overcoming barriers and other “how to’s” priti patel, md, mph division of healthcare quality...
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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
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%
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