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VFC-AFIX Quarterly Conference Call Minutes
July 2008

Grantee Roll Call

Present: Alabama, Alaska, Arkansas, Arizona, California, Chicago, Colorado, Connecticut, District of Columbia, Florida, Georgia, Hawaii, Indiana, Kansas, Kentucky, Massachusetts, Minnesota, Missouri, Montana, North Carolina, North Dakota, Nebraska, New Hampshire, New Jersey, New Mexico, Nevada, New York City, New York State, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Utah, Virginia, Virgin Islands, Washington, Wisconsin, West Virginia, Wyoming.

Updates

VFC -related-Nancy Fenlon

Items sent out via all Grantee message & to AFIX/VFC Staff
The following three items were sent out last week as all grantee messages and to VFC/AFIX staff on the VFC/AFIX contact list and should be reviewed carefully:

• Non-compliance with VFC Requirements Algorithm
  
  The Non-Compliance Algorithm was sent out with changes that were discussed at Vaccine University in May. CDC is also looking at ways to make the follow-up more flexible such as having the option of doing a focused VFC compliance visit with both secondary and tertiary educational follow-up and perhaps shorting the length of follow-up required for both types of educational intervention. CDC will be accepting and reviewing comments on the Non-Compliance with VFC requirements algorithm through August 31st. Currently, CDC plans to release the final algorithm on or about October 1st, 2008. It is expected that the Fraud and Abuse Module will be revised later this fall or winter to reflect the use by the grantees of final non-compliance algorithm.

• VFC Vaccine University Alumni Newsletter
  
  This document was originally scheduled to be a hand out at Vaccine University but due to my extenuating circumstances, I was not able to complete it in time for VU. The initial issue focused on a key Storage and Handling question – specifically providing a definition a dorm style refrigerator and the issue also highlighted some key points from the VFC “track” at Vaccine University. I hope to be able to create a VFC Alumni News Letter on quarterly basis and have grantees submit their “best practices” and be able to spotlight some grantee activities in future Alumni Newsletters.

• VFC Frequently Asked Question and Answers document
  
  A newly revised VFC Frequently Asked Questions and Answers document is available. The revision date on the document is July 16th and was sent out as an all grantee message and to the VFC/AFIX contact lists. The new questions went live on the VFC website on Monday, July 21, 2008 and are labeled “new” on the website. There are six “new” questions in total – 5 are brand new and 1 was a existing question that had additional information added to the answer.
  Four of the questions are related to storage and handling and are the last 4 questions in that section. Two I would like to briefly discuss today- one is CDC’s official definition of a dorm style refrigerator and the second question requires all grantees to work with currently enrolled VFC providers to eliminate the use of dorm-style refrigerators as permanent storage units no later than December 31, 2009 and effective immediately all newly enrolling VFC providers cannot use dorm style refrigerators as permanent storage units for VFC vaccine. A short informational message regarding these actions was forwarded to the AAP this morning.
  
  The enhanced and final new questions are the first two questions under the VFC Provider enrollment section. The enhanced question discusses that CDC requires an enrollment visit be made to all prospective VFC providers and that administration of the VFC site visit questionnaire cannot be administered during that initial enrollment visit. A minimum of 3 months must pass between enrollment and the initial VFC site visit with administration of Site Visit Questionnaire so that certain high priority questions can be answered accurately.

VFC Site Visit Questionnaire

CDC’s VFC Site Visit Questionnaire has been a topic of discussion within the Immunization Services Division at CDC and was discussed at Vaccine University during Friday morning’s “The VFC Reference Stacks” presentation. I would like to take a few moments on today’s call to review some facts & recent observations about the VFC Site Visit Questionnaire and what actions CDC is taking to ensure the VFC Site Visit Questionnaire is administered as outlined & required in the VFC Operations Guide. Since how the VFC Site Visit Questionnaire is administered will impact how the non-compliance algorithm will be used and the accuracy of the information provided to CDC in the VFC Management Survey. So it is important to have a clear understanding of the Site Visit Questionnaire so it can be administered accurately and the results will provide useful information.

• CDC’s VFC Site Visit Questionnaire is updated annually and the next’s year version is posted on the VFC Website in both PDF and word format in the fall generally by mid –October. Each new release of CoCASA also has the most current VFC Site Questionnaire embedded. So CoCASA 4.0 which is scheduled to be released in early 2009 will contain the 2009 VFC site visit questionnaire.
• CDC’s VFC Site Visit Questionnaire contains two sections. Section One is required to administered as it is written. Section Two is optional and does not have to be administered. All questions in Section One must be answered especially the high priority questions identified with a red! in the questionnaire. Each high priority question monitors the provider’s compliance with a VFC program requirement. Grantees report the aggregate results of each high priority question from VFC Site Visit Questionnaires administered annually in the VFC Management Survey If a provider answers a high priority question incorrectly a corrective action plan must be developed and implemented to make sure that provider becomes compliant with that high priority question.
• CDC has observed over last few months- that a number of grantees have developed their own site visit questionnaire which is very acceptable but CDC has noted that not all of these grantee specific questionnaires have included all section One questions which is not acceptable.
• Another observation identified was it appears that some grantees have field staff who do not answer all high priority questions when administering CDC’s site visit questionnaire

Since the questionnaires’ results are used to complete the VFC Management Survey and the Survey results are used to generate the OMB report- it is critically important that all steps in the process be done as carefully as possible to make sure that accurate data is being reported to OMB to support the continued funding of both the VFC and AFIX programs.

CDC is taking steps to improve the quality of the information received in VFC Management Survey related to VFC Site Visit Questionnaire.

