Overcoming Barriers and Other “How To’s”

Priti Patel, MD, MPHDivision of Healthcare Quality Promotion

National Center for Preparedness, Detection, and Control of Infectious Diseases

The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the views of the Centers for Disease Control and Prevention

Outline

Healthy People goals Barriers to Implementation Evidence-based Strategies Resources

Healthy People 2010 Immunization Goals for

Renal patients and providersImmunization Patients Staff

Pneumococcal pneumonia

90% n/a

Hepatitis B 90% 98%

Influenza 90% * (all)

* No HP objective yet but recommended by CDC, ACIP and HICPAC for all healthcare workers

Patient Influenza Vaccination Rates by Network,

STIC 2005-066 11 15 All

# of Centers(≥ 20 pts) 360 241 176 777

Mean (SD)* 73.5%

(19.5%)

78.7%

(15.2%)

76.9%

(15.8%)

75.9%

(17.6%)

Median 78.5% 81.8% 80.9% 80.0%

IQ range (25th-75th percentile)

64.5% to

87.0%

71.4% to

89.9%

69.1% to

86.5%

68.2% to

87.9%

Facilities ordered by rate (n=777)

Vacc

inati

on r

ate

100%

90%

80%

70%

60%

40%

20%

0%

Influenza vaccination rates across Networks 6, 11, and 15 (2005-06)

15.1% below 60%

19.8% at or above 90%

Why aren’t more patients immunized?

Barriers

Patients Providers Institutions Systems

Barriers & Strategies: High Risk Adults

High-Risk Adult Population

ESRD Patients

Persons targeted for vaccination because they are at increased risk for complications from influenza

Criteria– Persons aged 65 or older*– Residents of nursing homes

and chronic care facilities*– Persons with chronic lung,

heart, or renal disease, diabetes, immunosuppression, or neurologic disorders that can compromise respiratory function*

– Pregnant women

Barriers to Adult Immunization:

Patient & Provider Not knowing immunizations are

needed Misconceptions about vaccines Lack of recommendations from

health care providers

Access to healthcare Opportunities for prevention Cost / Reimbursement

Barriers to Adult Immunization:

Systems

ESRD Population

Other High-Risk Adult Populations

Vaccination rates among Adults ≥ 65 years by

Race / ethnicity, 2000-2001

0

10

20

30

40

50

60

70

Influenza Pneumovax

WhiteBlack

Hispanic

% I

mm

un

ized

CDC. MMWR 2003; 52(40):958-962

Strategies

Task Force on Community Preventive Services reviewed evidence for various interventions

Recommended interventions – Enhance access to vaccines– Provider or systems-based– Increase community demand for

vaccines

STIC Interventions

Standing orders Provider reminder systems Provider assessment and feedback Patient reminders Patient education Others

Standing Orders Definition: written order stipulating that all

persons meeting certain criteria should be vaccinated, thus eliminating the need for individual physician’s orders for each patient

Advantages:– The most consistently effective method for

increasing adult vaccination rates– Easy to implement

Disadvantages:– Only reaches patients already contacting

the health care system

Standing Orders: Implementation

Decide what criteria will be used to indicate patient eligibility for vaccination

Write standing order Meet with staff to discuss

implementation of the standing order

Monitor vaccination rates (suggested)

Resources needed: – Standing order

www.immunize.org/standingorders/

Sample Standing Order Policies

Available at the Immunization Action Coalition Website

Provider reminder systems

Informs the provider that individual patient is due for vaccine

Examples: – Notation, prompt, or sticker

in patient chart– Standardized checklists– Computerized database or

registry

Chart Reminders: Tips

Can be as simple as a colorful sticker on the chart

Should be prominently placed in the chart

Reminders that require some acknowledgment, even a simple checkmark by the physician, are more effective

