Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Nursing Home Vaccination: 
Reaching Healthy People Goals 
JUNE GIBBS BROWN 
Inspector General 
APRIL 2000 
OEI-01-99-00010  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's Boston Regional Office prepared this report under the direction of Mark R. Yessian, Ph.D., 
Regional Inspector General and Joyce M. Greenleaf, Assistant Regional Inspector General. 
Principal OEI staff included: 
REGION  HEADQUARTERS 
Kenneth Price, Lead Analyst  Susan Burbach, Program Specialist 
Chaletta Clark, Program Analyst  Elise Stein, Program Specialist 
To obtain copies of this report, please call the Boston Regional Office at (617) 565-1050. 
Reports are also available on the World Wide Web at our home page address: 
http://www.hhs.gov/oei  E X E C U T I V E   S U M M A R Y  
PURPOSE 
To identify ways to accelerate fulfillment of the Healthy People 2010 objective of 
vaccinating 90 percent of nursing home residents against influenza and pneumococcal 
disease. 
BACKGROUND 
Influenza and pneumococcal vaccines are proven to reduce death and hospitalization 
among nursing home residents.  Accordingly, an objective set forth by the Department of 
Health and Human Services (HHS) in its Healthy People 2010 public health goals is to 
increase vaccination rates for influenza and pneumococcal disease in nursing homes to 90 
percent.  However, despite Medicare coverage of both vaccines, data suggest that nursing 
homes fall short of this mark.  The National Nursing Home Survey from the Centers for 
Disease Control and Prevention (CDC) indicates that in 1995, 61 percent of nursing home 
residents received an annual influenza vaccination and only 22 percent have ever received 
the pneumococcal vaccine.  In response, CDC and the Health Care Financing 
Administration (HCFA) have a number of efforts underway to encourage nursing homes 
to vaccinate their residents. 
This report draws on State initiatives to increase influenza and pneumococcal vaccination 
coverage in nursing homes.  We chose to profile State initiatives because States are taking 
an increasing role in adult vaccination and their efforts can help illuminate ways to reach 
Healthy People goals.  We gathered data for this study through literature reviews, 
telephone discussions with Federal officials and industry experts, site visits to States and 
nursing homes, and structured interviews with State officials and nursing home staff. 
FINDINGS 
Our review of State initiatives suggests that four levers of change can be 
influential in reaching the Healthy People 2010 objective for vaccinating nursing 
home residents. 
1.	 Making Vaccination a Standard Part of Admission.  Integrating vaccination 
into the admission process enables nursing homes to address vaccination for every new 
resident in a routine, systematic manner. 
1 
Nursing Home Vaccination  OEI-01-99-00010  2.	 Collecting Uniform Data on Vaccination Coverage.  Uniform data on 
vaccination coverage allows public health officials, long-term care regulators, and the 
nursing home industry to identify gaps in coverage and take action to close them. 
3.	 Facilitating Nursing Homes Access to Vaccines.  Easier access to vaccines, 
through improved ordering, distribution, and reimbursement mechanisms, can help 
ensure that vaccines are readily available to nursing homes. 
4.	 Enhancing Education About Vaccine Safety and Efficacy.  Better 
understanding about vaccine safety and efficacy among nursing home residents, staff, 
physicians, and residents families can help to increase vaccination in nursing homes. 
OPPORTUNITIES FOR IMPROVEMENT 
HCFA and CDC conduct a number of activities aimed at increasing nursing home vaccination. 
Key efforts from HCFA include its simplified roster billing procedures, its nursing home Resident 
Census, and its outreach through the Medicare PROs.  Key CDC efforts include its new handbook 
on nursing home vaccination, its biannual National Nursing Home Survey, and its vaccination 
guidelines.  In addition, the agencies frequently collaborate to educate nursing homes and others 
