Increasing Two Year Old Immunization Rates of LHD Clients Via Automated System of Reminder Recall

State: FL Type: Neither Year: 2015

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Broward County is located in the southeastern portion of the State of Florida with Miami-Dade County to the south and Palm Beach County to the north.  Broward County’s 2013 population estimate of 1,838,844, represents 9% of the State’s population, and is the second most populous county of the 67 counties in the State of Florida and eighteenth most populous county in the United States (US Census).  Its diverse population includes residents representing more than 200 different countries and speaking more than 130 different languages.  31.4% of the residents are foreign-born.   Broward County is a minority/majority county demonstrated by its 2013 population by race (Black 28.5%, Asian 3.6%, Hispanic 26.9%, other races 4.1%, more than one race .2%, for a total of 59.5% and White 40.8%). The Florida Department of Health in Broward County (DOH-Broward) is the official Public Health Agency in Broward County and has been operational since 1936. It is part of the Integrated Florida Department of Health (DOH) and operates in cooperation with the Broward County Commission under Florida Statute 154. DOH-Broward’s mission is “to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts”.  DOH-Broward is the lead agency providing core public health functions and essential services in the county as part of a complex public health system that includes hospitals, clinics, planning agencies, community-based organizations and others.  DOH-Broward provides population/community-based services to the county’s 1.8 million residents and over 10 million annual visitors, and is responsible for assessing, maintaining and improving health and safety within the county.   The public health issue was to increase two year old immunization rates to meet or exceed state targets. The highlighted health issue was evidenced by the low immunization rates for the 2 year old population of DOH-Broward clients. The goal and objectives proposed by this practice are to meet and maintain the state target of 95% of 2 year old LHD clients fully immunized. The Performance Excellence  Team conducted initial analysis and identified several areas for improvement. The systematic approach to the issue allowed us to clearly define the issue, measure the throughput and output of the processes, analyze the alignment of the activities, implement a series processes to facilitate the operations, and control and monitor the achieved results. An issue identified was a lack of a unified approach to addressing immunization rates among two years old.  School aged children were required to be up to date on immunizations to enter the school system but it was difficult to track children who were not a part of the school system. Dedicated staff was hired on July 28, 2014 to monitor, control, and ensure practice compliance.  The process to identify children ages 0-24 months that were not current on recommended CDC vaccination schedules was outlined. A system of communications such as phone calls, reminder postcards, and accurate documentation in the FLSHOTS database was enacted.  As a result, the state target of 95% was met and it has been maintained ever since.  The impact of this practice translated into a higher 2 year old Immunization Rate in Broward County ensuring an improvement in the overall health of the 2 year old population in alignment with the state strategic vision to become the healthier state in the nation.
Florida Department of Health in Broward County promotes and protects the public’s health through the reduction and eventual elimination of vaccine-preventable diseases by providing vaccine administration, education on receiving timely immunizations, surveillance, and monitoring. Vaccines prevent infectious disease and save lives in the people who receive them and protect those who come into contact with unvaccinated individuals.  Vaccine-preventable diseases can be very serious, may require hospitalization, or even be deadly – especially in infants and young children. The highlighted health issue was evidenced by the low immunization rates of 2 year old LHD population. The goal and objectives proposed by this practice are to meet and maintain the state target of 95%. Since 2006, DOH-Broward has historically had low two year old immunization rates. In 2013, the LHD two year old immunization rates were 53% of the 95% state of Florida goal. Due to immunization requirements for entering schools, it is easier to track immunization schedules for school aged children than for two year olds. To meet this important public health objective, root causes of why rates were so low needed to be examined. The Performance Excellence Team was tasked with researching reasons why the 2 year old immunization rates were historically low, conducted initial analysis, and identified several areas for improvement. A systematic approach to examining low two year old immunization rates allowed the team to clearly define the issue, measure the throughput and output of the processes, analyze the alignment of the activities, implement a series processes to facilitate the operations, and control and monitor the achieved results.  A lack of dedicated staff assigned to track these two year old immunization rates was identified.  