1. Overcoming Barriers and Other “How To’s” Priti Patel, MD, MPH Division 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

2. Outline Healthy People goals Barriers to Implementation Evidence-based Strategies Resources

3. Healthy People 2010 Immunization Goals for Renal patients and providers ImmunizationPatientsStaff Pneumococcal pneumonia 90%n/a Hepatitis B90%98% Influenza90%* (all) * No HP objective yet but recommended by CDC, ACIP and HICPAC for all healthcare workers

4. Patient Influenza Vaccination Rates by Network, STIC 2005-06 61115All # of Centers (≥ 20 pts) 360241176777 Mean (SD)* 73.5% (19.5%) 78.7% (15.2%) 76.9% (15.8%) 75.9% (17.6%) Median78.5%81.8%80.9%80.0% IQ range (25 th -75 th percentile) 64.5% to 87.0% 71.4% to 89.9% 69.1% to 86.5% 68.2% to 87.9%

6. Why aren’t more patients immunized? Barriers Patients Providers Institutions Systems

7. 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

8. Barriers to Adult Immunization: Patient & Provider Not knowing immunizations are needed Misconceptions about vaccines Lack of recommendations from health care providers

9. Access to healthcare Opportunities for prevention Cost / Reimbursement Barriers to Adult Immunization: Systems ESRD Population Other High-Risk Adult Populations

12. Vaccination rates among Adults ≥ 65 years by Race / ethnicity, 2000-2001 % Immunized CDC. MMWR 2003; 52(40):958-962

13. 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

14. STIC Interventions Standing orders Provider reminder systems Provider assessment and feedback Patient reminders Patient education Others

15. 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

16. 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

17. www.immunize.org/standingorders/ Sample Standing Order Policies Available at the Immunization Action Coalition Website

18. 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

19. 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

20. 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

21. 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

22. 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

23. Provider assessment and feedback Evaluate performance of providers in delivering vaccinations Give this information to providers

24. 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

25. 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

26. 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

27. 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

28. 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

29. Patient Education Provide patients information on vaccinations Can include posters, brochures, videos, newsletters, classes or lectures Should improve understanding and generate demand for vaccines

30. 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

31. 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

32. Other Interventions to Consider Immunization Education Day / Week Immunization Counseling Staff Vaccination Initiative Monitoring Patient Immunization Wallet Cards Check-boxes incorporated into order sheets Address patient and provider misconceptions

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

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

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

36. 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