All right, we're going to start up again. Next presenter is Dr. Konstantin Baryshnev, who's at Conservative Care Occupational Health Clinics. All right, tell us how to really pronounce your name. There is a simple and easy way to pronounce it. Just call me Dr. B, and that will solve the problem. At first, I really want to thank Dr. Baker, Dr. Bukta, Dr. Jordan, Isabel, for all your help, and finally for giving us this opportunity to actually participate in something which is very important and dear to our heart, and do it the right way. We were just talking to Dr. Baker about our previous experiences. Back in 2007 or 2008, there was an outbreak of whooping cough in Arkansas. I was trying to do something right for the community, and we changed our vaccination from just tetanus boosters to Tdap. It didn't last very long. We got a phone call from the insurance company, which was asking us, what are you doing, guys? Why are you administering Tdap in the workman's comp settings? It costs more, and it's not work-related. They put a stop on it, and then I learned my first lesson. Do not do something without knowing what you're doing. Now with this grant, with this opportunity, I think finally we will be able to do our vaccinations the right way, document it the right way, assess the vaccinations need, educate people, because we are a freestanding occupational clinic, which has ... Oh, by the way, yeah, let me tell you about the disclosure. So basically funding for this made possible in part by the Center for Disease Control and Prevention, and I do have an individual stock in Moderna. I mean, it doesn't make any difference. We still administer the Pfizer vaccine, but I mean, I do have it, and I have to disclose it. So let's start with our kind of little bit of the description of the work situation in Arkansas. Poultry business is very big in Arkansas. So pretty much one in four agricultural jobs in Arkansas is poultry. There are 37,260 people across the state, and approximately employed by the poultry industry, and 70,749 jobs in supplier and accelerator industries. About a third of the people are Latina. More than one in five are African American or Asian, and I'll tell you why it is important. So basically infectious diseases have ... Infectious disease control have challenges in Arkansas and across the nation, actually. People have prolonged close workplace contact with co-workers for a long period of time. They share workspaces. They share transportation to and from the workplace. They share congregate housing, and basically they have this frequent community contact with fellow workers. In the nation, I mean, we have more than half a million workers in animal slaughtering and processing industry, and 3,500 companies nationwide. The workers with COVID-19 and COVID-19-related deaths identified and reported through May 31st of last year from 21 states, at least 17,358 cases and 91 COVID-19-related deaths. Among the animal slaughtering and processing workers whose ethnicity were known, approximately 39% were white, 30% were Hispanic, 25 African American, and six were Asian. However, among 9,919 workers with COVID-19 with race and ethnicity reported, approximately 56 were Hispanic, 19 were African American, 13 were white, and 12 were Asian, suggesting that Hispanic and Asian workers might be disproportionately affected by COVID-19 in this workplace setting. And Arkansas has been identified as one of the most desperate COVID-19 hotspots in the United States, so much so that CDC and NIH traveled to Arkansas to investigate the disparities. So the report showed that 45% of all adults hospitalized with COVID-19 in northwest Arkansas were Hispanic, 19% were Marshallese Pacific Islanders people. Hispanic and Marshallese people account respectively for 17% and 2.4% of the region's population respectively. Now, I don't know, but I think Arkansas has, actually northwest Arkansas has the second largest population of Marshallese people outside of the Marshall Islands. So they have a consulate office in Springdale, Arkansas. A queen of Marshall Islands still resides in northwest Arkansas. So I mean, Marshallese is an extremely important population in northwest Arkansas, wonderful, hardworking people, extremely unhealthy, very unhealthy. A lot of people are overweight, a lot of people have diabetes, a lot of people have hypertension, very low risk of the, I mean, very low rate of the immunizations. Now before COVID-19, we were collaborating with the health departments on, let's say, T-spot testing of the Marshallese. Why is that? Because there was an, well actually, increased incidence rate of tuberculosis among Marshallese people in Arkansas. There was a case of TB meningitis in the infant, you know, who actually, whose family was tested, but the infant was at that time housed with another family because the community settings of the Marshallese people is a little bit different. You know, it doesn't mean that it's your, your kid is raised in that house, it can be raised by, you know, your neighbors, it can be raised by your relatives. So there is a very interesting dynamic, community dynamic