2018 AFIX TrainingSudha Setty, MPH and Annie Fedorowicz, MPH

May 31, 20181

Presenter Credentials

Sudha Setty is the AFIX/Quality Improvement Coordinator with the Minnesota Department of Health Immunization Program. She has ten years of experience as an epidemiologist working with quality improvement activities and Immunization Information System data use. Sudha has a Master of Public Health degree from the University of Minnesota School of Public Health.

Annie Fedorowicz is the Adolescent and Adult Immunization Coordinator with the Minnesota Department of Health Immunization Program. She provides educational outreach to health care providers and facilitates collaboration among stakeholders to address immunization disparities and improve immunization coverage in Minnesota. Annie has a Master of Public Health degree from the University of Minnesota School of Public Health.

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Objectives

After participating in this webinar, you will be:• Familiar with all AFIX components

• Familiar with the newest assessment report features in MIIC

• Able to complete an AFIX visit and all associated paperwork

• Able to identify resources that support AFIX programming

• Able to facilitate an Enhanced Adolescent AFIX session

• Able to identify resources to support Enhanced Adolescent AFIX sessions

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Agenda

1. Introduction to Quality Improvement (QI) and AFIX

2. AFIX program update

3. AFIX in Minnesota

a) Assessment

b) Feedback

c) Incentives

d) Information Exchange (X)

e) Administrative requirements and resources

4. Enhanced Adolescent AFIX program4

What is Quality Improvement (QI)?

Quality Improvement (QI) is the use of a deliberate and defined improvement process and the continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality that improve the health of the community.

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What does QI involve?

•QI commonly involves:• A quality improvement team

• Training

• Methods for selecting improvement opportunities

• A process for analysis and redesign

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What is AFIX?

•Assessment, Feedback, Incentives, and eXchange

•CDC QI process informed by research

•Used to improve provider-level immunization rates and practices

•Quantitative and qualitative components

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What does AFIX involve?

•Face-to-face interaction

•Sharing MIIC-based immunization reports

•Educating providers on using MIIC to improve immunization rates and practices

•Maintaining contact with immunization champions at clinic site and/or system level

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AFIX Program Update

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2017-18 AFIX Statistics

•CDC grant objective: • 195 normal AFIX visits (25% of MnVFC enrolled sites)

•Visits completed:• 130 complete (initial visit and follow up completed)

• 115 more require follow up

• Can submit until 12/31/2018

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2018-19 Goals

•2018 CDC AFIX requirement: • 25% of all VFC clinics must receive AFIX visit

•Total MN visits needed: • 195

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AFIX in Minnesota

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AFIX Visit Components

•Assessment• MIIC assessment reports

•Feedback• Face-to-face site visit

•Incentives• Formal and informal

•Information Exchange (X)• Follow-up 3-6 months after face-to-face visit

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Clinic Lists

•MDH priorities guiding clinic selection:• Large population

• Low immunization coverage

• MnVFC status

• Enhanced AFIX eligible

•MIIC selection criteria:• Primary Care Clinic provider type indicator

• Childhood and adolescent immunization coverage rates

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Assessment

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CDC AFIX Eligibility Recommendations

•Active or suspended MnVFC participants• New MnVFC participants

•Serves >30 patients in assessment age ranges

•Low immunization coverage (MIIC-based rates)

•Requests AFIX visit

•Has new staff who need immunization-related training

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Assessment

•Use standardized method for immunization data collection and analysis to:

• Quantify clinic’s vaccination coverage

• Evaluate clinic’s immunization practices

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Minnesota AFIX Assessment Requirements

•MIIC assessment reports include all elements

•Childhood data elements:• 4 DTaP, 3 IPV (Polio), 1 MMR, 3 Hib, 3 HepB, 1 VAR, 4 PCV13, 2-3 RV, 1 Hep A

• Childhood Immunization Series

•Adolescent data elements:• 1 Tdap, 1 MCV4, MCV Booster, 1 HPV, complete HPV

• Childhood immunizations: UTD HepB, 2+ MMR, 2+ Varicella, 2+ HepA, 4+ Polio

•Reports must be run ≤5 business days before initial visit18

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Adolescent Summary Report Changes

•Addition of childhood vaccines• UTD Hep B, +2 MMR, +2 Var, +2 Hep A, +4 Polio

• Vaccine status determined on date of assessment

• Did not include vaccines that adolescents have aged out of/can no longer receive

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Additional Assessment Reports: Childhood Not Up-To-Date

