Immunization Community Based Outreach Program (CBO)

State: PA Type: Model Practice Year: 2007

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The Immunization Community Based Outreach (CBO) program targets children, aged 10-24 months, who are behind for recommended immunizations according to the Philadelphia KIDS Immunization Registry. The Immunization CBO Program works to ensure that preschool children in Philadelphia are properly immunized against the following vaccine-preventable diseases: measles, mumps, rubella, diphtheria, tetanus, pertussis, polio, haemophilus influenza type b, hepatitis B, hepatitis A, rotavirus, pneumococcal infections, and varicella so as to prevent outbreaks of these diseases.

The goal of the CBO Program is to protect the children of Philadelphia from vaccine preventable diseases by ensuring high immunization coverage levels citywide. Philadelphia Department of Public Health (PDPH) is able to track immunization coverage levels at the city, neighborhood, provider, and child level by the evaluating data maintained in the KIDS Immunization Registry. The CBO Program works to ensure all children have complete immunization records in KIDS Immunization Registry and targets those who are not up to date with age appropriate immunizations for education and outreach services. Outreach workers deliver key immunization education messages to families in the city of Philadelphia and provide assistance in helping parents get their children into the doctor's office for immunizations.

Through community health educators, the CBO Program delivers important health education information and services to parents and guardians in the city of Philadelphia. This program has helped the city of Philadelphia increase immunization coverage levels for preschool children from a low of 46 percent coverage among children 19-35 months for the 4:3:1:3 series (Four or more doses of DTP, three or more doses of poliovirus vaccine, one or more doses of any measles containing vaccine, and three or more doses of Hib) in 1992 to 80 percent coverage in 2005. The CBO Program has and will continue to help Philadelphia maintain immunization coverage levels above the national average.