over there, which, you know, was overlooked by the, by the public health department. So they ask us, can you help us? Can you help us to do some testing? And we did some testing at the time, a quite successful program, I mean, we did the testing of the Marshallese people who would come to our clinic with a T-spot, you know, because we didn't want to do the, you know, the tuberculin skin test, we just, we were afraid that they would not return to read the results. So it was before the COVID-19, COVID-19 screwed everything up. So, but that's why, you know, I'm saying that, you know, Marshallese population is extremely important in our area and important from the different standpoint, but most, they're employed, employed predominantly in the poultry industry through the companies and, you know, Tyson's, Siemens, George's, Cargill, you know, you name it, I mean, multiple poultry companies. So Marshallese deaths from COVID-19 disease were estimated to be more than 200 per 1,000, much higher than overall death ratio of 5.10 per 1,000 in the state. So approximately 30% of cases and deaths in Arkansas were among African-American people who represent 15% of Arkansas overall. As a result of the COVID-19 pandemic, life expectancy among African-American people declined by minus 2.7 years. That's the lowest level since 2001. In rural Arkansas, counties with high proportion of African-American people, COVID-19 cases and deaths continue to be disproportionately high. Now vaccination rates in Arkansas, I mean, Arkansas rank among the bottom five in the nation in vaccination rates, only 53.5% of Arkansans are fully vaccinated compared to, you know, 66%, I mean, there was 66.9% in the United States, approximately 63% of adult Arkansans over 18 are fully vaccinated. Overall less than 20% of eligible Arkansans have received a booster. Vaccination rates are low in the rural area and both rural and urban counties for minority and low-income population. Hesitancy is a primary reason for low vaccination rate as well as practical issues and social determinants of health being significant barriers. So what are the objectives of this project for us? At first, we want to determine the current vaccination rates and examine the need for additional vaccine. We're going to talk about it, how we're going to do it later. But it's extremely important piece of the puzzle for us because we deal with multiple clients. Our clients ranging from huge, you know, companies, big, you know, poultry companies to different municipalities, from mom and dad shops to, you know, the, let's say, firefighters and police officers. And everybody has their own need. Everybody has their own, I would say, demands. Let's say the situation I described, you know, to my colleagues was, I mean, is the situation we have right now with firefighters and police officers. Our firefighters are fully vaccinated. They have hepatitis A and hepatitis B on board. Our police officer predominantly in most of the municipalities, as far as I know, they do not require to be vaccinated with hepatitis B vaccine. Now why is that? I mean, they are exposed to blood-borne pathogens. I mean, they get needle stick exposure. I mean, I see a lot more police officers stuck with needles than, let's say, firefighters. So I mean, in my world, I think they need to be vaccinated, but it's very hard to convince their, you know, chiefs to actually, you know, vaccinate them. So we have to, we have to do the assessment and we have to educate their superiors. And the way we want to do it, we're probably going to do it for the whole municipalities, not only the police officers, but also, let's say, the, you know, sewage workers, also the, you know, cleaning people and all of that, all the municipal workers. So that's, that's, that's important of the assessment and determine the current vaccination rate and the need for additional vaccines. So what vaccines should be, you know, should we offer? You know, what vaccination? So right now it's obviously influenza, COVID-19, also hepatitis A, hepatitis B, tetanus. And hopefully it's going to be Tdap, you know, this time. So now we need to lean on current work in the relationship to investigate vaccine hesitancies. As I said, there are over, you know, we work with over 3,000 different companies and has close working relationship with all poultry companies in Benton and Washington County. So all of the poultry companies, they consult us on all of their problems, pretty much. So that's, that's actually, that's a very good position for us to, you know, to start and, and, and, and, and, and develop this project. So we need to, we are developing currently the education plan that focus on increased vaccine coverage through cultural and linguistic appropriate plan, plain language. We do have it in Marshallese. We are, you know, developing in Burmese language because we have a Burmese population. We have, you know, you know, nurses who are, you know, ethnic Marshallese. We are working with Arkansas Department of Health very closely and with, you know, the city health officers who are already doing this already engaged in, but