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2014 Model Practices

Application Name: 2014 Model Practices : Public Health Institute at Denver Health (PHIDH) : Denver's In-School Immunization Program
Applicant Name: Ms. Sarah R. Rodgers
Name of Practice:
Denver's In-School Immunization Program
Submitting LHD/Agency/Organization:
Denver Public Health
Street Address:
605 Bannock St
Submitting LHD/Agency/Organization/Practice website:
Practice Contact:
Sarah Rodgers
Practice Contact Job Title:
Clinic Administrator
Practice Contact Email:
Head of LHD/Agency/Organization:
Bill Burman
Provide a brief summary of the practice in this section. Your summary must address all the questions below. 
Size of LHD jurisdiction (select one):
In the boxes provided below, please answer the following:
1)Where is LHD located? 2)Describe public health issue 3)Goals and objectives of proposed practice 4)How was practice implemented / activities 5)Results/ Outcomes (list process milestones and intended/actual outcomes and impacts. 6)Were all of the objectives met?  7)What specific factors led to the success of this practice? 8) What is the Public Health impact of the practice?
Denver Public Health Department (DPH) is located in Denver, Colorado and serves the 600,158 (2010 Census) residents of the City and County of Denver. The recent epidemic of pertussis (whooping cough) and high rates of influenza demonstrate that protection from vaccine preventable diseases remains important for all children. Expansions in immunizations over the past decade have challenged the ability for primary care providers to administer all vaccines and maintain robust immunization rates among their patients. Because maintaining immunization rates is a health imperative, supplementary venues to deliver vaccinations have been suggested. School-located vaccination programs have been proposed as an important adjunct to the medical home for accomplishing annual universal influenza vaccination. For adolescents, multiple vaccines are recommended and required for school entrance and delivering these to school aged-children raises challenges. Adolescents are less likely to seek preventive health services in traditional medical homes compared to other age groups. Developing a sustainable and effective vaccination program outside the medical home is essential for improving the delivery of vaccinations on a population level. Denver’s In-School Immunization Program (ISIP) was initiated in 2008 when DPH received two Centers for Disease Control (CDC) grants to assess the feasibility and cost of providing vaccines to students in schools and billing third-party payers for vaccinations services provided. One grant funded the provision of influenza vaccine to students in select Denver elementary schools; the other grant funded the provision of all vaccines to adolescents attending selected Denver middle or pre-kindergarten through 8th grade schools. Since the grants completion in 2011, ISIP has continued to conduct clinics using supplemental funding. The goal of ISIP is to provide vaccines to children through a comprehensive, school-located vaccination program at selected Denver Public Schools (DPS). ISIP strives to be financially sustainable by billing covered students’ insurers for vaccines and administration fees, as well as utilizing the Vaccines for Children (VFC) program for Medicaid, underinsured, and uninsured students. By minimizing barriers to vaccine access and providing services at no cost to families, this program provides a safety-net for Denver children to obtain vaccinations at low or no cost. The program is unique because it offers vaccination services to all children irrespective of insurance status. The objectives of the program are: 1) offer ISIP at selected DPS schools; 2) create a sustainable and financially viable immunization program and minimize reliance on external funding (revenue made will cover program costs); 3) improve overall processes and eliminate program inefficiencies; and 4) improve billing procedures to increase reimbursements. Over the 4 years of the program, there has been ongoing refinement in service delivery and billing processes with improvements in clinic operations and higher reimbursements. Work has focused on enhancing the current partnerships with the school district and our agency’s billing department to ensure that appropriate selected schools conduct the program effectively and that all aspects of billing (contracts, billing, claims, and denials) are handled well. Standard work has been developed for all aspects of the program with tasks now being completed more efficiently. Enhancements have been made to the consent document, making it easier to complete and which now provides information on finding a medical home. Educational tools were developed to address parental concerns on vaccines. ISIP continues to impact the health of the public in many ways.
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With the recent epidemic of whopping cough, the need to vaccinate children against  pertussis using the DTaP and Tdap vaccines has increased. In 2012 the highest rates of pertussis in Denver were in infants <1 year of age, with the second peak being around age 10 years. Provision of Tdap vaccination at the appropriate time is important to avoid the disease or reduce its severity. In 2012-2013, 136 Tdap vaccines were administered to our middle school students. Providing this service helps protect the student from infection which in turn reduces the spread of disease in the community.  
