Health System Spotlight with Oregon Health and Science University: Improving Immunization Access for Older Adults-Health System Spotlight: Oregon Health and Science University

Video Transcription

All right. Hi, all. My name is Brianna Terima, and I'm presenting with John. And we're going to share one way that we improved immunization access for older adults. Next slide.  So we're from Oregon Health and Science University, where there are 12 primary care clinics, all with age-friendly health system status, committed to care excellence.  We are involved in the Internal Medicine and Geriatrics Clinic at Markham Hill. We currently have over 50 faculty members and over 3,500 patients.  Here's a picture of Markham Hill, where we're located. And we are the only clinic participating in this trial for OHSU. Next slide.  So we started with creating a cause and effect diagram, shown here, where we identified some potential areas for improvement and change. We're actually only going to be talking  about the one in orange, where we identified that there's an inability to offer Medicare Part D vaccines in our clinic due to billing everything. So I guess next slide.  We identified that patients were neglecting to go to the external pharmacy when we referred them out, even if the pharmacy was located in the same building.  So we identified that this is a potential area for improvement. So one of the ways that we discussed potentially addressing this was to pay for the out-of-network patient co-pays.  But after looking into that briefly, we identified that that was too expensive and unsustainable. So our next plan of action was reaching out to our pharmacy  team to see if it was possible to offer vaccines in our clinic. And so I'm going to pass it over to John to discuss how that went. Yeah, as Brianna was outlining, and I'm  sure this is probably an issue that is shared across many, many health systems, many clinics, is that one of our biggest barriers, obviously,  is connecting patients, getting them Medicare Part D covered vaccines, connecting them to getting the vaccine actually put in their arm. So by working with our pharmacy, which  is co-located in our building, it's not co-located within our clinic, it's actually two floors down from us, we were able to design a workflow through our EHR  and through the practical aspects of the flow of our clinic to get patients these vaccines at the time of service, so at the time of the visit. So next slide.  So we connected with our pharmacy team, and then the first step that we took, which is really kind of arguably the most critical step,  was establishing a collaborative drug therapy management, or CDTM, document with our pharmacists, which allowed our pharmacists to be able to, in quotes,  prescribe these vaccines to patients Medicare Part D payers and run them through insurance. Now, as you all know, pharmacists across the country  already have the ability to prescribe Medicare Part D covered vaccines. However, doing it this way allowed the flow between our clinic and the pharmacy.  So what we did is we built a new order for each of the Medicare Part D vaccines in our electronic health record, which is Epic, which is almost essentially like a dummy order.  And so our staff will order the vaccine using that dummy order in clinic, and they'll communicate with the pharmacy to prepare the vaccine.  And then the pharmacy brings the vaccine to us. And the reason that dummy order is necessary is it allows our staff to document that the vaccine is given, but it  doesn't have a charge associated with it because the charge is being billed through the Medicare Part D facing side of things. We worked with our IT team to build that dummy order.  And I'll show you when we go to the next slide. We designed this new workflow. So the medical assistant places the vaccine order in Epic.  And really what it is is it kind of comes up in Epic and it says, you type Shingrix, and there's two Shingrix options. There's the regular flavor Shingrix,  and then there's Shingrix Medicare Part D. That's literally the language that it says. And so the MA places the order. Our physicians or other providers  can, of course, order vaccines as well. Here at OHSU, we have pretty robust delegation protocols. So our medical assistants can order any routine vaccines  that a patient is due for without consulting with their provider first. So generally, it's the MA ordering the vaccine. Once the MA places the order and, of course,  talks to the patient to make sure they want it, they then use a dedicated Teams channel. And Microsoft Teams really doesn't matter that it's Microsoft Teams.  That's just the platform that we use here at OHSU to communicate with our pharmacy staff who are dedicated to this project to say, hey, this patient,  this MRN, this date of birth, this name needs this vaccine. The pharmacy staff on the other side, in this case, literally downstairs from us, prescribe the vaccine,  run it through Medicare Part D, prepare it, put a label on it, draw it up, and deliver it to kind of a, essentially, special secured box that we have at our front desk.  