they have their limitations. I mean, they administer their vaccine at the churches, you know, and you know, they don't capture the tarp. So we can expand it into their workplaces, which I think will capture a lot more people than just wait, you know, outside of the church to deliver a, you know, a vaccination. And like, you know, Dr. Raj said, you know, sitting there, you know, with a needle waiting for them to, you know, come out, you know, just be a little bit more present, you know, when you are in the settings of basically, you know, congratulations, you pass your physical, you're pretty much ready to be employed, you know, here, you know, there is opportunity to be vaccinated there, you know, so, and implement various forms of vaccination events to reach population needs. So, I mean, I think like in a few weeks, there will be a big health fair at Siemens. Siemens is a locally very big, large poultry company, which is very, very receptive to our suggestions. And, you know, they want us to, they want me to speak there. They want me to come there and educate them on vaccination. That's perfect, you know. And I think it's a great opportunity to actually establish a working relationship and maybe have the vaccinations clinic over there at Siemens, Siemens chicken plant. And it's, oh, and they have several chicken plants, actually. I don't know which one is it going to be, probably in Solomon Springs. So, in objective number one, we will leverage on pre-existing company relationship and clinic visits to collect data on vaccine hesitancy and population need. This objective will work through so-called social process of trusted organizations to influence what people think and feel. And objective two will focus on vaccination behavior by determining the actual number of vaccination workers in Benton and Washington County. On objective three, we're also focused on what people think and feel as we implement coordinated communications and health education plan that focuses on building vaccine confidence for culturally and linguistica-appropriate communication using plain language. The communications plan will also leverage social process by partnering with trusted community health sources, which in our case, Arkansas Department of Health. We also will primarily work by improving practical issues and increasing convenience to implement company onsite vaccinations events to reach population most in need. Rural and remote locations and urban neighborhoods with low access and low vaccinations rate. And ensure that all community members are able to receive vaccinations. So and here we come with this, you know, obviously to this PDSA model, you know, we're missing one slide, but I guess I'll have to talk about it without, but all right. So you know, we have the plan in place. We carry out our plan. We study the data and we're going to act and we, you know, the way the stage we're in right now, there is a, so to kind of do it automatically to avoid overburdening and relying on the micromanagement of our nursing staff. We're trying to partner with our EHR, with CSTOC to establish so-called the Iron Bridge. What Iron Bridge is, my understanding is that it's the, you know, separate company which develop IL-7, which is a type of the length, HL, I'm sorry, not IL, it's HL-7, Health Language 7. So HL-7 communication type between the Web IZ, which is the state immunization registry in Arkansas and our CSTOC, which is our EHR system. So right now they're working on pre-testing of the system where our vaccination date is going to be automatically transferred to the state Web IZ. But I asked them today if we can do it both ways and they said yes. They said yes. So potentially what's going to happen is that we're going to know at the time of the scheduling of the appointment who needs what, which is, you know, a huge step. That's an assessment. So we will know when patients come to the clinic what vaccinations are missing and we don't have to manually rely and come to the nurse and say, you know, log into the Web IZ. No, it's going to be automatically. And automatically when we administer the vaccine it's going to be. So that's perfect. I mean, that's automatization saves a lot of hassle. And you know, we all know that nurses are overburdened with tasks. They can make mistakes. We don't want the mistakes. We want it to be done automatically at the level, you know, of this electronic communication, which is developed by the, you know, by our, I would say, contractor. It's called Iron Bridge. I don't know. You know, Iron Bridge. So the team will meticulously document process improvement during weekly team meetings. So the challenges and best practices can be documented and disseminated. Our community partners include Northwest Arkansas Council on Healthcare Transformation Division and Dr. Martha Shakley and also, Sharkey, I'm sorry. Also a city health officer, Dr. Martha Shakley is a city health officer for Fayetteville. And they also engage in process improvement using the PDSA model for our meetings. We will select challenges most relevant to take community partners and for the process involvement. So