If you want to improve adolescent immunization rates in your clinic and your community, eight family medicine residencies across the United States have some best practices to share with you.
Arizona AFP staff member Christy Boring, left, joins poster award winners Jacqueline Huynh, M.D., center, and Christine Chan, M.D., of the University of Arizona Alvernon Family Medicine Residency in Tucson, in discussing their project to improve vaccination rates among adolescents. "We can't claim victory yet," said Chan.
As winners of the AAFP Foundation's 2017-2018 Adolescent Immunization Awards, each of the residencies received $11,200 to provide support for quality improvement projects that aimed to improve immunization rates in adolescents ages 11-21 for the following vaccine-preventable diseases: influenza; tetanus, diphtheria and pertussis (Tdap); HPV infection; and meningitis. The awards were made possible with support from Pfizer Inc.
Six of the residencies raised the rates for most or all of the recommended vaccines -- sometimes spectacularly -- and the other two residencies increased rates for a few of the vaccines.
AAFP News interviewed residents or faculty members at the residencies about the best practices that worked for them.
- Eight residencies that won the AAFP Foundation's 2017-2018 Adolescent Immunization Awards share techniques that helped them boost vaccination rates for the following vaccine-preventable diseases: influenza; tetanus, diphtheria and pertussis; HPV infection; and meningitis.
- The techniques used include creating a team approach, strongly recommending all vaccines, implementing standing orders, trying new technologies, understanding electronic medical record capabilities, leveraging community outreach and offering incentives.
- By implementing their projects, six of the residencies raised the rates for most or all of the recommended vaccines -- sometimes spectacularly -- while the other two residencies increased rates for a few vaccines.
Create a Team Approach
Not surprisingly, they all agreed that everyone in the clinic, including front desk staff, should be on the immunization team.
"We discovered that many patients with misconceptions about the influenza and HPV vaccines would direct their questions to clinical support staff, their first point of contact at the clinic, and would not receive consistent responses," said Jacqueline Huynh, M.D., resident co-lead on the immunization project at the University of Arizona Alvernon Family Medicine Residency in Tucson.
A good first step is training for everyone. "We drilled down to each and every individual to explain why these immunizations are very important," said Nicole McGuire, D.H.Sc., education coordinator for Union Hospital Family Medicine Residency in Terre Haute, Ind. "We discovered that our residents were unaware of the cancer aspect of HPV, including throat cancer in males."
"It shocked me that some providers could list the tetanus shot but couldn't remember the other recommended vaccines," said Huynh. "This pointed out the need to get back to basics in our training."
Jordan Roberts, M.D., lead resident on the immunization project at St. Mark's Family Medicine Residency in Salt Lake City, told AAFP News that an HPV vaccine training session even sparked an about-face by a faculty attending physician who had been hesitant to immunize his teenagers.
During that session, a survivor of HPV-related cancer said she wished she'd been born in the HPV vaccine era, said Roberts. "Promiscuity didn't cause her cancer; her partner cheated. The attending physician realized that you could raise your kids 100 percent right, and it still might happen to them."
Support staff also should participate in goal-setting, said Adam Rensch, M.D., resident lead on the immunization project at Lincoln Family Medicine Residency Program in Nebraska. "Then the project feels more personal, not just a mandate and one more thing to get done."
Another tip from Rensch: Identify a team member who is passionate about quality management and can serve as the vaccine champion. This takes some workload off the physicians, he said.
Strongly Recommend All Vaccines, Including HPV
When discussing the vaccines, Roberts recommends sandwiching HPV between Tdap and meningococcal so there's no difference in the strength of recommendation for each of them. "The strong recommendation is the only thing we did differently regarding the physician-patient dynamic, and our immunization rates for HPV and the flu just soared."
Poster award winner Jordan Roberts, M.D., left, of the St. Mark's Family Medicine Residency in Salt Lake City, explains his project to Eddie Richardson, M.D., Board Chair of the Georgia AFP.
At the University of Arizona residency, everyone -- including the front desk staff -- received standardized language for the strong recommendations, said Huynh. Clinicians have leeway to customize the language depending on patient or parent concerns.
Implement Standing Orders
Standing order protocols established during the immunization project helped bring out a team mindset at the Memorial Health Savannah Family Medicine Residency in Georgia, said resident Natalie Britt, M.D., who worked on the project.
With standing orders, vaccine reports are printed for all adolescent visits, not just well-child visits, she said. In the pre-clinic huddle, each resident and nurse team reviews the reports to see which vaccines are due. If a patient is willing to be vaccinated and has no questions for the clinician, the nurse can order and administer them during triage time.
The standing orders also make nurse-only visits for vaccines possible -- especially important for the HPV vaccine, since three doses may be needed, Britt said. After the new protocol was implemented, front desk staff wrote and called all unvaccinated or undervaccinated patients to schedule nurse visits to catch up.