Chart Reminders: Implementation

Design or identify a chart reminder to use

Make copies to be inserted into all appropriate patient records

Assign a staff person to place the reminders in a prominent place in the chart

Resources Needed:– Staff time– Chart reminders

Computerized Record Reminder

Computer print-out of reminders that appear on a patient’s record

Use software to determine dates that certain immunizations are due or past due and then print reminder messages, usually overnight, for patients with visits scheduled for the next day

Advantages:– Inexpensive once computerized system is

in place– Efficient

Disadvantages:– Only reaches patients with office visits

Computer Record Reminder: Implementation Design or identify a computerized

reminder system to use Train professional staff in the use of

the computerized reminders. Resources Needed:

– Computer program linked to medical records or billing data to generate reminders

– Computerized medical records

Provider assessment and feedback

Evaluate performance of providers in delivering vaccinations

Give this information to providers

Provider assessment and feedback

Advantages:– Competition increases motivation and provider

compliance with vaccination recommendations– Immediate feedback on each provider’s

performance– Easy to implement– Each provider can use his/her own approach to

improve vaccination rate– Evaluation is built into this approach

Disadvantages:– Time to train staff and implement strategy– Requires continual tracking of vaccination rates

Provider assessment and feedback: Implementation

Determine number of eligible patients (denominator) May need to generate lists of patient names Create or adopt target-based poster on which to

track number of patients vaccinated Hold meetings with staff to explain the graphic

denominator-based tracking system Each week, providers should record all influenza

vaccinations given to at-risk patients, tabulate the cumulative weekly total, and calculate the percentage of the target population vaccinated

Resources Needed:– Staff time– Poster to track vaccinations given

Patient Reminders Notification to patients that vaccinations are

due Gives patient opportunity to come in for

vaccination Can be delivered by telephone, letters, or

postcards

Patient Reminders Advantages:

– Phone contact ensures that the message is understood

– Reaches patients who may otherwise not have scheduled visits

– Easy to implement, requiring minimal staff time

Disadvantages:– Relies on patient to make & keep appointment– Not useful in practices with a population that

changes residences frequently– May need bilingual reminders– Generating the list of patients who should

receive reminders may be difficult in some practices

Patient Reminders: Implementation

Generate a list of patients to be reminded (manually or via computerized billing or medical records)

Review list to remove patients who have died, transferred to another provider, left the area, or received vaccinations

Develop reminder Send reminders or place calls (6 calls a

day, 5 days a week for eight weeks = 240 patients contacted)

Schedule appointments Resources Needed:

– Staff time– Telephone script or postcards

Patient Education Provide patients information on

vaccinations Can include posters, brochures,

videos, newsletters, classes or lectures

Should improve understanding and generate demand for vaccines

Patient Education Advantages:

– Inexpensive and easy to implement, requiring minimal staff time

– Patients can ask questions and receive feedback

– Does not require generating a patient list Disadvantages:

– Only reaches patients already in contact with health care providers

– Using only written materials not useful in practices with low literacy levels

– May need bilingual information sheets

Patient Education: Implementation

Create or identify appropriate patient information sheet* or use the Vaccine Information Statement (VIS)

Assign a staff person to distribute information sheet or VIS

Follow-up to answer questions Resources Needed:

– Staff time– Handouts

VIS sheet: http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-flu.pdf* See the STIC Toolkit for Educational Materials

Other Interventions to Consider

Immunization Education Day / Week Immunization Counseling Staff Vaccination Initiative Monitoring Patient Immunization Wallet Cards Check-boxes incorporated into order

sheetsAddress patient and provider misconceptions

Myth-busting

http://www.cdc.gov/flu/professionals/flugallery/2007-08/pdf/f_factmyth_8x11.pdf

Myth-busting

http://www.cdc.gov/flu/professionals/flugallery/2007-08/pdf/f_factmyth_8x11.pdf

Myth-busting

http://www.cdc.gov/flu/professionals/flugallery/2007-08/pdf/f_factmyth_8x11.pdf

Protect patients,Protect healthcare personnel,

Promote quality healthcare

Prevention Is Primary!

The information in this presentation has not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy