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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

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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

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  • Healthy People goals

  • Barriers to Implementation

  • Evidence-based Strategies

  • Resources

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Healthy People 2010 Immunization Goals for Renal patients and providers

* No HP objective yet but recommended by CDC, ACIP and HICPAC for all healthcare workers

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Why aren’t more patients immunized?



Institutions Systems


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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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  • 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 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

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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


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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 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

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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 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

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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/downloads/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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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