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Philadelphia Department of Public Health
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Immunization Community Based Outreach Program (CBO)
The Immunization Community Based Outreach (CBO) program targets children, aged 10-24 months, who are behind for recommended immunizations according to the Philadelphia KIDS Immunization Registry. The Immunization CBO Program works to ensure that preschool children in Philadelphia are properly immunized against the following vaccine-preventable diseases: measles, mumps, rubella, diphtheria, tetanus, pertussis, polio, haemophilus influenza type b, hepatitis B, hepatitis A, rotavirus, pneumococcal infections, and varicella so as to prevent outbreaks of these diseases. The goal of the CBO Program is to protect the children of Philadelphia from vaccine preventable diseases by ensuring high immunization coverage levels citywide. Philadelphia Department of Public Health (PDPH) is able to track immunization coverage levels at the city, neighborhood, provider, and child level by the evaluating data maintained in the KIDS Immunization Registry. The CBO Program works to ensure all children have complete immunization records in KIDS Immunization Registry and targets those who are not up to date with age appropriate immunizations for education and outreach services. Outreach workers deliver key immunization education messages to families in the city of Philadelphia and provide assistance in helping parents get their children into the doctor's office for immunizations. Through community health educators, the CBO Program delivers important health education information and services to parents and guardians in the city of Philadelphia. This program has helped the city of Philadelphia increase immunization coverage levels for preschool children from a low of 46 percent coverage among children 19-35 months for the 4:3:1:3 series (Four or more doses of DTP, three or more doses of poliovirus vaccine, one or more doses of any measles containing vaccine, and three or more doses of Hib) in 1992 to 80 percent coverage in 2005. The CBO Program has and will continue to help Philadelphia maintain immunization coverage levels above the national average.
Low immunization coverage levels leave populations susceptible to vaccine preventable diseases as evidenced by the 1990 measles outbreak in Philadelphia. Beginning in October 1990, a large measles outbreak involving predominantly unvaccinated preschool age children occurred in Philadelphia. Between October 1990 and March 1991, there were 9 measles-associated deaths and a total of 1500 confirmed measles cases. Outbreaks such as this are reminders of the importance of vaccinating infants and young children; when public health officials and systems are working and outbreaks don't occur, it is easy for parents to forget about the importance of immunizations. The CBO Program is a vehicle through which the PDPH can continue to remind parents about the importance of immunizations and work with them to get their children up to date for immunizations. Moreover, the CBO Program ensures that PDPH is aware of community responses to immunizations and can prevent clusters of unvaccinated children. The CBO Program builds upon the principles of infectious disease case investigation, social work case management, as well as the fundamentals of immunization reminder-recall programs. The CBO Program relies heavily on the Immunization Program's KIDS Immunization Registry. The Philadelphia KIDS Immunization Registry is a computerized database, containing immunization information for all children living in Philadelphia. The KIDS Registry has been collecting immunization data since 1994 and provider practices are required by Philadelphia Health Code §6-210 to report all ACIP/AAP recommended immunizations administered to children under the age of seven. The registry serves as a repository for the immunization data that are reported, and automatically calculates each child’s up-to-date status, including series completion and next due dates, based on the immunizations contained in the registry. Algorithms programmed into the registry also enable outreach staff to target specific age cohorts missing specific vaccines for outreach and assign them to the correct outreach organization based upon the patient's address.
Agency Community RolesThe PDPH Immunization Program is responsible for CBO Program planning, management, case assignment, and evaluation. PDPH has a contractual relationship with two large Philadelphia community-based health and human service organizations that conduct the community outreach and education for children, their parents, and community members in the zip codes and/or census tracts assigned by PDPH. The community organizations are recognized as leaders in their respective communities and reflect the cultural diversity of the communities they serve. Each organization is staffed with one program coordinator, one administrative assistant, and numerous outreach workers. The community outreach workers are responsible for contacting providers, parents, and guardians through phone, fax, letters, and home visits to determine the child’s immunization status. The outreach workers review immunization histories and ensure the complete history is captured in the KIDS Immunization Registry. In cases where the child is not up-to-date, the outreach workers educate the family on the importance of timely immunizations, the appropriate immunization schedule, and resources available to aid the family in securing primary healthcare and immunization services. If necessary and agreed to by the parent or guardian, the outreach worker will facilitate the healthcare visit, including scheduling the appointment, arranging for transportation, and accompanying the parent or guardian. The community organizations are also responsible for representing PDPH at various health fairs and health education events in their community. The PDPH Immunization Coordinator meets with each of the community organizations on a monthly basis to discuss program operations, program outcomes and measurements, in addition to immunization updates and best practices in providing outreach services. The CBO community organizations are key partners in determining best practices, opportunities for program improvement, opportunities to reach new or difficult populations, and developing appropriate education materials. Quarterly meetings and trainings are also provided for all immunization outreach workers as an opportunity for each outreach organization to discuss their successes and challenges and share opinions and strategies. Costs and ExpendituresThe funding source of this practice is the Centers for Disease Control and Prevention. The CBO Program budget represents 30 percent of the Immunization Program operating budget. ImplementationImplementation of the CBO Program included the following steps:   Demonstration of need: Using the KIDS Immunization Registry and geo-coding software, PDPH was able to identify neighborhoods in the city of Philadelphia with low immunization coverage rates. Staff identification and training: PDPH hired one full time outreach coordinator to provide oversight and management of the program. PDPH contracted with local community organizations to provide culturally appropriate health education and outreach services to the neighborhoods identified as having low immunization coverage rates. An initial orientation with each organization on the immunization schedule has been supplemented with ongoing monthly meetings and semi-annual immunization updates session from PDPH staff and the Centers for Disease Control and Prevention. Development of child referral process and case management: PDPH uses the KIDS Immunization Registry to generate field referral investigation (FRI) forms for each child being referred to an outreach