•Childhood Not Up-To-Date Report• Immunity

• Late up-to-date

• Refusal

• Medical contraindication

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Additional Assessment Reports: Missed Opportunities

•NEW: Missed Opportunities Reports

•A “missed opportunity” is when a vaccine could have been given to a client at their last vaccination visit but was not

• Childhood

• Adolescent

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Feedback

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Feedback/Initial Site Visit

•In-person conversation sharing assessment information

•Two-way discussion focusing on:• Putting clinic MIIC rates into practice context

• Understanding any current problems with clinic’s MIIC use

• Sharing resources to support clinic’s continued MIIC use

•Results in development of QI activities

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Pre-Visit Outreach

•Schedule initial visit• Welcome all staff involved in clinic’s immunization work flow

• Offer several days and times for ≤1.5 hour-long visit

•Educate clinic staff on what to expect• Discussion of clinic rates• AFIX questionnaire

• QI plan with two activities• Follow up contact in 3-6 months

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Pre-Visit Materials

•AFIX questionnaire• Clinic staff may complete questionnaire before or during visit

• Guidance on questionnaire available on MIIC website

•MIIC assessment reports• Run and send reports• Instruct clinic to see if rates reflect internal clinic data• Can send additional reports as appropriate

•Instructions on how to inactivate non-active patients• Clinics may have different definitions of “active patient”

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Multiple Clinics at One Visit

•Minnesota has many health care systems of varying sizes

•1-2 staff members in charge of QI/data tracking for 2+ sites

•AFIX site visitor may discuss multiple clinics in 1 visit

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Preparing for Multiple Clinics at One Visit

•Check with your contact to see if other clinics can be looped into one visit

•Talk to Sudha before conducting multi-site visit

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How To Talk About MIIC Reports

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Feedback Process: Assessment Reports

•Review assessment reports• Childhood and adolescent• Additional reports as appropriate

•Start with positive• Above state average/met Healthy People 2020 goal• Highest rates among vaccines• Low missed opportunities

•Transition into areas for improvement • Lowest rates among vaccines

•Share anecdotes from other clinic encounters33

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Feedback Process: Developing QI Objectives

•Review questionnaire line by line• Each question should have “Yes” or “No” checked • Help clinic complete questionnaire if not complete

•Help clinic select 2 QI objectives • Can be childhood and/or adolescent• Can be “custom objectives” based on current improvement activities and/or

organization goals

• QI Project column should have two checked boxes by end of visit

•Use guide to site visit strategies to prepare for staff questions and provide resources

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Examples of QI Activities

• Improve HPV rates 5 percentage points within 6 months

•Ensure front desk staff remind patients to schedule next appointment

•Use MIIC to see if vaccines are due at current patient visit

•Ensure immunization champion has active MIIC login

• Inactivate patients in MIIC no longer seen by clinic

•Contact no-show patients/parents to reschedule visit 3-5 days after no-show

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Feedback Process: Tips

•Clinic staff sometimes reluctant to believe MIIC rates reflect true coverage

• Clinic may have inactive patients associated with assessment denominator –run Client Follow-Up list

• Clinic data may not be getting into MIIC accurately – contact MIIC Help Desk

• Clinic may be in line for real-time data exchange and onboarding – contact MIIC Help Desk

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Poll: What are some of the things clinic staff have said to you regarding MIIC data?

Feedback Process: Tips

•Clinic staff may question MIIC report relevance and accuracy if EMR reports show higher coverage

• Emphasize MIIC as statewide source of immunization data

• MDH and LPH use MIIC to identify immunization gaps and to plan interventions

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Feedback Process: Tips

•Clinic may already have excellent immunization coverage• If childhood rates are high, discuss adolescent rates

• Statewide HPV and Meningitis booster coverage still below HP 2020 goals

• Tdap and MCV4 required for school entry

• If childhood and adolescent rates are high, and clinic sees adults, run Adult Assessment Report

• Can help clinic ensure excellent practices across all ages

• Not AFIX-required

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Feedback Process: Tips

•Use Missed Opportunity Reports• Point out how series/individual vaccine rates could improve if MOs drop

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Feedback Process: Follow-Up Plan and Resources

•Follow-up plan:• Notify clinic about follow-up contact in 3-6 months

• Will check progress on QI plan and implementation• Will review new immunization rates and compare to site visit rates

•Resources to leave with clinic:• Be creative!• CDC

• MDH

• Region-specific materials47

Feedback Process: Documentation

•Submit to MDH within 10 business days:• Childhood and/or adolescent assessment reports

• Completed AFIX questionnaire

• Must indicate clinic’s chosen immunization improvement activities (using yes/no checkboxes)

