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Policy Innovation Profile

Long-Term Care Facilities Cede Control of Immunization Policies to Regional Pharmacy, Significantly Increasing Influenza Vaccination Rates Among Workers


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Snapshot

Summary

As part of the Raising Immunizations Safely and Effectively (more commonly known as RISE) program, 14 long-term care facilities cede control of vaccination-related policies and processes to a regional pharmacy. The facilities work collaboratively with the pharmacy to implement and enforce these standardized policies and processes to boost influenza vaccination rates among facility workers. This policy change significantly increased worker vaccination rates in participating facilities, enabling all facilities to reach the Healthy People 2010 goal of vaccinating 60 percent of workers in long-term care settings and several facilities to exceed the Healthy People 2020 goal of vaccinating 90 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of worker immunization rates in participating long-term care facilities, along with post-implementation trends in the proportion of these facilities meeting national goals for immunizing workers.
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Developing Organizations

UPMC
UPMC (formerly known as the University of Pittsburgh Medical Center) created the RISE program, a network of long-term care facilities, in 2001.end do

Date First Implemented

2005
The new policy took effect in 2005, before the start of the 2005–2006 flu season.

Problem Addressed

Influenza-infected workers in long-term care (LTC) settings can spread the potentially deadly disease to vulnerable, elderly residents. To address this issue, the Centers for Disease Control and Prevention (CDC) set the goal of having 60 percent of such workers immunized each year by 2010 and 90 percent by 2020. Yet worker vaccination rates in LTC facilities remain well below these levels, in part because high staff turnover within these facilities reduces adherence to institution-specific policies. Regional and national pharmacies that already serve LTC facilities are in a position to help promote adherence, but very few play that role today.
  • Potential for transmission by health care workers: Employees of LTC facilities who become infected with influenza often expose elderly, vulnerable residents to the virus.1,2 Even if these residents have been immunized against the flu, the risk of a potentially deadly outbreak remains, since vaccine efficacy tends to be lower in older adults.3,4,5,6,7
  • Low immunization rates among workers: Because immunizing workers has been shown to reduce the risk of influenza illness and influenza-related deaths among LTC residents, the CDC established Healthy People 2010 and Healthy People 2020 goals of immunizing 60 percent and 90 percent of LTC workers, respectively.8,9 Yet immunization rates generally remain below these levels; for example, before this program began, worker vaccination rates generally ranged from 40 to 50 percent in LTC facilities in western Pennsylvania.10
  • High turnover as contributing factor: Low vaccination rates among workers in LTC facilities stem in part from high turnover of staff and managers within individual facilities. It is not uncommon for a facility's staff to turn over completely every few years. (Some facilities in western Pennsylvania have annual turnover of 50 percent or higher among frontline staff and 25 percent or higher among nursing and other managers.) Newly hired managers may not be familiar with and hence may not adhere to existing policies related to vaccinations, or they may decide to discard such policies and implement new ones.11,12,13
  • Unrealized potential of regional or national pharmacy as administrator of policy: The vast majority of LTC facilities do not have an onsite pharmacy, relying instead on contracts with regional or national pharmacy chains that review each resident's medications and supply medications (including vaccines) to the facility. In most cases, relationships between these pharmacies and LTC facilities tend to be stable over time. (There are substantial “switching costs” associated with changing pharmacies, due to the time and effort involved in entering information on each resident and his or her medications into the pharmacy’s information system.) Consequently, these pharmacies are in a good position to take charge of instituting and promoting adherence to vaccination-related policies. Yet very few play this role today.

What They Did

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Description of the Innovative Activity

