Vaccines have a proven track record to cost-effectively prevent death and disability from infectious diseases. Unfortunately, fueled by worries over vaccine additives and discredited connections between vaccines and autism, parental opposition to childhood immunizations is growing. Combined with rising vaccine costs and other challenges, it's becoming harder for states to achieve a seemingly simple goal of immunizing a high percentage of children.

In keeping with its population health-focused vision to "make our communities the healthiest in America," MaineHealth, northern New England's largest integrated health system,has invested in a multisector partnership to respond to this challenge. We have positively shifted Maine's curve of childhood immunization rates: In 2013, 71 percent of the state's children were up-to-date on vaccines, compared with 67 percent in 2010. That marks a steady gain toward MaineHealth's goal to have 82 percent of children ages 19 to 35 months immunized by 2016.

Maine's statewide approach depends on experts working outside traditional silos to pool their time and resources. That's especially true for Maine because the state lacks a county-level public health infrastructure. Working with public and private sector organizations, with geographic regions and even with nontraditional groups is essential.

Confronting a Decline in Vaccination Rates

Childhood vaccination rates in Maine reached a crisis point during the late 1990s. Due to growth in the number of recommended vaccines and an increase in prices for some newer vaccine formulations, federal funding for immunizations plummeted while vaccine costs rose sharply. Maine went from having one of the best childhood vaccination rates in the country to one that was substantially below the national average.

To confront the problem, stakeholders convened the Maine Immunization Coalition, a new organization to advocate for a universal financing system for childhood vaccinations. After several years of negotiations involving health care providers, parents, schools, pharmaceutical companies, insurers and others, the coalition's efforts resulted in the Maine Universal Childhood Immunization Program, which provides all children with the vaccinations recommended by the Centers for Disease Control and Prevention at no cost to their families.

This service is possible because the law also created a specific group — the Maine Vaccine Board — which collects fees from payers to buy vaccines from the CDC at lower costs.

The Maine Center for Disease Control & Prevention distributes the vaccines to health care providers in Maine who, in turn, supply them to families. Only the cost of administering the vaccines is charged to insurers.

Lawrence Losey, a pediatrician and vice chair of the coalition, says the universal program provided a foundation to build on. "The first thing needed was to make vaccines available where and when kids were seen by medical providers," he explains. "Then, practices moved toward proactivity vs. reactivity to keep better track of kids who were behind schedule."

That's no easy task in Maine, a mostly rural state beset by high levels of poverty. Children may lack access to a medical home where they can receive patient-centered, comprehensive and team-based quality care. Furthermore, many medical practices don't have the necessary systems to monitor compliance with the recommended vaccination schedule efficiently. Providers also may not have enough time or be comfortable discussing why vaccines are safe and important, especially with parents who might be hesitant to have their children immunized.

Building First STEPS

Maine Quality Counts, a regional health care improvement collaborative, recently worked with MaineHealth on the First STEPS (Strengthening Together Early Prevention Services) initiative to improve childhood immunization rates at 24 Maine pediatric and family practices.

Funded by a grant from the Centers for Medicare & Medicaid Services, MaineCare's Improving Health Outcomes for Children project, based out of the Muskie School of Public Service, contracted with Maine Quality Counts to develop and deploy First STEPS. The aim of the project is to create standardized child health quality metrics, build a health information infrastructure to support the reporting and use of quality information, provide tools and education to pediatric and family practices for building medical homes, and create the Maine Child Health Improvement Partnership.

First STEPS' goal was to increase childhood and adolescent immunization rates at participating practices by 4 percent between September 2011 and September 2012. Strategies included (1) monthly coaching calls; (2) learning sessions; (3) collaboration among First STEPS, MaineHealth, Maine Health Management Coalition's Pathways to Excellence Program, Muskie School of Public Service and IHOC to align quality metrics and public reporting strategies; and (4) implementation of information technology improvements to facilitate tracking practice-specific rates and identify children who may be due or overdue for vaccinations.

After one year, the increase in vaccination rates among children ages 2 to 13 years exceeded expectations, rising from 74.2 percent at baseline in 2011 to 79.3 percent one year later, a 5.1 percent increase overall. By December 2012, it rose to 81.3 percent. In November 2013, at 26 months, the rate had increased to 85.3 percent, a total increase of 11.1 percent from baseline.

Understanding What Works

Participating practices identified effective strategies, including training for medical staff in discussing vaccines with hesitant parents, having providers closely monitor vaccination rates, updating vaccinations in Maine's Immunization Information System, and using recall/reminder systems to identify past-due children. A text message reminder system alerting parents about scheduled vaccine visits decreased no-show appointment rates: Compared with other types of reminders, which have an average no-show rate of 14 percent, those receiving texting reminders had a no-show rate of 6 percent.

Amy Belisle, M.D., director of Child Health Quality Improvement at Maine Quality Counts, says improvements in data management and using standardized vaccine schedules were crucial to the program's success: "All providers in a practice really needed to use the same schedule within the recommendations of the CDC's Advisory Committee on Vaccination Practices." Clinicians also were encouraged to reduce the number of shots administered to children by maximizing the use of combination vaccines, and to talk about the importance of vaccines during all pediatric and adolescent visits — not just at well-child visits.

But these conversations can be challenging, especially with parents who express deep concern about childhood immunizations. A recent article in Pediatrics found that pro-vaccine messages — including discussions about vaccine safety or the dangers of preventable illnesses — can actually reinforce deeply held aversions to vaccination. So, stakeholders in Maine are beginning to explore various communication models regarding vaccines: One emphasizes providers' recommendations while another acknowledges parental concerns first and then employs a shared decision-making approach.

Social media may offer opportunities to encourage childhood vaccination. With anti-vaccine groups maintaining a strong online presence, the public health community must also harness these channels to promote scientific information and policies. MaineHealth, in collaboration with the Maine Immunization Coalitioin, has created, a website and social media strategy providing evidence-based information, news and resources to communities through its blog and strong Facebook and Twitter presence.

Meanwhile, efforts to boost vaccination rates confront a growing urgency. In 2014, the CDC reported that measles cases nationwide had reached their highest level since 2000, and Maine has experienced incredibly high rates of whooping cough over the past several years.

As exemplified by this approach to improving childhood immunization rates in Maine, multifaceted partnerships that embrace the collective impact approach and tailor programs to the unique needs of their communities will be increasingly important as health systems move toward population health improvement and management, guided by models like the Triple Aim and accountable care. Establishing a common agenda and messages, as well as mutually reinforcing activities, will let us improve and protect the health of our communities.

Cassandra Cote Grantham, M.A., is the program director for child health; Kathryn J. Colby, M.P.H., is the program manager for child health and community health improvement; and Deborah A. Deatrick, M.P.H., is the senior vice president for community health, all at MaineHealth, Portland.