• Must indicate clinic’s chosen improvement objectives (using QI plan column)

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Feedback Process: Documentation

•Optional documentation pieces• Notes, additional reports, and documentation of current clinic/system QI plan

• MDH saves all documents and uploads them to CDC AFIX Data Tool

•MIIC organization “Notes” tab• Can be good place to track limited AFIX information

• Name and contact information of QI contact

• Related clinics that can be grouped into a site visit

• Information on current clinic or system QI efforts

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Feedback Process: Documentation

•When submitting paperwork for multi-site visit:• Include assessment reports for each clinic

• If all sites had same QI objectives, submit one questionnaire for all

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Incentives

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Incentives

•Used to motivate clinic staff to: • Develop more effective immunization delivery systems

• Improve immunization coverage rates

•Two types: informal and formal

•No requirements or paperwork for this component

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Informal Incentives

•MDH, CDC, and other QI resources•Free immunization materials•Educational in-services for staff

•Ongoing immunization updates•Assistance with developing an immunization quality improvement plan

•Letters of recommendation

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Informal Incentive Examples

•Inter-Clinic Competition• Clinics that share a building keep penny jars for number of vaccines given

• Count pennies donated

• Winning clinic gets prize from other participating clinics

•Letters of recommendation from LPH jurisdiction• Published in local papers

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Formal Incentives

•Certificates of participation, improvement, and collaboration

•Promotion of clinic as “Immunization Champion”/role model

•Recognition of clinic with significant improvement or high coverage levels at:

• Local or state conferences

• Educational seminars

• Professional meetings

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Formal Incentive Examples

•National awards• CDC Childhood Immunization

Champion Award

• CDC HPV Champion Award

•MN awards• Annual coverage awards

•Regions may develop awards

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Information Exchange (X)

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Information Exchange (X)

•Follow-up with clinic to monitor and support progress on QI strategies from site visit

• Helps maintain continuous quality improvement

• Supports clinic to improve immunization services

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Follow-Up Contact

•Every clinic gets follow-up 3-6 months after the initial visit• Discuss and document clinic’s progress on QI strategies

• Provide clarifications and technical assistance

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Preparing for Information Exchange (X)

•Schedule contact• Face-to-face

• Conference call/webinar

• Template slides available

• Email correspondence

•Re-run assessment reports

•Re-run other reports discussed at initial visit

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Requirements for Follow-Up: Rates

•Share new rates• Same childhood and adolescent vaccines

• Rates from other reports

•Compare rates from previous reports and new reports

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Requirements for Follow-Up: QI Activities

•Check on progress on QI activities since initial visit•Document progress on AFIX follow-up form•Send follow-up form to MDH once follow-up contact is complete

•For progress less than 100% complete, request estimated completion date

• Further follow-up via email, conference call, or in-person• Once clinic has reported 100% implementation, resubmit follow-up form to

MDH

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One Information Exchange (X) for Multiple Clinics

•If initial visit was multi-site, do multi-site follow-up

•When submitting paperwork for follow-up that included multiple clinics:

• Include reports for each clinic

• If all sites had same QI objectives, submit one AFIX follow-up form for all

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Administrative Requirements and Resources

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AFIX Paperwork

•Send all AFIX paperwork to MDH AFIX inbox within 10 business days of visit/follow-up

• Email: Health.AFIX.Mailbox@state.mn.us.

• Monitored by Sudha and data entry staff

• Can also send AFIX questions there

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AFIX Resources

• CDC:• AFIX: http://www.cdc.gov/vaccines/programs/afix/index.html

• MDH:• AFIX: http://www.health.state.mn.us/divs/idepc/immunize/registry/afix.html

• QI Toolbox: http://www.health.state.mn.us/divs/opi/qi/toolbox/

• Office of Performance Improvement: http://www.health.state.mn.us/divs/opi/

• QI Resources:• Community Guide, Vaccinations section:

http://www.thecommunityguide.org/vaccines/index.html

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Enhanced Adolescent AFIX Program

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Program Objectives

•Goal: Improve HPV vaccination rates through AFIX process

•Enhance AFIX process by:1. Providing physician/prescriber peer-to-peer education on making a strong

HPV vaccine recommendation during AFIX visits

2. Conducting follow-ups (eXchange) through webinars

•Reach prescriber-level (MD, APRN, PA) clinicians at 100 clinics in addition to normal AFIX visit goals

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Partnership with MAFP

•Subcontracted with Minnesota Academy of Family Physicians (MAFP) to:

• Recruit and manage scheduling/stipends for family physician champions

• Manage CME accreditation for peer-to-peer education session:

• 0.5 CME/CEU available to participating clinicians

• Market programming to members

• Support AFIX site visitors to recruit participants

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Grant Timeline Changes

•September 30, 2019 is new grant deadline

•CDC budget extension was approved

•MDH extended MAFP subcontract

•Implementation timeline to reach 100 clinics:• All sessions in scheduling phase by April 2019

• All sessions initiated by June 2019

• All sessions complete by grant deadline

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Grant Progress

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100 clinics

28 clinics

51 clinicsLet’s get to 100

sessions by June 2018!

