your ally in protection - texas immunization conference · 2019. 10. 17. · 10/16/2019 1 your ally...
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Your Ally In Protection:
How Pharmacies Can Improve Adult Access to
Immunization
Texas – The Lone Star State
• 261,232 square miles
• Total population: 28,304,596
• Total adult population (18-64 yrs):
16,560,325
• More than 7,460 pharmacies in Texas
*Source: 2015 Small Area Health Insurance Estimates Program, US Census Bureau
Centers for Disease Control and Prevention PPHF
The Adult Prevention and Public Health Fund (PPHF) awarded in 2015
Large provider groups, community health centers and pharmacies:
a. Offer education to clinic staff b. Evaluate data and policies c. Encourage use of the Texas
Immunization Registry, ImmTrac2
Targeted facilities for site visits:• Pharmacies
• Pharmacy list obtained from Texas Pharmacy Association (TPA)
• ASN Program
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Texas Pharmacy Partnerships
Prior to Adult Prevention and Public Health Fund (PPHF)
• ImmTrac2 use:
▪ Large chain pharmacies headquarters submit data on behalf of sub-sites
▪ Few independent pharmacies
▪ Barriers
▪ Consent process
▪ Low pharmacist and staff knowledge of the registry
▪ DSHS interaction: Low
Texas Pharmacy Association (TPA)
• Partnership opportunities
• Newsletter articles
• Conference presentations and booths
• Shared information and resources about ImmTrac2
• 2018 Texas Pharmacy Association Conference
• Presentation
• Exhibition Hall Booth
• Immunization Resources
• ImmTrac2 Resources
Establishing New Pharmacy Partnerships
Large Chain Pharmacies
(Walgreens, HEB)
• Pharmacy site visit participation
• Barriers:
• Approval process long for site visit
• Adoption of consent process strict
• Already developed materials
Independent Pharmacies
• Pharmacy site visit participation
• More flexibility with adoption of registry consent process.
Establishing New Pharmacy Partnerships
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Goal of Adult PPHFTo remove barriers to vaccines and improve vaccination coverage rates for adults in Texas.
CDC Standards for Adult Immunization Practice1. Assess immunization status for all patients
at every encounter.2. Strongly recommend vaccines patients need.3. Administer needed vaccines or refer patients
to a provider who vaccinates.4. Document vaccinations that patients receive.
https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html
Pharmacy Site Visits
Pharmacy Site Visits
Target populations• Pharmacies
• Large Chain• Independent
Objectives
• Offer education to clinic staff
• Encourage reporting the number of vaccine doses administered to adults to ImmTrac2 (Texas immunization registry)
• Increase adult immunization coverage rates
• Increase partnerships
Adult PPHF Pharmacy Site Visits
2017 Initial Pharmacy Site Visit
Pharmacy site visit:
• Standards for Adult Immunization Practice
• Storage and handling
• Provide immunization educational resources and encourage immunizations trainings
• Reviewer: Adult and Adolescent Immunization Coordinators (AAIC)
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Adult Immunization Program Quality Assurance
2018 Pharmacy Site Visits
• CDC Standards for Adult Immunization Practice
• Provide immunization educational resources
• Reviewer: DSHS Contractor
Adult Immunization Program Activity (Adult PPHF)
2017: Pharmacy Site Visits
• December 2017 - February 2018
• 8 Initial site visits completed
• Independent pharmacy
2018: Pharmacy Site Visits
• June - August 2018
• 1,225 pharmacy sites
• Independent pharmacy
• Large chain pharmacy
Results - Assess
Do you/your staff assess a patient’s needs at every visit?
47%
52%
1%
Always Sometimes Never
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Results - Assess
What do you use to assess a patient’s vaccine needs?
98%
36%
1%
EMR/HER Patient Records ImmTrac2
* Response could include multiple selections.
Results - Recommend
Do you or your staff recommend vaccine(s) to patients?
