1. CMS-CDC Immunization Standing Orders Program (SOP) Project: Nursing Home Immunization Practices and Barriers to SOPs in 12 States L McKibben, A Shefer, H Roberts, P Stange, J Krider, D Bratzler APHA 129 th Annual Meeting, Oct. 23, 2001 Atlanta, GA

2. SOP Project Background  Healthy People 2010 Goals for influenza and pneumococcal vaccinations are 90% for all persons > 65 years old, including nursing home residents  Nation did not reach HP 2000 goals of 80% for these immunizations in nursing home residents  Advisory Committee on Immunization Practices endorsed evidence-based standing orders programs (MMWR 49:RR-1,3/2000)

3. Influenza and Pneumococcal Vaccinations, Nursing Homes, United States, 1995, 1999* *CDC unpublished data, National Nursing Home Survey

4. 1999 Baseline Objectives of the SOP Project  To assess:  Current & planned immunization program types  Perceived barriers to SOPs  Need for training resources  Capacities to track immunizations

5. Methods  Self-administered, 2-page questionnaire:  4-6 responses on current and planned program types  9 responses for SOP barriers for each vaccine  8 responses for training needs  2 responses for tracking practices  Mailed July 1999 to all Medicare or Medicaid certified nursing homes in 7 intervention & 5 control states  Overall response rate of 77%

6. Response Rates: Intervention States PRO Jurisdictions TOTAL # of NURSING HOMES # RETURNEDRATE (%) FL72552172% MA50242384% MN41638994% KY25619074% NM746589% ID735880% DC191579% Totals2065166180% Note: 2 states (HI & MT) used alternate surveys

7. Response Rates – 5 Control States PRO Jurisdictions TOTAL # of NURSING HOMES # RETURNED RATE (%) OH100868968% PA76659878% WI41334082% SC15812177% NV513875% Totals2396178675%

8. Immunization Program Types  Preprinted Admission Orders (PPAO):  Standardized Forms included in admission package for personal physician signature; may address future as well as current vaccination needs. May require periodic updating.  Standing Orders (SOP):  Institutional policy authorizes appropriate nursing staff to immunize residents by institution- or medical director-approved protocol w/out need for written or verbal order from personal physician.

9. Immunization Program Types  Physician reminders and education:  Procedures in place for educating and/or reminding physicians and residents on importance of I&P vaccines. May include stickers on charts, letters to physicians’ offices, posters, etc. Procedures require physician order for each immunization.  No formal procedures in place:  Residents are immunized upon request and/or upon personal physician’s individual discretion. Physician’s orders are required for each immunization.

10. Types of Program, Baseline 1999 Intervention States, N = 1,598 * Program Types Flu program %Pneumococcal program % PPAO56%41% SOP9%7% Reminder/ Educ 29%28% None6%24% No response<1% * 1,598 represents complete survey & OSCAR data

11. % Plan to Change Y2000 Programs, Intervention States, N = 1,598  5% to change flu program (n=73)  39 of these plan to change to PPAO  23 of these plan to change to SOP  9% to change pneumo program (n=144)  62 of these plan to change to PPAO  32 of these plan to change to SOP

12. Type of Program, Baseline 1999 Control States, N = 1,772 * Program Types Flu program % Pneumococcal program % PPAO 46%31% SOP 8%7% Reminder/ Educ 38%30% None 8%32% No response<1% * 1,772 represents complete survey & OSCAR data

13. % Plan to Change Y2000 Programs, Control States, N = 1,772  6% to change flu program (n = 104)  56 planning to change to PPAO  24 planning to change to SOP  10% to change pneumo program ( n= 181)  81 planning to change to PPAO  26 planning to change to SOP

14. Barriers to SOPs: Flu Vaccination, Intervention States, N=1,598 Barriers Frequency % of Total No legal authority 891 54% Need to educ MDs 862 52% No Advantage67941% Liability66840% Inappropriate43026% Staff turnover33420% Cost27116% Reimbursement26316% Lack of Support1247%

15. Barriers to SOPs: Pneumococcal Vax, Intervention States, N=1,598 Barriers Frequency % of Total No legal authority 887 53% Need to educ. MDs 869 52% Liability65339% No advantage63738% Inappropriate52632% Staff turnover33020% Cost28517% Reimbursement26516% Lack of support1328%

16. Barriers to SOPs: Flu Vaccination, Control States, N=1,772 Barriers Frequency % of Total No legal authority 948 53% Need to educ. MDs 909 51% No Advantage75943% Liability67538% Inappropriate48827% Staff turnover32718% Cost26615% Reimbursement21812% Lack of Support1599%

17. Barriers to SOPs: Pneumococcal Vax, Control States, N=1,772 Barriers Frequency % of Total No legal authority 940 53% Need to Edu. MDs 902 51% No advantage71740% Liability66337% Inappropriate58833% Staff turnover31318% Cost27115% Reimbursement22012% Lack of support1579%