Nationally and in Colorado, human papillomavirus (HPV) vaccination completion rates remain low. To address this issue, ISIP has focused on completing the HPV vaccine series to help prevent HPV-related diseases. Each school year every school participating in the program has 3 clinics strategically spaced to be initiate and complete the HPV vaccine series. During the 2012-2013 school year, 160 students (boys or girls ) received 499 HPV vaccines, of which 33% completed series. Provision of HPV vaccines in the schools offers an effective approach to complete the vaccine series and eliminate the need to miss school in the process.
Supplemental materials:
You may provide no more than two supplement materials to support your application. These may include but are not limited to graphs, images, photos, newspaper articles etc. (Please use one of the following: pdf; txt; doc; docx; xls; xlsx; html; htm)
Model Practice(s) must be responsive to a particular local public health problem or concern. An innovative practice must be 1. new to the field of public health (and not just new to your health department) OR 2. a creative use of an existing tool or practice, including but not limited to use of an Advanced Practice Centers (APC) development tool, The Guide to Community Preventive Services, Healthy People 2020 (HP 2020), Mobilizing for Action through Planning and Partnerships (MAPP), Protocol for Assessing Community Excellence in Environmental Health (PACE EH). Examples of an inventive use of an existing tool or practice are: tailoring to meet the needs of a specific population, adapting from a different discipline, or improving the content.  
In the boxes provided below, please answer the following:
1)Brief description of LHD – location, jurisdiction size, type of population served 2)Statement of the problem/public health issue 3)What target population is affected by problem (please include relevant demographics) 3a)What is target population size? 3b)What percentage did you reach? 4)What has been done in the past to address the problem?5)Why is current/proposed practice better?  6)Is current practice innovative?  How so/explain? 6a)New to the field of public health OR 6b)Creative use of existing tool or practice 6b.1)What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO’s Toolbox etc.) 7)Is current practice evidence-based?  If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.)
DPH’s overarching mission is to promote, improve, and protect the health and well-being of the residents of Denver and beyond. This is accomplished by creating a strong infrastructure that supports, evaluates, and improves internal operations, communications, data systems, financial systems, and facilities while expanding its leadership role and image within the City and State. DPH’s current activities address a number of public health issues within the City and County of Denver. Programs include 1) Epidemiology and Surveillance Program, 2) Health Promotion Program, 3) Prevention and Training Center, 4) Infectious Diseases/AIDS Services, 5) Sexually Transmitted Disease Control Program, 6) Public Health Preparedness, 7) Vital Records, 8) Tuberculosis Control Program, and 7) the Immunization and Travel Program. DPH is organizationally housed under Denver Health and Hospital Authority (DH), a safety-net hospital system with integrated services ranging from acute care to primary care and prevention services. Denver’s population of 600,158 (2010 Census) constitutes 24% of the metropolitan area population. Denver is a racially and ethnically diverse city with 52% White, 10% Black, 32% Hispanic, and 3% Asian. Nearly 18% of Denver residents were born outside of the United States, and a language other than English is spoken in 29% of Denver homes. The median income in Denver is $46,693, and 19% of its citizens have incomes below the federal poverty line. ISIP has provided vital immunization services to adolescents and young children at DPS for four years. ISIP helps to immunize one of the most vulnerable populations (young children) from influenza each year and also ensures that middle school students receive the adolescent platform of vaccines in addition to influenza vacccination. School-located vaccine programs have been proposed as an important adjunct to the medical home for accomplishing annual universal influenza vaccination. Focusing on the adolescent platform in middle schools is especially important for two reasons. First, adolescents have historically been difficult to reach for immunization updates. Second, the current pertussis epidemic in Colorado illustrates the importance of making sure that children remain up-to-date with their routine vaccines to best mitigate the spread of vaccine preventable diseases. While every student attending DPS should receive an influenza vaccination annually, most children are not up-to-date with this recommendation. Many families of uninsured or underinsured students do not have the financial means to obtain the influenza vaccine annually. Without offering ISIP at schools, approximately a quarter of enrolled students would have not obtained the vaccination last year. Not only does ISIP provide an alternative and convenient location for immunization delivery, it is the model for the nation in billing third-party payers for immunization services and providing immunizations to anyone regardless of insurance status. ISIP minimizes barriers to access and provides a safety net for Denver children to obtain vaccinations at low or no cost.
