Primary Care and Immunization Compliance

[MHDNURSE]

I used to work at a pediatric primary care clinic in Washington DC. We had the immunization requirements for entering school posted in our waiting rooms, the residents who worked at the clinic all had copies of the requirements for kids entering Kindergarten, the front desk knew to schedule all four year check-ups on or after the fourth birthday, and I can say that 99.9% of our kids who came in for their four year check-ups received the required immunizations they would need to begin Kindergarten. Once in a blue moon, we would have a parent call saying the school was excluding them because they were not UTD and we could always figure out what had happened (kid no-showed and never rescheduled, or was febrile the day they should have been vaccinated, etc.). Sometimes the school made a mistake and got dates wrong, etc.

Now I live in MA and am a school nurse here and I am shocked at how many of our kids do NOT have immunizations that are required for Kindergarten. My own kids go to a practice that does not routinely immunize at the four year visit, so all those kids who have an UTD physical to enter K, might not have UTD immunizations because they turn five after the visit but before they start K. And as I look through student's immunization forms, it looks like it is a free for all at the pediatrician's offices and they all practice differently. I just submitted the annual Kindergarten Immunization Survey for my state and I have 10 kids out of compliance. Of those 10, 9 all had physical exams sometime in the last 4-6 months and their primary care providers, for whatever reason did not immunize them with DTaP, IPV, MMR and Varicella. I find it hard to believe the parents did not mention they would be starting school in the Fall. I don't get it. So now they are trying to get appointments to go back in, the clinics say "you are UTD and your insurance won't cover another visit until a year from now" Not sure what to do here and they of course get frustrated with ME because I am telling them they are out of compliance and the peds are telling them they are UTD.

I miss my super organized clinic in DC that was ON IT with immunizations!

What are you seeing in your area and have any of you worked with the local pediatricians offices to streamline this process a little better.

Many if not all of my students have Mass Health (Medicaid).

Thanks.

[Farawyn]

NY is pretty good with compliance. My biggest challenge is the second meningococcal.

[ruby_jane, BSN, RN]

Ironically those who are on Medicaid here in the NTX seem to be better-covered than those with no insurance. Medicaid providers have a program called First Steps and that program alerts them to all the services available by age. With private pay it's about 50-50. When I changed districts I had to start paying attention to the preK/K (the "four year old shots"). We had a lot of late starters this year and I've never seen so many catch-up schedules.

[UrbanHealthRN, BSN, RN]

I'm in the pre-K group so I don't have to enforce the K-required vaccines, but I have to enforce every vaccine up to that point.

I'm on the same page as you, MHD. I did clinic work for several years and we were always excellent with keeping our patients UTD. The kids here at school, though, are a bit more varied with vaccine compliance, and some of it definitely comes from the providers, based on phone calls I've made to pedi offices.

I'm not sure why kids are or are not getting certain vaccines at their physicals, but here's a couple thoughts of mine:

1) the DTaP vaccine, due to its waning effectiveness before a child is due for TDaP, is being deferred until the 5 or 6 year PE by some pedis (provided it's still done before a child starts K). This is why I'm seeing many kids get their MMR/Varicella at 4 year PEs and DTaP at 5 years.

2) why won't pedi offices take the kids back for a vaccine visit? It can be a nurse-only visit, or be billed by the pedi just for vaccine administration. Insurance will definitely cover this.

[OldDude]

Our local pediatric offices keep track of nothing and send out no reminders. One office doesn't even participate in entering immunizations into the state registry. But they never forget to collect a copay or bill you for something not covered by an insurance policy.

[mdavis2018]

I run into the same issues, where the local offices do not keep detailed records.

[DowntheRiver]

I am not a school nurse but used to be a vaccine nurse for the DOH in Florida. Most Pediatricians carried vaccines but not all Pediatricians carried vaccines due to cost and volume. So, we'd see kids that had routine physicals but did not receive vaccines. So, maybe that is a possibility as to what happened?

[OldDude]

I am not a school nurse but used to be a vaccine nurse for the DOH in Florida. Most Pediatricians carried vaccines but not all Pediatricians carried vaccines due to cost and volume. So, we'd see kids that had routine physicals but did not receive vaccines. So, maybe that is a possibility as to what happened?

We have two pediatric offices in town; both of which are part of a large multi office operation in the area. They stock immunizations and I'm sure they get them at a volume discount. I believe they've come to realize, with some exceptions as always, some parents are going to be proactive and you don't need to remind them of wellness milestones. On the flip side, they've realized they are wasting time, productivity, and money on reminding those parents that are not proactive and will only visit when it's the last minute or the child is not allowed enrollment anyway.

I see similar circumstances and behavior in parent interactions at school.

[DowntheRiver]

We have two pediatric offices in town; both of which are part of a large multi office operation in the area. They stock immunizations and I'm sure they get them at a volume discount. I believe they've come to realize, with some exceptions as always, some parents are going to be proactive and you don't need to remind them of wellness milestones. On the flip side, they've realized they are wasting time, productivity, and money on reminding those parents that are not proactive and will only visit when it's the last minute or the child is not allowed enrollment anyway.

I see similar circumstances and behavior in parent interactions at school.

We have several small pediatric offices still. They are being swallowed up by the large corporations but I caThose aren't cheap, but n still think of 4 that are in the area, and I am in a huge metro area in Central Florida.

Vaccines are just expensive to store. We kept about 10,000 vaccines on hand at all times and the back-up generators to save our supply weren't cheap. We also charged manufacturer's cost for vaccines since we were the HD and they still could get pretty pricey, at least for adults since all children get vaccines for free via VFC.

[ruby_jane, BSN, RN]

Vaccines are just expensive to store. We kept about 10,000 vaccines on hand at all times and the back-up generators to save our supply weren't cheap.

I occasionally wake up confused, thinking I am back in public health-ville and my refrigerator alarms have gone off. We had thousands of dollars of federally funded vaccine in those refrigerators and no back up generators back in the day.

[OldDude]

I occasionally wake up confused, thinking I am back in public health-ville and my refrigerator alarms have gone off. We had thousands of dollars of federally funded vaccine in those refrigerators and no back up generators back in the day.

Vewy Scawey...

[Farawyn]

Our local pediatric offices keep track of nothing and send out no reminders. One office doesn't even participate in entering immunizations into the state registry. But they never forget to collect a copay or bill you for something not covered by an insurance policy.

How does the DOH react to this? Don't they get fined?