As part of the RISE program, 14 LTC facilities cede control of vaccination-related policies and processes to a regional pharmacy. The facilities work collaboratively with the pharmacy to implement and enforce these standardized policies and processes to boost influenza vaccination rates among facility workers. Key elements of the new policies and related processes are detailed below:
  • Agreement to transfer vaccination-related policies to regional pharmacy: Before implementation of this program, each of the 14 participating facilities had its own vaccination policies for residents and workers. These policies were typically part of the facility’s nursing policies and procedures manual (which governs most facility operations). Under the new approach, each facility cedes control of immunization policies and procedures, transferring them to their partner regional pharmacy, RxPartners, Inc. (The facilities cede control of all vaccination-related policies, including those related to workers, residents, and the management of outbreaks.) Under the regional pharmacy’s policies, LTC facilities agree to do the following with respect to worker immunizations:
    • Abide by standing order: The regional pharmacy’s medical director approves the pharmacy’s policies and procedures, thus creating a standing order that applies to influenza vaccination administration. As part of the agreement, the facilities accept this standing order and consequently do not require a physician order to administer the vaccine to workers. This approach is consistent with a 2002 policy directive from the Centers for Medicare and Medicaid Services, which stated that pneumococcal and influenza vaccinations can be administered without a physician order.
    • Eliminate consent form: Participating LTC facilities agree to eliminate the requirement that those receiving a vaccination sign a consent form, which is a proven barrier to workers being immunized. Consent forms tend to be lengthy documents that detail any and all potential problems that can arise from being vaccinated, even though influenza vaccinations have been shown in studies to be highly beneficial and pose virtually no health risks. Federal regulations do not require consent forms, nor do most States (including Pennsylvania). Workers are instead given the CDC’s Vaccine Information Statement before they receive the vaccine to inform them of the risks, benefits, and potential adverse events. This information is also conveyed during educational sessions with workers.
    • Require declination form: Participating facilities require any worker who chooses not to be vaccinated to sign a declination form that clearly states the risks of forgoing a vaccination, including the potential to spread a dangerous virus to family members, friends, and facility residents. Under the policy, participating facilities make repeated attempts to ensure that unvaccinated workers read and sign the form and in rare cases may discipline an unvaccinated worker who does not do so. Workers who do not get vaccinated are required to wear a mask or take other precautions to prevent spread of the virus during outbreaks.
    • Offer convenient vaccines at no cost to workers on all shifts: Participating facilities agree to offer influenza vaccines each year at no cost to their workers and to make vaccinations available on multiple days to workers on all three shifts in an easy-to-reach location within the facility.
    • Designate local champion: Each participating facility designates a local champion who works with pharmacy staff to boost immunization rates among workers and takes charge of related issues within the facility, such as monitoring vaccine supply, maintaining records related to vaccinate administration, and submitting this information to the regional pharmacy.
  • Regional pharmacy support before and during flu season: Regional pharmacy staff work with the designated champion at each facility to promote vaccination of workers in advance of flu season each year. Key components of this support are detailed below:
    • Distribution of educational materials: The regional pharmacy provides a copy of a training video that focuses on immunizations and the health care worker. The video was developed by AMDA (formerly known as the American Medical Directors Association), a professional organization made up of medical directors, attending physicians, and others who practice in LTC facilities. The pharmacy also provides brochures that have been developed by various organizations based on CDC materials. Each facility is free to decide which materials to use and how to use them. In some cases, facilities make minor changes to customize the materials for the local environment.
    • In-service training: Regional pharmacy staff periodically go to participating LTC facilities to host in-house education and training sessions to raise awareness of vaccination-related policies and the importance of workers being immunized each year. During the first few years of the program, pharmacy staff often hosted such sessions. Over time, staff within many participating facilities began hosting the sessions on their own.
    • Annual campaign at each facility: Each year, pharmacy staff and the local champion announce a kickoff date to begin the worker immunization campaign and arrange for the provision of vaccines to workers on all three shifts in an easily accessible location. LTC facility staff generally take charge of administering the vaccines, and some facilities offer small incentives to workers who get immunized. In most facilities, the vast majority of workers who want to be immunized get the vaccine within the first week of the campaign, after which facility leaders reach out to unvaccinated workers. The campaign typically lasts for several weeks. (The kickoff date also applies to facility residents, who are generally immunized over a much shorter time period—typically 2 days.)
    • Performance monitoring and feedback: Using data submitted by the local champions, the pharmacy tracks worker immunization rates and provides regular feedback on performance to individual facilities. Feedback includes comparisons with benchmark data for the group as a whole. These reports tend to be brief, making use of simple, easy-to-understand graphics that highlight performance versus peers.
    • Regular communication via email distribution list: The pharmacy uses an e-mail distribution list to facilitate communication with individual facilities. This list allows for distribution of the performance data and also serves as a vehicle for facility representatives to ask questions and for the pharmacy to update participating facilities about influenza prevention and management. 

Context of the Innovation

UPMC is a large, integrated, nonprofit health system. In 2001, UPMC (then known as the University of Pittsburgh Medical Center) formed the RISE program, a network of 16 LTC facilities in western Pennsylvania focused on improving immunization rates. The network began by concentrating on boosting immunization rates among residents. Recognizing the potential for health care workers to spread the influenza virus among vulnerable elderly adults (for whom vaccinations can be less effective), RISE program leaders decided in 2004 to expand the initiative to focus on improving vaccination rates among workers.

Did It Work?

