Florida Department of Health in Sarasota County
Increasing HPV Completion Rates in DOH-Sarasota 13-17 Year Old Clients
The Department of Health in Sarasota County (DOH-Sarasota), one of 67 health departments in the integrated Florida Department of Health, is accredited by the Public Health Accreditation Board. It provides public health services including immunizations, along with primary care at three sites through a Federally Qualified Healthcare Center public-private partnership. It is the county's only safety-net provider.
Sarasota County's 412,569 residents are 91.7% Caucasian, 4.8% African-American, 8.9% Hispanic plus multiple other ethnicities. Only 14.5% of the population is under the age of 18 and 50% of households earn less than $50,000 annually. Many of these two community segments depend on DOH-Sarasota for primary and public health care, including children's immunizations.
Human Papilloma Virus (HPV) vaccine, although recommended by the Centers for Disease Control (CDC), is not required for school entry in Florida. As protection against vaccine-preventable disease is a public health initiative, ensuring children are HPV vaccinated prior to sexual activity is advised by the CDC and the Advisory Committee on Immunization Practices. HPV vaccine is offered at DOH Sarasota at no cost to adolescents along with school entry immunizations. Acceptance for dose #1 was high, however the completion rate for the two or three dose series was disappointing as parents tended not to return with their children. This created the public health issue of too many partially-vaccinated children. Protection against the virus requires a completed series.
To decrease the HPV vaccine completion gap, the DOH-Sarasota Immunization Department embarked on a Quality Improvement (QI) Initiative which was implemented at all agency vaccine outlets. The goal was to increase the completion rate for the vaccine. The public health objective was to increase the protection level against HPV infection and potential future cancer in these children.
Process: In September, 2016, the agency completion rate for HPV vaccine was 26.3%, less than the FL rate of 28.3%. A QI project was implemented with the goal of increasing 13 17 year old DOH-Sarasota clients with completed HPV vaccine series by 50% or more. The target date to reach 39.45% was December 2017.
Staff agreed to routinely offer HPV vaccine to all adolescents age 13-17, regardless of the reason for the immunization clinic visit. A return appointment was set prior to the child leaving the clinic. Prior to age 14, dose #2 is scheduled 6 months later and the child is complete. At 15 or older, dose #2 is scheduled 2 months out, followed with an appointment for dose #3 at least 4 months later. Immune-compromised children always receive the 3-dose schedule. A reminder call was placed the day before the scheduled appointment for doses #2 and #3. If that appointment was cancelled, another one was made immediately, and a reminder call was again made the previous day. There is rarely a second incidence of cancelled appointments; the overall no showâ€ rate for this vaccine is negligible.
Also initiated was the creation of a printed prescriptionâ€ signed by the Medical Director, indicating when additional doses of HPV vaccine are due. It was noted that giving an MD-signed prescription to the parent reinforced the importance of returning to complete the series.
Most significantly, a list of names and phone numbers of those between the ages of 13 and 17 who need additional doses of HPV was generated monthly from Florida's on-line vaccine tracking database (FL SHOTS) The list was divided and each member of the team, who received additional training in the appointment module of the electronic health record, called each name, notifying parents that their children need another dose of HPV vaccine. They then offered to make an appointment. If the child had already received the dose elsewhere, the date of the vaccine and the identity of the provider was requested and valid information was entered into the tracking system. If another dose was required, the caller offered an appointment for the 3rd and final dose.
Results: Quarterly progress reports showed milestone improvements and by September, 2017, the agency completion rate for HPV vaccine for 13-17 year olds was 47.2%, as compared to the FL completion rate of 28.3% for the same age group. The target goal had been exceeded, a 79.4% improvement over the baseline of 26.3%. Results were 3 months ahead of schedule. Persistent application of interventions, with emphasis on making calls to those who needed additional doses of HPV vaccine and making an immediate appointment, were the keys to this project's success.
