No Arm Left Behind: School Physicals and Immunization Access Project

State: IL Type: Model Practice Year: 2016

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Champaign-Urbana Public Health District (CUPHD) in collaboration with the Carle Family Medicine Residency Program has been running school physical and immunization clinics since 2012. The clinics provide free physical exams to all children with immunizations billed to Medicaid or available for the uninsured and underinsured for a small fee. The clinics were created to provide options for children from families with low-incomes to get timely back-to-school health examinations which are required by Illinois Law. The state of Illinois requires all school children to meet certain medical requirements before entering schools. Students who do not comply with these requirements by October 15th of each year must leave school until they are compliant. Noncompliance with health requirements, particularly immunizations, poses significant public health threats. Noncompliance also results in needless missed school days and may have an impact on students' educational outcomes.

The clinics address difficulties found in the traditional medical model, including unequal access, fees for services, tight and inconvenient schedules and fragmentation of services. The clinics tailor to the needs of the local community, where there has been a large influx of immigrant populations and a higher percentage of low-income children -- populations at high risk for being uninsured or underinsured.  Goal: to prevent missed school days and decrease vaccine-preventable diseases by increasing compliance with school health requirements with a focus on medically undeserved children. Objective: to increase compliance with back-to-school health requirements in Champaign County.

CUPHD realized the need for these special clinics from past experience. Discussions with Champaign Unit 4 School District personnel, the few existing school nurses, and the ‘health secretaries’ working at each school site made it clear that many children were not prepared for school entrance due to lack of health requirements. Additionally CUPHD received many, seasonal calls and inquiries from clients seeking physicals and immunizations to prevent school exclusion of their children.

Upon the growth of the collaborative relationship with the Carle Family Medicine Residency Program, the opportunity presented itself for a ‘one stop shop’ for these needed services.  A mechanism of early assessment by the school health secretaries in the spring of each year was established; Clinic dates and times were scheduled in the same time frame so the summer clinics could be promoted before school was out for the previous year.   School District staff then referred those in need of services to present at the established clinic dates.

 