Enhanced Adolescent AFIX Strategies

•Continue to prioritize these visits!

•Strategy 1: standard Enhanced Adolescent AFIX • Schedule the physician peer-to-peer education session during the initial AFIX

site visit

•Strategy 2: convert normal AFIX to Enhanced Adolescent AFIX • Schedule the physician peer-to-peer education session during the AFIX follow-

up webinar

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Enhanced Adolescent AFIX Recruitment

•Identify eligible sites using your 2018 AFIX clinic list

•Keep the following in mind:• Can’t visit sites more than once with enhanced AFIX

• Can’t do standard enhanced AFIX visits for sites that already received initial normal AFIX but can consider conversion

•Contact MDH with eligibility questions

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Enhanced Adolescent AFIX Recruitment cont.

•Market using recruitment email templates

•Figure out what works best in lead physician/prescriber schedules (i.e. standing staff meeting, physician lunches, etc.)

•Contact MDH for recruitment assistance

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Scheduling Physician Educator Webinars

•Technology and logistical planning is a challenge

•Consult SharePoint checklists

•Use clinic’s or health system’s internal technology if possible

•Contact MDH if the site:•Does not have adequate technology

•Wants an in person physician presenter

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Resources on RC SharePoint

•Updated “Enhanced Adolescent AFIX” library•Grant Background:

• Grant application

• MDH grant narrative

• Presentations from CDC trainings

•Site Visitor Guidance:• MDH AFIX training and RC call presentations• Checklists for standard and conversion enhanced adolescent AFIX

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Resources on RC SharePoint

•Pre-Site Visit Tools:• Sample recruitment email template for standard Enhanced Adolescent AFIX

•Site Visit Tools:• Physician peer-to-peer education slides• Sign-up sheets for MAFP so attendees can receive 0.5 CME/CEU• HPV vaccination and HPV-associated cancer data hand-outs

•Follow-Up Tools:• Sample recruitment email template for converting standard AFIX to Enhanced

Adolescent AFIX • Slide template for AFIX site visitors to use during follow-up sessions

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Resources that Support Action Steps

1. Encourage your practice to support HPV vaccination. • Minnesota HPV-associated cancer incidence data fact sheet:

http://www.health.state.mn.us/divs/healthimprovement/data/quick-facts/hpvcancer.html.

• Iowa Department of Public Health (IDPH) HPV video: https://idph.iowa.gov/immtb/immunization/hpv.

• Reference HPV-associated cancer survivor stories at ShotByShot.org: www.shotbyshot.org/?s=HPV.

2. Align HPV communication across your clinic.• Share CDC’s Talking to Parents about HPV Vaccine resource with clinic staff: www.cdc.gov/hpv/hcp/for-hcp-

tipsheet-hpv.pdf.

• Share ACS’s HPV VACs Just the Facts: www.mysocietysource.org/sites/HPV/ResourcesandEducation/Lists/Clearinghouse/Attachments/320/HPV%20Vaccine%20-%20Just%20the%20Facts%203.9.2016.pdf.

3. Practice giving a strong recommendation.• Reference MDH’s Just Another Shot: Reframing the HPV Vaccine video with colleagues:

www.health.state.mn.us/divs/idepc/immunize/hcp/adol/hpvvideos.html.

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Enhanced Adolescent AFIX Staffing

•Enhanced Adolescent AFIX lead: Annie Fedorowicz

•Enhanced Adolescent AFIX support:• Data management and coordination assistance: Maureen Leeds

• Consultation on programming: Sudha Setty

•Continue to use AFIX mailbox for paperwork submission• No additional documentation needed for enhanced AFIX

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Questions?

• AFIX:• Sudha Setty, AFIX/QI Coordinator

• Sudha.setty@state.mn.us

• Enhanced Adolescent AFIX:• Annie Fedorowicz, Adolescent and Adult Immunization Coordinator

• Anna.Fedorowicz@state.mn.us

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