well-child – The National Academy for State Health Policy

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States Include Catch-up Routine Immunization Strategies in Back-to-School Planning

July 27, 2020/in Policy Hawaii, Michigan, Oregon, Texas Blogs, Featured News Home Chronic Disease Prevention and Management, COVID-19, Immunization, Maternal, Child, and Adolescent Health, Population Health /by Rebecca Cooper

As states consider strategies to reopen schools safely this fall, ensuring that children receive their appropriate, on-schedule vaccines continues to be an important safety and prevention strategy. Because the COVID-19 pandemic has dramatically reduced the volume of in-person children’s preventive care visits across the country – many providers have reported a 70 to 80 percent decrease in well-child visits with fewer children receiving immunizations – catching children up on missed routine immunizations is critical, regardless of whether schools offer in-person instruction.

The American Academy of Pediatrics states that, “existing school immunization requirements should be maintained and not deferred because of the current pandemic,” and according to a 2014 study, vaccines will prevent 40,000 deaths and 20 million illnesses over the lifetimes of US children born in 2009. As a result, many school districts are implementing strategies that include immunizations along with other health priorities, like social distancing, mask wearing, and increased hygiene measures, for students in their back-to-school plans.

The Centers for Disease Control and Prevention’s (CDC) priorities for the fall include catching children up on needed routine vaccinations and ensuring that adults and children get their annual flu shots to stay healthy and reduce the risk of coinfections and the burden on the health care system. CDC also recently released guidance to assist local public health agencies in establishing satellite vaccination clinics for routine vaccinations, including back-to-school immunizations and annual flu shots. Considering the immense pressures teachers and school administrators face as policymakers grapple with school reopening decisions, continuing to provide protection from preventable diseases is critical.

Keeping children protected from vaccine-preventable diseases is not contingent on in-person learning. States need to continue to plan for catch-up vaccinations even if states and school districts have not yet solidified their reopening plans amid rising national COVID-19 case counts, and children should have all necessary protections from vaccine-preventable diseases. However, because some states are requiring all schools to open, it is especially important to ensure there is a process for appropriate back-to-school vaccinations to be administered to keep children healthy. Several states and counties have already released back-to-school immunization plans:

Hawaii: Effective July 1, 2020, additional immunizations will be required for students entering childcare facilities or schools. By the first day of school, all students entering childcare or school in Hawaii must have either a completed health record form or an appointment already scheduled with a health care provider, as well as a completed tuberculosis (TB) clearance form. Students who have not completed the requirements will not be allowed to attend school until the requirements are met. The updated immunization requirements were enacted prior to the pandemic to conform with national recommendations and reflect what already existed as standard medical care in Hawaii. State officials chose to maintain this guidance despite uncertainty from COVID-19.
Michigan: Its Department of Health and Human Services (DHHS) is urging families to catch their children up on needed vaccines that were postponed during the COVID-19 pandemic. Michigan providers are implementing new procedures to ensure patients can come in for well-child visits and get caught up on immunizations, including the flu vaccine, in the fall. Additionally, bipartisan legislation was introduced that requires proof of vaccination before entering 12th grade to ensure an accurate immunization status for high school students, and directs the DHHS to adopt the CDC-recommended immunization schedule.
Texas: The state announced that school vaccination rules are in effect for the 2020-2021 school year that students should be up-to-date, or in the process of receiving their vaccinations, or have a valid exemption when school starts. Texas’ school vaccination rules are in effect regardless of where the education is received (on campus or via virtual learning).
Oregon County: Oregon county health Departments began scheduling 2020-2021 school year catch-up immunizations during the summer to help limit the number of individuals in provider offices receiving vaccines at any one time, and to help prevent running out of supplies, because the department is only able to place new vaccine orders once a month.

In the midst of an uncertain infectious disease climate, states continue to prioritize maintaining immunization rates, and states can use back-to-school immunization requirements as a tool to ensure timely vaccine catch-up. However, vaccine requirements are a contentious issue and state legislatures across the nation continue to debate this topic. Prior to the start of the COVID-19 pandemic, Colorado and Maine, for example, enacted new school entry immunization laws that created more stringent procedures for obtaining immunization exemptions. These states are working to prevent future outbreaks, considering the evidence that unvaccinated populations can lead to community outbreaks.