the evaluation is going to be done using the RE-AIM framework. RE-AIM has been used in many published articles to translate research into practice and help the programs and improve effectiveness in real world settings. So to what extent, RE-AIM, R stands for reach, to what extent does the program reach the intended population? We're going to look at the number of people in the target population, number of patients served by ethnicity and race, number of eligible patients counseled, and number and percent of patients with access to their immunization records. And effectiveness, RE, effectiveness, is to what extent has the program improved vaccination rate? Number and percent of patients who have documented vaccine assessment in their records, number and percent of providers' recommendations that resulted in vaccination, number of patients refusing the vaccinations, and number of patients referred. So it is going to be done using the program records, vaccination site records, post-vaccination survey of our clients, and records from our Kansai Department of Health. Adoption. To what extent is the program adopted by our clinic and partner organization? It's frequency and quality of provider recommendations, number and percent of providers using EHR and WebIZ to screen and forecast vaccination needs. I hope it's going to be close to 100 percent. I hope, you know, obviously. And number and type of new technologies used in vaccination need assessment is going to be from program records and planned surveys. Implementation. To what extent is the program delivered as intended? And it's going to be number and percent of patients who have documented vaccine assessment in their records, number of eligible patients counseled, number of immunizations administered at another site that's captured in patient records, number of patients' records in WebIZ, and number of new users in WebIZ. Implementation is going to be done through program records, partner organization survey, program finances, and planned survey. So maintenance. What evidence is there to indicate that the program is sustainable? So changes to ensure appropriate immunization assessment, recommendation, vaccine offers, and other documentation. Number and types of improvements to referral system procedures. Changes in how immunizations are documented in WebIZ and HR. And I already told you that we are doing it right now. We are changing completely how immunizations are documented. From our very low rate of documentation, many mistakes when we don't document vaccine administered. So hopefully capturing most of it automatically. All right. And that's where we are right now. And you know, I guess I'm open for questions if you are interested in asking. It's a completely different setting, but it's very exciting to us and for us to do it the right way. Yeah, that's great. Any questions? And so as you can probably tell, everybody's at a different stage because they came on to the collaborative agreement at different times. So everybody can be in slightly different stages in the planning. The last presenter will be Dr. Marcia Ishikara and also Arthur Sanchez, both of who are at the University of California, San Diego. And I'll pull up their slides. Is this you guys? Yep. Yes. All right. Thank you, everybody, for hanging with us here. We're almost there. And we'll try to zip this through. So I'm Marcia Ishikara, Medical Director for UC San Diego. And we have Arthur, our champion with many hats. We have nothing to disclosure. So just talk a little bit about background of UC San Diego. We're part of the University of California, San Diego. We have about... We're the largest employer in San Diego County, with about 41,000 employees, that about half campus researches and health health system. The demographics mirror San Diego, very multidiverse population, and that's something we really love, the diversity and embrace in San Diego. Historically, I think that's one of the different approach that we have, is that, you know, we made a lot of lemonades out of COVID lemon. Because we had quite a robust EHR system, an extremely ambitious C-suite, and great relationship with Petco Park, with the baseball team, we were able to launch a drive-through vaccination for the whole entire San Diego population. It was pretty much on a Monday, the CMO bring us a group of folks, and it's like, I wanted to launch this by the weekend. I thought it was insane, but we did it with volunteers. So with that experience, we also were able to develop better our EHR system for COVID. So one of my, the co-PI, a great mentor, is Dr. Siddharth Paddy, that is a champion in epic population medicine. And our approach is strength, so be strategist to reach employees, nurturing guidance, trust in healthcare. So we have two different approaches. One is, we would like to focus and develop further our EHR systems, and have real-time dashboard. I'll go a little bit more in detail over that. I presented earlier, yesterday, on how we were able to firewall our systems, and all the products of the integration. Then Arthur is going to talk about our people approach, how we