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Results

The change in policy significantly increased vaccination rates among workers in participating LTC facilities, enabling all of the facilities to reach the Healthy People 2010 goal of immunizing 60 percent of workers and several to exceed the Healthy People 2020 goal of immunizing 90 percent.
  • Significant increase in immunization rates: During the first flu season after implementation of the policy (2005–2006), immunization rates averaged 58 percent across the 14 participating facilities, well above the 40- to 50-percent average in the 3-year baseline period (the 2001–2002 season through the 2003–2004 season). Rates have increased steadily since that time, reaching 76 percent in 2010–2011 and remaining right around that level the following year. (Data from the 2012–2013 season are not yet available.) These rates are among the highest reported by a network of independent LTC facilities using a voluntary approach.10
  • Many more facilities reaching CDC goals: The number of participating facilities that meet CDC’s Healthy People goals has increased steadily over time. During the 4-year period before implementation, only 1 of the 14 facilities ever reached the Healthy People 2010 goal of immunizing 60 percent of workers, and this facility did so during only one of the four flu seasons. After implementation of the policy, the number of facilities reaching the 60-percent goal increased markedly, with 5 facilities meeting it the first year, 6 the second year, and 13 the third year. By the fourth year (the 2010–2011 flu season), all 14 participating facilities reached the 60-percent goal, including 8 that exceeded 80 percent and 3 that exceeded 90 percent (the Healthy People 2020 goal).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of worker immunization rates in participating long-term care facilities, along with post-implementation trends in the proportion of these facilities meeting national goals for immunizing workers.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Creating steering committee to develop, oversee program: During the spring of 2003, a steering committee formed made up of representatives of the regional pharmacy and local LTC facilities. This committee took charge of developing the program, meeting regularly to review research related to worker immunizations (e.g., the need for consent forms) and develop key components of the new policies and related procedures. This process was effective in securing buy-in from facilities. For the first few years after the new policies went into place, the committee met roughly five times a year. Beginning with the 2009–2010 flu season, the committee reduced the frequency of its meetings to once a year.
  • Recruiting facilities: The steering committee served as the primary vehicle for gaining buy-in and convincing LTC facilities to participate. In addition, leaders of the RISE program and the regional pharmacy periodically reached out to facility leaders through phone calls, inperson meetings, and written communications. Ultimately, 14 of the 16 LTC facilities in the RISE network agreed to participate in the worker vaccination initiative. (One facility that chose not to participate already had above-average worker immunization rates.)

Resources Used and Skills Needed

  • Staffing: The new policies and procedures require no new staff, as existing staff at the regional pharmacy and participating LTC facilities incorporate vaccination-related activities into their regular job responsibilities.
  • Costs: Program-related costs tend to be quite minimal, consisting primarily of printing expenses for LTC facilities that distribute educational materials related to worker immunizations. Participating LTC facilities have between 50 and 400 employees, with the average annual cost to immunize these workers being approximately $1,000 per facility.
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Funding Sources

Agency for Healthcare Research and Quality; Pfizer, Inc.; Pharmaceutical Outcomes Research in Aging Program; Pittsburgh Claude D. Pepper Older Americans Independence Center; AMDA Foundation
These organizations provided grants that helped cover costs related to developing the policy and evaluating its impact, including literature searches to determine the feasibility of eliminating consent forms and studies to evaluate worker immunization rates over time.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Approach regional or national pharmacy serving LTC facilities: As noted, most LTC facilities rely on a regional or national pharmacy to handle medication-related issues for residents, including reviewing regimens and supplying medications. Leaders of these organizations may not have considered the potential for supporting LTC facilities with immunization-related activities, including policies related to worker immunizations. Most pharmacies have a medical director and an infection control practitioner who are likely in a position to work with LTC facilities to boost worker immunization rates.
  • Start with a few early adopters: Program developers should initiate the effort with LTC facility leaders who understand and support the approach. Over time, other facilities may join as their leaders see the benefits of doing so.
  • Offer education and training support to facilities: LTC facilities do not have adequate staff or financial resources to develop educational and training materials. Consequently, the pharmacy partner needs to provide this support, including distributing written materials and offering onsite training. As noted, many educational materials already exist, having been developed on the basis of CDC resources.
  • Do not expect immediate results: This program is unlikely to have a major impact in the first year or two, as it takes time to change the culture within facilities to emphasize the importance of workers being vaccinated. Consequently, program leaders should not expect significant improvements for several (3 to 6) years.