about the importance of vaccination.  For example, they host the National Adult Immunization 
Conference, which provides States, nursing homes, and others with a forum to share effective 
practices for increasing vaccination rates. 
Beyond these efforts, the levers in this report prompt us to identify options for additional action 
toward fulfillment of the Healthy People objective for nursing home vaccination.  We direct three 
options exclusively to HCFA and a fourth jointly to HCFA and CDC.  We focus primarily on 
HCFA because it has responsibility for quality oversight of nursing homes and thus could more 
directly influence nursing homes actions.  However, we recognize that CDC plays an important 
role and that its involvement will be vital to progress in each area. 
HCFA could require nursing homes to assess residents for vaccinations upon 
admission.  Such a requirement would integrate vaccination into the admission process 
and ensure that nursing homes offer needed vaccinations in a routine and systematic 
manner.  HCFA could strengthen its existing nursing home regulations on infection control 
by instructing nursing home surveyors to probe for policies and procedures that follow the 
latest vaccination guidelines published by CDC.  Tools such as standing orders and 
revolving consent forms could help nursing homes meet the requirement. 
HCFA could add vaccination to the Minimum Data Set, which nursing homes 
collect during routine Resident Assessments.  The Minimum Data Set is data that 
HCFA requires nursing homes to collect during in-depth, recurring evaluations of 
residents health status, called Resident Assessments.  Adding vaccination to this data set 
would provide HCFA and CDC with data that are better-suited for focusing improvement 
efforts than those available from either the National Nursing Home Survey or the 
2 
Nursing Home Vaccination  OEI-01-99-00010  Resident Census. 
HCFA could increase the use of the PROs, fiscal intermediaries, and carriers to 
teach nursing homes about Medicare roster billing.  The recent implementation of 
Medicares prospective payment system for nursing homes underscores the need for 
additional education about Medicare roster billing.  To make the most effective use of its 
resources, HCFA could use billing or other data to identify and focus efforts on nursing 
homes that have the most difficulty billing Medicare. 
HCFA and CDC could use the Minimum Data Set to identify and reach out to 
nursing homes with low vaccination rates.  If HCFA chose to use the Minimum Data 
Set to collect vaccination data, it and CDC could use these data to identify and reach out 
to lagging nursing homes through their networks of regional and field offices.  This 
approach would leverage the expertise of local HCFA and CDC staff, who are familiar 
with local nursing homes and the populations they serve, as well as the educational 
barriers that nursing homes face. 
COMMENTS ON THE DRAFT REPORT 
We received comments from HCFA, CDC, and the HHS Assistant Secretary for Program 
Evaluation (ASPE). 
The HCFA and ASPE concurred with the opportunities for improvement we identified.  In 
its comments, HCFA outlined its plans for adding vaccination to the MDS, for increasing 
the use of Medicare contractors and PROs to teach nursing homes about Medicare roster 
billing, and for using MDS data to target education.  Regarding mandating that nursing 
homes assess residents for vaccinations upon admission, HCFA outlined efforts it and its 
contractors are taking to persuade nursing homes to integrate vaccination into the 
admission process.  However, it agreed that if these efforts are unsuccessful, it could 
consider making vaccination a mandatory Condition of Participation for nursing homes. 
We are pleased that HCFA has agreed to take action in each of the areas we identified. 
Based on comments from CDC, we strengthened language related to integrating 
vaccination into the admission process, referenced ACIP recommendations for vaccination 
of nursing home staff, and clarified language throughout the report. 
3 
Nursing Home Vaccination  OEI-01-99-00010  T A B L E   O F   C O N T E N T S  
PAGE

