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Appendices

Immunization Program Operations Manual (IPOM)

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Appendix A - Vaccine Information Statements

Immunization Provider Responsibilities:

  • Provide clients (or parents/legal representatives) the most current VIS for each vaccine before it is administered.
  • Ensure that clients have the opportunity to read the VIS or have it read to them and ask questions prior to administration of the vaccine.
  • Provide supplementary educational information (oral or written) as appropriate.
  • Offer clients a copy of the appropriate VIS(s) to take home with them.

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Appendix B - Immunization Websites

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Appendix C - Community Guide

The Guide to Community Preventive Services: Vaccines

Vaccinations to Prevent Disease: Universally Recommended Vaccinations: These interventions aim to increase the use of universally recommended vaccines - those that should be administered to all people in a given age group.

Vaccinations to Prevent Disease: Targeted Vaccinations: Interventions aim to increase vaccination coverage for influenza, pneumococcal disease, hepatitis B among adults at high-risk for infection or complications of infection because of occupational, behavioral, or health factors.

Multiple interventions implemented in combination Recommended
Provider reminders when used alone Recommended

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Appendix D - Immunization Practice Standards

National Vaccine Advisory Committee: Standards for Child and Adolescent Immunization Practices


Availability of vaccines

  1. Vaccination services are readily available.
  2. Vaccinations are coordinated with other health care services and provided in a medical home when possible.
  3. Barriers to vaccination are identified and minimized.
  4. Patient costs are minimized.

Assessment of vaccination status

  1. Heath care professionals review the vaccination and health status of patients at every encounter to determine which vaccines are indicated.
  2. Health care professionals assess for and follow only medically accepted contraindications.

Effective communication about vaccine benefits and risks

  1. Parents/guardians and patients are educated about the benefits and risks of vaccination in a culturally appropriate manner and in easy-to-understand language.

Proper storage and administration of vaccines and documentation of vaccinations

  1. Health care professionals follow appropriate procedures for vaccine storage and handling.
  2. Up-to-date, written vaccination protocols are accessible at all locations where vaccines are administered.
  3. Persons who administer vaccines and staff who manage or support vaccine administration are knowledgeable and receive on-going education.
  4. Health care professionals simultaneously administer as many indicated vaccine doses as possible.
  5. Vaccination records for patients are accurate, complete, and easily accessible.
  6. Health care professionals report adverse events following vaccination promptly and accurately to the Vaccine Adverse Event Reporting System (VAERS) and are aware of a separate program, the National Vaccine Injury Compensation Program (VICP).
  7. All personnel who have contact with patients are appropriately vaccinated.

Implementation of strategies to improve vaccination coverage

  1. Systems are used to remind parents/guardians, patients, and health care professionals when vaccination are due and to recall those who are overdue.
  2. Office- or clinic-based patient record reviews and vaccination coverage assessments are performed annually.
  3. Health care professionals practice community-based approaches

Source

National Vaccine Advisory Committee: Standards for Adult Immunization Practices


Make vaccinations available

  1. Adult vaccination services are readily available.
  2. Barriers to receiving vaccines are identified and minimized.
  3. Patient "out of pocket" vaccination costs are minimized.

Assess patients’ vaccination status

  1. Health care professionals routinely review the vaccination status of patients.
  2. Health care professionals assess for valid contraindications.

Communicate effectively with patients

  1. Patients are educated about risks and benefits of vaccination in easy-to-understand language.

Administer and document vaccinations properly

  1. Written vaccination protocols are available at all locations where vaccines are administered.
  2. Persons who administer vaccines are properly trained.
  3. Health care professionals recommend simultaneous administration of all indicated vaccine doses.
  4. Vaccination records for patients are accurate and easily accessible.
  5. All personnel who have contact with patients are appropriately vaccinated.

Implement strategies to improve vaccination rates.

  1. Systems are developed and used to remind patients and health care professionals when vaccinations are due and to recall patients who are overdue.
  2. Standing orders for vaccination are employed.
  3. Regular assessments of vaccination coverage levels are conducted in a provider’s practice.

Partner with the community

  1. Patient-oriented and community-based approaches are used to reach target populations.

Source [7 pages]

National Vaccine Advisory Committee: Standards for Adult Immunization Practices


Make vaccinations available

  1. Adult vaccination services are readily available.
  2. Barriers to receiving vaccines are identified and minimized.
  3. Patient "out of pocket" vaccination costs are minimized.

