Immunizations and well visits

hoosier guy · Aug 29, 2012

You can lead a horse to water...

Tinabeanrn · Aug 29, 2012

Awe..how are you going about asking them to bring the little one in for a well child visit?

nightengalegoddess · Aug 29, 2012

I have one patient who parents refuse to immunize, I'm fine with that as all the proper documentation on vaccine refusal is cocomplete, my issue is they only bring the child in for acute appt's .they have never kept a appt for a well child, they walk in at the end of the day, and insist the child be seen. Last time the child was brought in they were concerned about pertussis, it wasn't, today at the end of a horrible day, the child was brought in for concerns of measles, turned out to be fifth disease from classical presentation. I have tried to get the child in for a well visit with no luck . Any suggestions to get a kid in who is 3 for a well child visit ? I have reminded the parent repeatedly to bring the child in. Thanks

Hi. I was that kind of parent before I was a nurse. I did not believe in Western Medicine, but I sure knew as many signs and symptoms as I could from reading obssesivley. For some parents...old world types......they see no reason to fix anything unless it is broken. They have little trust in western medicine.....but will seek us out when tragedy strikes. I see these parents as being as responsible as possible within their values. They see something wrong, they bring the kid in. They are afraid of vaccinations....and there is a lot of study to prove they are right......and these parents have a hard time weighing the forgoing of immunizations to the taking......weighing the possibilites of neurological damage that is irreversible to the possibility that their child may survive many of the ailments....just as some did in the old world. They don't bring the kid in,,,,,because they don't see any reason to pay the money for you to tell them the kid is ok. They are obviously concerned or else they would NEVER bring the child in. So...there is NO WAY to fix this one. A good parent knows when a child is ok....and knows when the child is NOT ok...I would be grateful the child is ok at all....and that the parents are concerned at all.

Frankly, I did not bring my child in unless something was wrong. And I was just like these annoying people!! But my son is fine. And he got the immunizations I thought most important....AND.....he is lucky. Although I DO respect the nurses like you who volley for well child checks....your aim is true...your heart is full....thank you for being you......

pedspnp · Aug 29, 2012

Thanks for a completely differrent perspective, you have some very valid points. I never took my children in unless they were sick , or if they needed yearly physicals. This child has never had a well visit, and when I do see him, I try to adress growth and development in the time I have, but she only wants to discuss the acute issue. I guess I'll just have to accept this is how she chooses to have the child cared for from a medical stand point. Of course I do document the discussion about well visits and her response. Again thanks and also for the kind words.

CRF250Xpert · Aug 29, 2012

If you fire the pt will you go hungry or will that spot in your practice get instantly filled with a family that actually wants to hear what you have to say and wants to participate in the care of their child?

I am a huge fan of getting rid of the dead weight in my life so I can get in the folks that actually want care. Every time I get an opportunity to fire a non-compliant obese, hypertensive Diabetics with hyperlipidemia and CKD - I get rid of them. Life is too short to spend every day wondering "how can I get this person to xyz?"

The real answer is you and I can't make anyone do anything. If they don't want to participate in the plan - wave goodbye. That approach has made my life so much better versus hammering my head against folks who don't care and blame me for all of their problems.

ToughingItOut · Aug 30, 2012

So...these parents have been genuinely concerned that their child might have measles...and pertussis...yet they will not vaccinate? Instead, they insist upon dragging their potentially highly contagious child through a pediatric clinic full of other susceptible infants and children and demand to be seen. Excellent parenting people.

BlueDevil,DNP, DNP, RN · Aug 30, 2012

We will not see children who's parents refuse to vaccinate, so I don't have that problem. They either abide by the CDC schedule or find another practice (which is getting increasingly difficult in this area, few providers will take them). Parents are provided a copy of the policy at the first visit, so no one is caught by surprise. All patients are also required to have a CPE annually or they cannot remain a patient of the practice. We are not an urgent care. We do primary care, and that means you have to actually present for primary care at least once a year to be a patient in the primary care practice, lol. This rule, I am told, is actually imposed upon the company by the underwriter of our group malpractice policy. We do not do acute visits for people who are not established primary care patients, and we certainly do not ever prescribe for anyone lacking basic primary care screenings.

Some patients balk at this, but we are pretty much full, so it isn't really a problem. If they get mad and leave in a huff, it opens up a spot for someone who does want some primary care-which is after all, our fundamental purpose. Most of the time it is simply a matter of reminding them. If they fail to comply, they get dismissed. It is so hard to get in with a PCP here (and no specialty provider will see them w/o a PCP either), no one wants that!

Perhaps your group should consider some kind of formal policies in a similar vein.

Lovanurse · Aug 30, 2012

At the office I uses to work at, if they are due for a WCC, they get one. We used every opportunity to do the WCC even if they only schedule for sick visits. It usually works out because people cancel and fail to show anyway. Plus, these kiddos are usually well (no co-morbidities) , so it doesn't take that much extra time to just do it.

pedspnp · Aug 31, 2012

In our practice, if they are sick we do not do WCC visit as they usually need immunizations. I don't immunize if they are sick. Plus WCC are given a 30 minute slot vs 15 for a sick visit. Besides when you go too code you can't code for a well visit, immunizations plus a strep test and dx code for pharyngitis. We also do ASQ's at certain intervals and these are or can be time consuming for the parent and what parent wants to out a 6 page form with a crying puking kiddo.Most of my patients are on public aid and Medicaid is very picky about reimbursement. Most of my parents do bring them in for WCC it's just this one in particular who doesn't bother. I feel that a through WCC benefits the child along with it being a AAP guiedline. While your idea may work at your office it would never work at mine.

Lovanurse · Aug 31, 2012

Yes. Had the exact same population and that was the reason why we had to use every opportunity to vaccinate because of non-compliance. Especially teenagers. In most cases, if there's no fever, you get vaccinated. There are ways around the coding situation. See link below. Immunization Coding Questions and Answers from the AAP Coding Hotline

Lovanurse · Aug 31, 2012

"Every opportunity should be taken to provide appropriate vaccinations. The decision to delay vaccination because of a current or recent acute illness depends on the severity of the symptoms and their cause. Although a moderate or severe acute illness is sufficient reason to postpone vaccination, minor illnesses (such as diarrhea, mild upper respiratory infection with or without low-grade fever, other low-grade febrile illness) are not contraindications to vaccination."http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-2-the-pre-travel-consultation/general-recommendations-for-vaccination-and-immunoprophylaxis.htm