DOH Sarasota's web-site provides clinical and educational information regarding HPV vaccines. The immunization page is located at: http://sarasota.floridahealth.gov/programs-and-services/clinical-and-nutrition-services/immunizations/index.html
HPV vaccine, a two or three dose series depending on client age at initial dose and general physical health, showed a combined CHD clinic vaccine completion rate of 26.3% in 13-17-year-old immunization clinic clients as of September 14, 2016. The HPV vaccine, proven to be a protection against HPV infection and HPV cancer, requires the completion of the series for maximum efficacy. As HPV infection and cancer rates are increasing in epidemic proportions, and as approximately Â¾ of all clients were not receiving the doses subsequent to Dose #1, DOH-Sarasota determined that this was an issue of public health importance that needed to be reversed through innovation, resources and tenacity.
The target market for this initiative is children between 13-17 years as many in this age group are not sexually active and therefore have not been exposed to the virus. Using Sarasota County student registration for grades 7-11, the population size, county-wide, is 20,188. The target for this initiative, however, were the approximately 9,997children who utilize the DOH-Sarasota pediatric or immunization clinics for vaccines. Of this cohort, 5,541 had received at least the first dose of HPV vaccine.
Per the CDC, each year about 40,000 HPV-associated cancers are diagnosed in the US. Surveillance shows that within 8 years of collecting data, HPV infections decreased significantly in vaccinated teens (https://academic.oup.com/jid/article-abstract/216/5/594/3892427?redirectedFrom=fulltext. Additionally, the CDC indicates that if all women were immunized with HPV vaccine, it may be possible to prevent 2/3 of the world-wide cervical cancers. https://www.cdc.gov/hpv/hcp/need-to-know.pdf. By increasing the number of children completely vaccinated prior to sexual activity and the opportunity to contract the virus, the number of HPV infections and related cancers can be decreased in ensuing generations, thereby significantly improving health outcomes and making a public health impact of vital importance.
Traditionally, when a child received the first dose of HPV vaccine, the parent or guardian was advised the child needed to return in two months for the second dose. There was no check on whether or not they did return. It was determined that, by age 13, most had received the last of school-required vaccines and it was unlikely that they had a subsequent required immunization visit planned. Hence the dismal completion rate of 26.3%.
Staff were able to identify the several possible causes which negatively impacted the parent/child returning to the clinic for the additional vaccine doses. They looked to develop a procedure that had more success than simply advising the parent to return to complete the series. Parents benefit from reminders and education. In researching the multiple tools available to assist with community and public health issues, the ones that seemed to most align with this problem were found in the Client Reminder and Recall Systems (https://www.thecommunityguide.org/findings/vaccination-programs-client-reminder-and-recall-systems) and Provider Reminders (https://www.thecommunityguide.org/findings/vaccination-programs-provider-reminders) as outlined in Vaccination Task Force Findings of The Guide to Community Preventive Services (https://www.thecommunityguide.org/topic/vaccination)
By implementing the interventions outlined by the Community Preventive Services Task Force, plus adding improvements through innovative agency-developed action steps, the completion rate for all three immunization and pediatric sites began to show an almost instantaneous improvement. Initial data was developed when staff scrolled the FL SHOTS identifying the children who had not completed the series. They then began a call campaign, making appointments for the administration of subsequent doses. Provider reminders were put in place at the agency's pediatric clinics with charts tagged to ensure no missed opportunities when the child is in-house. HPV vaccine was included when administering all routine immunizations, increasing parental acceptance. Official-looking prescription padsâ€ were developed and printed. The script is personalized to the client, completed with the due date of the next dose in the HPV series, signed by the agency's Medical Director and presented to parents. All immunization clinical staff members received training on the client appointment program and made follow-up appointments for parents when in the clinical rooms, alleviating any wait at discharge. Parents receive reminder phone calls for the appointments and a second call should the appointment be missed. Data is collected quarterly on the completion rates, graphed and shared at agency quality improvement meetings. Positive outcomes for some of the interventions outlined in the Guide to Community Preventive Services were expected as they are evidenced-based. It was additionally presumed, however, that the agency-developed action steps that supplemented those evidence-based interventions were integral in boostingâ€ the HPV vaccine completion rates in just 12 months to 47.2%, which is 18.9% over the FL completion rate of 28.3%. [A copy of the HPV vaccine prescriptionâ€ presented to parents can be viewed at: https://drive.google.com/open?id=0B9MwiBlhpXRgVGJuNUpqQVkybWpVaHh3Y0l5bS1kSlBGUUpz ]