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Initially, this program was established as part of two CDC funded grants that assessed the feasibility and acceptability of conducting school-located vaccination clinics (adolescent and influenza) and billing third party payers. When ISIP was started in 2009, processes previously utilized by Denver Community Health Services (DH primary care program) were modeled providing immunizations in a school setting. However, because DCHS only previously vaccinated students eligible for the VFC program and did not bill health insurance, additional billing and inventory management processes were developed based upon best practices and standard protocols used at DH. Several models for providing school-located vaccination programs in other locales were examined to develop an optimal and efficient program (e.g., Vaccinate before you graduate in Rhode Island and IZ Xtreme in El Dorado County, California). ISIP’s target populations have been elementary students for influenza vaccinations and adolescent students for the adolescent platform of vaccines (tetanus-diphtheria-acellular pertussis (Tdap), meningococcal (MCV4), and human papillomavirus vaccines (HPV)) in addition to influenza and catch-up vaccinations. This past year, ISIP provided vaccinations to students in 19 (15 elementary and 4 middle) DPS schools with high numbers of low income students who either did not have a healthcare provider or could not afford regular healthcare. On average, the selected middle schools had close to 70% free and reduced lunch rates and the elementary schools had 90%. For the adolescent program during the 2012-2013 school year, the population consisted of 55% Medicaid insured, 23% privately insured, 11% CHP and 11% uninsured. For the elementary program, 73% of the population was Medicaid insured, 11% CHP , 10% privately insured and 5% uninsured. In the 2012-2013 school year, 1,892 children (24% of approximately 7800 total students) at 15 elementary schools consented to receive the influenza vaccine in school. Out of those consenting students, 1,613 children received the influenza vaccine – 21% of the DPS population served. ISIP administered a total of 1,305 vaccines to adolescents in the 2012-2013 school year. Three clinics were conducted at each of the four participating DPS middle schools, of which 371 students (14% of the combined student populations of these schools) returned consent forms. Among the consenting students, 327 students (13% of approximately 2500 total students) received at least one vaccine through ISIP. Over the past year, DPH has been using a results accountability framework to link population-level goals (e.g., reduce morbidity and mortality from vaccine preventable diseases) to program-level goals (e.g., effectively implement a school-located immunization program). In public health, population-level goals are the primary target of interest, but the accountability for them is often shared with others in the community. DPH is not able to conduct all of the work needed to address the reduction of vaccine preventable diseases. This is a shared responsibility. Instead, ISIP is aligning its efforts using evidence-based strategies and program-specific roles to ensure a logical connection between population goals and program-level goals that are directly under its control.
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Using this framework, ISIP has aligned its programmatic work (how much did we do, how well was it done, and is anyone better off) with the overall population-level goal it wants to achieve. For the DPH Immunization program, with the population goal being a reduction in vaccine preventable diseases, ISIP has been focusing on enhanced partnerships and the use of evidence-based strategies to increase vaccination uptake. Over the past year ISIP has aligned its strategies to implement a number of endeavors to increase vaccine uptake including: expanded onsite and outreach clinical services for all clients irrespective of ability to pay; ongoing provision of vaccines in schools; implementation of comprehensive billing for all immunization services offered; use of Lean tools to improve vaccine inventory, streamline clinic flow, and avoid waste of vaccines; support and mentorship to other Colorado LPHAs to enhance their billing capabilities; teaming up with research activities to study effective approaches to increase vaccine uptake in public and private practices; and provide support for DH’s efforts to more broadly address the pertussis epidemic through vaccine cocooning. All of these activities have performance measures that align with the population goal of reducing vaccine preventable diseases. As part of the approach, ISIP continues to improve program efficiencies. For example, each month billing data is sent to the program administrator. This report list all charges, insurance type, and amount reimbursed. Analyzing the data is tedious. During the past summer a plan was developed to implement an automated billing tracking system in order to accurately track denials and reimbursement without the long tedious process. This system will track patients who indicate that they are privately insured, but are identified as not being eligible when immunization services are billed. Using this system will allow ISIP to reconcile vaccines with the VFC program. This often occurs as many parents indicate that they have private insurance at the time of registration but at the time of the clinical service have lost insurance coverage. This innovative process should reduce personnel cost, increase program efficiency, and provides an effective approach to reconcile vaccines (private versus public) more easily than current processes. Additionally, ISIP has learned the importance of working collaboratively with partners to strategically choose schools for the program based on school district needs and individual school’s administration interest (including school nurse). For example, DPS nursing administration wanted to offer additional services to improve vaccination coverage of their elementary students. During the past spring, a pilot project was implemented to provide pediatric immunizations in two select elementary schools. All pediatric vaccines were offered. This pilot program focused on catch-up vaccination of five year old (kindergarten age) children, specifically the diphtheria, tetanus and pertussis (DTaP) vaccine. The pilot project successful provided a total of 70 vaccines to students in these two elementary schools. ISIP plans to continue to offer these additional pediatric vaccination services in the 2013-2014 school year after the success of this pilot program. This addresses one of Colorado’s 10 Winnable Battles to reduce infectious diseases by increasing the percentage of children up-to-date on their DTaP immunizations at school entry.
