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1 Thank You for Joining! New England Nursing Home Quality Care Collaborative Learning Series: Immunizations Webinar Will Begin Shortly. Call-In Number: (888) Access Code: This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQIN_C2_092016_0758 1

2 Shot from the Heart Part 2: Everyone s Role in Protecting Residents by Ensuring Immunizations Stefan Gravenstein, MD, MPH, CMD Professor of Medicine Clinical Director, Healthcentric Advisors Director, Center for Geriatrics and Palliative Care University Hospitals and Case Western Reserve University Adjunct Professor of Medicine, Brown University Russ Cooney, B.A. Program Coordinator, Healthcentric Advisors Michael Patno RN, CRC Regional Director of Clinical Reimbursement 2

3 Objectives Hear from one nursing home about how they were able to improve their immunization program. Answer immunization questions raised during the first presentation as well as those identified in the post event survey. Provide Information on ACIP Recommendations on Zoster Vaccination. Discuss the immunization tracking tool, answer remaining questions and solicit feedback. We will release the tracking tool during the event and pilot it s use in facilities who express interest. 3

4 Located in Barre, VT 96 bed facility LTC/SAR Michael Patno RN, CRC Consulting/training nationwide Regional Director of Clinical Reimbursement Currently overseeing Medicare/Medicaid/MDS at Rowan 4

5 Special Focus Facility One Star Rating Major Changes in Leadership: New Administrator, D.O.N., Staff Development, Unit Managers, MDS Changes in Ownership Multiple Challenges Was Removed From Being a Special Focus Facility! 5

6 O0250A and/or O0300A coded as Not Assessed (-) Led to a very low rate of vaccination for the QM s Required a team effort to improve Information gathering, obtaining orders and administering the vaccinations when appropriate. 6

7 Did a 120 day look back on the MDS Ran report for the sections O0250A and O300A that were Not Assessed and used a dash (-) mark Reviewed the Vermont Immunization Registry to determine if flu or pneumovax was given Reviewed hospital records if applicable Called primary care provider for confirmation If information was not available, offered vaccine to resident Obtained order and gave if resident or family consented If resident was not in house, VT. Immunization Registry was accessed or primary care provider was called 7

8 If information was obtained that showed the resident had the vaccinations, all MDS s within that time frame were modified to show the change and resubmitted Admission Coordinator access all hospital records for vaccine information if available Residents and families interviewed on admission VT Immunization Registry is accessed as needed Primary health provider is questioned as needed If needed, the vaccines are offered here 8

9 1 st quarter 2015 Flu immunization rate at 88.4% Pneumonia immunization rate at 73.6% Ending May, 2016 Flu immunization rate at 96.3% Pneumonia immunization rate at 98.4% MDS is key to monitoring QM Print from CMS monthly and review as a team Action plans to address areas of concern 9

10 Stefan Gravenstein, MD, MPH, CMD Professor of Medicine Clinical Director, Healthcentric Advisors Director, Center for Geriatrics and Palliative Care University Hospitals and Case Western Reserve University Adjunct Professor of Medicine, Brown University 10

11 Questions From the First Event What immunizations should be given in Nursing Homes? How can we make influenza vaccines mandatory in our facility? If we have standing orders for flu vaccine, do we have to have signed acknowledgment of Vaccine Information Statements (VIS s)? How does influenza cause heart attacks? Where can I find educational materials to decrease infection rates? Should residents be given Shingles and DTAP vaccinations? Where can I find a list of other types of vaccines and their recommendations? 11

12 Other Questions? Please type into chat and we will answer as time allows. 12

13 What immunizations should be given in Nursing Homes? Employees should be up to date on all CDC recommended vaccinations for adults. This includes TdaP, influenza, hepatitis B, pneumococcal vaccines according to CDC recommendations At initial employment, they have record of prior immunity to MMR, or get updated to these. Residents should be up to date on these vaccines too, except hepatitis. Also, shingles vaccine, would be ideal. 13

14 How can we make influenza vaccines mandatory in our facility? Making annual influenza vaccination a condition for employment for incoming/new employees. Due to the high staff turnover in most facilities (50% or more in many, and uptake is lowest in those facilities with the greatest turnover), this will increase overall uptake over the course of a few years. 14

15 If we have standing orders for flu vaccine, do we have to have signed acknowledgment of Vaccine Information Statements (VIS s)? Providing a VIS is a standard of care. The standing orders for vaccination and the VIS should be offered at the time of initial placement of the standing order to the resident or legally authorized representative. Your facility policy should dictate how VIS are distributed for subsequent years and whether this can be articulated in the standing order (e.g., made available at the nurse's station each year when influenza vaccine is given and/or mailed to the LAR and patient on each recurrent vaccination date). 15

16 How does influenza cause heart attacks? Influenza and other infections increase inflammation, which increases the risk for forming clots It is assumed that following infection (whether influenza or UTI), that the increased propensity to clot conveys a risk of clotting in the heart or head, thereby increasing vulnerability to and risk for a heart attack or stroke 16

17 Where can I find educational materials to decrease infection rates? There are many sources to find educational materials. Below are some of the better ones:

18 Should residents be given Shingles and DTAP vaccinations? Ideally, residents should be up to date for both of these Both TdaP (not DTaP) and shingles Their insurance may or may not pay for these vaccinations This is not a "requirement" but are recommendations Pressure sores increase risk for tetanus and in the US, most tetanus cases occur in older adults, often with pressure sores 18

19 Where can I find a list of other types of vaccines and their recommendations? General vaccine tables Search CDC adult vaccines Pneumococcal vaccine information Search Pneumococcal Vaccine Timing for Adults ACIP recommendations 19

20 ACIP Recommendations Herpes Zoster (Shingles) ACIP current recommendation is that herpes zoster vaccine be routinely recommended for adults aged 60 years. Vaccination providers considering the use of Zostavax among certain persons aged 50 through 59 years despite the absence of an ACIP recommendation should discuss the risks and benefits of vaccination with their patients. Insurance coverage for Zoster immunization varies by plan. 20

21 Questions in Chat 21

22 Flu Immunization Tracking Patient Information Influenza Vaccination Information Resident Name Unit Admission Date Discharge Date Phys/Stand Order? Vax Given Not Elligible Vax Refused Missed Opportunity Lot # Date Given Inj. Site? L/R Russ 2 11/5/16 12/1/16 Y Yes /7 R Val 1 11/9/16 11/18/16 Y 1 No Jeanne 1 11/15/16 Y Yes Alex 1 11/22/16 12/17/16 y 1 No Yes Yes Total Offered/Not Elligible/Refused: 2 Total Missed Opportunities 4 % Rate 33% 22

23 Want to pilot the Immunization Spreadsheet? Contact Russ Cooney: Pilot will run from: October 1, 2016 to March 31, 2017 (Flu Season) We ask that you track at least: Influenza and Pneumococcal We welcome feedback and will provide technical assistance, as needed Full directions are on the first page of the spreadsheet 23

24 Contact your Nursing Home Quality Improvement State Lead Connecticut Florence Johnson: Maine Danielle Watford Massachusetts Sarah Dereniuk: New Hampshire Pamela Heckman: Rhode Island Nelia Silva Odom: Vermont Gail Harbour: 24