# Presentation: 210366

## Raising Immunizations Safely & EffectivelyHealth Care Worker CampaignRISE-HCW

- David A. Nace, MD, MPH
- Director, Long Term Care and Flu Programs
- University of Pittsburgh Institute on Aging
- July 18, 2008
- naceda@upmc.edu

## Objectives

- Review the background work that led to RISE-HCW
- Describe the RISE-HCW program
- Present the RISE-HCW outcomes

## Questions from the 1990’s

- 1) Can a facility reach a HCW influenza immunization rate of 60% or greater?
- 2) IF SO, can the facility maintain HCW influenza immunization rates of 60% or greater over time?
- 3) IF SO, can the program be deployed to other facilities?

## BHWP PilotCommunity Based Long-Term Care (LTC) Facility

- 1996 – Identified influenza immunization as QI Indicator
- 1996-98 – flu outbreaks
- 2002-03 – implemented declination form
- 2002-03 – Act 95 implemented
- 2004-05 – national shortage

## Slide 5

**Notes:**
This slide is a flowchart of the process of organizational change, from identification of a potential problem through needs analysis, interventions, outcome assessment, and feedback.

## Slide 6

| Organizational Barriers |
| --- |
| inadequate vaccine supplies |
| general vaccine inaccessibility |
| lack of positive incentives for immunization |
| requirement of written consent |
| limited record keeping |
| lack of any feedback or shared learning |

## Slide 7

| Individual Barriers |
| --- |
| limited leadership knowledge and support |
| poor staff knowledge about influenza |
| negative staff attitudes about the vaccine and injections |

## BHWP HCW Rates

- BHWP HCW Rates

- Nace DA**, **Hoffman EL, Resnick NM, Handler SM. Achieving and Sustaining High Rates of Influenza Immunization Among Long-Term Care Staff. *J Am Med Dir Assoc* February 2007; 8(2):128-133.

**Notes:**
This graph shows the percentage of staff vaccinated from 1996-2006. 

## Questions from the 1990’s

- 1) Can a facility reach a HCW influenza immunization rate of 60% or greater?
- 				A = YES
- 2) IF SO, can the facility maintain HCW influenza immunization rates of 60% or greater over time?
- 				A = YES
- 3) IF SO, can the program be deployed to other facilities?

## PLTCVPPromoting LTC Vaccinations Project

- AMDA Foundation / Pfizer 2002 QI Award
- 2002-2003 Season
- 6 LTC Facilities in Western PA
- Goals
- Improve resident immunization rates
- Flu & pneumococcal
- Improve HCW immunization rates
- Flu

## PLTCVPPromoting LTC Vaccinations Project

- Design
- 3 usual care and 3 collaborative groups
- All facilities
- received the ADMA Immunization Toolkit
- Access to project team for questions/information
- Collaborative group (3)
- Single collaborative training session October 2002
- Email / Phone contacts every 1-2 months Oct – February

## PLTCVP ResultsPromoting LTC Vaccinations Project

| Facility | Δ HCW Flu % | Δ Resident
 Flu % | Δ Resident Pneumococcal % |
| --- | --- | --- | --- |
| UC1 | -10.6 | 12.6 | -33.8 |
| UC2 | -16.7 | -64.7 | -2.0 |
| UC3 | 16.9 | -10.3 | -6.0 |
| C1 | 10.3 | 26.8 | 38.7 |
| C2 | 21.9 | 5.1 | 20.3 |
| C3 | 0.4 | -19.9 | 30.6 |

## PLTCVP ResultsPromoting LTC Vaccinations Project

| Facility | 2002 HCW Flu Rate % | 2003 HCW Flu Rate % | Δ HCW Flu %
 |
| --- | --- | --- | --- |
| Non Collaborative 1 | 23.1 | 12.5 | -10.6 |
| Non Collaborative 2 | 47.1 | 30.3 | -16.7 |
| Non Collaborative 3 | 17.8 | 34.7 | 16.9 |
| Collaborative 1 | 56.9 | 67.2 | 10.3 |
| Collaborative 2 | 14.3 | 36.2 | 21.9 |
| Collaborative 3 | 46.4 | 46.8 | 0.4 |

## Focus Group Evaluation

- Usual barriers identified
- Staff turnover problem
- Nursing & CNA turnover of 30-55% average annually
- Nick Castle
- 1996-2004 OSCAR data
- 43% ADM, 39% DON
- Facility UC2 champion team – 200% during study

## Slide 15

**Notes:**
This slide indicates the inverse relationship between staff turnover and institutional memory.

##  RISE Program Raising Immunizations Safely & Effectively

## Slide 17

**Notes:**
This slide lists the organizational structure of the RISE Program.

## RISE-HCWRaising Immunizations Safely & Effectively-Healthcare Workers

- Created 2004-2005 season
- Collaborative effort
- Rx Partners, LTC – a LTC pharmacy
- University of Pittsburgh Institute on Aging
- 9 Western PA LTC facilities
- Pharmacy based program

