Protocol for Assessing VFC Eligibility Screening

1.	Before beginning the assessment, each grantee should create a tally sheet for staff to use for manually calculating a provider's VFC-eligibility screening percentages. The necessary elements to collect are outlined in item #4 of this protocol. Before starting the review, the assessor should ask the provider/office staff what method they use for documenting VFC eligibility screening. It is important for the assessor to understand how VFC eligibility screening is done for both VFC eligible and ineligible patients. Remind the provider that VFC-eligibility screening should take place for every child at each immunization visit, although it is only necessary to update the original screening form if the child's status has changed.

2.	Ask when the provider first began to receive VFC vaccine, and document this on the tally sheet.

3.	Randomly select a sample of 30 patient records. The sample should be drawn from the entire practice, not just the subset of VFC-eligible patients. For newly enrolled providers, the sample should include only patients who made an immunization visit after the office began receiving VFC vaccine.

One of the following methods can be used to select a random sample:

a.	Use a random number table or systematic random sampling method to select the sample. Although the sample may be drawn from all children 0–18 years of age, the assessor may want to narrow the sample to the age range most likely to have received an immunization (e.g., 3–35 months of age) since the provider enrolled in the VFC program.

b.	Divide 30 by the number of shelves holding patient charts. This will determine the number of charts to pull per shelf (i.e., if there are 10 shelves, select 3 charts per shelf). Randomly select a starting point on the shelf and sequentially review each chart until you find the appropriate number of charts from each shelf.

c.	Review the appointment book. Select the first 30 children who visited the practice during the previous week. You may need to extend the time period in order to select the appropriate number of children who received immunizations.

d.	If conducting a combined VFC/AFIX visit, a subset of the sample selected for the AFIX assessment can be used to screen for VFC eligibility documentation. Randomly select 30 charts from the sample selected for the AFIX assessment (>50 charts). The sample will be limited to the age group selected for the purposes of AFIX; however, since these records have already been selected for an assessment, a random numbers table or a systematic random sample can easily be used to select 30 charts from the original AFIX sample. Use these 30 charts to determine eligibility screening using the protocol below. 

4.	For each patient, document the following on a tally sheet:
•	Name or Chart Number
•	Date of Birth (must be between 0 and 18 years old, or in the selected age range)
•	VFC eligibility: mark appropriate category: Medicaid, Uninsured, Underinsured, Native American/Alaska Native, or Not VFC-Eligible
•	Did patient visit since office began receiving VFC vaccine*
•	Screening documented in chart**

*If a child has not visited since the office began receiving VFC vaccine, the child is not eligible for this assessment. Depending on the method used to obtain the sample, replace this record by selecting either the next eligible patient on the list, the shelf, or in the appointment book.
**Use the definition from Item #1 to determine if screening was documented in the chart.

5.	Total the column titled "Screening documented in chart."
•	If the column totals 30, the practice screens 100% of patients for VFC eligibility.
•	If the column totals 29, there is a high probability that the practice screens at least 95% of patients for VFC eligibility.
•	If the column totals 28, there is a high probability that the practice screens at least 90% of patients for VFC eligibility.
•	If the column totals 27 or lower, there is a high probability that the practice screens fewer than 90% of patients for VFC eligibility.

6.	When giving the results to the provider, include a list of children who were found not to have proper screening documentation.

Caution must be used when interpreting the VFC screening results. This methodology is not designed to provide exact point estimates, but instead it will help you determine if a provider is performing above or below a certain level. When you identify a provider who scores low on documenting VFC-eligibility in the chart, you may want to schedule a more in-depth assessment of the provider's screening practices.