DOH-Broward lacked a defined process to monitor and track this important population. The successful implementation of these activities was the result of an integrated work of Performance Excellence and Community Health Departments. The activities implemented were: • hire additional dedicated staff tasked with identifying and contacting client’s parent/guardians who were behind on immunization schedules• write a process outlining steps needed to be taken to improve two year old immunization rates among LHD clients• file and data validation• data collection and normalization• data maintenance• automated client recall list• consistent follow ups• automated printing and mailing of reminder postcards Additional staff was hired to monitor, control, and ensure practice compliance.  As a result, the state target of 95% was met within two months of implementation of the changes and it has been maintained ever since.  The impact of this practice translated into higher 2 year old LHD clients Immunization Rates in Broward County meeting the public health goal of improving the overall health of the 2 year old populations in alignment with the state strategic vision “to become the healthiest state in the nation”.  A reminder recall system was implemented to contact parent/guardians of two year old LHD immunization clients. Based on various reports generated from FLSHOTS, the state of FL immunization tracking system, a systematic approach was developed to list all clients aged 0-24 months who have not completed their recommended immunization schedule in a master file using Microsoft Excel. This list is innovative in that reminder recalls are divided into three categories that are color-coded. The three color categories represent: the frequency of client contacts so there is a visual identifier to view data in graphical format: 1. Green represents first contact2. Yellow represents second contact3. Red represents last/final contact The immunization challenges faced by The Florida Health Department in Broward County are also shared by many other Local Health Departments. Therefore, this Model Practice is being presented as an innovative responsive practice to an ongoing public health issue which is the low immunization levels at the 2 year old population which increases the risk of contracting diseases.  Some of these diseases may lead to ongoing health issues or even death.  The target is all two year old children served by DOH-Broward. Traditionally, low-income and the underserved populations have less access to healthcare due to financial or undocumented status which leads to lower immunization rates amongst these populations. According to the 2010 U.S. Census, the median income for a household in Broward County was $41,691, and the median income for a family was $50,531. Males had a median income of $36,741 versus $28,529 for females. The per capita income for Broward County was $23,170. About 8.7% of families and 11.5% of the population were below the federal poverty line, including 15.3% of those under age 18. The 2 year old population in Broward County represents approximately 3-5 percent of the state population of 2 year olds. Many 2 year old clients receive immunizations through a private provider instead of at the LHD. Nevertheless, the Florida Health Department in Broward County dedicated immunization staff consistently monitors the FLSHOTS immunization historical records of the Broward County 2 year old population in order the ensure child’s immunization status as up-to-date. This systematic approach to data validation and follow up practices has allowed us to reach and maintain the state target of 95% in less than 2 months since the inception and implementation which aligns us to the CDC Winnable battle of Global Immunization.
Global Immunization
The highlighted health issue was evidenced by the low immunization rates of 2 year old LHD population in Broward County. The goal and objectives proposed by this practice are to meet and maintain the state of Florida target of 95% for 2 year old LHD clients fully immunized. The overall goal of this Model Practice is to increase the 2 year old Immunization Rates through a culture of process improvement. In order to achieve the desired results, the Performance Excellence Team worked collaboratively with the Miami-Dade County Health Department to develop a network where skills and knowledge are shared. Moreover, the DOH-Broward WIC (Women, Infant, and Children) team was also part of the initial discussions which gave momentum to this integrated effort and birth to this Model Practice. Staff from WIC was assigned to contact clients identified on the reminder recall lists, update the databases, and gather information. If a client’s contact details were inaccurate, the WIC database would also be checked for current contact details as WIC reviews client immunization schedules during WIC visits and refers many clients for immunizations.  If updated contact details were unable to be obtained, FLSHOTS and the WIC database notes requesting updated contact details would be entered into the systems note pads as WIC clients visit a WIC site every three months which increases the opportunities to identify these clients for updating immunizations. In addition, a systematic approach was developed in conjunction with the clinic site supervisors to expedite any clients who seek immunization services at a DOH-Broward service site aged 0-24 months which increased throughput and decreased wait times. Timeline for improvement activities: • On June 12, 2014 DOH-Broward Director requested Data & Statistics Manager to look into the process of cleaning up the childhood records of those in FLHOTS and to benchmark with other county health departments such as Miami Dade.