Assess patients’ vaccination status

  1. Health care professionals routinely review the vaccination status of patients.
  2. Health care professionals assess for valid contraindications.

Communicate effectively with patients

  1. Patients are educated about risks and benefits of vaccination in easy-to-understand language.

Administer and document vaccinations properly

  1. Written vaccination protocols are available at all locations where vaccines are administered.
  2. Persons who administer vaccines are properly trained.
  3. Health care professionals recommend simultaneous administration of all indicated vaccine doses.
  4. Vaccination records for patients are accurate and easily accessible.
  5. All personnel who have contact with patients are appropriately vaccinated.

Implement strategies to improve vaccination rates.

  1. Systems are developed and used to remind patients and health care professionals when vaccinations are due and to recall patients who are overdue.
  2. Standing orders for vaccination are employed.
  3. Regular assessments of vaccination coverage levels are conducted in a provider’s practice.

Partner with the community

  1. Patient-oriented and community-based approaches are used to reach target populations.

Source [7 pages]

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Appendix E - The Four Components of AFIX

The AFIX approach incorporates four key elements to improve immunization service delivery, improve vaccination coverage levels, and reduce missed opportunities.

1. Assessment of the healthcare provider's vaccination coverage levels and immunization practices

 

Introduction

Assessment is the cornerstone of the AFIX process. Assessment refers to the evaluation of medical records to ascertain the immunization level for a defined group of people. This step, along with Feedback of the results, is essential in assessing a practice’s immunization rates. Accurate Assessments done in provider settings can identify overall coverage levels and pinpoint problem areas that the provider may not have known existed. It enables providers and their staff to make data-based decisions on how to improve performance.

The results from an Assessment can be used to guide strategies for improving immunization service delivery and office policies. Continuous, ongoing Assessments and follow up of performance are also essential in order to effectively monitor change in provider immunization services and practices. Assessment increases awareness.

The purpose of an Assessment is to:

  1. Quantify a provider’s vaccination coverage levels
  2. Identify opportunities for improvement of vaccination coverage levels and reduction of missed vaccination opportunities

Assessment Tools

CDC has developed Assessment software known as CoCASA (Comprehensive Clinic Assessment Software Application). CoCASA is widely used and is instrumental for efficient and effective Assessments in provider offices. CoCASA can be downloaded from the NCIRD's Vaccines & Immunizations web site. The time necessary for the Assessment depends upon which Assessment method is selected and the quality of the record keeping practices at the provider office.

CDC recommends that awardees continue to work toward utilization of the Immunization Information Systems (IIS) for Assessment and toward ensuring that all provider immunization records are entered into the IIS. IIS functionality continues to expand. Population-based IIS will be the cornerstone of the nation’s immunization system. Responsibility for IIS development rests with state and local communities, with assistance from federal and state agencies, and private partners. With the increased IIS functionality comes the ability to execute population-based Assessments, utilize a Geographic Information System (GIS), and provide real-time interface with other data systems. This functionality and interface can streamline the process for Assessment of immunization coverage.

CoCASA provides detailed reports on the specific diagnosis of the problem, for example, whether children start their series on time, whether and when patients drop out of the system, and whether vaccines are given simultaneously. CoCASA can also help to raise awareness on issues such as record keeping and documentation and the need for reminder and recall systems.

Preparing for an Assessment

In order to conduct an accurate, reliable Assessment, issues such as how immunizations are documented, what type of record selection will be used, how to determine sample size and selection, and the development of Assessment working definitions need to be addressed prior to the actual Assessment process. Working definitions for "active clients" and children in the Moved or Going Elsewhere (MOGE) category, for example, should be established and agreed upon if comparisons are to be made to other provider sites. In general, standardized data collection allows for more accurate comparability among provider types within and between states. CDC has outlined several Assessment methods to assist public and private providers in assessing their immunization coverage levels. For technical details on planning and conducting provider Assessments, please refer to Assessment Methods

Helpful Assessment Hints and Tips

Assessment requires not only the ability to interpret Assessment findings but also the ability to use observational skills to determine particular office processes that may be facilitating the administration of immunizations (strengths) or obstructing immunization administration (areas of opportunity).

