CMS-CDC Immunization Standing Orders Program (SOP) Project: Nursing Home Immunization Practices and Barriers to SOPs in

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 129th 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 Influenza and Pneumococcal Vaccinations, Nursing Homes, United States, 1995, 1999* *CDC unpublished data, National Nursing Home Survey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 Note: 2 states (HI & MT) used alternate surveys

7. Response Rates – 5 Control States

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 1999Intervention States, N = 1,598 * * 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 1999Control States, N = 1,772 * * 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

15. Barriers to SOPs: Pneumococcal Vax,Intervention States, N=1,598

16. Barriers to SOPs: Flu Vaccination,Control States, N=1,772

17. Barriers to SOPs: Pneumococcal Vax,Control States, N=1,772

18. Training Topics Needed,Intervention States, N=1,598

19. Training Topics Needed,Control States, N=1,772

20. Consistent Place to Record Vaccinations,Intervention States, N=1,598

21. Centralized Tracking of Vaccinations,Intervention States, N=1598 * Computer or Log book

22. Consistent Place to Record Vaccinations,Control States, N=1,772

23. Centralized Tracking of Vaccinations,Control States, N=1772 * 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

27. 1999 Influenza Immunization Program, by Provider Category,Intervention States

28. 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 < or > 50 beds Bivariate Analysis: Co-variates

29. Certification Status & Program Types

30. Chain Affiliation & Program Types

31. Provider-based & Program Types

32. Provider Category & Program Types

33. Facility Size & Program Types

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