Sustaining This Innovation

  • Monitor and share data on policy’s impact: Program leaders should collect and regularly share performance data with participating facilities, using easy-to-understand graphs that show how each facility is doing relative to its peers. These reports not only help facilities identify and address areas where performance is lacking, but also serve to keep facility leaders and staff motivated and engaged.
  • Keep abreast of State and national requirements: The Joint Commission and other organizations have made immunization of health care workers a priority. The Joint Commission now requires hospitals to report worker immunization rates. While LTC facilities are not yet required to do so, they may be in the future. In addition, Federal or State laws and regulations related to immunization of health care workers could change in the future, including the potential for mandates requiring immunization of workers in certain settings.
  • Consider mandatory vaccinations: Over time, voluntary efforts are unlikely to achieve 100-percent immunization rates. As noted, immunization rates under this initiative seem to have plateaued at a level where approximately three out of four workers in participating facilities get immunized. Consequently, facility leaders may eventually conclude that an institutional mandate requiring workers to be immunized is needed. While a mandate likely should not be an organization’s first foray into worker immunizations, it might be a logical next step after a voluntary program reaches the limits of what can be achieved.

More Information

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Contact the Innovator

David A. Nace, MD, MPH, CMD
Director of Long-Term Care and Flu Programs, Division of Geriatric Medicine, University of Pittsburgh
Chief of Medical Affairs, UPMC Senior Communities
3471 Fifth Ave, Suite 500
Pittsburgh, PA 15213
(412) 692-2360
E-mail: naceda@upmc.edu

Innovator Disclosures

Dr. Nace reported having no financial or business/professional relationships relevant to the work described in this profile, other than the funders listed in the Funding Sources section. 

References/Related Articles

Nace DA, Handler SM, Hoffman EL, et al. Impact of Raising Immunizations Safely and Effectively (RISE) program on healthcare worker influenza immunization rates in long term care settings. J Am Med Dir Assoc. 2012;13(9):806-10. [PubMed]

Footnotes

1 Poland GA, Tosh P, Jacobson RM. Requiring influenza vaccination for health care workers: seven truths we must accept. Vaccine. 2005;23(17-18):2251-5. [PubMed]
2 Talbot TR, Bradley SE, Cosgrove SE, et al. Influenza vaccination of healthcare workers and vaccine allocation for healthcare workers during vaccine shortages. Infect Control Hosp Epidemiol. 2005;26(11):882-90. [PubMed]
3 Fiore AE, Shay DK, Broder K, et al. . MMWR Recomm Rep. 2009;58(RR8):1-52. [PubMed]
4 Horman JT, Stetler HC, Israel E, et al. An outbreak of influenza A in a nursing home. Am J Public Health. 1986;76(5):501-4. [PubMed]
5 Taylor JL, Dwyer OM, Coffman T, et al. Nursing home outbreak of influenza A (H3N2): evaluation of vaccine efficacy and influenza case definitions. Infect Control Hosp Epidemiol. 1992;13(2):93-7. [PubMed]
6 Jefferson T, Rivetti D, Rivetti A, et al. Efficacy and effectiveness of influenza vaccines in elderly people: a systematic review. Lancet. 2005;366(9492):1165-74. [PubMed]
7 Osterholm MT, Kelley NS, Sommer A, et al. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. Lancet Infect Dis. 2012;12(1):36-44. [PubMed]
8 U.S. Department of Health and Human Services. Healthy People 2010 Midcourse Review [Web site]. Available at: http://www.healthypeople.gov/2010/.
9 U.S. Department of Health and Human Services. HealthyPeople.gov [Web site]. Healthy People 2020.
Available at: http://www.healthypeople.gov/2020/default.aspx.
10 Nace DA, Handler SM, Hoffman EL, et al. Impact of Raising Immunizations Safely and Effectively (RISE) program on healthcare worker influenza immunization rates in long term care settings. J Am Med Dir Assoc. 2012;13(9):806-10. [PubMed]
11 Castle NG, Engberg J, Men A. Nursing home staff turnover: impact on nursing home compare quality measures. Gerontologist. 2007;47(5):650-61. [PubMed]
12 Donoghue C. Nursing home staff turnover and retention. An analysis of national level data. J Appl Gerontol 2010;29(1):89-106. Available at: http://jag.sagepub.com/content/29/1/89.short.
13 Decker F, Gruhn P, Matthews-Martin L, et al. Results of the 2002 AHCA survey of nursing staff vacancy and turnover in nursing homes. American Health Care Association. 2003 Feb 12. Available at:
http://www.ahcancal.org/research_data/staffing/Documents/Vacancy_Turnover_Survey2002.pdf.
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Original publication: April 09, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.