99%
1%
Yes No
Results - Administer
Do you vaccinate in your facility?
99%
1%
Yes No
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Results - Refer
If you do not carry all recommended vaccines, do you refer the patient to another facility?
99%
1%
Yes No
Results - Refer
What type of clinics do you refer patients for vaccination services?
37%
95%
47%
State or Local Health Department Pharmacy Other
* Response could include multiple selections.
Results - Document
Do you or your staff check if you patient is currently listed in ImmTrac2?
5%
95%
Yes No
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Results - Document
If you or your staff do not find the patient in ImmTrac2, is consent collected?
4%
96%
Yes No
Pharmacy Registry Activity
• Pharmacies registered in ImmTrac2
2018: 2,749
2019: 3,420
• Immunization submitted:
2018 (January): 2,322,628
Accepted – 395,913 (17%)
Rejected – 1,026,320 (44%)
Other* - 900,395 (38%)
2019 (April): 6,228,543
Accepted – 912,515 (15%)
Rejected – 5,314,991 (85%)
Other* - 1,037
Key Findings
Pharmacies are:
• Not using the registry to assess immunizations compared to EMR/HER
• Incomplete immunization record
• Over/under immunization
• Actively vaccinating and sending information to ImmTrac2
• Number of accepted immunizations in ImmTrac2 shows need to improve adult consents
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Challenges
• Short amount of time for site visit with pharmacist.
• Reduced education:
• Immunization resource education
• ImmTrac2 consent process education
• Pharmacy access to ImmTrac2 (web-based)
• Adoption of ImmTrac2 consent process in large pharmacy chain systems
Moving Forward
Continue to:
• Strengthen relationships with pharmacies
• Work with pharmacies to:
• Adopt a process to assess patient immunization records using ImmTrac2
• Educate on ImmTrac2 consent process to increase the number of accepted immunizations
Thank You!Denise Starkey, MPH, MA
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Your Ally in Protection:How Pharmacies Can Improve Adult Access to Immunizations
Debbie Garza, R.Ph., CEO
October 24, 2019
Texas Pharmacy Association
Since 1879, TPA has been the state’s leading advocate for ALL pharmacy professionals.
As THE voice for all Texas pharmacists for nearly 140 years, TPA continues in the important transformation of the patient-pharmacist relationship and the evolution of the role of pharmacy professionals as active health care providers.
Texas Pharmacy Overview
• Texas Pharmacies (>8,000)• >3,100 Chain
• >1,600 Independent
• Texas Pharmacists• 27,000 Licensed
• Pharmacists are the most accessible providers• 91% of Texans live within 5 miles of a pharmacy
• Pharmacists are highly educated• Doctor of Pharmacy (Pharm.D.) degree can take 6 to 8 years
to obtain
• Many pharmacists complete a one- or two-year postgraduate residency program
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Today
1984 1987 1990 1993 1996 1999 2002 2005 2008 2011 2014 2017
Pharmacies served as mass-vaccination clinics run by other visiting health care providers1800s – 1990s
Only 9 states allow pharmacists to immunize 1995
Maine was the last of the 50 states to allow pharmacists to vaccinateSept 12, 2009
>300,000 pharmacists are now licensed immunizers 2019
Washington State Pharmacists Association initiated the first ongoing formalized training for a group of 50 pharmacists in vaccine administration
1994
APhA began its nationally recognized training program for pharmacists, Pharmacy-Based Immunization Delivery
1996H1N1 virus pandemic sparked fear
April 25, 2009
Pharmacy & Vaccination Authority
Texas pharmacists allowed to vaccinate1997
Despite This Fact…
• Adult vaccination rates are low, increasing their susceptibility to serious illness and complications.
• Every year, at least 45,000 adults in the United States die from vaccine-preventable diseases.
• A majority of adults who die from vaccine-preventable infections had visited their health care provider in the year before their death and they were still were not vaccinated.