States will also need to consider strategies to ensure school-aged children will have equitable access to the COVID-19 vaccine when it becomes available. In Wisconsin, for example, both the state legislature and the Department of Health Services can add new vaccines, such as a potential new COVID-19 vaccine, to Wisconsin’s list of required vaccines for school children and children in childcare settings. Other states are taking preventive action to ensure they have a system in place for vaccine distribution when it is available. For example, New York amended a law authorizing licensed pharmacists to administer any approved vaccine for COVID-19 to include children between the ages of 2 and 18.

Schools are often under local jurisdictions and while considering federal guidance and local public health risk, most decisions will be made at the state and local levels. But, regardless of the variation, states have to make challenging decisions about reopening schools in the midst of the COVID-19 pandemic. One critical step they can take to ensure student’s health is prioritizing immunizations to ensure children are protected from preventable disease regardless of whether schools reopen in-person. The National Academy for State Health Policy will continue to monitor state back-to-school immunization policies, state efforts to keep children protected from vaccine-preventable diseases, and their implications for children.

This blog was written with support from the Centers for Disease Control and Prevention.

States Establish New Telehealth Policies to Safeguard Well-Child Care and Immunizations

May 11, 2020/in COVID-19 Blogs, Featured News Home Chronic Disease Prevention and Management, COVID-19, EPSDT, Health Coverage and Access, Health IT/Data, Healthy Child Development, Immunization, Lead Screening and Treatment, Maternal, Child, and Adolescent Health, Population Health, Workforce Capacity /by Rebecca Cooper

The COVID-19 pandemic has reduced access to children’s preventive care across the country, with some providers reporting a 70 to 80 percent decrease in well-child visits, and far fewer children receiving vital in-person services, such as immunizations. Some primary care practices also have limited their services or shut down to comply with mandatory social distancing policies. To ensure children and families are able to stay safe and receive appropriate care, states are providing new guidance for telehealth visits.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT), the required Medicaid benefit for comprehensive and preventive health care services for children and youth up to age 21, includes well-child visits and immunizations. Well-child visits are necessary to prevent disease, administer scheduled immunizations, track healthy growth and development, identify health concerns early when they are easier and less costly to treat, and address parental and caregiver concerns.

In addition to a drop in well-child visits because of the pandemic, the US Centers for Disease Control and Prevention (CDC) released data showing that provider requests for childhood immunizations began dropping within a week of the national emergency declaration, signaling an immediate decline in routine immunizations for children. Several states, including California, Indiana, Kentucky, New Hampshire, North Carolina, South Carolina, Tennessee, and Washington State, have issued specific bulletins with information on EPSDT/well-child visits, including clarification of what services can be delivered via telehealth and billing guidance, so that these services can be provided during the pandemic to maintain healthy child development.

The Centers for Medicare & Medicaid Services (CMS) has also provided states with overarching telehealth guidance to promote access to care. Through executive orders and legislative authority, many states are ensuring telehealth services are easily accessible and that patients are not deterred from seeking necessary care during the pandemic that they would otherwise be unable to receive in person. States are also working to ensure that telehealth policies do not exacerbate existing disparities in care. Some examples of general state telehealth policy changes include:

Arkansas and Missouri recently relaxed the requirement that telehealth visits must only be conducted with previously established patients.
Arizona mandated that cost sharing for telehealth visits should be lower than in-person visits.
Oregon stipulated that cost sharing for telehealth services should not be greater than that for in-person visits.