organization. The KIDS Immunization Registry also houses case management information including data elements that detail case assignments, case outcomes, and case closure dates. Development and distribution of culturally appropriate health education materials: PDPH works with the outreach organizations to ensure that immunization education materials given to parents/guardians are culturally appropriate and easy to understand. Relationship building between outreach organization and Immunization Providers: Outreach workers have regular contact with pediatric and family practice providers in the city of Philadelphia for the purposes of conducting record checks, making immunization appointments, and follow up on patient care. PDPH is responsible for sharing appropriate provider contact information with the outreach organizations and educating providers about the CBO Program. Ongoing process evaluation and feedback: PDPH runs monthly reports to track the number of cases closed per organization and per worker. Reports also detail closure types (i.e. brought to care, medial exemption). Ongoing quality checks and feedback: PDPH conducts qualitative reviews of closed cases to ensure all outreach protocols were met during outreach episodes. Ongoing impact evaluation and feedback: PDPH runs quarterly and annual reports to evaluate the impact that the CBO Program has on the immunization coverage levels across different neighborhoods of Philadelphia. The CBO Program works on a monthly cycle. Each month approximately 600-800 new children are generated for the CBO organizations and closed cases are to be returned to PDPH on the first of each month to ensure appropriate closure procedures were taken and for the purpose of tracking monthly worker productivity. The outreach organizations are given up to 5 months to work and close cases of children who are severely immunization delayed.
Objective 1: By generating outreach referrals for nine outreach workers, reach all children 10 and 20 months, not up to date for age appropriate immunizations in targeted neighborhoods. Performance Measure: In 2006, each outreach worker was expected to work and close 80 case referrals per month. Feedback: Monthly closure reports are reviewed by the PDPH Outreach Coordinator as well as community organization managers. Closure reports help ensure worker productivity and have been essential in making adjustments to work load estimates allowing the program to adjust resources to target high-risk populations. PDPH has found that as the number of false referrals generated for the CBOs decreases - more time is needed for each outreach worker to work 80 true cases. Outcome: In 2006, the average monthly closure among outreach workers was 70.2 cases. The number of cases allowed PDPH to generate referrals for all 10 month children in high risk neighborhoods. PDPH has yet to reach all 20-month children not up to date in targeted neighborhoods. Staff is using the productivity report to adjust closure expectations for CY2007. Objective 2: Decrease the number of false referrals to the CBO program. Performance Measure: Decrease the number of false referrals to the CBO program by 30 percent. Data Collection: Outreach workers are responsible to close each case with a specific outreach code in the KIDS Immunization Registry. By closing cases with a disposition of "1A - immunization history receieved from provider, child UTD", PDPH is able to track the number of false referrals. Logistics: Monthly reports generated from the KIDS Immunization Registry allow for analysis of montly disposition codes by worker as well as aggregate analysis.  Feedback: The PDPH Outreach Coordinator began to look at the number of 1A disposition codes by provider and zipcode. By conducting this analysis, action was taken to help decrease reporting errors and increase data quality for providers causing false referrals to the CBO Program. Outcome: Between January 2005 and Decemeber 2006, the number of false referrals to the CBO program decreased by 40 percent PDPH has expanded the outreach program to include the PBO efforts to help meet this objective and the overall program goal. Objective 3: Return all children 10 and 20 months, not up to date for age appropriate immunizations to their medical home for care. Performance Measure: In 2006, return over 50 percent of children referred to outreach to their medical home for immunizations and well-child care. Data Collection: Outreach workers are responsible to close each case with a specific outreach code in the KIDS Immunization Registry. By closing cases with a disposition of "2-child BTC -UTD", PDPH is able to track the number of kids brought to care. Logistics: Monthly reports generated from the KIDS Immunization Registry allow for analysis of montly disposition codes by worker as well as aggregate analysis. Feedback: The PDPH Outreach Coordinator is able to look at all closure codes and has deemed the biggest barrier to reaching the objective is the inability to locate 30 percent of the childen referred to the CBO Program. Outcome: PDPH is meeting with other city agencies and insurance companies to find new ways to locate children not up to date for their immunizations.
SustainabilityThrough ongoing evaluation and increasing immunization coverage levels, PDPH has demonstrated the success of the program to CDC and city officials and consequently, the program has remained funded for over 10 years. The flexibility of the program's structure has enabled the CBO Program to evolve as needed to address coverage of new immunization recommendations and/or new age cohorts. In 2004, PDPH implemented a supplemental program, Provider Based Outreach (PBO) to help ensure the completeness of the KIDS Immunization Registry and decrease the number of children who were up to date for immunizations, but were refered to the CBO Program because their complete immunization history was not captured in the KIDS Immunization Registry. The implementation of this supplemental program has decreased false referrals to the CBO program by 40 percent between 2004 and 2006. This enhancement has enabled the CBO outreach workers to reach more families and PDPH expects that this will help increase immunization coverage levels in the near future. Lessons LearnedLessons learned include: Monthly closure reports are reviewed by the PDPH Outreach Coordinator as well as community organization managers. Closure reports help ensure worker productivity and have been essential in making adjustments to work load estimates allowing the program to adjust resources to target high-risk populations. PDPH has found that as the number of false referrals generated for the CBOs decreases - more time is needed for each outreach worker to work 80 true cases. Outreach workers are responsible to close each case with a specific outreach code in the KIDS Immunization Registry. By closing cases with a disposition of "1A - immunization history received from provider, child UTD", PDPH is able to track the number of false referrals. The PDPH Outreach Coordinator began to look at the number of 1A disposition codes by provider and zipcode. By conducting this analysis, action was taken to help decrease reporting errors and increase data quality for providers causing false referrals to the CBO Program. Outreach workers are responsible to close each case with a specific outreach code in the KIDS Immunization Registry. By closing cases with a disposition of "2-child BTC -UTD", PDPH is able to track the number of kids brought to care. The PDPH Outreach Coordinator is able to look at all closure codes and has deemed the biggest barrier to reaching the objective (return all children 10-20 months, not up to date for age appropriate immunizations to their medical home for care) is the inability to locate 30 percent of the childen referred to the CBO Program.
 
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