Rhode Island is a great place to be a kid. Children and families in the state excel at key indicators of good health, strong families, and quality early learning experiences. An estimated 98 percent of Rhode Island children have health insurance coverage, and most kindergartners are immunized at rates that exceed national standards. This success is a result of a long-standing commitment to children’s health and critical statewide infrastructure that supports ongoing focus on children, including a comprehensive children’s information system called KIDSNET, a dedicated Children’s Cabinet, an Early Learning Council, and an ongoing pediatric medical home initiative.

Having these supports in place, Rhode Island was well-positioned to respond to the needs of young children and families during COVID-19. The state was a nationally recognized leader in safely re-opening child care early on during the pandemic, allowing families to continue to work and young children the chance to maintain social connection and high quality early learning experiences. After the initial public health response to the pandemic, state leaders began actively monitoring key children’s health indicators to look for signs of secondary impacts from the COVID-19 pandemic. One area of growing concern was a decline in childhood immunizations.

The Center for Health Care Strategies (CHCS) recently spoke with Ben Shaffer, Rhode Island’s Medicaid director, to learn how cross-sector partnerships in the state helped accelerate a response to declining vaccination rates during COVID-19. Rhode Island is a participant in Aligning Early Childhood and Medicaid, a national initiative led by CHCS with support from the Robert Wood Johnson Foundation, through which the state is working to create greater alignment between Medicaid and early childhood services to better meet the needs of young children and their families.

Q: How did the state realize that there was a sharp drop in childhood immunizations during the COVID-19 pandemic?

A: In May 2020, the Rhode Island Department of Health identified a significant decline in vaccine rates, noting that 33 percent fewer immunizations were administered from March through May 2020 compared to the same period in 2019. During stakeholder calls, our Medicaid and commercial payers noted similar declines in their own data and raised concerns. Around the same time, the popular press reported on the worldwide decline in vaccination as an effect of the public health emergency.

Q: How did this information get the Governor’s attention?

A: Members of the Health Cabinet, including the Secretary of the Executive Office of Health & Human Services, Director of Health, Health Insurance Commissioner, myself, and the Governor’s staff escalated the data and concerns about the drop in immunizations to the Governor. This took place through the COVID-19 structure the Governor’s office established to ensure quick communication on emerging issues. Governor Raimondo has demonstrated an unwavering commitment to children’s development and health throughout her term, most notably through her Third Grade Reading Action Plan, Universal Pre-K proposal, and expansion of Family Home Visiting, so it was not at all surprising that immunizations would become such an important aspect of her COVID-19 response, particularly after seeing compelling and worrying data.

Q: What actions were taken to increase childhood immunizations?

A: Governor Raimondo spoke publicly at her regular COVID-19 press conferences about the observed decline in immunizations and encouraged families to take their children to their pediatrician as COVID-19 case rates declined and stabilized at low levels. She also called on her Health Cabinet and pediatric leadership in the state to implement a coordinated response to ensure that one public health crisis was not compounded by a second, preventable outbreak. The Governor’s charge was to get immunization rates to pre-pandemic levels by the time schools started in the fall.

To meet that charge, the Governor’s Office, Rhode Island Department of Health, Office of the Health Insurance Commissioner, and Medicaid program convened a bi-weekly COVID-19 Pediatric Advisory Council to establish regular communication with the pediatric leadership in the state and to develop a targeted and data-informed set of strategies. This Pediatric Advisory Council identified incoming kindergarteners and seventh graders as priority populations to bring up-to-date with booster schedules, and the measles-mumps-rubella vaccine as a clinical priority. The Rhode Island Department of Health developed a set of cohort metrics using our children’s health dataset (KIDSNET) and analyzed performance data bi-weekly. Having a concrete and measurable goal that everyone coalesced around was a foundational aspect of this work and enabled a high degree of coordination.

Q: What action did Medicaid take specifically to increase vaccination rates?

A: As the Medicaid program, we directed our three managed care organizations (MCOs) to provide biweekly reports on immunization rates, as well as develop written plans for improving immunization rates. MCOs were encouraged to implement approaches that connected children to their medical homes, per the recommendation of pediatric leadership, and to ensure that all immunization data was reported on KIDSNET to allow for universal tracking. MCOs implemented outreach campaigns, member incentives, and supported practices with data and technical assistance.

Medicaid and the Office of the Health Insurance Commissioner jointly implemented a Pediatric Primary Care Relief Program, which provided financial relief payments to pediatric primary care providers, contingent on practices developing and implementing an immunization performance improvement plan. This program was funded with the state’s Coronavirus Relief Fund provided by the CARES Act. Common themes from providers’ immunization quality improvement plans included: (1) using data to inform action; (2) implementing targeted, proactive outreach; and (3) expanding access to the medical home.

Q: What were the key assets Medicaid relied on in its response?

A: The importance of Governor Raimondo’s commitment to children’s health and well-being cannot be overstated. When the pandemic began, all of our departments were stretched so thin, and adapting basic operations and service provision to the changing context became mission-critical. Having the Governor consistently state, in no uncertain terms, that getting children up-to-date on immunizations was a priority helped our health agencies coordinate and dedicate the appropriate resources to a response. The Governor’s public message also helped motivate families and reassure parents that doctors’ offices were safe.

The second asset was our strong pediatric primary care foundation. Rhode Island is home to the first pediatric-focused multi-payer, multi-practice patient-centered medical home transformation initiative, known as PCMH-Kids. The majority of pediatric primary care practices in the state — federally qualified health centers and community practices alike — have undergone transformation through this program, and Medicaid and commercial payers continue to financially support the care coordination functions of pediatric medical homes. We are proud to have a strong level of coordination with high-caliber pediatric leadership in the state who represent a workforce with demonstrated commitment to excellence and continuous quality improvement.

Data infrastructure proved critical to support practices and help us monitor our progress. Our Department of Health operates our children’s health information system, which collects and stores immunization data nearly universally, as well as other vital screenings and public health services. Once the Pediatric Advisory Committee and Health Cabinet identified clinical priorities and metrics for tracking, we were able to monitor performance on a biweekly basis and provide practice-level reports to providers to support their efforts to get kids into the office. This infrastructure was critical to ensuring that our medical home-focused approach was sufficient.

Lastly, funding was essential. Like many providers at the time, pediatricians were in a precarious financial position. Being able to provide financial relief showed that we were partners willing to put real resources behind the challenge. At the same time, linking the funding to meet our collective goal reinforced the seriousness of the issue and expectations in recovery.

Q: What are the impacts of the actions taken to increase immunizations during COVID-19?

A: As of September 2020, Rhode Island’s statewide kindergarten immunization rates have surpassed September 2019 levels, and seventh grade immunization rates were within one percent of September 2019 levels. While the total number of vaccines administered is still down 21 percent between March and August 2020 compared to 2019, we feel confident that our interventions supported pediatric providers in prioritizing patients appropriately — focusing on the age groups and boosters identified as priorities and getting children into the office before they were “behind” clinical guidelines.

Our ability to have state agencies, payers, and providers coalesce around common priority metrics (the kindergarten and seventh grade cohort metrics) and an overarching strategy (connect kids to their medical homes) with additional funding (CARES Act) not only led us to successfully improve our immunization rates, but also set a solid foundation for rapid responses going forward. We now have a proven playbook as we make plans for this season’s flu vaccination, which is more important and challenging than ever given the risks associated with COVID-19, as well as preparation for administering a COVID-19 vaccine when it becomes available.