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Champaign-Urbana Public Health District
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No Arm Left Behind: School Physicals and Immunization Access Project
Champaign-Urbana Public Health District (CUPHD) is the local public health authority for the Cities of Champaign and Urbana and Champaign County, Illinois. Champaign County is located in east central Illinois and has 998.39 square miles with a population density of 201.8 people per square mile. In 2013 the US Census Bureau estimated the population to be 204,897 residents, a 1.9% increase since 2010. The current population of Champaign County is composed of 74.5% Caucasian, 12.8% African American and 9.6% Asian (2013 U.S. Census Bureau estimate). The percentage of Hispanic residents in Champaign County in 2013 was 5.1%. Foreign-born residents make up 11.5% of Champaign County's total population.  CUPHD has a mission to improve the health, safety and wellbeing of the community through prevention, education, collaboration, and regulation. An indication of this commitment is demonstrated through achievement of accreditation by the Public Health Accreditation Board (PHAB).  CUPHD offers an array of programs and services that reach people of all ages in Champaign County. CUPHD devotes time and effort to serve priority populations including impoverished women and children populations who are particularly vulnerable and lack adequate access to health services and resources.  Public Health issue Vaccine preventable diseases pose significant public health threats. US immunization programs have been very successful in eradicating smallpox, eliminating polio and reducing most other vaccine-preventable diseases by 98-99% (Salmon et al., 2005). The major contributor to this success is compulsory immunization.  Unfortunately, the number of school-age children with non-medical vaccine exemptions has been allowed to increase.  In some states these exemptions have exceeded 5% (Centers for Disease Control and Prevention, 2012). CUPHD examined data on vaccine-preventable disease incidence and noncompliance numbers for the school health requirements in Champaign County, Illinois. The pertussis incidence in Champaign County has been on the rise since 2010. It rose to over 11 per 100,000 in 2012 from less than 2 per 100,000 in 2009.  Additionally, in 2015 the cities of Champaign and Urbana experienced a mumps outbreak. From April 2015 until October 2015 there were 159 cases of mumps directly linked to the outbreak and another 135 throughout Illinois. Goals and Objectives of the practice Reduce non-compliance rate with back-to-school health requirements in Champaign County for vaccinations and school physicals. Practice implementation/activities The clinic is a collaboration between the CUPHD and the Carle Family Medicine Residency Program. It specifically addresses problems with traditional medicine, including unequal access, fee-for-services, tight and inconvenient schedules, and fragmentation. It is specifically tailored to the needs of the local community, where there is a large immigrant population and a high percentage of low-income children--populations at high risk for being uninsured or underinsured. The clinic provides free physical exams and dental exams to all children, and Tdap and other immunizations which can be billed to Medicaid or available for the uninsured and underinsured for a small fee. By providing free exams and low-fee immunizations, the clinic is addressing the unequal access problem of traditional medicine. The clinics are conveniently located at CUPHD’s main site. The clinics are scheduled on Saturdays in consideration of the needs of pediatric clients who require the presence of parents or guardians to receive services. Many low-income parents are required to work during the week at jobs that don’t allow them to take off for an appointment. This is often in conflict with regular office hours of a medical practice. This clinic also addresses the fragmentation of services problem by providing a “one-stop shop” where clients can get school health physicals, dental exams, and immunizations at the same location, on the same day, with one simple check-in process. Results/Outcomes According to the administrative data from the practice about 100 clients were served at each clinic (the clinic operates 5 times per year, so the annual clients served were around 500). According to compliance data from the Illinois Board of Education (http://www.isbe.state.il.us/research/htmls/immunization.htm), the non-compliance rate with back-to-school health requirements in Champaign County has decreased from 1.6% in 2011-2012 school year (the year before the practice started) to 1.4% in 2012-2013 school year (the year when the practice started). The non-compliance rate continued to decrease to 1.3% in the 2013-2014 school year. Overall, the objective has been met. Public Health Impact The most immediate impact is that children will be complaint on school required vaccinations and school physicals and will not be excluded from school thereby negatively affecting their academics. Other benefits include a highly vaccinated community providing herd immunity against vaccine preventable diseases. Finally a regular school physical is critical in identifying underlying conditions detected early and avoiding complications. Website: www.c-uphd.org          