EXECUTIVE SUMMARY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

FINDINGS

Four Levers of Change  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8

Admission Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8

Uniform Data  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

Vaccine Access  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10

Education  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11

OPPORTUNITIES FOR IMPROVEMENT  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13

COMMENTS ON THE DRAFT REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  17

APPENDICES

A:	 Measurement Initiatives  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  18

Mandate Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  21

Purchase Initiatives  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  23

Education Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  25

B:  Comments on the Draft Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  27

C: Endnotes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  34

4 
Nursing Home Vaccination  OEI-01-99-00010  I N T R O D U C T I O N  
PURPOSE 
To identify ways to accelerate fulfillment of the Healthy People 2010 objective of 
vaccinating 90 percent of nursing home residents against influenza and pneumococcal 
disease. 
BACKGROUND 
Life-Saving Vaccines That Are Covered by Medicare 
Influenza and pneumococcal vaccines are proven to reduce death and hospitalization 
among nursing home residents.1,2  Vaccination guidelines from the Advisory Committee on 
Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) 
state that nursing home residents age 65 and over should receive the influenza vaccine 
annually and the pneumococcal vaccine once in their lifetimes.3,4  ACIP guidelines also 
recommend that staff who care for nursing home residents receive annual influenza 
vaccinations as well.5  Both vaccines are covered by Medicare. 
Accordingly, an objective set forth by the Department of Health and Human Services 
(HHS) in its Healthy People 2000 public health goals is to increase vaccination rates for 
influenza and pneumococcal disease in nursing homes to 80 percent of all residents by the 
year 2000.6  The newest objective recently put forth in Healthy People 2010 aims to 
increase vaccination coverage even further  to 90 percent by the year 2010.7 
Usage Lags in Nursing Homes 
However, data suggest that vaccination rates in nursing homes lag far behind the objective 
set forth in Healthy People.8  For example, the CDC National Nursing Home Survey 
indicates that in 1995, 61 percent of nursing home residents received an annual influenza 
vaccination and only 22 percent have ever received the pneumococcal vaccine.9  The 
survey also indicates that the dual vaccination rate may be as low as 21 percent.10  These 
low rates show that nursing homes miss a significant opportunity to reduce death and 
hospitalization by giving more residents these vaccines. 
Many factors help to explain low vaccination rates in nursing homes.  Barriers include 
failure to get physician orders and resident consent to vaccination, poor documentation of 
vaccination, difficulty with reimbursement and Medicare billing, concerns about the safety 
and efficacy of vaccines, and low priority of vaccination in the nursing home. 
5 
Nursing Home Vaccination  OEI-01-99-00010  Current Federal Activity in Nursing Homes 
HHS agencies conduct a variety of outreach to encourage nursing homes to vaccinate 
their residents.  For example, as part of its Influenza and Pneumococcal Campaign, the 
Health Care Financing Administration (HCFA) publishes fact sheets and guides to help 
nursing homes understand Medicare coverage and reimbursement for vaccines.  CDC 
publishes ACIP guidelines for vaccine usage, provides technical assistance to nursing 
homes, and surveys them on vaccination coverage rates.  Both agencies work with outside 
groups that wish to increase vaccination coverage in nursing homes.  Finally, Medicare 
Peer Review Organizations (PROs) in several States are leading improvement projects to 
help nursing homes increase vaccination coverage. 
State Vaccination Initiatives Can Be Key 
State vaccination initiatives can play a key role in increasing vaccination rates.  As part of 
these initiatives, States assemble resources from broad coalitions to increase vaccination 
coverage within a given target population.  State initiatives may involve Federal, county, 
and local government, public health networks, provider associations, community 
organizations, and others.  In fact, a variety of State initiatives, ranging from grass-roots 
education to rule-making, have played large roles in the success of childhood vaccination 
in the United States.11  Similarly, State initiatives to improve vaccination coverage among 
nursing home residents are beginning to play an essential role as adult vaccination 
continues to increase in priority. 
This Inquiry 
This report draws on State initiatives to increase influenza and pneumococcal vaccination 
coverage in nursing homes.  It is not an evaluation of State initiatives nor is it a definitive 
list of all State efforts to increase vaccination coverage in nursing homes.  Rather, we use 
States experiences to explore the actions necessary to speed attainment of the Healthy 
People 2010 objective for nursing home vaccination. 