Understanding Immunization Barriers Among Somalis
Because almost 40 percent of its clinic patients are of Somali descent, the University of Minnesota Family Medicine Residency in Minneapolis decided to focus its immunization project on this patient population. HPV vaccination rates in the Somali community are low, and Somali women have one of the highest incidences of cervical cancer in the world, said Sharondeep "Sharon" Toor, M.D., resident lead on the project. Yet a literature search turned up nothing on this population's attitudes about adolescent vaccinations.
To learn more, the residency conducted focus groups at area community centers with a total of 32 Somali men and women ages 18 to 25. Bilingual facilitators asked questions to ascertain participants' knowledge, beliefs and attitudes about adolescent immunizations, with some focus on HPV. No physicians attended the focus groups in case their presence might intimidate participants.
Toor said she was surprised by some of the responses when she read the focus group transcripts.
"We learned that their past experiences in getting immunizations were sometimes painful and traumatic, especially if they got several immunizations at once during the refugee screening process," Toor said. "For that reason, later in life, some Somalis have chosen to avoid immunizations."
The transcripts also revealed a lot about the influence of parents, culture and religion.
Participants acknowledged that during adolescence, their parents or health care professionals usually made immunization decisions for them. Some said that doctors didn't do a good job of explaining immunizations in an understandable way. And sometimes the interpreter wasn't able to describe what the doctor wanted the patient to know.
"One participant said that because they were Muslim, they weren't sexually active before marriage and didn't get STDs, so they didn't need the HPV vaccines," said Toor. "I'm not sure they were aware of the high HPV prevalence in Somali women."
Toor said she also was surprised that the Somalis were eager for the residency to provide face-to-face immunization education in schools and at health fairs. "It's really important to go to the source when you have a community group you want to target," she noted. "They appreciate it and feel more cared for, and they know you're concerned and want to help them."
The residency has now surveyed all clinicians and support staff to learn how they currently deal with adolescent immunizations for Somalis and their own assessment of vaccination barriers.
Next comes the creation of a new "standard work" designed to improve vaccination rates among young Somalis seen in the practice. Toor said it will focus on catch-up protocols during nonpreventive health visits, as well as targeted education and outreach to older Somali teens and young adults.
"We have learned that we need to keep talking to Somali teens as they get older, especially after they turn 18 and can officially make health care decisions for themselves," she said. "Several of our young adults said they would choose to complete their own vaccinations after learning more about the reasons for them."
Although the residency raised immunization rates for only two vaccines during the project period, Toor said she's confident more rates will rise after the new standard work is implemented. "Good quality improvement can take time," she said.
Reach Out to Patients
At St. Vincent's Family Medicine Residency Program in Jacksonville, Fla., staff used the electronic medical record (EMR) system to generate letters, texts, patient portal messages and phone calls to patients needing vaccinations. "Getting people into the office is your first battle, and this was an effective and easy way to reach hundreds of people," said Lauren Woodard, D.O., resident lead on the residency's project.
Good timing increases the effectiveness of outreach materials, the Lincoln residency's Rensch noted. Schedule immunization campaigns for late summer and early fall, when adolescents come in for school and sports physicals, or a few weeks before the holiday season or spring break so patients can have appointments without missing school.
Try New Technologies
As part of its immunization project, the Duke Family Medicine Residency Program in Durham, N.C., used geographic information system mapping to learn more about the clinic's adolescent population.
"Folks in our department helped us map where our adolescents actually live, and we figured out their schools," said Alexa Namba, D.O., M.P.H., resident lead on the project. Armed with this information, residents staffed an immunization information booth at area health fairs.
"We had wonderful discussions with whole families," said Namba. "When we talked about the HPV vaccine, we spoke about how the virus has no symptoms, is very common and can lead to cervical cancer. One middle school girl remarked, 'You mean this shot will keep me from getting cancer? Who wouldn't want that?' It was a moment I wish we could have shared with all our adolescent patients and families."
The Duke residency also started distributing iPads loaded with information about adolescent immunizations for patients to watch while waiting for the doctor.
The University of Arizona project introduced tablets for the same purpose. The tablets show short videos the residency produced to answer questions about adolescent immunizations, said Huynh. The residency won the 2018 Big Shot for Arizona Award from the Arizona Partnership for Immunization for its work on improving vaccination rates.
Understand EMR Capabilities
Namba suggested investigating your facility's EMR to better understand what it can do. "If you're part of an institution with an IT specialist, don't be afraid to reach out about the EMR's full capabilities," she said. "If capabilities you want aren't available, it may only take an ask from a provider to motivate the institution to expand or modify the EMR."