• There are no formalized vaccination delivery programs for adults.
• U.S. survey data show that the average wait time for an appointment with a primary care physician is about 20 days.
Why Is This?
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Healthy People 2020
Vaccine Age Stratification Coverage Rate* HP 2020 Goal**
Influenza >65 years 66.7% 70%
Influenza >18 years 43.6% 70%
Tdap >65 years 61.3% 90%
Tdap >19 years 20.1% Not Set
Hepatitis A >19 years 9.0% Not Set
Hepatitis B >19 years 24.5% Not Set
Herpes Zoster >60 years 27.9% 30%
HPV Females 19-26 years 40.2% 80%
HPV Males 19-26 years 8.2% 80%
*Source: MMWR Surveill Summ 2016;65(No. SS-1):1–36. DOI: http://dx.doi.org/10.15585/mmwr.ss6501a1**Healthy People 2020 Goals (presented where set by the United States Public Health Service)
Influenza
• Most (>95%) pneumococcal deaths in the United States are in adults.
• Yet 80% of adults with conditions that put them at increased risk and 40% of adult ≥65 years remain unvaccinated.
Pneumococcal
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• Herpes zoster is common: approx. 1 million cases each year in the U.S.
• Herpes zoster vaccination coverage in 2017• ≥60 years = 34.9%
• Incidence increases with age:• 50–59 years = 5 cases per 1,000 population
• ≥80 years = 11 cases per 1,000 population
Herpes Zoster
Economic Burden
Vaccine-preventable diseases cost the U.S. billions each year.The U.S. spends about $26.5 billion annually treating four major vaccine-preventable diseases among U.S. adults (≥50 years).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4486398/
$16B$5.1B
$5B
$397.7M
Flu
Pneumococcal
Shingles
Pertussis
Priority is low Lack of information
Hesitancy due to fear and
oppositionsLack of accessibility
Systemic and operational obstacles
Barriers
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The Unmet Need
By 2025, the U.S. could see a shortage of as many as 31,100 primary care physicians. Even if nurse practitioners and physician assistants are fully utilized, patient needs will not fully be met.
Texas has 463 designated HPSAs and only 67% of the primary care needs in those areas are currently being met. Pharmacists can help.
Evolving Role of Pharmacists
Trusted Professional
Medication Expert
Health care Provider
1. Provide easy access
2. Extended vaccines available
3. Flexible and extended hours
4. Community outreach
5. Lower cost• Average direct costs paid per adult vaccination were lower
in pharmacies compared with physician offices and other medical settings by 16%–26% and 11%–20%, respectively.
Pharmacist Role
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• Applies to all patient care services delivered by pharmacists in any practice setting
• Example – Immunizations: assessing, administering, and/or referring
• Immunization Integration• Rx intake• Patient counseling• MTM• Disease Management• Transitions of care
Pharmacist Patient Care Process
Providing consistency for patients and health care
http://www.pharmacist.com/resource-guide-immunization-services?dfptag=imz
• Community/Public Health Need• Immunization rates• Consumer/patient access • Vaccine-preventable disease protection
• 86% of community pharmacies provide immunizations
• Act as community educators throughactively screening all patients for missing or recommended immunizations
Why Pharmacists?
Texas Voters Agree
Pharmacists help patients use medicines safely and stay healthy. Their extensive education empowers them to do even more to improve patient health and quality of life. That’s why voters in Texas support Medicare enrollees being able to receive services from their pharmacists.