listen, develop partnership, and bridge gap, and again, embrace San Diego diversity. Our goals, common to, you know, everybody in the grant, is to access vaccination study, never occupational health visit, to auto reconcile external vaccination information. So what we're doing, actually, we're doing inside the EHR system. So we're, for COVID, we were able to automatically get it uploaded into our system. So any person who come, even if they do that CVS, we're able to see that in COVID, but not for flu. So we're working on process of how can we do that, and develop immunization smart set, again, how to make the process automated. In regards to the real-time dashboard, well, I went to Penn, and every time it was Marcia, you cannot manage what you cannot measure it. And you know, right now, what happen is, in large institution that will have 20,000 employees, there's a lot of homegrown flu vaccination softwares to track how the vaccination is, because it's all reportable through CDC. But it's really hard to break down who they are, what is the ethnicity, what is the unit. We just see numbers bumping up. And then, you know, pretty much there's not much of a targeted intervention. So that's what we'd like to do, and we're making great progress on that. And also, how can we develop more automated EHR? How can we have better peer-to-peer for vaccination rates, okay? It's kind of a complicated map here, but pretty much, you know, I just would like to show is that although sounds simple, we spend actually many, many hours, and we hired an IT analyst instead of project manager for a couple months to try to leverage what we built in COVID, but also to manage within several systems. One thing that is very unique about UC San Diego is that with COVID, because we were so aggressive on our response, we were able to put the HR database into our EHR database, meaning when John starts, he will have electronic medical records, and then we'll have within the firewall his immunization status on that, and there's the onboarding. So we're able actually to pull by job code, title, and manager, and there's a process to upload and download. But again, we're managing a 40,000 population, and there are different denominators. Before coming to UCSD, it's like, that's impossible. How can you not know how many people work for you? Well, there are two different employers, at least, UC San Diego Health and UCSD campus, so there's a lot of mismatch on who they are, and we are slowly trying to, and we create a population based on health and campus, and we're trying to see. We did a couple simulations, and we're trying to see which one is the truth, and then we compare to the HR data with the ethnicity. So the HR data with the employee ID gets uploaded to the EHR. Then, because it takes quite a lot of power and will slow the EHR system, that gets uploaded to a SQL server, and that's when it gets into another system called Tableau, that you will see in a lot of institutions some beautiful dashboards, and then on that, you can even interface with Qualtrics, for example, symptom screenings, and then you can make into a dashboard, and I'll show a couple examples of that, okay? One is that we built in COVID is by job, by union, what are the vaccines? So you can see, you know, there are three of these, and we just put two out of three populations. You have 11,000 in one, 9,000 in the other, so it's broken down. So the nurses in one pocket, and then how are their vaccination status in COVID, and this changes day by day. And then the supervisor dashboard, that's something that we slowly have been building this. There's a symptom screening that will come into, you know, interface on that, but this also helped tremendously on increase our influenza compliance rate, because as you can see here on the second row, the influenza immunization. So this, I get this weekly, you know, it has the reporting, Marcia Saccari, and then it has the employee name, so if Arthur did not get his flu shot, he would be totally red flag here. Then I have to call, hey, Arthur, what's up? And so, again, I strongly believe that the person that geared, very powerfully can gear true compliance and true vaccination is the supervisor. And just for having this clear dashboard increase our health system immunization rate for flu. Then Arthur's going to talk a little bit more about what are we doing, you know, analyzing our ethnic distribution and our plans, and we'll go from then on. So when we were starting this project, one of the things we did was we tried to look at what's the ethnic distribution of our employees at UCSD. And if you look, approximately 28% of our employees are Asian, and 21% are Hispanic. And we think that, again, this mirrors the multicultural diversity in San Diego, but also might present some opportunities. Particularly being Hispanic, I know that we kind of have a different need in terms of healthcare and how we perceive healthcare. Interestingly enough, when we ran our numbers, almost 55% of our health custodians are Hispanic, Latino, and of those, when we looked at their COVID booster numbers, only 54% were boosted. Similar