Problem statement and public health significance Vaccine preventable diseases pose significant public health threats. US immunization programs have been very successful in eradicating smallpox, eliminating polio and reducing most other vaccine-preventable diseases by 98-99% (Salmon et al., 2005). The major contributor to this success is compulsory immunization.  Unfortunately, the number of school-age children with non-medical vaccine exemptions has been allowed to increase.  In some states these exemptions have exceeded 5% (Centers for Disease Control and Prevention, 2012). This exposes the community to increased risk of outbreaks of vaccine-preventable diseases. Illinois has allowed both medical and religious exemptions to vaccines. In practice, however, there was no way for school personnel to differentiate between a religious, a philosophical exemption, or someone who simply had not received the required vaccinations.  This allowed parents of children who were out of compliance to simply claim a religious exemption.  In 2015, that “loophole” was tightened and legislation was passed in Illinois that requires a health care provider to sign the certificate confirming they have provided education to the parents or legal guardians about the benefits of immunizations and the health risks of not vaccinating students (Joint Commission on Administrative Rules, 2015). CUPHD examined data on vaccine-preventable disease incidence and noncompliance numbers for the school health requirements in Champaign County, Illinois. The pertussis incidence in Champaign County has been on the rise since 2010. It rose to over 11 per 100,000 in 2012 from less than 2 per 100,000 in 2009.  Additionally, in 2015 the cities of Champaign and Urbana experienced a mumps outbreak. From April 2015 until October 2015 there were 159 cases of mumps directly linked to the outbreak and another 135 throughout Illinois. Champaign County has a considerable immigrant population. Champaign is home to the Central Illinois Refugee Center and the University of Illinois at Urbana-Champaign. During the summer, Champaign County welcomes a large influx of international students and visiting scholars, some of whom bring school-age children with them. Many immigrant populations come from countries where immunizations are not required or the requirements are poorly enforced. Unvaccinated persons in this community have a real potential to being exposed to a vaccine-preventable disease, and then spreading it or starting a communitywide epidemic.  This poses a threat to the public health of the local community and beyond. Target Population: All income eligible students attending school in Champaign that were unable to receive vaccinations or school physicals were our target. Why is the Current practice better and innovative 1) Convenience- The clinics offer a “one-stop shop” where clients can conveniently receive multiple services at the same location. One-stop shop specifically addresses the fragmentation of care--a significant problem of the current community health care delivery system. 2) Timing-The clinics are open on Saturdays around the time school starts. Pediatric clients are a special patient group because they are dependent on their parents or legal guardians to receive services. For many working, low-income parents, their employment does not offer much flexibility or paid leaves. Their work schedules often coincide with office hours of primary medical providers, limiting their access to necessary care. Offering services at a time that is convenient to the parents of the targeted children increases utilization of needed care. 3) Commitment-The main partner, the Carle Family Medicine Residency Program, is an ongoing program at the Carle Hospital in Champaign. The practice serves the mutual interests of the residents and the interests of CUPHD  
Global Immunization|Nutrition, Physical Activity, and Obesity
Community collaboration CUPHD provides leadership in implementation of the practice. In collaboration with the Carle Family Medicine Residency Program, CUPHD leads the charge in providing space, equipment, advertisement, and all personnel except physicians. CUPHD utilizes existing Maternal and Child Health employees to staff the intake and immunization administration portion of the clinic collaboration. The staff at CUPHD also collected data for the evaluation of the practice.  CUPHD’s main partner, Carle Family Medicine Residency Program, provides medical residents to conduct the school physicals. The schools and the community support this practice by facilitating the distribution of flyers and information about the practice. The collaboration is an excellent example of a public-private agency collaboration that serves mutual interests and multiple purposes while keeping costs low. The Residency Program requires residents to conduct a community-oriented primary care project during their third year of residency. The clinic was established as means for the residents to fulfill that requirement and practice their skills. CUPHD leads the effort to respond to public health and health equity issues including lack of vaccination coverage and shortage of school health requirement services that are convenient and affordable to low-income clients. The clinics are a great way for the medical residents to be exposed to public health, our clients, and the issues related to health care access.  Both CUPHD staff and residents report great satisfaction with participation in the clinics.  The atmosphere of the Saturday clinics is festive and friendly.  Clients and their families always express appreciation. Time frame for the practice This is an ongoing practice which is conducted every year starting in summer and ends in September which is the deadline for school exclusion.   Other Stakeholders Champaign Unit 4 was a key stakeholder. They ensured that information was distributed to all students regarding the special clinics Start up or in-kind cost There was no start up cost associated with this practice. In kind cost included the time donated by Physicians and Residents running the clinics on the weekends. Staff that worked on weekends were allowed to flex their time during normal work week.  All marketing was done via website and social media.    