While expanded telehealth policies increase access to primary care virtually during the pandemic, limiting in-person visits can reduce children’s ability to receive timely immunizations . Childhood immunizations are a cost-effective way to prevent disease, and vaccines are one of the most important public health tools to ensure health in a community, however, overall immunization rates are decreasing during the pandemic. The American Academy for Pediatrics (AAP) guidance encourages providers to prioritize in-person newborn care and well-child visits and immunizations for infants and children up to 24 months, and new CDC data shows a less prominent decline in immunizations for children under 24 months compared to children over 24 months. To address these immunization lags and promote access to other important preventive care, states have released guidance based on the needs of their own populations and their own provider capacity. For example:

Indiana and Kentucky’s policies for EPSDT visits note that providers need to complete the components of the visit that could not be done via telehealth (e.g., immunizations) in a follow-up visit within six months of the end of the public health emergency.
South Carolina and Tennessee’s guidance notes that when pediatric well care is provided via telehealth, the providers must inform the Medicaid enrollee (or parent/guardian) of any immunizations that would normally be administered and schedule a time to administer the vaccines as soon as possible after the telehealth visit. The providers bill for administering the immunization whenever it is delivered outside of the telehealth visit, such as on a different day, at a separate location, or through a drive-up immunization model.
Several states, including Maine, are encouraging practices to schedule well-child visits and administer immunizations in the morning and sick visits in the afternoon to keep the healthy and sick segregated. Other guidance to maintain well-child visits includes separating patients spatially, by placing patients with sick visits in different areas of the clinic or a different location from patients who are present for well visits.
Washington, DC and North Carolina’s guidance recommends providers utilize telehealth visits wherever possible, and that the subsequent, in-person follow-up visit should be as soon as is safe, based on the provider’s discretion. Washington, DC’s guidance also notes that if possible, pediatric immunizations, vital signs for infants up to 12 months, blood lead level screenings for children under 26 months, and infant anemia screening should not be delayed.

States also choose the billing codes and modifiers to track telehealth well-child visits and the subsequent follow-up visits for immunizations and other in-person services. For example:

Alabama directs providers to use code 02 in the place of service field to indicate telemedicine and use the modifier CR, for a “catastrophic event.”
Washington State providers must use EPSDT codes plus the CR modifier. For in-person follow-up appointments to complete the EPSDT visit, providers should use code 99429 with the CR modifier.
Kentucky providers should use 02 in the place of service field, and no modifiers are needed. For vaccine administration, providers bill code 90460 at the time of vaccine administration.
Alaska providers should use 02 in the place of service field, and modifiers 95, GT, or GQ to indicate a telehealth visit.

Well-child visits are an important vehicle for providers to assess healthy child development. There are many potential long-term implications of the pandemic on these visits, including primary care practices permanently shutting down due to lack of funding. Limited workforce capacity may lead to potential pent-up demand for pediatric preventive services resulting in:

A reduction in immunizations that can lead to an increase in vaccine-preventable diseases;
Less access to blood lead level screenings, which also has implications for children’s health outcomes; and
Reduced identification of adverse childhood experiences and trauma, with less capability to connect children and families to needed treatment and follow-up services.

State Medicaid and public health agencies are working closely to follow guidance from the Department of Health and Human Services (HHS), CMS, and CDC, with guidance from the AAP and American Academy of Family Physicians (AAFP) to ensure well-child visits are as uninterrupted as possible, so children can receive preventive services like immunizations, and subsequent vaccine-preventable outbreaks do not occur.

The National Academy for State Health Policy is continuing to monitor state and federal guidance to support states in ensuring children stay healthy during this pandemic and beyond.

This blog is supported by the David and Lucille Packard Foundation and the Centers for Disease Control and Prevention (CDC). To learn more about state efforts to promote healthy child development, please visit NASHP’s Healthy Child Development State Resource Center.

Vermont Uses an Accountable Care Organization Model to Promote Developmental Screenings during Well-Child Visits

May 13, 2019/in Policy Vermont Reports Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Health System Costs, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Quality and Measurement, Safety Net Providers and Rural Health, State Insurance Marketplaces, Value-Based Purchasing /by Megan Lent and Carrie Hanlon

Without early identification and treatment of development delays, children may face long-lasting and costly consequences. With more states reporting their developmental screening Child Core Set measures and new federal initiatives promoting value-based payment for children’s health, Vermont’s innovative affordable care organization’s approach can provide valuable insights. This fact sheet describes Vermont’s strategy to prioritize developmental screenings of children covered by Medicaid during well-child visits.