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ISIP is one of the only programs like it nationwide – few school-located vaccination outreaches are able to offer vaccines to all students irrespective of insurance status, and most only offer the flu vaccine. ISIP provides a unique opportunity for DPS families to be able to receive vaccinations at no cost in a school setting with minimal parental involvement (they do not need to be present at the time of the clinics, thus not missing work), and has served as an important piece to the puzzle of improving Colorado’s overall childhood immunization rates.
Does practice address any CDC Winnable Battles?  Select all that apply.
Global Immunization
The LHD should have a role in the practices development and/or implementation. Additionally, the practice should demonstrate broad-based involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.  
In the boxes provided below, please answer the following:
1)Goal(s) and objectives of practice
2)What did you do to achieve the goals and objectives? 2a)Steps taken to implement the program 3)Any criteria for who was selected to receive the practice (if applicable)? 4)What was the timeframe for the practice 5)Were other stakeholders involved? What was their role in the planning and implementation process? 5a)What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s) 6)Any start up or in-kind costs and funding services associated with this practice?  Please provide actual data, if possible.  Else, provide an estimate of start-up costs/ budget breakdown.
The goal of ISIP is to provide vaccines to all children through a comprehensive school-located vaccination program at selected DPS schools that is financially sustainable. ISIP is offered to all students in selected DPS schools irrespective of insurance status. Clinics have been offered every school year since 2009. For the 2012-2013 school year, 15 influenza clinics were offered in October and November. For the adolescent program, 3 clinics were offered at four schools throughout the year with adequate spacing in order to complete specific vaccination series (e.g. HPV, Hepatitis A and B). Two clinics were conducted in April and provided all childhood vaccines in two elementary schools. The goals and objectives described represent the activities conducted in the 2012-2013 school year. All objectives were completed and an evaluation was completed. Additional graphs and supporting documentation have been included in the supplemental materials. Objective 1: Increase DPS student vaccination rates by providing vaccines in select DPS elementary and middle schools. Activities: • Prepare easy-to-complete consent packets (one for every family in target schools). Systematically distribute consent packets during school registration to all families. ISIP program staff should be available to explain the program and answer any parent questions at registration activities. • Post information about clinic dates in schools (School websites, posters, reminders, and announcements) before each clinic. • Review consent packets and review school records of consenting students prior to each clinic. When indicated, ISIP connects a student with an accessible primary care provider. • Update students’ vaccination records in schools. • Hold vaccination clinics in schools. o One influenza vaccine clinic at 15 DPS elementary schools (October-November) o Three adolescent vaccination clinics at four DPS middle schools (3 visits each – October, January, and April) o One catch-up pediatric vaccination clinic at two elementary schools (April) • Input record of vaccines provided into DH’s immunization registry and state registry (CIIS) after each clinic. Update vaccine records provided to student’s family and primary care provider when indicated by parent (May). Objective 2: Continue progressing towards a sustainable model for delivering vaccines in schools, including utilization of third-party billing and the VFC program. 1. Improve billing accuracy by developing infrastructure for an automated billing tracking system. a. Develop plan to streamline billing analysis process and data reporting to decrease time spent analyzing billing data and obtain reports. b. Work with DH Billing Department and DPH Informatics to implement a system which automatically reconciles private vs. public immunizations once billed. c. Discuss strategies to avoid using inappropriate vaccine type (public vs. private). d. Develop a process to accurately use a billing tracking system to project subsequent year vaccine purchases. 2. Maximize and diversify financial funding opportunities by reviewing, revising, and creating billing contracts. 3. Monitor financial viability. a. Review actualized monthly revenue tracking system. b. Monitor existing contracts to ensure the continuation of adequate reimbursement (i.e. administration and vaccine fees reimbursed). c. Monitor reimbursement of newly created or revised contracts to track trends and accurate reimbursement.