## RISE-HCWOrganizational Structure

## Slide 20

| Facility | Beds *skilled only when multi-level | No Staff
(2007) | Urban/Rural | County | Union |
| --- | --- | --- | --- | --- | --- |
| A | 139* | 356 | Urban | Allegheny | No |
| B | 59* | 158 | Urban | Allegheny | Yes |
| C | 100 | 107 | Rural | Venango | No |
| D | 150 | 199 | Urban | Butler | No |
| E | 59 | 96 | Rural | Mercer | No |
| F | 145 | 176 | Urban | Allegheny | No |
| G | 180 | 243 | Urban | Allegheny | No |
| H | 60* | 294 | Urban | Butler | Yes |
| I | 214 | 180 | Rural | Venango | No |

## RISE-HCW Objectives

- _Primary_
- 60% HCW Influenza Immunization Rate
- _Secondary_
- 80% HCW Influenza Immunization Rate

## Steering Committee Tasks

- Spring
- Season activity
- Vaccination rates
- Vaccine supplies &orders
- Summer
- Vaccination rates
- Barrier assessment
- Educational planning
- Communications
- Fall
- 2 meetings
- Early implementation barriers
- Mid-season push

## Facility Responsibilities

- Leadership Contact Team
- Communication of information
- Accountability
- Leadership buy-in
- Sense of urgency
- Designate Flu Champion
- Coordinate immunizations
- Coordinate education
- Data collection
- Dissemination of outcomes

## Pharmacy Responsibilities

- Vaccine Supplies
- Defines Immunizations Process
- Policy and Procedures
- Forms
- MAR
- Preprinted labels
- Data collection
- Vaccination Clinic
- Initial start date at each facility
- Facility is responsible for administration
- Liaison between Steering Committee &  Facilities

## RISE-HCWTools Used

- Declination Form
- Encouraged
- Incentives
- Pizza party for winning facility
- News coverage of positive outcomes
- Education
- Training and reference materials
- Formal training sessions
- AMDA video
- RISE Prevention & Management Network

## Slide 26

**Notes:**
This graph shows the varying levels of immunization coverage from nine facilities over the course of 8 years (2001-2008). While there was an overall increase, not all facilities maintained the increase over time. 

##  RISE – ProgramInfluenza Prevention & Management Network

- 18 campuses in Western PA
- Distribution list-serve
- Guidance
- Immunization issues
- Surveillance
- Outbreak detection
- Outbreak management
- Policy development
- Regulatory assistance

## Questions from the 1990’s

- 1) Can a facility reach a HCW influenza immunization rate of 60% or greater?
- 				A = YES
- 2) IF SO, can the facility maintain HCW influenza immunization rates of 60% or greater over time?
- 				A = YES
- 3) IF SO, can the program be deployed to other facilities?
- 				A = YES

## Models of Mandatory Program Systems

## Models of Voluntary Program Systems

- NRT  - Non-respondent tracking

## NRT – non-respondent tracking

| Facility | Rate | Declination | NRT |
| --- | --- | --- | --- |
| Caring Place | 90% | Yes | Complete |
| Grove Manor | 88% | Yes | Complete |
| Cranberry Place | 86% | Yes | Complete |
| Sugar Creek Station | 83% | Yes | Complete |
| Asbury Heights | 75% | Yes | Partial |
| Seneca Place | 70% | Yes | Complete |
| Sherwood Oaks | 66% | Yes | Partial |
| Heritage Place | 61% | No | Partial |
| Canterbury Place | 32% | No | None |

## Recommendations

- Pharmacy Based Program
- Overcomes turnover issue
- Mandatory – Action Based Program
- Explicit declination forms
- Complete non-respondent tracking
- Leadership Accountability
- Require evidence based action if no improvement
- Don’t stipulate specific rate
- Use Care Bundles

## 2008-2009 Pittsburgh HCW Immunization Plans 

**UPMC Health System**
- President’s Dashboard item
- HCW Immunization Rate
- Declination Return Rate
**UPMC Health Plan**
- Use of *MyHealth* Internet Survey
**Allegheny County Health Department**
- Healthcare Facility Reporting of HCW Rates
- Website posting < 60%

## 2007-08 UPMC Flu Vaccination Rates

_**Facility**__**	**_**	****	****	**_**Immunization Rate Estimates**_
**UPMC Presbyterian Shadyside ( & WPIC)****	****33%**
**UPMC South Side****	****	****	****	****37%**
**UPMC McKeesport****	****	****	****	****44%**
**UPMC Children’s****	****	****	****	****44%**
**UPMC Magee****	****	****	****	****	****40%**
**UPMC St. Margaret’s****	****	****	****	****48%**
**UPMC Northwest****	****	****	****	****67%**
**UPMC Horizon****	****	****	****	****	****50%**
**UPMC Passavant****	****	****	****	****42%**
**UPMC Braddock****	****	****	****	****56%**
**UPMC Bedford****	****	****	****	****	****52%**
**UPMC Mercy****	****	****	****	****	****44%**
**Physician Services Division****	****	****	****30%**

## Team Members 

- RISE Steering Committee
- Sandra Carroll
- Daniel Grant
- Jay Harper
- Steven Handler
- Shikha Iyengar
- Mary Ann Suda
- Mark Tannis
- Barry Young
- Paula Carlock
- Scott Stephens

- Facilities and their teams
- Asbury Heights
- Canterbury Place
- Caring Place
- Cranberry Place
- Grove Manor
- Heritage Place
- Seneca Place
- Sherwood Oaks
- Sugar Creek Station