The HPV Vaccine Completion Rate Initiative was presented to the agency's Performance Management Council and was included as a key part of the Readiness for Emerging Health Threatsâ€ strategic issue area of the DOH Sarasota 2017 Strategic Plan. It was also given the significance of being designated as the agency's public health quality improvement initiative for the 2017 Quality Improvement Plan. The goal is to demonstrate readiness for emerging health threats through increasing HPV vaccination rates for HPV cancer prevention. The objective was to target agency 13 to 17-year old pediatric clinic and walk-in immunization clients and reach an overall HPV vaccine completion rate of 39.45% for all sites by December 31, 2017. This age group is likely to be non-sexually active and most probably free of HPV infection. It provides a high public health impact by ensuring the utmost HPV protection through a completed series.
First steps were to gather together the DOH Sarasota data for completion rates of second and third doses in the HPV vaccine series for children 13-17 years and to identify the causes which negatively impacted the parent/child returning to the clinic for the additional vaccine doses. Agency pediatric clinic and immunization program staff collaborated on brain-storming about barriers for their individual client bases. Researching other areas that had similar completion issues and investigating the solutions put into place was advantageous in developing this program. Additionally, evidence-based tools and models were researched, seeking one (or more) which would provide a framework for developing action steps for moving forward. The Client Reminder and Recall Systems (https://www.thecommunityguide.org/findings/vaccination-programs-client-reminder-and-recall-systems) and Provider Reminder (https://www.thecommunityguide.org/findings/vaccination-programs-provider-reminders in The Guide to Community Preventive Services (https://www.thecommunityguide.org/topic/vaccination) were singled out as the best programs to replicate for the intended outcomes.
The second major step was to identify all DOH Sarasota clients between 13-17 years who had not completed the HPV vaccine series as per the FL SHOTS immunization registry. There were no other criteria for inclusion in this QI initiative. Staff began a call campaign from that cohort, making appointments for the administration of subsequent doses. Pediatric clinic staff instituted provider reminders by tagging charts to ensure no missed opportunities for initial or follow-up HPV vaccine. Staff offered HPV vaccine when any routine immunizations were due. Parental acceptance was high. Specific HPV vaccine prescription pads were developed, signed by the agency medical director and personalized to each client, designating the due date of next vaccine in the series. Follow-up appointments were made at time of vaccine administration by the staff member working with the client. This eliminated client wait time at the reception desk facilitating the next step in the process. Reminder phone calls were made prior to appointments and again for missed appointments. Data was collected quarterly and completion rates were shared with all stakeholders from front-line staff to the agency's Senior Leaders.
As this was an internal Quality Improvement initiative, the main stakeholders were the DOH-Sarasota Immunization Program Staff at two sites, Pediatric Clinical Staff at three sites, the QI Department and agency Senior Leaders. The immunization program and pediatric clinical staff collaborated on developing the program at the front-line level. The QI coordinator worked closely with the teams to interpret and illustrate the data collected. Senior Leaders provided input when progress was shared at Performance Management Meetings. The public health teams of the Health Department additionally work closely and collaboratively with the School District of Sarasota County. The School District is a solid partner in advancing the vaccination of children and is strict in allowing this health department to enforce FL school entry requirements. The combined DOH and SB School Health teams are additionally HPV vaccine advocates and, when a student record indicates s/he lacks a follow-up dose, the school health RN assists in facilitating an appointment. As such, the county enjoys high vaccine coverage rates for students, which now includes HPV vaccine, as it is offered routinely when students receive required 7th grade vaccines.