numbers for campus. Our clerical and Adelaide health, around 40% are Latino, and only 63% were fully boosted. Same thing with our health technicians, 30%, and only 59% are boosted. So our methods, right, what we're doing is we want to listen. We want to understand why vaccine hesitancy exists in our workers, and especially with being inclusive of underrepresented minorities. Part of the ways we're doing that is we're trying to review the reasons for vaccination waivers, to see why people are waiving, you know, or obtaining waivers to obtain vaccines, and talk to the employees and their supervisors, and I've kind of started doing that in my clinics, right, when I'm talking to patients. I'm seeing them for workers' comp injuries, and just kind of feel them out and understand what's going on. And the other thing is conducting literature review to understand vaccine hesitancy in underrepresented minorities. We're also looking to build partnerships, so we want to work with them. We not only want to understand them, but we want to work with them and give them what they need. We're also leveraging our partnerships with HR, our leadership from the top down, from the C-suite down, our diversity task force, and ACOEM to work on this. We think that it's so important for us to all work together to drive these vaccination initiatives. And finally, we're working on creating a toolbox for vaccine engagement, and I'll talk a little bit more about that later. We want to bridge gaps, right? We want to launch an inclusive vaccination engagement campaign that is customized based on job function, multiculturally competent, and sustainable. And the goal of all of this is to build trust, right? We talk a lot about building trust. So we want to leverage social media. I have my mother-in-law sending me, like, memes on WhatsApp all the time, right? So we know that everybody's kind of looking at these things. Employee meetings. We've kind of found out when we were doing the discovery portion that our EH&S folks meet with our, particularly our custodians, which is one of the big groups that we're targeting, and we want to take advantage of those meetings. Again, developing this engagement toolbox to essentially have these tools available to our workers to increase engagement. We want to have vaccination events, and I want to talk a little bit about that because we're doing something really cool with our EMR to figure out where we need to have these vaccination events. And then the big one is our promotores, and I'll talk a little bit about that here in just a second. Promotores are also known as community health workers, peer leaders, patient navigators, or health advocates, and they play a vital role in promoting community-based health education and prevention in a manner that is culturally and linguistically appropriate. And we think that by taking these promotors, we can create a pipeline of trusted multicultural influencers. The promotores model is well-recognized. It's scalable, and it's an effective agent of change for minority outreach. And again, this approach has been suggested by the U.S. Surgeon General and is a published approach to hesitancy and are applicable to underrepresented minorities. And I think for me, particularly being involved with our transition, EMR transition, is the screenshot of data that we can pull from our EMR. And basically, this is San Diego County, and it's broken down by zip code. And it tells us where we have employees that are overdue for their influenza vaccine. So we think that using this data, and we're not 100% sure how we're going to use it, but we're learning. We might be able to do targeted vaccination events in these particular areas to drive our vaccination rates. So I think with that, questions? So it comes from our EMR. Part of that diagram that Dr. Zakari was talking about, where we take the HR database and the EMR database, and we kind of combine the information, it allows us to create these populations, so employee populations. And we're pulling in the registry information from the state, and the county actually has a registry, too. And like that, we're able to extrapolate that data. And we can do it for not just influenza. We can do it for other vaccines, too. So it's a really cool feature. And again, new to us, this population health sort of thing. So we're learning how to develop that. And that's one of the good things, because we've got integrated sort of the large EMR. And it's by home zip code. By home zip code, yeah. It's the patient's home zip code, whatever they list in their EMR. Which I think is done automatically, too, when they become an employee, the data matches from UCPath. Well, hopefully we exposed you to a variety of techniques, and methods to improve vaccine rates, address vaccine hesitancy. Again, we have kind of a wide range of practice styles that reflect somewhat our OEM diversity. Thank you for staying for both sessions. And if there's any other questions, please come up. Have a nice evening. APPLAUSE

vaccinations

Arkansas

COVID-19

vaccine hesitancy

EHR system

community outreach

occupational health settings