We collected data for this report in two stages.  First, we located a pool of State initiatives 
by conducting literature reviews and holding discussions with officials from CDC, HCFA, 
State governments, representatives of trade groups, and vaccination coalitions.  We then 
categorized the initiatives according to four broad approaches: measurement of 
vaccination rates, vaccination mandate, vaccine purchase, and education.  We then 
purposely selected one to three State initiatives from each category, based on their scope, 
length of time underway, and experience, among other aspects.  The States whose 
initiatives we chose were Massachusetts, Montana, Illinois, New Jersey, Delaware, 
Oklahoma, Louisiana, and New York. 
During the second phase of our data collection, we gathered information to generate a 
profile of each of the eight State initiatives.  During this phase we conducted structured 
interviews with officials from each State, either over the telephone or on-site; conducted 
6 
Nursing Home Vaccination  OEI-01-99-00010  structured interviews on-site at six nursing homes in three of the States; and held 
conversations with other stakeholders, including nursing home trade associations and 
Medicare PROs. 
This inquiry describes key levers of change to increase vaccination coverage in nursing 
homes.  Along with each lever, we give a brief summary of corresponding State  initiatives 
(See Appendix A for a full description of each States initiative).  In addition we use these 
levers to identify options that HHS could take to accelerate fulfillment of Healthy People 
objective for nursing home vaccination. 
We conducted this inspection in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
7 
Nursing Home Vaccination  OEI-01-99-00010  F I N D I N G S  
Our review of State initiatives suggests that four levers of change can 
be influential in reaching the Healthy People 2010 objective for 
vaccinating nursing home residents. 
1. 	 Making Vaccination a Standard Part of Admission.  Integrating vaccination into the 
admission process enables nursing homes to address vaccination for every new resident in a 
routine, systematic manner. 
When nursing homes fail to address vaccination during admission, vaccination can become 
a disjointed and complex process.  For example, after admission, obtaining simple, yet 
critical information about the residents vaccination history and allergies becomes more 
difficult.  Physicians can forget to assess residents for vaccination and to write orders for 
vaccines.  Getting the residents or his/her familys consent to vaccination can become a 
major hurdle after admission.  The admission period is optimal because it brings together 
people and information that are key to the vaccination process  including the resident, 
his or her family, medical records, and the nursing home staff and physicians who are 
responsible for the residents care.  In addition, the admission period is ideal for 
implementing systematic vaccination tools such as revolving consent forms, which require 
nursing homes to gain consent only once for annual influenza vaccinations, and standing 
orders, which eliminate the need for physicians to write individual orders for vaccines.12 
When vaccination is a standard part of admission, nursing homes can use this collection of 
resources to ensure that vaccination is automatically addressed for every new resident.13 
In fact, CDC guidelines from the ACIP recommend that nursing homes use the admission 
process as part of their influenza vaccination programs. 
New Jersey 
New Jersey administrative code mandates that nursing homes offer every resident 
influenza and pneumococcal vaccines upon admission.  To meet State requirements, 
nursing homes must assess every admission for vaccination and document acceptance or 
refusal of vaccines in each residents vaccination record.  Nursing home staff we spoke 
with said they used vaccination protocols to make vaccination a standard part of their 
admission process.  They did not find the procedures to be particulary burdensome to 
implement.  Citing high compliance with the mandate and few disease outbreaks in nursing 
homes, State officials said their efforts have made a difference in vaccination coverage. 
Delaware 
Since 1990, regulations from the Delaware State Board of Health have required nursing 
homes to vaccinate their residents against influenza and pneumococcal disease according 
8 
Nursing Home Vaccination  OEI-01-99-00010   to the recommendations of the ACIP.  To comply with the mandate, nursing homes must 
maintain evidence on-file of annual influenza vaccination and one-time pneumococcal 
vaccination for every resident.  The Board of Health assesses compliance with the 
mandate during the infection control portion of its annual licensure surveys of nursing 
homes.  During early enforcement of the mandate, Board of Health surveyors cited about 
10 percent of nursing homes with deficiencies for not complying with the mandate  
mainly due to problems documenting contraindications to vaccination.  State officials said 
that beyond these isolated problems during the first year of the mandate, they have had no 
difficulty obtaining full compliance. 
2. 	 Collecting Uniform Data on Vaccination Coverage.  Uniform data on vaccination 
coverage allows public health officials, long-term care regulators, and the nursing home 