This initiative, which had such significant results in HPV vaccine completion rates, was truly almost budget-neutral. There was a minimal cost (< $100) for printing the special HPV vaccine prescription pads, the program required no additional staffing and the HPV vaccine is provided either through the Vaccine For Children's program or with insurance-reimbursed purchased vaccine. Training staff to proactively present the HPV vaccine and to make appointments, as well as placement of the calls to names on the lists, were done during designated team meeting times.
The goal of this QI initiative was to increase the return rate of children for their second, and as necessary, third HPV vaccine dose at all DOH-Sarasota immunization outlets, thereby increasing the completion rate for the vaccine. The public health objective was to increase the protection level against HPV infection and cancer.
In evaluating the process of the intervention, it was learned that reviewing data on a regular basis results in the ability to determine if the interventions are continuing to work, if the staff is on target with following the process and if tweaks to the process need to be made. Although the quarterly reports showed continual improvement, at Quarter 2 the increase was not as significant as Quarter 1. A review of the process with the team members, visually explaining the data which proved that not following the action steps with every client can have negative impact, was impetus to get them back on track. Quarter 3 showed a much better gain in completion rates. Quarterly reports were additionally presented to Senior Leaders at Performance Management Council and the clinical pediatric and school health teams were continually kept in the loop regarding the project.
Outcome evaluation was positive and proved the initiative was successful. After 12 months, the data collected by the Immunization Program via the FL SHOTS vaccine registry showed that the completion rate for all sites, for clients aged 13-17, increased from 26.3% to 47.2%. This completion rate is significantly higher than the State of FL completion rate of 28.3% and the national completion rate of 43.3% for the same vaccine and same age group.
It was evident that the action steps worked. Identifying the market, calling the parents and making appointments, reminder phone calls, follow-up calls for missed appointments, special prescriptionsâ€ for second and third doses, tagging medical charts during pediatric visits, and including the HPV vaccine when advising parents of recommended vaccine were utilized at every opportunity. The processes used to generate the successful increase in HPV vaccine completion rates were inter-related and, while each may have been somewhat successful on its own, the combination of steps created a synergy that enhanced the results, which ultimately reached beyond the stated goal of the project. The project was a main agenda item at every immunizations staff meeting, with employees giving input on how each intervention was working. Although steps were tweakedâ€ as needed, as the action steps were based on best practices for improving vaccine rates, there were minimal changes to procedure. [A graph comparing 2016-2017 HPV vaccine completion rates for DOH-Sarasota, Florida and the US can be viewed here: https://drive.google.com/open?id=0B9MwiBlhpXRgVGJuNUpqQVkybWpVaHh3Y0l5bS1kSlBGUUpz ]
As the cost of this program was inconsequential other than staff time, the cost/benefit was immense. Major increases in HPV vaccine completion rates in 13-17-year-old clients (from 26.3% to 47.2% in 12 months) were accomplished by employing best practices, adding innovative new ideas and maintaining staff engagement in the process. In collaborating with internal partners, it is important to keep them engaged and informed of progress to maintain commitment and participation in meeting goals. The success of this initiative, and its fiscal neutrality, will allow it to be imbedded into on-going agency practice.
There were six main practice lessons learned from this project:
It takes an organized plan, with assigned duties and clear times lines, to keep the project going.
Shared goals and a common vision make it easier to keep the members engaged.
Team members need to understand the importance of the project and that their contributions matter.
Data must be collected regularly and reviewed with all stakeholders
Milestones and successes need to be shared and celebrated with team members on a regular basis.
Even small changes in percentage points can represent big results in the level of protection against HPV infection and the cancers it causes.
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