Definitions of Site Visits

A VFC site visit is a formal visit to a VFC-enrolled provider site for the purpose of evaluating the provider's compliance with the VFC program requirements. This evaluation relies on the completion of the most current VFC Site Visit Questionnaire. The VFC Site Visit Questionnaire requires the VFC staff to evaluate the following components of vaccine management:

1.	Appropriate vaccine handling, storage and ordering procedures. This includes a physical inspection of refrigeration units, temperature measuring devices, daily temperature recording, vaccine accountability, procedures for vaccine retrieval and storage in times of emergencies, and inventory management, including stock rotation to prevent outdating.
2.	Proper documentation of children's VFC eligibility status. This involves sampling patient records to ensure appropriate screening (e.g., those in the Medicaid program, uninsured, Alaska Native/American Indian, or underinsured), and the administration of VFC-purchased vaccines only to VFC-eligible children.
3.	Compliance with documentation and record retention requirements. This includes distribution of current Vaccine Information Statements and maintaining records in accordance with the National Childhood Vaccine Injury Act.
4.	Compliance with other program requirements. This includes not charging for the cost of the vaccine, not charging a vaccine administration fee that is higher than the maximum fee established by the state, and agreeing not to deny vaccinations because of the parent's inability to pay a vaccine administration fee.

An AFIX site visit is a formal visit to a private or public provider site to perform quality improvement activities, including the following:

1.	Measurement of immunization coverage levels and provider practices by abstracting and analyzing patient record information (may be done manually or electronically).
2.	Feedback of performance data to clinicians and office staff to make them aware of their immunization practices.
3.	Guidance to help staff diagnose service delivery problems and adopt interventions for improvement. This may include providing information and educational materials about current ACIP recommendations, valid contraindications, record keeping, patient flow sheets, and reminder/recall systems.

Please Note: These components of an AFIX visit may take place on different days or require separate trips to the provider/clinic; however they still represent one AFIX visit and should be counted as one visit. When using CoCASA to document site visits, if the Assessment and the "FIX" components occur on different days, the date the "FIX" was conducted should be used as the date of contact with the provider because that is the date that all components of the  "AFIX" visit were completed.

AFIX Qualitative visit is defined as an AFIX visit in which all components were implemented but during the assessment portion coverage levels were not generated because of the small number of patients in the designated age range for the assessment. Individual patient charts are used to illustrate assessment findings during the "FIX" components.

Please Note:: These components of an AFIX visit may take place on different days or require separate trips to the provider/clinic; however they still represent one AFIX visit and should be counted as one visit. When using CoCASA to document site visits, if the Assessment and the "FIX" components occur on different days, the date the "FIX" was conducted should be used as the date of contact with the provider because that is the date that all components of the  "AFIX" visit were completed.

A VFC/AFIX combined site visit is a formal visit to a VFC-enrolled provider site which integrates the completion of the site visit questionnaire and vaccine management review to ensure compliance with VFC program with an immunization record assessment and the "FIX" components of AFIX.

Please Note: When using CoCASA to document site visits, if the VFC/AFIX staff completes a VFC/AFIX combined site visit and all components of AFIX have been covered, select both an AFIX visit and VFC site visit in CoCASA. If a combined visit occurs but the "FIX" components are completed on a different date than the VFC and assessment components, the date of the "FIX" should be used as the date of visit with the provider because that is the date that all components of "AFIX" were completed.

A Repeat AFIX visit is any complete AFIX visit to a provider who had received a previous  assessment (as part of an AFIX visit) between January 1, 2000, and the current calendar year. The current calendar year visit would be considered a Repeat AFIX visit. (A coverage level assessment would be performed for a new cohort.) 

Example: Dr. Jones is a VFC-enrolled private physician who received an AFIX visit on 5/15/2006. Dr. Jones had previously received an AFIX visit on 9/22/2004. Dr. Jones's AFIX visit on 5/15/2006 would be considered a 'Private VFC Enrolled-AFIX Only' visit as well as a 'Private VFC Enrolled-Repeat AFIX' visit.

A VFC site visit follow-up is defined as any contact made with a VFC-enrolled provider to review progress towards correcting a problem identified during the most recent VFC site visit.

An AFIX contact is defined as any contact with a provider between AFIX visits for the purpose of following-up on the implementation of quality improvement activities.

A VFC contact is defined as any contact with a provider between VFC site visits (but not related to the most recent VFC site visit) for VFC related issues. For example, if a provider calls because the office has run out of VISs for HPV, the visit made to the office to bring additional VIS copies would be considered a VFC contact.

An educational visit is defined as a special visit to the provider's office to perform an educational in-service (e.g., to discuss recent changes to the immunization schedule). An educational visit is separate from VFC site visits or AFIX visits, which already incorporate an educational component.

A VFC enrollment visit is defined as a visit to the provider's office to enroll a provider into the VFC program.