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Providing appropriate vaccination information to families and obtaining written informed consent are critical elements for offering a successful school-located vaccination program. Information and an approved consent form was distributed to parents at school registration and via packets sent home with students. The legal departments for ISIP and DPS were required to approve the consents used. Parents were asked to provide written consent for their child to be vaccinated at school. Parents of adolescents were given the opportunity to decline consent for specific vaccines if desired. Within the consent form, ISIP requested health insurance information, a copy of each student’s vaccination record, and information regarding insurance enrollment. Completed signed consent packets included student demographics, parental documentation for refusing specific vaccine administration, insurance status, and a health questionnaire that assessed medical issues that could impact provision of a specific type of vaccine. Clinics are conducted by DPH nurses during school hours without requiring the presence of guardians. Insurers are billed for vaccines and administration fees and eligible students receive vaccines through the VFC program. Parents do not receive bills. During or immediately after clinics, clerical personnel enter vaccination data into the state immunization registry. At the completion of the final clinic, each family and their identified primary care provider receive an immunization record. The partners who conducted this program over the past year were DPH and DPS (prior years had involved other DH departments). Each of the partners has important roles in ensuring that the program is successful. DPS administration and nursing services were actively involved in establishing all of the processes needed to performing pre-clinic activities within the purview of Federal Education Rights Protection Act (FERPA) (e.g., obtaining parental consent, reviewing school immunization records) and for conducting the on-site clinics. Because of FERPA regulations, DPH is not allowed to review immunization records or consents until receiving parental approval. To address this barrier, DPH funded a paraprofessional that was hired by the school district to support in-school activities for this program. This paraprofessional worked closely with the ISIP team to support all activities and ensure that clinics were conducted smoothly. More recently, this paraprofessional worked at both DPH and DPS to assist with pre/post-clinical duties which helped to reduce personnel costs of the program. ISIP has also developed a strong relationship with DH Billing and Finance Department. In the first year of this program, this partnership was not well utilized. For the past three years, ISIP has worked with DH Billing staff to address billing issues and improve billing processes. Because of this, reimbursement rates have increased by more than 50% since the start of the program. This partnership with DH Billing Department has resulted in ISIP being included in any commercial contract revisions and billing issues discussions as they arise.
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ISIP staff meets quarterly with DH Billing Department as well as DPS nursing administration to discuss issues and address concerns in order to improve processes. Start up costs for developing this program was not measured. These costs would be difficult to quantify due to the extensive planning needed to develop and implement this program which involved a number of partners at DH, DPH, DPS, and the evaluation team that worked to develop and implement this program. Additionally, these start up costs do not represent the true costs to develop a program because ISIP also involved an extensive evaluation component to the program. However as part of the CDC study, a micro-costing approach was used to assess the cost to administer a vaccine through the program during the 2010-2011 school year. Estimated vaccine administration costs were calculated to be $23.98 per vaccine for the adolescent project and $24.69 per influenza vaccine for the elementary school project, which is within the range of cost estimates from pediatric private practices. ISIP continues to utilize state-funded VFC vaccine for students, who had no insurance, were underinsured, or who had Medicaid. This practice allows it to recoup much of the cost of vaccinating these particular students. As previously described, ISIP continues to streamline its billing processes, partnering with the DH Billing Department to maximize its ability to obtain reimbursements from public and private insurances. These actions have contributed to the financial health of the program.
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Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.

Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
In the boxes provided below, please answer the following:
1)What did you find out?  To what extent were your objectives achieved?   Please re-state your objectives from the methodology section.
2)Did you evaluate your practice? 2a)List any primary data sources, who collected the data, and how (if applicable) 2b)List any secondary data sources used (if applicable) 2c)List performance measures used.  Include process and outcome measures as appropriate. 2d)Describe how results were analyzed 2e)Were any modifications made to the practice as a result of the data findings?
An evaluation plan was developed to assess completion of objectives and progress made towards completing program goals. This plan assesses a number of important parameters. Number of vaccinations administered was collected in the DH Immunization Registry. Information was collected on consented students to analyze total number of students vaccinated among those consenting, insurance eligibility, race and ethnicity, school location, etc. Success in the program was defined by maintaining the partnerships described above, assessing the number of vaccines provided to elementary and adolescent students, determining the amount and rate of reimbursement, calculating the revenue generated and percentage of program costs covered, and planning for the development of an automated billing tracking system. All objectives were achieved for the 2012-2013 school year and several additional objectives were added to the upcoming 2013-2014 school year. All objectives for the 2013-2014 year are scheduled to be completed. Billing data is tracked using an internal billing system and reports are sent via excel spreadsheet monthly. Data are analyzed by the program administrator. Each year a final report on ISIP program is developed and shared with stakeholders. Results were also presented at the Colorado Public Health of the Rockies Conference in September 2013. Measures of Objective Consent Process 1. Consent packets completed and distributed 2. Number of consent packets returned 3. Vaccination Records 1. Number of students updated in school vaccination record system 2. Number of students eligible to receive vaccines according to records Clinic Proceedings 1. Clinic dates scheduled and clinics held 2. Number of children vaccinated Impact 1. Number of students receiving influenza vaccine (vaccination coverage rate) 2. Number of adolescents brought up-to-date with adolescent vaccines a. Number of children receiving Tdap b. Number of children receiving MCV4 c. Number of children receiving HPV d. Number of children completing the HPV series 3. Number of elementary students brought up-to-date with pediatric vaccines The following data and graphs are represented in Appendix A which is attached in the application. During the 2012-2013 school year, 1,892 children (24% of the population) at 15 elementary schools consented to receive the influenza vaccine in school. Among consenting students, 1,613 children received the influenza vaccine representing 21% of the DPS population. This was a decrease from the previous year when 2,126 children (25% of the DPS population) received the influenza vaccine. A time study was conducted during the 2012-2013 school year and indicated that on average elementary students were out of class 2 minutes and 30 seconds to receive their influenza vaccine. In 2011-2012 and 2012-2013, one clinic was offered at each of the 15 participating elementary schools. In 2009-2010 and 2010-2011 (data not shown), two clinics were offered at each of the participating elementary schools. The second clinic established to administer influenza vaccine for children needing a second dose during the season was deemed not cost effective.
