Strategy
Utilizing the Centers for Disease Control and Prevention (CDC) Vaccine Replacement Model in Kroger pharmacies to increase enrollment in the VFC program.
Challenge
The Indiana Department of Health (IDOH) identified a critical need to enhance access to immunization services for all families, especially those who face barriers due to income, location, or the limited availability of appointments in traditional healthcare settings. This need became even more pressing due to the COVID-19 pandemic in 2020-21, which led to a significant drop in childhood and adolescent immunization rates across Indiana. The disruption in services, facility closures, and the development of vaccine fatigue contributed to this decline, with the adolescent cohort being the most significantly impacted. Vaccination rates for HPV, MCV4, and Tdap among adolescents aged 11 to 18 decreased by more than 10%.
Furthermore, one out of three high school seniors were not up to date on their vaccinations and were at risk of aging out of the VFC program without receiving their necessary immunizations. This gap in service created a substantial public health concern, as it threatened overall immunization rates and, consequently, the health and safety of the broader community. To address this, Dave McCormick, division director for IDOH, sought to expand the network of vaccination providers and implement alternative solutions to ensure that every family had access to essential immunization services.
Solution
IDOH had a vision that pharmacies would be the key to bridging the gap to bring immunization rates up while ensuring health equity across the state. It should not matter if you have no insurance, are underinsured, or on Medicaid if you need a vaccination. In some rural areas of the state, the pharmacy may be the most convenient, or even the only, place to get a vaccination. Pharmacies offer an excellent opportunity for touch points especially in the adolescent space and optimizing patient care. There are expanded hours of operation for busy families that cannot take time off do to work, school, or extracurricular activities.
The 112 Kroger grocery store pharmacies across the state of Indiana were already enrolled as COVID-19 providers and had already been vetted to meet Indiana’s storage and handling requirements. The goal was to come up with a model that would work for large retail chain pharmacies as VFC providers and streamline a process to enroll pharmacies in the VFC program in a way that would set them up for success.
IDOH decided to implement the CDC’s Vaccine Replacement Model (VRM). This model was designed to enhance vaccine accessibility and streamline administration within large healthcare systems, including hospitals and pharmacies. Using this model, the Kroger pharmacies would not have to carry two different stocks of vaccine in their inventory. This approach not only ensures comprehensive immunization coverage for all patients, but also optimizes the utilization of available resources. IDOH did hire a VRM specialist to oversee this process.
IDOH also offered the Kroger pharmacies a waiver on manually logging temperatures. As long as the pharmacies utilize a cloud-based temperature monitoring device that would alert several people in the event of a power outage and/or temperature excursion, the pharmacists and pharmacy techs would not have to manually record their temperatures twice a day. They would simply have to log into their portal to check their temps.
Kroger leadership was thrilled with the description of the replacement model and temperature monitoring waiver. Pharmacies have been experiencing staffing shortages since the COVID-19 pandemic. They were interested in the idea of being able to offer VFC vaccines without having to add to their workload.
The enrollment committee also produced a VFC training video that was specific to Kroger pharmacies, assisted in filling out the provider agreements in the immunization information system (IIS), and received permission from the CDC to perform virtual enrollment visits, further cooperating with the pharmacy staff’s tight schedules.
The practice took place throughout the state of Indiana, beginning in 2023, following the challenges posed by the COVID-19 pandemic. Dave McCormick spearheaded the initiative to expand the VFC program to include pharmacies, with a pilot of the VRM conducted in October 2023. This effort involved both virtual and in-person meetings across Indiana to develop and implement the model, secure stakeholder buy-in, and facilitate the successful enrollment of pharmacies into the VFC program.
There were over 80 hours of initial meetings and reoccurring meetings for over a year for planning. It took four months for the VRM to be developed and approved by IDOH leadership and CDC. There were eight hours to put VFC Enrollment Binders together and mail them to the Kroger pharmacies. The enrollment committee also assisted in filling out the provider agreements in the IIS so the pharmacists did not have to spend time. There were initial trainings for the Kroger staff done virtually through teams, and each field staff in their respective area did the enrollment site visit virtually.
For this initiative, the IDOH Immunization Division also worked with the following partners:
- Indiana Pharmacy Association: Promoted the concept of pharmacies as VFC providers and developed partnerships advocating for health equity.
- Indiana Immunization Coalition: Facilitated collaboration among stakeholders across the state.
- Kroger Pharmacy: Actively participated in the initiative, enrolling 112 of their pharmacies into the VFC program.
Outcome
Pharmacies are essential in bridging gaps in vaccination coverage, especially for adolescents. While pharmacies successfully vaccinated during the pandemic, Division Director Dave McCormick recognized the need to address barriers that prevented VFC-eligible families from accessing the same level of service. Initially told that pharmacies could not be VFC providers, he persevered, leading to the successful enrollment of independent pharmacies and later, large retail chains like Kroger, into the VFC program.
Through his leadership, collaboration, and innovative problem-solving, the director ensured the successful implementation of the VRM in 112 Kroger pharmacies across Indiana by September 1, 2024. This achievement not only improved access to vaccines but also set a precedent that Kroger may follow in other states, such as Kentucky and Ohio.
A critical lesson learned involved ensuring that pharmacy electronic health/medical record (EHR/EMR) systems could communicate effectively with the state’s IIS, exchanging both patient and vaccine data. Testing this integration early in the enrollment process would save time and prevent stress later.
The key to the successful enrollment of a large retail pharmacy chain in the VFC program was the dedication and cooperation of all parties involved. Both pharmacy leadership and the state immunization program had to be committed to the process, willing to work through challenges, and find innovative solutions.
Since this initiative has just commenced, comprehensive evaluation data is not yet available. Although five independent pharmacies have been successfully onboarded as VFC providers for over a year, they did not participate in the Vaccine Replacement Program, and therefore, their data does not reflect the impact of this recent pilot.
Indiana Immunization Information System (IIS) is called CHIRP (Children’s and Hoosier Immunization Registry Program):
- In 2021, 20.7% of the total number of HPV vaccines were given at a pharmacy for 11-18 years olds
- 5% % of the total number of MCV4 vaccines were given at a pharmacy
- 3% % of the total number of TDAP vaccines were given at a pharmacy
- 4% % of the total number of MENB vaccines were given at a pharmacy
- In 2023, 37% of all 11-18-year-olds received a vaccination from a pharmacy that was not either COVID or influenza
Supplemental Materials