Then our front desk staff let the MA staff know that the vaccine has arrived. MA goes and grabs it. They scan it. We use barcode medication administration.  So they scan it using a barcode scanner, which, of course, ensures it's the right vaccine, right patient, right dose, all of that.  And then our clinic bills for the administration fee. And so we worked with the folks in the pharmacy to make sure that when we're billing the Medicare Part  D payer for the vaccine, that we're pulling out the administration fee. So the patient's not being billed for the administration fee two times. It's separated.  So the pharmacy is billing the vaccine itself, and then the clinic is billing the administration fee. Next slide. So we started doing this in, really, I would say, late January.  And this is what we have accomplished so far. So this chart is patients who are 65 and up with Medicare. And so, obviously, COVID and influenza,  although we're focusing on increasing rates of uptake for the purposes of the grant we're working on, those are not Medicare Part D vaccines.  But three of the others here are, RSV, Shingrix, and Tdap. And you can see that our numbers, of course, started at zero because we weren't  giving any of these before, but have kind of deliberately increased on a month-by-month basis. So we haven't seen huge uptake with RSV.  Obviously, that vaccine's kind of a bit of a gray area right now. But we've been giving a lot of Shingrix and a lot of Tdap. And we really expect these numbers  to keep going up and up and up. This is essentially two and a half months' worth of data. So we expect that as we continue this program, we will see kind of a real meaningful uptake  in our administration rates. And then, of course, as we re-enter the fall, we'll see more flu and COVID vaccines given, and then also now with the additional COVID booster.  We expect those numbers to go up as well. Next slide.  All right, so what have we found? And I'll answer the question I saw in the chat in a second. So obviously, it's much more convenient for patients  to get Medicare Part D vaccines in the clinic than it is for them to go to the pharmacy to get it. And keep in mind, it's not as though the pharmacy downstairs from us is new.  The pharmacy has been co-located with us for, I don't know, 20 years maybe. But even asking patients after they wrapped up their visit  to go walk downstairs to get the vaccine at the pharmacy, our rates of conversion were abysmal. And I'm sure that that's shared across most health systems.  I think there's a psychological factor.  I need to get out of here. And oh my god, the line for the pharmacy is so long. I'm not waiting for that. And so we have found that the uptake and satisfaction  with our patients has been really high. We have not really had any kind of serious disruption to our clinic workflow at all. Really, one of the biggest things  we really need to pay attention to when we do this is it's very important that we assess whether the patient wants or needs the vaccine as early as possible during the visit.  Because although it is not an extremely long length of time to obtain the vaccine from the pharmacy, it's still a length of time.  So if we determine that the patient needs the vaccine as the visit is ending, that's going to add 10 to 20 minutes on their stay in the clinic. And we like to avoid that.  So we try and get this done as quickly as possible. One of the next steps that we're taking, we have hired a medical assistant to kind of champion this program.  And over the next few weeks and months, we're going to begin scrubbing patient charts before they come in and reaching out to them to understand,  hey, looks like you do for a Shingerix vaccine. You're coming in on Tuesday. Is that something you want? And so that way we can really kind of get ahead of the game  besides just waiting for the visit.  The hurdle was doing a little bit of work with our electronic health record to make sure that the billing is right, to make sure that the things are getting documented correctly.  We had some very small hiccups with that in the beginning, but nothing that was insurmountable. It was really just, we had never done this before.  So it was just learning, how do we do this?  Let me see here. There was a question in the chat. So yeah, the only epic thing that we built  were basically dummy orders. So there's a Shingerix Medicare Part D dummy order,  Tdap Medicare Part D dummy order, RSV Medicare Part D dummy order. And what we have on the backend is what makes it a dummy order is not that it isn't, it is completely reportable.  It's completely, it appears in Epic just like a regular Tdap. The only difference is the backend charge has a new charge class. So before our choices were either supplied by patient  or supplied by clinic. And now it is, we have a pharmacy supplied option which drops no charge.  So the dummy part of it is really the charge part. The functionality of the order is identical.  