industry to identify gaps in vaccination coverage and take action to close them.14 
Without uniform, reliable data on vaccine use in nursing homes, it is nearly impossible to 
focus meaningful efforts on increasing vaccination rates.  Public health officials are unable 
to learn where the vaccine delivery system is breaking down.  Regulators have no way to 
scan for nursing homes with lagging vaccination rates.  The nursing home industry cannot 
discover and share best practices of those with exceptional rates.  Yet, these activities 
form an essential ingredient of focused and informed action to increase vaccination rates. 
In the absence of data from these activities, efforts to increase vaccination rates may 
amount to little more than grasping at straws.  In fact, half of the States we profiled for 
this report had to conduct a survey of nursing homes as the first step in their initiative to 
increase vaccination coverage. 
Massachusetts 
Massachusetts has made progress in collecting uniform data on vaccination in nursing 
homes.  For the past 3 years, the State has conducted a Pneumonia Survey to learn 
about vaccination practices in nursing homes.  Using the survey, the State has been able to 
learn where vaccination rates lag and where to target educational efforts.  For example, it 
learned from its survey that, in 1997, 82 percent of nursing home residents in the State 
received an influenza vaccination.  However, it also learned that pneumococcal 
vaccination and vaccination of nursing home staff trail far behind that of influenza. 
Preliminary data from the 1998 survey show that rates are climbing, but still have room for 
improvement.  The State plans to use these data to design educational programs for 
nursing homes and to challenge those with low vaccination rates to improve. 
Montana 
To track vaccination in nursing homes, the Montana Immunization Program conducted 
vaccination surveys in 1991, 1994, 1996, and 1998.  The survey collected data on resident 
and staff vaccination levels as well as data on vaccination policies.  Program officials use 
the survey data to assess progress on reaching the Healthy People 2000 vaccination goals 
and to guide educational strategies.  For example, 1998 survey data revealed that 
Montanas nursing homes exceed the Healthy People 2000 objective for influenza 
vaccination but lag in pneumococcal vaccination and vaccination of nursing home staff. 
9 
Nursing Home Vaccination  OEI-01-99-00010  To address these and other issues, Program officials are compiling a vaccination training 
manual for their field nurses to use when they visit nursing homes.  They have also shared 
survey data with nursing homes to highlight the States progress toward meeting the 
Healthy People 2000 goals and to make best practice recommendations. 
Illinois 
Since 1993, Illinois has surveyed nursing homes to collect vaccination data and to increase 
nursing homes awareness of strategies to prevent influenza and pneumococcal disease. 
The survey collects data on nursing homes vaccination coverage, policies for staff and 
resident vaccination, and Medicare billing activity.  Although State officials consider self-
reported vaccination rates unreliable, they make use of aggregate data by sharing it with 
other stakeholders in nursing home vaccination.  For example, officials share aggregate 
survey data with the States survey and certification agency, who use it to bring attention 
to vaccination during on-site visits to nursing homes.  Officials also share data with the 
Illinois Adult Vaccination Coalition, of which the State is a founding member.  The 
coalition includes the Medicare PRO and Part B carrier, nursing home trade associations, 
and the HCFA regional office, among others. 
3. 	 Facilitating Nursing Homes Access to Vaccines.  Easier access to vaccines, through 
improved ordering, distribution, and reimbursement mechanisms, can help ensure that 
vaccines are readily available at nursing homes. 
Hurdles that stand between nursing homes and vaccines place the vaccination of nursing 
home residents in jeopardy.  For example, low reimbursement and burdensome 
paperwork, such as applying for billing numbers and completing lengthy claims forms, can 
discourage nursing homes from vaccinating their residents.  Another hurdle can be the 
process for ordering influenza vaccine  which nursing homes must complete months in 
advance of the flu season.  Even when nursing homes are committed to offering influenza 
vaccine to all residents, failure to order vaccines early enough and the resulting vaccine 
shortages can create unexpected crises  sometimes dangerously compromising nursing 
homes immunity levels during the peak of flu season.15 
Oklahoma 
Since 1991, Oklahoma has enhanced access to vaccines by providing free influenza 
vaccine to nursing homes and, beginning with the 1999 flu season, it plans to provide free 
pneumococcal vaccine as well.  State officials report that the largest challenge they face is 
getting enough funding to meet demand for vaccines.  For example, in 1998, the State was 
unable to provide influenza vaccine to 17 percent of facilities due to funding limitations. 
Additionally, officials project that funding limitations will prevent their pneumococcal 
vaccine program from meeting demand as well.  As a result, Oklahoma officials have 
