To boost childhood immunization rates in Sacramento, Calif. beyond the state's 53% norm, Blue Cross of California's (BCC) developed a multi-level immunization program that led to 62% of its 2-year-olds getting immunized.
The innovative program, launched in 1995, reached thousands of members and providers through an aggressive outreach program that relied on frequent reminder notices, persistent phone calls (to members) and follow-up house-calls.
Outreach workers established that 85% of beneficiaries under the age of 2 visit their primary care physicians within 120 days of becoming BCC members. During these visits, two-thirds of the children were immunized through Blue Cross and other community resources.
To get the program off the ground, the educational process involved interpreters for non-English speaking beneficiaries and addressed an overall unfamiliarity with managed care for Medi-Cal members, according to Chris Champlin, BCC's director of health education and promotions, who headed up the marketing communications effort for the program. "It was a brand new process [for Medi-Cal members]; a lot of them had defaulted into our health plans without really being aware of it and many of them feared that there was a cost associated with getting immunization services done."
Reminder Intervention Campaign
BCC used a three-prong communications approach that started with a massive "reminder" direct mail campaign to members, then a "notification" direct mail effort to providers, and finally an outreach push that attempted to close the loop between members and providers on the importance of preventive care and immunizations. Marketing dollars for the program was absorbed by Champlin's department (budgetary dollars could not be disclosed) but the direct mail push commanded most of the program's expenditures at.20/mailing for 20,000 pieces.
The first component involved more than 10,000 immunization reminders sent to Sacramento parents. These letters explained the importance of keeping immunizations current and specified that an immunization was due for the child. At the bottom of the letter a tear-off appointment card was enclosed with the primary care physician's name, address and phone number and provided space for the parent to fill in an immunization appointment date and time.
BCC then provided 10,000 of its primary care physicians with lists of members who needed immunizations within 60 days. BCC also gave its physicians a more urgent listing of members who had not responded to the initial reminder notices, asking them to attempt to contact their assigned patients to schedule an immunization appointment. On a monthly basis, physicians were given updated lists and asked to contact their patients.
Reaching Out
If claims had not been submitted by the 120-day deadline, outreach workers were dispatched to get immunization results. Relying on lists generated by ZIP codes, outreach workers made more than 240 home visits a month in 1996. During these visits, outreach workers:
- arranged for an interpreter (if necessary);
- reviewed the child's immunization status (some children had been immunized but BCC had not been notified by the parents);
- determined if barriers existed in obtaining care from the assigned physician;
- explained the importance of relying on a primary care physician for routine and preventive care;
- scheduled immunization appointments (if necessary); and
- arranged for an interpreter during the medical visit (if necessary).
To gain better Medi-Cal Fee-for-Service outreach expertise, BCC created partnerships with The Center for Community Health and Well-Being (CCHW), a Sacramento-based community based organization and The Center for Outreach Workers (COW). CCHW allowed BCC to access hundreds of its hard-to-reach (often homeless) members who were receiving social support, referrals and prenatal/postpartum care through the organization. And BCC contracted with COW for outreach workers (who had experience dealing with disadvantaged populations).
Expanding the Program
To sustain its positive outcomes, BCC has introduced the immunization program to five new counties. In each of these counties, outreach workers have been hired to track immunizations. BCC has also negotiated with San Francisco State University to develop an academic training program for outreach workers specific to immunizations and other managed care preventive care initiatives.
Additionally, BCC is extending the reach of its immunization outreach to rural areas through community-based organizations, county-specific immunization coalitions, the support of a statewide immunization registry and local events that provide free or low-cost childhood immunizations (the costs have not been determined yet).
Last year, BCC's immunization outreach program made the American Association of Health Plans top 10 list of innovative immunization programs, earning a "1997 Celebrating Innovation in Immunization Award." The award recognized 10 health plans nationwide in three categories: Innovative Quality Improvement Childhood Immunizations, Quality Improvement Adult Immunizations and Private/Public Partnerships, Childhood Immunization. (BCC, Chris Champlin, John Monihan, 818/703/2566)