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ISIP administered a total of 1,305 vaccines to adolescents in the 2012-2013 school year. A similar time study was conducted during the middle school clinics. On average, students were out of class for 5 minutes. Three clinics were conducted at each of the four participating DPS middle schools. At these schools, 371 students (14% of the population) returned consent forms. Out of the consenting students, 327 students (13% of total school population) received at least one vaccine through ISIP. This was a decrease from the previous school year, with 522 students (19% of the population) consenting and 482 students (17% of the population) receiving at least one vaccine. For the adolescent project an average of four vaccines was administered per participating student, the highest number given since the program was started. The total amount of vaccines given per clinic during the first round of clinics was also the highest in the 2012-2013 school year with 195 vaccines per clinic. The number of vaccines per clinic in the second and third round of clinics was fewer than the previous year. The average number of HPV vaccines administered increased dramatically this past school year due to the program’s ability to administer the vaccine to both males and females. Previously, ACIP only recommended the vaccine for females. There was also an increase in the number of students receiving any dose of the HPV vaccines, with 160 students completing the HPV series through the program.
Objective 2: Create a sustainable and financially viable immunization program and continue to minimize reliance on external funding by improving billing processes (revenue made will cover program costs). Steps to Accomplish Objective 1. Improve billing accuracy by developing infrastructure for an automated billing tracking system a. Develop plan to streamline billing analysis process and data reporting i. Decrease time spent to analyze billing data and obtain reports b. Work with DH Billing Department and DPH Informatics to discuss development of system which automatically reconciles private vs. public immunizations once billed c. Discuss strategies to avoid using inappropriate vaccine type (public vs. private) d. Develop process to accurately use billing tracking system to project subsequent year vaccine purchases 2. Maximize and diversify financial funding opportunities by reviewing, revising and creating billing contracts a. Work with DH Finance and DH Billing Contract Department to develop and revise contracts that include the provision of immunization services through DPH 3. Monitor financial viability a. Review actualized monthly revenue tracking system b. Monitor existing contracts to ensure the continuation of adequate reimbursement (i.e. administration and vaccine fees reimbursed) c. Monitor reimbursement of newly created or revised contracts to track trends and accurate reimbursement Measures of Objective 1. Automated Billing Tracking System a. Timeline developed for implementation b. Implementation plan developed 2. Contracts a. Number contracts created b. Number of contracts revised 3. Financial viability a. Monthly reports reviewed b. Monitor trend-line reimbursement data 4. Costs covered a. Total revenue b. Average revenue per vaccine/per child a. Percentage of programmatic costs covered b. Cost of vaccination services provided to students with private insurance receiving no payment (underinsured) c. Cost of administration fees provided to students with no insurance 5. Number of services billed a. Number of private insurance claims processed b. Number of Medicaid claims processed 6. Number of private and VFC eligible children vaccinated 7. Number of private and VFC vaccines used 8. Percent of claims paid The following data and graph is represented in Appendix B in the attached application. Billing data for the 2012-2013 school year demonstrated an increase in reimbursement compared to previous years. Reimbursement for vaccines has increased by 18% for the elementary influenza vaccines (86% of total) and reimbursement for adolescent vaccines increased by 14% (81% of total). This increase is important for the future financial sustainability of the program. Many changes have been made as a result of our ongoing review of billing information. First, based on the prior year’s billing data, ISIP identified errors in its CHP clients’ billing ($.01 charges on flu vaccine). This past year ISIP worked with DH Billing Department to rectify that error. Next, ISIP staff has worked with to determine if immunization coverage with commercial contracts already existed and if not, work to include ISIP in its revisions. Most recently, ISIP worked with Kaiser Permanente to establish a school-located clinic contract for immunization services. This contract is important in order to ensure adequate reimbursement for services provided to these patients and to allow ISIP to continue to offer services to all children who consent for the program irrespective of their insurance coverage type.
