Overcoming Barriers and Other

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Overcoming Barriers and Other How Tos

• 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
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Outline

• Healthy People goals
• Barriers to Implementation
• Evidence-based Strategies
• Resources

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Healthy People 2010 Immunization Goals for Renal
patients and providers
Immunization 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
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Patient Influenza Vaccination Rates by Network,
STIC 2005-06
6 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
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Why arent more patients immunized?
Barriers
Patients
Institutions Systems
Providers
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Barriers Strategies High Risk Adults

• 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

High-Risk Adult Population
ESRD Patients
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Barriers to Adult Immunization Patient
Provider

• Not knowing immunizations are needed
• Misconceptions about vaccines
• Lack of recommendations from health care
  providers

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Barriers to Adult Immunization Systems

• Access to healthcare
• Opportunities for prevention
• Cost / Reimbursement

ESRD Population
Other High-Risk Adult Populations
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Vaccination rates among Adults 65 years by
Race / ethnicity, 2000-2001
Immunized
CDC. MMWR 2003 52(40)958-962
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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

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STIC Interventions

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

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Standing Orders

• Definition written order stipulating that all
  persons meeting certain criteria should be
  vaccinated, thus eliminating the need for
  individual physicians 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

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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

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

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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

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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

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Computerized Record Reminder

• Computer print-out of reminders that appear on a
  patients 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

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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

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Provider assessment and feedback

• Evaluate performance of providers in delivering
  vaccinations
• Give this information to providers

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Provider assessment and feedback

• Advantages
• Competition increases motivation and provider
  compliance with vaccination recommendations
• Immediate feedback on each providers 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

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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

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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

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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

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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

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Patient Education

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

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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

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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

See the STIC Toolkit for Educational Materials
VIS sheet http//www.cdc.gov/vaccines/pubs/vis/do
wnloads/vis-flu.pdf
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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
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Myth-busting
http//www.cdc.gov/flu/professionals/flugallery/20
07-08/pdf/f_factmyth_8x11.pdf
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Myth-busting
http//www.cdc.gov/flu/professionals/flugallery/20
07-08/pdf/f_factmyth_8x11.pdf
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Myth-busting
http//www.cdc.gov/flu/professionals/flugallery/20
07-08/pdf/f_factmyth_8x11.pdf
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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