• On June 18, 2014 after contacting Miami-Dade County Health Department a fact finding field trip was conducting to learn more about FLSHOTs cleanup and maintenance. The Organizational Development Team traveled to Miami Dade and met with Miami-Dade County Health Department who explained the process to run FLSHOTS reports, contact clients with immunization reminder calls, and clean-up inactive data in FLSHOTS.• On June 20, 2014 The Organizational Development Team met with DOH-Broward Director to develop the DOH-Broward process for improving 2 year old immunization rates in Broward County and staff training was developed.• On June 25, 2014 a FLSHOTS Reminder Recall training was conducted and The Organizational Development Team met with an immunization nurse to understand the process for monitoring immunization records.• On July 28, 2014 additional staff was hired to assist with FLSHOTS Reminder Recall for two year olds FLSHOTS clients.• On August 5, 2014 The Organizational Development Team traveled to Miami Dade to meet with Miami-Dade County Health Department and benchmark with their FLSHOTS successful process. Miami-Dade County Health Department explained to us their processes. • On August 6, 2014 newly hired staff created a template in Excel to print immunization reminder messages on postcards.• On August 7, 2014 first batch on postcards were mailed to clients.• On August 8, 2014 the FLSHOTS rate is at 95%.• On August 11, 2014 the FLSHOTS rate has remain above 95%. Despite the successful accomplishments from concept to deployment, this Model Practice is regarded as a continuous timeframe as the 2 year old population is dynamic and continuous in its nature.  
This Model Practice was created in response increase the two year old immunization rates of LHD clients in Broward County and the state set target of 95%. All efforts and activities were developed and implemented in order to ensure successful compliance to state set target.  The improvement of the overall health of the 2 year old population in Broward County however is a long-term goal as it encompasses several other performance indicators not included in this submittal. The cross-functional team between Organizational Development, Continuous Improvement, and WIC were assembled to assess the current situation, analyze the options, and make recommendations used the systematic approach as follows: define the issue, measure the throughput and output of the processes, analyze the alignment of the activities, implement a series processes to facilitate the operations, and control and monitor the achieved results. Primary data source utilized was the FLSHOTS database.  Data elements are gathered from the FLSHOTS database by the staff using assessment reporting and exporting feature available in the program. After the assessment file is created, subsequent queries are used to identify and select the desired records. (i.e. the "No Immunization Reports" identifies clients missing immunizations so those clients may be contacted to be advised of deficiencies in immunization requirements). • PERFORMANCE METRICS:• Indicator:   Percent of 2 Year Olds CHD Clients Fully Immunized - Broward • Definition:    % of 2 year old fully immunized (Immunization 0-24 Months Rate (2yrs)• Calculation:   # of 2 year old fully immunized / # of 2 year old CHD clients• Data Source:   FLSHOTS (Florida Shots)• Target Source:  DOH Performance Snapshot• Target:   95%• Frequency:  Daily• Data Entry Delay:  30 days As part of the Florida Health Department in Broward County culture of continuous improvement, the data processes including reminder recalls, follow-ups, and data entry have been automated in order to ensure efficiency, effectiveness, and reliability of data. This Model Practice has been tested and validated as it has enabled the successful achievement of the desired results of meeting and maintaining the 2 year old immunization rate at 95%.
Lessons learned were that establishing metrics was necessary to track immunization rates on a daily, monthly, and annual basis. In addition, continous monitoring of metrics was needed to imrove processes. This dedication has improved immunization rates for DOH-Broward in a short time frame. All staff need to be on board and utilizing the same processes. All DOH-Broward staff is fully committed to maintaining 2 year old immunization levels at 95% or higher. DOH-Broward further showcases this commitment in the 2014-2019 Strategic Plan where maintaining two year old immunization rates at 95% or higher are addressed. This Model Practice was designed and developed utilizing existing and additional resources. Processes for reporting and documenting data were standardized. Collaboration with various programs in analyzing results and errors resulted in a more streamlined and efficient process. DOH-Broward adopted the changes to the immunization processes to improve immunization rates for LHD clients for DOH-Broward. Therefore, this Model Practice is sustainable and will be continued.
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