of less than six feet, reinforced handwashing and surface disinfection. Now let your patients know! Tell them you are open. Share the ways you and your staff are working to protect them (and yourself). Educate and empower them about ways they can also protect themselves. Social media, phone, portal messages and snail mail can all be effective ways of sharing information with your patients about how you will do your best to keep everyone safe during visits.
There is a lot going on, and some parents simply don't have well-child visits on the top of their to-do lists. Help them out by being proactive. Use reminder tools to encourage them to schedule a visit and perhaps even alert them to overdue preventive care services. Consider having a staff member who can schedule the appointment in real-time reach out, saving the parent and the practice the extra step of needing to call back to schedule. Text reminders, email and patient portals are also helpful tools here as well.
Even patients who overcome their fears and arrive for visits may still feel anxious or uncomfortable. Changes to office procedures, use of personal protective equipment and physical distancing may heighten this discomfort. Facemasks can obscure some of the usual facial expressions we use when gauging distress. Consider adding an intentional acknowledgement of the situation in addition to your usual warm and welcoming style when greeting the patient. Open the door to the conversation about their concerns and listen with curiosity and attentiveness.
Don't assume your younger patients have lived a care-free pandemic vacation. Children have also been impacted by the changes in routine, loss of relationships and restrictions. Well-child checks can be an opportunity to identify new traumas and challenges facing the family, given the increase in incidence of intimate partner violence, child abuse, homelessness, joblessness and grief over recent deaths. Consider sharing resources such as the Parent/Caregiver Guide to Helping Families Cope with the Coronavirus Disease 2019 from the National Child Traumatic Stress Network.
If you need a refresher or practical tips on addressing the impact of social determinants of health or adverse childhood experiences on families in your practice, there are a number of articles and resources from the AAFP and its EveryONE Project.
Margot Savoy, M.D., M.P.H., is a member of the AAFP Board of Directors and a former AAFP Vaccine Science Fellow.