Yeah, so our Microsoft Teams instance at OHSU  is considered to be secure and HIPAA compliant. We have multi-factor authentication to log into Teams here. And so we have not had any issues from a security standpoint.  And then from a patient safety standpoint in the Teams communication, we require three patient identifiers to order the vaccine properly. So they can't just write,  like, oh, get a Tdap for Mrs. Smith. We require the MRN date of birth and patient name.  And then is there no charger?  So I'm not sure I under, Eric,  I'm not sure I'm understanding the question right. If you wanna pop off mute and ask. Yeah. Happy to. Just knowing that Epic is such a big system  and a lot of the times where there's this unique use case,  it could be accidentally used by like a PCP office and like where the charge is intended. Now I get it. So yeah. Okay, so yes, we anticipated that.  And we have made that special, this special order, cause this is only occurring at our clinic right now. We have made that part of our preference list  for this clinic that are walled off from access from across our health system. So they can't use it.  That's awesome. Thank you. Because yes, we were worried about the exact same thing, which is like, well, what if some other clinic just starts using this by mistake  and they run into all kinds of trouble. So yeah, we've kind of, we've hidden it from them essentially.  And then we do stock, we stock RSV vaccine in the clinic, Abrizo. However, the stock that we use, we do not use for this program for patients getting the Medicare Part D vaccines.  They come up from the pharmacy and we just stock that in our refrigerator, as far as I know, just like our other general vaccines.  Other questions?  Yeah, so I mean, in summation, obviously this is, it's a workaround, right? But it's a workaround that I think closed a gap that was a real thorn in our side for a long time,  which is, you know, this is something pharmacy could already do. This is something we could already recommend to our patients, but that kind of physical gap between the two domains  was really prohibitive to getting anything done.  One of the questions that did come up, and I'm wondering if anyone's thing is like, well, why don't you just stock the vaccines in their clinic  and kind of work with pharmacy to prescribe it? But because there are issues around dispensing in the clinic, we can't do that.  So the vaccines have to come up directly from the pharmacy. So that's kind of the one funky part of this, that the vaccine has to be physically delivered. But by and large,  this has been very successful for us clinically. I think the patients like it. We have had no problems with charges on the insurance side of things. And we've given, you know,  obviously a few hundred vaccines with no misadventures. So we've been happy.  How many dummy orders? So three.  We do have separate order. So we created one for Tdap, RSV, and one for Shingle. So that's three. And then we have separate orders for vaccines that are not part of this program.  So, and they're identifiable by name. So like one of the orders looks like Tdap, you know, Medicare Part D only, and the other one is just Tdap. You know, same with Shingrix, RSV.  They're very identifiable in the language that appears on the order. Basically the order says, you know, like, hey, if you're not doing this for a Medicare Part D patient,  don't use it. Don't click it.  It's very obvious.  Any other questions about this? I don't think there's any.  But thank you so much.

Video Summary

Brianna Terima and John from Oregon Health and Science University explained how they improved immunization access for older adults by offering Medicare Part D vaccines in their clinic. They identified a barrier where patients neglected to go to an external pharmacy for vaccines, leading to low uptake. By collaborating with the pharmacy team, they designed a workflow to prescribe and administer vaccines during the clinic visit. They created dummy orders in the electronic health record and communicated through a dedicated team's channel. This approach increased convenience and patient satisfaction while maintaining clinic workflow. Data showed increasing uptake of vaccines like Shingrix and Tdap. Their future plans include proactively reaching out to patients for needed vaccines and ensuring correct billing and documentation.

Asset Caption

On the April 2024 SSAAI Quality Improvement and Data Leads call, Jonathan Soffer and Bryanna De Lima from Oregon Health & Science University presented on their quality improvement initiative to improve vaccination rates for Medicare Part D patients by arranging for pharmacy delivery of vaccines to the patients during their appointments in the clinic. The attached slide deck includes a screen shot of an example of a dummy order in OHSU’s electronic health record, which was not included in the recorded presentation.

Keywords

immunization access

older adults

Medicare Part D

pharmacy collaboration

vaccine uptake