Both measured and observed information should be presented to the provider during the Feedback process. A significant amount of work is required to prepare for an Assessment and must be completed before arriving at the provider’s office. When you are finished with your Assessment make sure that you leave the work area clean and neat and leave the charts in a neat pile or re-file as agreed upon with the office staff.

Measured Information (Quantitative Data):

What are your Assessment findings?

  • Coverage Levels
  • Missed Opportunities
  • Late Starts
  • Valid vs. Invalid Contraindications
  • Drop-offs
Observed Information (Qualitative Data):

What did you observe in the office?

  • Immunization information available for patients?
  • Immunization information clearly displayed for patients?
  • Immunization schedule displayed in all exam rooms?
  • Current ACIP schedule available to staff?
  • Staff questioning parents on immunization status or reviewing immunization histories?
  • Immunization telephone reminder service for patients?
  • Other barriers to immunizations

What did you observe in the record review?

  • Immunization records are comprehensive and easily visible in patient charts?
  • Immunizations recorded in standardized place and method?
  • Records well organized and legible?
  • Immunization status assessed and documented at acute care encounters?
  • Immunization electronic recall service for patients?

 

2. Feedback of results to the provider along with recommended strategies to improve processes, immunization practices, and coverage levels

 

3. Incentives to recognize and reward improved performance

 

4. eXchange of healthcare information and resources necessary to facilitate improvement

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Appendix F - Use of Vaccine Purchased with 317 Funds

Awardees may not administer vaccines purchased with 317 funds to fully insured children or adults, except in limited circumstances described below. An underinsured child may receive Vaccines for Children (VFC) funded vaccine if the child is seeking vaccinations in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) or under approved deputization agreements.

The terms "underinsured" and "fully insured" are defined as follows:

Underinsured: A person who has health insurance, but the coverage does not include vaccines or a person whose insurance covers only selected vaccines. Children who are underinsured for selected vaccines are VFC-eligible for non-covered vaccines only. Underinsured children are eligible to receive VFC vaccine only through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) or under an approved deputization agreement.

Fully Insured: Anyone with insurance that covers the cost of vaccine, even if the insurance includes a high deductible or co-pay, or if a claim for the cost of the vaccine and its administration would be denied for payment by the insurance carrier because the plan’s deductible had not been met.

In circumstances other than "exceptions" specified in this policy, 317 vaccine funds may not be used to provide vaccines for:

  • Fully insured children and adults seen in public clinics
  • Fully insured children and adults seen in private provider offices
  • Adults on Medicare Part B or Medicaid
  • Fully insured adults seen in STD/HIV clinics or drug treatment centers
  • Fully insured parents of newborn infants participating in Tdap cocooning projects
  • Fully insured adults at high risk for acquiring Hepatitis A
  • Fully insured children and adults with a high co-pay or deductible
  • Vaccines for college entry given at Public Health Clinics or College health facilities to fully insured students
  • Fully insured children and/ adults in low medical access areas
  • Fully insured adults in LTCs/eldercare
  • Fully insured children in school-based health centers or clinics
  • Fully insured "high risk" occupational groups (e.g. EMS, first responders, health care workers) for hepatitis A or B or other diseases
  • Fully insured adults and children receiving vaccines as part of a community wide outreach event (including mobile vans and health fairs)
  • Children who are insured by SCHIP standalone programs

Exceptions: 317 vaccine funds may be used to vaccinate the following:

  • Newborns receiving the birth dose of hepatitis B prior to hospital discharge that are covered under bundled delivery or global delivery package (no routine services can be individually billed) that does not include hepatitis B vaccine
  • Fully Insured infants of hepatitis B infected women and the household or sexual contacts of hepatitis B infected individuals
  • Uninsured or underinsured adults
  • Fully insured individuals seeking vaccines during public health response activities including:
    • Outbreak response
    • Post-exposure prophylaxis
    • Disaster relief efforts
    • Mass vaccination campaigns or exercises for public health preparedness
  • Individuals in correctional facilities and jails (except as outlined in VFC Operations Guide)

Notes:

  1. Please note that recipients of PPHF funds for the Hepatitis B Pilot may use the vaccine funds awarded for this project on populations noted in their grant application through the project period end in 2014.
  2. American Indian and Alaska Native patients whose only source of health care is provided by an Indian Health Service, Tribal, or Urban Indian health care organization are not considered fully insured and may be vaccinated with 317 funded vaccines if the Indian Health Service, Tribal, or Urban Indian health care organization does not provide certain vaccines.

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