Source: NACDS Morning Consult 2018
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• Adult Immunizations
• Senior Immunizations
• Back-to-School Immunizations
• Travel Immunizations
Creating Awareness Beyond Flu
• Most common place of vaccination: doctor’s office• Children: 64.6%• Adults: 34.7%
• Other common places of flu vaccination reported by adults• Pharmacy: 28.2%• Workplace: 17.0%
• Increasing number of adults getting influenza vaccination in community pharmacy• 2004–2005: 6%• 2017–2018: >25%
Vaccine Administration (2017‒18)
http://www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2017.htm
Access to patient
vaccination history at point-of-
care
ACIP Guidelines review to identify unmet
vaccination needs
Pharmacists assessment of patient-
specific unmet needs
Patient education
about vaccine
needs and status
Administra-tion of
recommend-ed vaccines
Documenta-tion in IIS to communicatewith other providers
Unmet Vaccination
Needs Resolved
Project IMPACT Immunizations
41.4% Increase in Vaccination Administration
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What efforts and strategies have been implemented to increase adult vaccinations?
Advisory Committee on Immunization Practices (ACIP)
Goal: To provide advice that will lead to a reduction in incidence of vaccine-preventable disease in the U.S. and increase the safe use of vaccines.
ACIP
CDC Adult Immunization Recommendation
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CDC Adult Immunization Recommendation
• National Vaccine Advisory Committee• Recommends ways to achieve optimal prevention of human
infectious disease through vaccine development and provides directions to prevent adverse reactions to vaccines.
• Standard for Adults Immunization Practice• To provide guidance to health care providers across the
spectrum of health care.
• Updated 2013; reinforced immunization as routine part of health care.
• 2014: NVAC released recommendations for adult immunization standards, recognizing pharmacists as having a vital role in increasing adult vaccination rates.
NVAC
The update called on ALL health care professionals to ensure adult patients are fully immunized:
1. Assess the immunization status of all your patients at every clinical encounter.
2. Strongly recommend vaccines that your patients need.
3. Administer needed vaccines or refer your patients to a vaccination provider.
4. Document vaccines received by your patients.
Standard for Adults Immunization Practice
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• Highlights the need for professionals to be:• Well educated
• Up to date
• Be knowledgeable!
NVAC
To boost adult immunization rates, the first-everNational Adult Immunization Plan (NAIP) was released in 2016 by U.S. Health and Human Services.
Establishes four key goals, each supported by objectives and strategies to guide implementation through 2020:
1. Strengthen adult immunization infrastructure
2. Improve access to adult vaccines
3. Increase community demand for adult immunizations
4. Foster innovation in adult vaccine development and vaccination-related technologies
NAIP
• The Texas Immunization Registry is a no-cost service that consolidates and stores vaccine records from a variety of sources.
• All sources are stored in ONE electronic system.
• With more than 164 million immunization records, the Texas Immunization Registry is a major component of DSHS initiative to increase vaccine coverage across Texas.
ImmTrac2
https://www.dshs.texas.gov/immunize/immtrac/FAQs.shtm
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• Downfall:• Opt-in registry
• Consent form needed
• Mailing• Burden for healthcare professionals
• Software requirement
• Benefit:• Recording immunizations,
contraindications, and reactions • Validating existing vaccines to a vaccine schedule and
providing forecasts for vaccines due and past due • Producing recall and reminder notices, vaccine coverage
rates, and client reports
ImmTrac2
As medication experts,
pharmacists are playing an
increasingly important role in the provision of
health care services, moving
beyond the traditional
dispensing role
Pharmacists are capable of providing a range of services from
medication monitoring, patient
education, comprehensive
medication reviews, coordination of medications in
transitions of care, prevention and
wellness, and disease management
Outlined in the report, Improving Patient and
Health System Outcomes Through
Advanced Pharmacy Practice: A Report to the Surgeon General 2011, pharmacists’
patient care services have grown beyond
functions tied to medication product
and delivery
Pharmacists Can Play A Greater Role
Value of Pharmacy
• Pharmacists are the FACE OF COMMUNITY HEALTH CARE
• Pharmacists HELP PATIENTS use medicines safely and stay healthy
• INNOVATIVE pharmacy services do even more to IMPROVE patient HEALTH and QUALITY of life
• Pharmacy services IMPROVE healthcare AFFORDABILITY
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