If the EMR can run quality reports by provider, run adolescent immunization reports regularly, Rensch advised. "Having a list of their patients who are behind on immunizations helps each provider realize that even patients with frequent appointments may be behind on vaccinations." The reports ideally should show appointments already scheduled that could be used for catching up.
Standardizing how vaccination data are entered into the EMR is crucial. At the beginning of the immunization project at St. Vincent's residency, individual chart review -- which took weeks -- was necessary to get accurate baseline data, said Woodard. "Our EMR seemed to miss patients if the order was placed in a different way or if the immunization was not done at our office and had not yet been recorded."
She said her residency developed new EMR templates for adolescent annual wellness visits. "Having set encounter plans that include recommendation reminders and immunization order sets seemed to be an easy way to ensure that these things are discussed and ordered properly," she said.
Although several residents acknowledged that poor communication between a residency's EMR and the state's immunization database can be frustrating, Roberts at the St. Mark's residency seized an opportunity to improve that situation by asking staff at the Utah Statewide Immunization Information System (USIIS) to help establish a bi-directional interface between USIIS and the clinic's EMR. Now, when a patient comes into the clinic for any encounter, the state database is automatically queried and updates the clinic's EMR. If a needed vaccine is provided, the EMR automatically sends that information to the state database.
This homegrown bi-directional interface came about thanks to the clinic's medical director, who was a computer programmer before going into medicine, Roberts explained. "He got together with a person from the state database and a third party who helped with the interface, and they hashed it out in an hour-long phone call," he said. "The programming was done the next week. Surprisingly, with the right people, it was relatively easy. It was rocky the first day we tested it, but on day two it started working seamlessly."
The Utah Department of Health honored Roberts with its 2018 Silver Syringe Award for "Physician Champion" for his work on the immunization project.
Leverage Community Outreach
A few of the residencies included community outreach in their immunization projects.
"We developed partnerships with six local groups and piggybacked onto community events with our immunization booths," said the Union Hospital residency's McGuire. "They never hesitated to partner with us."
The residency used photos of kids vaccinated at the clinic on posters to promote free community flu shot events. One poster displayed photos of kids across the top and residents across the bottom, all in the same superhero pose with bandages above their flexed biceps. "We took that poster to community events, normalizing the shots and making it appear that these kids got the shots and they weren't scared, so you can do it, too," said McGuire. "People stopped by our booth and laughed. Doctors as superheroes really resonated with them."
Sometimes community outreach required flexibility on the part of the residency. "We wanted to make vaccination presentations in high school health and physical education classes, but we had difficulty scheduling them," said Natalie Britt of the Savannah program. "So, we got creative.
"We already were in the schools as sports medicine providers, so we decided to insert a 'vaccine minute' into sports physicals and injury clinics. We asked each athlete if they had gotten all of their vaccines and if they knew which vaccines they should get. We encouraged them to talk to their parents. Doing this, we educated more than 1,000 students about vaccinations."
Adolescent Immunization Award Winners
Winners of the AAFP Foundation's 2017-2018 Adolescent Immunization Awards, funded by Pfizer Inc., were:
Duke Family Medicine Residency Program
Lincoln Family Medicine Residency Program
Memorial Health Savannah Family Medicine Residency
St. Mark's Family Medicine Residency
Salt Lake City
St. Vincent's Family Medicine Residency Program
Union Hospital Family Medicine Residency
Terre Haute, Ind.
University of Arizona Alvernon Family Medicine Residency
University of Minnesota Medical Center Family Medicine Residency
Since many patients at the University of Minnesota Family Medicine Residency in Minneapolis are of Somali descent, that residency focused its immunization project on learning more about vaccination barriers in this group, reaching out to area community centers for help. The focus groups the residency conducted with young Somalis yielded some surprising results (see sidebar).
Offer Incentives to Stay on Track
The St. Mark's residency offered prize raffles for adolescents who finished the HPV series or received the flu vaccine or the Tdap or meningitis booster. "This worked really well," said Roberts. "For the first time I saw a kid be disappointed that he wasn't due for a vaccine, which was hilarious."
The Union residency tried free transportation as an incentive to get people to come to a Saturday "vaccine day" at an indigent clinic. "People took us up on that," said McGuire.
Creating change can be daunting, said St. Vincent's Woodard, "but I realized that one person or one small team can help to implement very large changes in a practice if they enlist the help of everyone."
Don't get discouraged when progress is slow, said the Duke residency's Namba. "As you educate families, there is the potential for progress to become exponential. You might have contact with an oldest sibling, and if he educates others in the family, that might be five kids. When the younger ones reach the age for vaccinations, you may have changed their trajectory."
Related AAFP News Coverage
FPs Share Best Practices at Adolescent Immunization Summit