18. Training Topics Needed, Intervention States, N=1,598 Training Topic Materials for staffOn-site training Model policy 59%30% Billing procedures 42%24% Influenza vaccine 50%26% Pneumococcal vaccine 55%29% Process/software for tracking 53%35%

19. Training Topics Needed, Control States, N=1,772 Training Topic Materials for staffOn-site training Model policy 54%23% Billing procedures 37%17% Influenza vaccine 43%18% Pneumococcal vaccine 49%21% Process/software for tracking 46%28%

20. Consistent Place to Record Vaccinations, Intervention States, N=1,598 Consistent place used:N (%) For influenza vaccine1364 (85%) For pneumococcal vaccine1235 (77%) For Neither151 (9%) Don’t Know43 (3%)

21. Centralized Tracking of Vaccinations, Intervention States, N=1598 Centralized tracking:N (%) For Influenza vaccine824 (52%) For Pneumococcal vaccine719 (45%) For Neither579 (36%) Don’t Know108 (7%) * Computer or Log book

22. Consistent Place to Record Vaccinations, Control States, N=1,772 Consistent Place used:N (%) For influenza vaccine1506 (85%) For pneumococcal vaccine1327 (75%) For Neither176 (10%) Don’t Know17 (1%)

23. Centralized Tracking of Vaccinations, Control States, N=1772 Centralized trackingN (%) For influenza vaccine1031 (58%) For pneumococcal vaccine821 (46%) For Neither635 (36%) Don’t Know41 (2%) * Computer or Log book

24. Summary I  SOPs are underutilized  Few NHs planning to change program types  More likely to change to PPAO>SOP  Vaccine history documented in consistent place in the resident’s chart  Many facilities need centralized tracking  Barriers to SOPs:  Legal & regulatory issues  Need for physician education

25. Characteristics of Nursing Homes Associated with Influenza Vaccine SOPs and other program types Exploratory analysis of SOP baseline survey & selected nursing home variables from OSCAR*. * CMS administrative database used in annual certification process.

26. Characteristics of Nursing Homes by State Type CharacteristicIntervention %Control % multiple-owned facility (chain) 61%50% provider category : Long, SNF Health Agency, NH Rehab Hospital 41% 54% 4% 1% 38% 46% 9% 7% bed size: Large (>120) Medium (51-120) Small (<50) 44% 45% 11% 41% 48% 12%

27. 1999 Influenza Immunization Program, by Provider Category, Intervention States Provider Category Type of Program SNF n=650 Unskilled n=873 Rehab n=65 Hospital n=16 PPAO63%53%25%44% SOP12%6% Reminder/Educ21%35%32%31% None4%6%37%19% Unknown<1% 00 Total100% P value <.01

28. Bivariate Analysis: Co-variates  Certification Status  Both (89%), Medicare (6.5%), Medicaid (4%)  Provider-based  Administered by hospital (10%) or by provider (90%)  Multi-facility organization  Chain or independent  Provider category  4 types: Long, SNF; Health Agency, NH; Rehab; Hospital  Facility size  50 beds

29. Certification Status & Program Types Program type vs No Program Pearson Chi- Square test for association P-value SOP vs None58.46< 0.0001 PPAO vs None214.60< 0.0001 Reminder/Educ vs None 96.64< 0.0001

30. Chain Affiliation & Program Types Program type vs No Program Chi-Square test for association P-value SOP vs None3.320.0684 PPAO vs None0.230.6353 Reminder/Educ vs None 0.010.9234

31. Provider-based & Program Types Program type vs No Program Chi-Square test for association P-value SOP vs None30.11< 0.0001 PPAO vs None158.93< 0.0001 Reminder/Educ vs None 87.87< 0.0001

32. Provider Category & Program Types Program type vs No Program Chi-Square test for association P-value SOP vs None63.76< 0.0001 PPAO vs None215.29< 0.0001 Reminder/Educ vs None 98.87< 0.0001

33. Facility Size & Program Types Program type vs No Program Chi-Square test for association P-value SOP vs None31.36< 0.0001 PPAO vs None110.99< 0.0001 Reminder/Educ vs None 79.77< 0.0001

34. Polytomous Logistic Regression*: Best 2 Models  Facility size; Multi-facility Org; Certification Status  P value = 0.7344 (higher p-value indicates best model)  Facility size; Multi-facility Org; Cerification status; Provider based; Provider- based*Certification status  P value = 0.2937 *CATMOD in SAS v8

35. Best Model: Coefficient Estimates **p<.01

36. Summary II: Influenza Vaccine Programs  Larger facilities (> 50 beds) more likely to have organized programs (all 3 types) for influenza vaccine  Chain facilities less likely to be using SOPs  Certification status (Both) has large effects on all 3 program types

37. Conclusions: Quality Improvement Opportunities for Intervention PROs  Promote centralized tracking of vaccinations  Promote SOPs for pneumococcal vaccine  Address legal authorities for SOPs  Provide education materials, especially model policies (ACIP); physician education about the benefits of SOPs; advantages of SOPs  Promote SOPs to chains  Promote SOPs to small facilities  ? Convert other program types to SOPs