started a program to recoup some of their vaccine costs by billing Medicare for doses 
given to Medicare-eligible nursing home residents.  However, they report difficulty getting 
homes to send in billing information that is required for Medicare reimbursement.  To 
overcome this problem, officials plan to hire a contractor to provide technical assistance to 
nursing homes and to bill Medicare on the States behalf. 
10 
Nursing Home Vaccination  OEI-01-99-00010  Louisiana 
Louisiana ensures access to influenza vaccine by providing it to nursing homes free of 
charge.  Citing a 90 percent vaccination rate, State officials say that vaccination has 
become standard procedure at Louisianas nursing homes over the 15 years that their 
influenza program has been in place.  Recently, the State began working with the local 
Medicare PRO to teach nursing homes how to bill Medicare for vaccination.  This would 
allow nursing homes to be paid for administering the influenza vaccine and would enable 
the State to recoup some vaccine costs.  However, despite the financial incentive for 
nursing homes, State officials report problems getting them to provide information that 
Medicare requires for reimbursement, such as each residents name, address, Medicare 
number, date of birth, signature, and the date the vaccination was given.  This difficulty 
with billing for influenza vaccine has prompted State officials to delay expanding their 
program to include pneumococcal vaccine, which was funded with the stipulation that the 
cost of the vaccine be recovered by billing Medicare. 
4. 	 Enhancing Education About Vaccine Safety and Efficacy.  Better understanding 
about vaccine safety and efficacy among nursing home residents, staff, physicians, and 
residents families can help to increase vaccination in nursing homes. 
Fear and misperceptions among nursing home residents, staff, physicians, and residents 
families about influenza and pneumococcal vaccines remain significant barriers to 
vaccination.  Residents and their families fears about catching the flu or pneumonia from 
vaccines can discourage residents from accepting vaccination.  Furthermore, residents 
reluctance to accept vaccination grows when their physicians lack confidence that vaccines 
effectively protect them from illness and death.  Staff who refuse vaccination not only 
compromise the safety of the residents they care for, but also provide little reassurance to 
residents who are uncertain about vaccination.  Even in nursing homes that systematically 
offer vaccines to every resident and staff member, fear and misperceptions about 
vaccination can restrain coverage to only marginal levels.16,17 
New York 
Since the 1970s, New York has informed nursing homes about influenza by sending an 
annual packet of information to all nursing homes in the State.  Sent during flu season, the 
packet contains guidelines on influenza vaccination, model consent forms, instructions on 
how to order vaccines, and a fact sheet for educating residents, among other things.18 
State officials admit that, due to resource limitations, a weakness of their educational 
program is their inability to personally follow-up with nursing homes to reinforce the 
information they send out in their packets.  Ironically, it is outbreaks of influenza and 
pneumococcal disease  which the States educational program aims to prevent  that 
provide officials with the best opportunity to educate nursing homes about vaccination, 
since officials must go on-site to investigate each outbreak.  Nursing home officials we 
spoke with appreciated the States efforts, but felt that it should do more to target nursing 
home residents, their families, and the residents doctors, who can be influential 
vaccination advocates. 
11 
Nursing Home Vaccination  OEI-01-99-00010  Other States 
Officials from States that conduct initiatives to measure vaccination rates, mandate 
vaccination, and purchase vaccines reinforced the importance of buttressing their efforts 
with education targeted toward nursing home staff, administrators, residents, and their 
families.  For example, Massachusetts and Montana both use survey data to guide 
provider education focused on lagging pneumococcal rates.  New Jersey officials wish to 
supplement their vaccination mandate with education focused on residents and families to 
reduce high vaccine refusal rates.  Officials in Oklahoma stress resident and staff education 
as one of the challenges they face to make the States vaccine purchase successful. 
12 
Nursing Home Vaccination  OEI-01-99-00010  O P P O R T U N I T I E S  F O R  
I M P R O V E M E N T  
The State initiatives we present in this report represent a core set of efforts focused on four levers 
to increasing nursing home vaccination.  Concerted attention to these levers could speed progress 
toward attaining the Healthy People 2010 objective for nursing home vaccination.  Undoubtedly, 
the experiences of the States we profiled can be instructive for States that are considering taking 
action to increase vaccination coverage in nursing homes.  As this report is not a conclusive list of 
State initiatives, we encourage States and nursing homes to share their experiences and stimulate 
discussion about effective practices for increasing vaccination rates in nursing homes. 