Overall, participation in both middle and elementary schools decreased in the 2012-2013 school year. Several factors are likely to have contributed to this reduction. First, the peak period for influenza cases occurred in January-February. This was after the elementary school influenza clinics ended (clinics were conducted in October and November). Thus, there was probably a low level of awareness about influenza and/or interest in the influenza vaccine among parents in the fall, causing them to consider influenza vaccination a low priority at that time. There was also less school nurse support at many of the schools. Due to the lack of nurse suppport, we believe there were less students signed up for the program. For the current year, ISIP attended most registrations and provided more education to parents regarding the influenza vaccine and how getting the vaccine early will help decrease the incidence and spread of influenza disease. For the middle schools, two factors likely contributed to lower participation rates. First, the program had lower numbers of new students signing up for the program in clinics 2 and 3. The decrease is due to less school nurse support during the 2nd and 3rd clinics. Without this support, there are very few new consents signed during the clinics in Janruary and April. Second, because some of the middle schools have paricipated in ISIP for several years, it is possible that the program has reached a saturation rate in some of these schools, such that the children currently attending those schools have largely been already immunized. In order to increase participation and vaccination rates in the next school year, ISIP adopted new strategies for conducting the program. A new marketing and advertising plan was developed in order to better reach and educate parents about the program and make program matierals more readily accessible. ISIP staff assessed each currently participating school for factors that may have limited participation such as saturation, support of the program by the school, and participation by parents. Changes in the schools participating in the program (elimination of current schools and addition of new schools) were done based on this review.
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that stakeholders are invested in its maintenance and to ensure it is sustained after initial development. (NACCHO acknowledges fiscal crisis may limit the feasibility of a practices continuation.)  
In the boxes provided below, please answer the following:
1)Lessons learned in relation to practice  2)Lessons learned in relation to partner collaboration (if applicable) 3)Is this practice better than what has been done before? 4)Did you do a cost/benefit analysis?  If so, describe 5)Sustainability – is there sufficient stakeholder commitment to sustain the practice? 5a)Describe sustainability plans
The program is maturing and continuing to improve financially. There have been several lessons learned over the past year. First, ISIP has focused on improving its current partnerships with DPS Nursing Administration and the DH Billing Department. These two partnerships have been crucial to the success of ISIP. Substantial progress has been made with these partnerships and will continue to be focused on during the upcoming school year. Second, carefully reviewing schools to be selected as part of ISIP is important to the success of maximizing the number of children vaccinated. Third, due to FERPA requirements this has required the program to hire a paraprofessional to review student records resulting in financial implications for the program. And finally, billing for immunization services is an ongoing learning process and will continue to be for several years. The program has worked strategically to develop plans in order to sustain the program. ISIP learned several lessons on how to carefully choose schools to maximize the benefits of the program for the most students. Over the past year there was less uptake of the influenza vaccine in certain elementary schools. This decrease was due to less interest in flu vaccination by some school staff and fewer available resources to encourage children/families to participate. Many elementary schools have minimal school nursing available to support participation in the program resulting in fewer students enrolling in several schools. Support by ISIP staff at these elementary schools was limited for various reasons. There were schools that had minimal support from the school nurse which in turn showed less student participation in ISIP. This continues to be a problem when school nurses have several other tasks and in some circumstances are only staffed one day a week at each of their schools.Thus, for the 2013-2014 school year, we reduced the number of elementary schools that would offer ISIP services in order to provide more directed attention for those schools that were more fully engaged in participating in the program. A few of middle schools may have reached saturation, with only new students (e.g., 6th graders and transfer students) requiring the adolescent platform of vaccines. ISIP plans to continue to host clinics at some of these schools due to the strong relationships developed with school staff and parents, but will continue to reexamine the need for ISIP in subsequent years. For our selected middle schools, there was less up-take for new students signed up in 2nd and 3rd clinics due to school nurse support. In the past years, school nurses would send out letters to parents of non-compliant students. The school nurse would attach an ISIP consent form for the parent to sign. This past year, there were several new school nurses who were new to ISIP. Because of this, the amount of vaccinations decreased in 2nd and 3rd clinics. In addition, for this year, ISIP has worked with DPS Nursing Administration to identify two new schools for the program while continuing to work with nurses from three existing schools on strategies to improve uptake of vaccines during the 2nd and 3rd clinics.