Evaluation CUPHD conducted outcome evaluation to assess the impacts of the practice. Multiple sources of data were used to evaluate the impacts of the practice include data from client surveys (primary data), administrative data from the practice, and data from the Illinois State Board of Education (secondary-data). According to the administrative data from the practice about 100 clients were served at each clinic (the clinic operates 5 times per year, so the annual clients served were around 500). According to compliance data from the Illinois Board of Education (http://www.isbe.state.il.us/research/htmls/immunization.htm), the non-compliance rate with back-to-school health requirements in Champaign County has decreased from 1.6% in 2011-2012 school year (the year before the practice started) to 1.4% in 2012-2013 school year (the year when the practice started). The non-compliance rate continued to decrease to 1.3% in the 2013-2014 school year. Overall, the objective has been met.   Data from the client survey further proved the success of the practice and showed that the target client population--medically underserved populations who are disproportionately uninsured and/or underinsured were reached. A 16 question survey was designed to collect socio-demographic information, health insurance status, reasons for choosing the clinic, perceptions of the services, and relevant schooling information about the children. The survey was available in four different languages including English, Spanish, French, and Mandarin. The survey unit was a household and one adult from each household was asked to complete the survey. A trained staff person administered the survey at the clinic on September 20, October 4, and October 18, 2014. The survey obtained approval from the Institutional Review Board (IRB) of the University of Illinois-Urbana Champaign and Champaign-Urbana Public Health District. A total of 40 surveys were collected. Seventeen surveys were collected on September 20; 10 on October 4; and 13 on October 18. The majority (70%) of the survey responses were in English, followed by Mandarin (12.5%), Spanish (10%) and French (7.5%). Based on the zip codes provided, the respondents came from all over Champaign County and neighboring cities, including city of Urbana, City of Champaign, Mahomet, Philo, Rantoul, Royal, Savoy, Seymour, Tolono, and Belle Rive, Illinois. Over one-third (36.8%) of the households surveyed had lived in Illinois for less than 6 months. Among them, 37% had lived in Illinois for less than month. The respondents were from diverse cultural and racial/ethnic backgrounds. Less than half (48.5%) of the respondents spoke English only, followed by Spanish (18.2%), Mandarin (15.2%), French (12.1%) and Korean (6.1%). Most of the respondents were non-Hispanic Black (41.0%), followed by non-Hispanic White (23.1%), Asian (20.5%) and Hispanic (15.4%). Two-thirds (68%) of the households had less than $25,000 in combined income last year. This is significantly less than the median income of households in Champaign County during the same period which was $44,765. The households surveyed also had an average of 4.2 people living in the household and an average of 1.8 school-aged children. Nearly half (47.5%) of the children did not have health insurance. For those who had health insurance, two-thirds were insured by Medicaid. When asked where they would go to get the required health exams, over half (56.4%) of the respondents said that they did not have anywhere else to go or did not know where to go. Over one-third (35.9%) responded that their children would be "very likely" or "extremely likely" to miss school because they could not get exams on time, and 25.6% said they would be "somewhat likely" to miss schools. The top three ranked reasons for choosing CUPHD were "it is free" (average ranking 2.06); "it is on Saturdays. It's difficult for me to find time on weekdays" (average ranking 2.38); and "it is convenient because my children can get physicals and shots at the same location" (2.63).     Based on the survey results, it is not difficult to see that the clients of the clinic are disproportionately racial and ethnic minorities, newly immigrated, and low-income children--populations that are medically underserved. For many of the clients, the clinic is the only place to get affordable and timely services. This suggests that the clinic has successfully reached its targeted population. The clinic is likely to continue to be in demand given the large influx of immigrant or migrating population in the community. The perceived benefits of the clinic are high, suggesting that the clinic has effectively addressed the needs of the clients.      
Sustainability   Several features of the clinic are keys to the success of the program.  1) Convenience- The clinics offer a “one-stop shop” where clients can conveniently receive multiple services at the same location. One-stop shop specifically addresses the fragmentation of care--a significant problem of the current community health care delivery system. 2) Timing-The clinics are open on Saturdays around the time school starts. Pediatric clients are a special patient group because they are dependent on their parents or legal guardians to receive services. For many working, low-income parents, their employment does not offer much flexibility or paid leaves. Their work schedules often coincide with office hours of primary medical providers, limiting their access to necessary care. Offering services at a time that is convenient to the parents of the targeted children increases utilization of needed care. 3) Commitment-The main partner, the Carle Family Medicine Residency Program, is an ongoing program at the Carle Hospital in Champaign. The practice serves the mutual interests of the residents and the interests of CUPHD. The Family Medicine Residents are required to take on one community project during their three years of residency training. The practice is an excellent opportunity for the residents to practice their skills and meet their program requirement. The interests from the residents in participating in the practice have been high from the start. In fact, the residents who initially participated and co-designed the clinic are leaving the residency program, and several new residents have already taken on this initiative and have started working at the clinic. This enthusiasm and continuity ensures that the practice will continue without interruption.     
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