CDC VFC Site Visit Questionnaire Submission Requirement

Beginning this fall, all grantees who have developed their own questionnaire will be required to submit their 2009 questionnaire to CDC for review and approval before beginning to use the questionnaire for their 2009 visits. Once CDC’s VFC Site Questionnaire for 2009 is finalized a due date for submission will be announced. CDC will make sure that grantees have time to review CDC’s 2009 Site Visit Questionnaire to make sure that their questionnaire mirrors section I of CDC’s questionnaire. To reduce some anxiety -CDC does not anticipate significant changes to the site visit questionnaire between 2008 &2009. As of today, the most significant change will be updating the dates of the VIS forms.

The second change has occurred in CoCASA 3.3 release and outlined in the Alumni News Letter that was sent out last week-

CoCASA 3.3 update:

CoCASA version 3.3 requires the user to answer all high priority questions from CDC’s 2008 VFC Site Questionnaire before the questionnaire can be saved. When a user opens the VFC-AFIX Evaluation Screen, if the selected provider’s most recent saved contact/visit in the visit history is VFC site visit with a 2008 questionnaire that has unanswered (blank) high priority question(s), CoCASA 3.3 will not let the user proceed until that 2008 VFC Site questionnaire associated with that VFC site visit date is completed. So, all unanswered (blank) high priority questions must be answered before CoCASA 3.3 will allow any other activities. If the provider selected has a VFC site with a saved 2008 VFC Site Visit Questionnaire with unanswered (blank) high priority questions but that visit is not the most recently saved contact/visit, the CoCASA will allow the user to enter new data and move throughout the software without requiring the questionnaire to be completed. When the VFC site visit with the incomplete 2008 VFC Site Visit Questionnaire is opened then the unanswered high priority question(s) must be answered for the site visit to be saved again. If a user does not have time to follow-up with the provider to complete the questionnaire at that time, there is a work around. The user can mark the site visit for deletion by highlighting the site visit and clicking the delete visit data button. This marks the site visit for deletion but does not delete the visit. This allows the user to continue with their planned activities without having to complete the questionnaire at that time. However prior to running the CoCASA reports to use to complete the VFC Management Survey, the field staff must contact the provider with the incomplete questionnaire and answer all unanswered questions. We are looking other options for CoCASA 4.0 release.

VFC Contact List Update

The VFC Contact list by state was updated on the VFC Website the week of July 7th. The update was done through a combination of following resources:
Using the VFC Contact and all contact information listed in VFC Management Survey (2007) submitted on March 1, 2008;
And any E-mails received after March 1st -asking me to update the VFC contact for a specific grantee.

To make sure this list is accurate -I need all grantees to go out double check the name and contact information that is posted on the VFC website to make sure it is correct. If it is not correct, please e-mail me and let me know what information is incorrect and the correct information that I should use on the website.

Site Visit Definitions

I want to remind everyone of the definitions that should be used to determine how to document site visits and follow-up contacts for VFC & AFIX. The definitions are located in Appendix 6 of the VFC Operations Guide (August 2007). Not all grantees are having these issues but enough are to discuss it on today’s call. After reviewing the VFC Management Survey, some discrepancies were noted between the number of VFC follow-up contacts reported in table 4 of the VFC Management Survey, and the number of follow-up planned and reported in Section III “Summary of Corrective Action Plans”. It would be expected that the number of VFC follow-up contacts reported in table 4 would be nearly the same as number follow-up contacts planned but the numbers for many grantees are not similar. For some grantees, it appears that many of the follow-up contacts are possibly being reported as Educational Visits instead of VFC Site Visit Follow-up or AFIX Follow-up. So, it would appear that while follow up was planned it did not occur –unless the educational visit are taken into consideration. So again it is important to use the definitions located in Appendix 6 and that the field staff also use the definitions correctly.

I want to mention, if your program uses CoCASA- the definition of the site visit and contacts are located in the software as a roll-over function. So, if you slowly roll over selection box for each type of contact the definition of that contact will appear in a pop-up box. If your program does not use CoCASA- the site visit definitions are located in Appendix 6 of the VFC Operations Guide and we will include them in minutes of this conference call. Again, I would like to stress the importance of categorizing the follow-up correctly as critically important because this information is presented to OMB to support the on-going funding of the VFC & AFIX programs- so it is important to classify the contacts correctly.

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.

VFC Coordinator Training (Proposed for 2009)

CDC is considering offering a VFC Coordinator Training program for any VFC Coordinator who was hired on or after January 1, 2008- if funding allows in 2009. This training will focus on the fundamentals of the VFC program and how to operationally implement the requirements outlined in the VFC Operations Guide and Frequently Asked Questions and Answers document at the state and local levels. The training will 1 ½ - 2 days and may be repeated several times to keep the participant numbers very small for each training session.

An all grantee message was sent out several weeks ago instructing the program manager to put into the 2009 grant application a request for travel funds to Atlanta if the program has VFC Coordinator that was hired after 01/01/2008. I will share more information with you, if it is determine that the trainings can be conducted in 2009.

Afix-related - Nathan Crawford

• Update regarding the AFIX training for 2009
  Being planned specifically as a Feedback training, early 2009. Continuing our focus on the Feedback as the central and key component of AFIX, we are planning a mini-conference or training on how to provide an effective Feedback. We will provide more information about the location and content of the training as soon as we are able.
• Q&A regarding the new AFIX Chapter of the IPOM and required activities.
• Update regarding CD-ROMS from VU
  CDC will soon be mailing out 3 CD-ROMS per grantee to each program manager. Please use the presentations on the CD in regular staff training and when training new staff.
• Brief overview and Q&A of new AFIX Standards
  Thanks again to those who provided input/feedback.
• Reminder that need to send NEW AFIX Standards review form
  When completing the AFIX self-assessment tool for the grant, please be sure to use the new version 2. And, please read the instructions carefully as they have changed slightly since version 1.

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