Overflow Sustain1
ISIP’s focus has been to increase overall coverage of immunizations given to DPS students, increase insurance reimbursement, and create a bill tracking system. ISIP continues to improve program efficiencies. Because many of these goals have been met, personnel time and duplicative work has decreased resulting in increased program efficiency. ISIP has done this by streamlining its processes and creating standard work among all staff. Tasks are now completed more efficiently due to implementing standard work processes. Additionally a more concerted effort has focused on enhanced education to parents about vaccine concerns and where to find a medical home. Billing reimbursement rates have increased. ISIP is confident that financial sustainability is attainable in the future based on many of the processes enacted over this past year. This year, ISIP focused on the actual cost of conducting its program. Over the four years ISIP has been in existence, overall crude costs per vaccine and per child have been reduced. For the 2012-2013 school year it was conservatively estimated that the cost to administer the program for the full year was approximately $157,000. This was a 50% decrease from projected program costs at the start of this program. Projected billing revenue for both projects for 2012-2013 was $35,000 with the program exceeding expectations by collecting $42,544. Thus, costs covered by revenue were 27%. Revenue has increased due to two major factors that ISIP has been working on since the inception of the program. First, ISIP provides services to a number of patients who are enrolled in the DH Medicaid Choice program. Due to billing system issues, DH Medicaid Choice has been unable to reimburse ISIP for immunization services provided to their members. Reimbursing for ISIP was new to DH Medicaid Choice and it took several years to establish the processes needed to obtain reimbursement. This past September, the processes were finalized and reimbursement is now being received for patients vaccinated through ISIP. The second issue related to traditional Medicaid reimbursement for administration fees. Until this year, Medicaid reimbursement for administration fees had been set at $6.33 per vaccine administered, which does not cover the administrative costs to deliver a vaccine.
With enactment of the Affordable Care Act (ACA), reimbursement rates for administration fees increased due to newly established attestation funds. Starting in January 2013, ISIP qualified to receive an increase of administration fees to $21.68 per vaccine administered in a quarterly reimbursement. Because of this, ISIP’s revenue has increased, resulting in a greater coverage of program costs. The processes of covering total program costs will continues to be a challenge, but with the enactment of the ACA there should be a reduction in the number of uninsured children and together with mandated first-dollar coverage for preventive services such as immunizations, this will increase the number of insured children and should reduce denials for immunizations not being a covered benefit. To offset the current issue of revenue not covering costs, DPH worked with local foundations to secure funding to continue the program for the 2013-2014 school year. However, the goal is to be self-sustaining in the future and not rely on external grants to continue this work. DPS has developed a 5-year health agenda which includes improving the physical health of its students by offering on-site services including school-located vaccination clinics. The DPH Immunization Program continues to work with the Colorado Department of Public Health and Environment on the billing initiative known as Project RIZO (Reimbursement Immunization Opportunity). The purpose of this initiative is to support local public health agencies (LPHA) to develop the capacity and knowledge necessary to bill public and private health plans for immunizations given to their insured patients. ISIP is a mentor for all LPHAs around the state in their billing efforts and processes. ISIP has provided guidance on how to start billing and remains a mentor for the state for billing questions and processes. Until issues related to the FFERPA requirements are addressed, ISIP will continue to require having a paraprofessional to assist in duties related to conducting the program. The ISIP team cannot review students’ documents or access students’ immunization records until written consent is completed by the parent/guardian. Thus, ISIP is required to hire a DPS paraprofessional who works in the schools, reviews and updates immunization records, answers family questions, distributes consent forms and reminders, and then sends completed forms to appropriate DPH staff. To improve program efficiency and reduce costs during the current school year, the paraprofessional worked part-time at DPH during non-clinic times. This paraprofessional performed clinic preparation duties and post-clinic activities previously done by DPH staff resulting in some program cost savings. The implementation of the ACA in 2014 will result in more individuals being insured, first dollar coverage for immunizations, and increases in Medicaid reimbursement for immunization administration fees. These changes should enable the realization of a financially sustainable school-located vaccination program. While the number of people without insurance will diminish over time, there will always be a certain percentage of uninsured (e.g., undocumented) children who have no resources. Thus, even after enactment of the ACA, there will always be a gap in funding to cover the costs of these individuals. DPH will continue to offer and fund services to all students irrespective of their insurance status as part of our public health mission. Sustainability of these efforts hinges on maintaining partnerships, addressing the challenges surrounding the FERPA regulations, information sharing, and effectively developing approaches to finance this program.
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