At the Federal level, HCFA, the agency with regulatory authority over nursing homes, and CDC, 
the agency charged with preventing and controlling disease, each have important roles to play in 
increasing vaccination coverage in nursing homes.  Both agencies have undertaken a variety of 
initiatives aimed at increasing vaccination among nursing home residents, often in partnership with 
one another. 
In the following discussion, we outline opportunities that the levers we identified present to 
HCFA and CDC in their efforts to increase nursing home vaccination.  We organize our 
discussion around each lever by first identifying key efforts that HCFA and CDC have taken and 
then proposing an option for additional action.  We direct three options exclusively to HCFA and 
a fourth jointly to HCFA and CDC.  We focus primarily on HCFA because it has responsibility for 
quality oversight of nursing homes and thus could more directly influence nursing homes actions. 
However, we recognize that CDC plays an important role and that its involvement will be vital to 
progress in each area. 
1. Making Vaccination a Standard Part of Admission. 
Both HCFA and CDC encourage nursing homes to offer vaccines to nursing home residents 
upon admission.  For example, HCFA, CDC, and the Medicare PROs have begun a new 
initiative to help nursing homes adopt standing orders to offer vaccination to residents upon 
admission.  Standing orders alleviate the need for physicians to write individual orders for 
each resident who needs vaccination.  Within its recommendations for prevention and control 
of influenza and pneumococcal disease, CDCs Advisory Committee on Immunization 
Practices continues to recommend standing orders as an important way of increasing 
vaccination coverage.  These recommendations are widely considered to be the standard of 
care for vaccinations. 
13 
Nursing Home Vaccination  OEI-01-99-00010  HCFA could require nursing homes to assess residents for vaccinations upon 
admission. 
Such a requirement would integrate vaccination into the admission process and ensure that 
nursing homes assess new residents for needed vaccinations in a routine and systematic 
manner.  To help nursing homes meet this requirement, HCFA could suggest that they use 
tools such as standing orders and revolving consent forms, which enable them to address 
annual flu vaccinations on a one-time basis.  HCFAs current regulations for certification of 
nursing homes state that they must have an infection control program designed to help 
prevent the development and transmission of disease and infection (42 C.F.R. 483.65). 
Although HCFA mentions vaccination in its guidance for assessing compliance with these 
regulations, it could give more prominence to vaccination at admission.  For example, similar 
to its guidance for assessing compliance with hand-washing requirements, HCFA could 
instruct nursing home surveyors to probe for written vaccination policies and protocols that 
follow the latest published standards, such as those from CDC. 
2. Collecting Uniform Data on Vaccination Coverage. 
HHS has in place two mechanisms for collecting data on vaccination coverage in nursing 
homes.  The first is the National Nursing Home Survey (NNHS), which CDC conducts every 
other year.  The NNHS gathers vaccination data through a chart review of residents records 
at 1,500 nursing homes across the United States.  However, the NNHS sample is not designed 
to generate State- and nursing home-level vaccination rates, which Federal, State, and local 
stakeholders need to identify gaps in coverage and focus improvement efforts.  The second 
mechanism HHS has in place is the HCFA Resident Census, which nursing home 
administrators complete prior to annual licensure and certification surveys.  This instrument 
collects data on the numbers of vaccinated residents in each nursing home.  However, the data 
are self-reported by nursing home staff and are not validated. 
HCFA could add vaccination to the Minimum Data Set, which nursing homes 
collect during routine Resident Assessments. 
The Minimum Data Set (MDS) is data that HCFA requires nursing homes to collect during in-
depth evaluations of residents health status, called Resident Assessments.  Adding 
vaccination to the MDS would provide HCFA and CDC with data that are better-suited for 
focusing improvement efforts than those available from either the NNHS or the Resident 
Census.  For example, because nursing homes complete a Resident Assessment for each 
resident upon admission and at regular intervals thereafter, MDS data could be aggregated to 
the State- and nursing home-levels, unlike data from the NNHS.  Moreover, Resident 
Assessments are based on documented evidence, including a review of the residents medical 
record and conversations with nursing home staff.  Thus, vaccination data collected in the 
MDS would likely be more accurate than self-reported data from the Resident Census. 
Finally, MDS data offer advantages in terms of timeliness and uniformity because nursing 
homes use standardized software to capture, edit, and transmit MDS data on an ongoing 
14 
Nursing Home Vaccination  OEI-01-99-00010  basis. 
3. Facilitating Nursing Homes Access to Vaccines. 
To lower financial and procedural barriers to vaccination, HCFA allows nursing homes and 
others to use a simplified billing procedure called roster billing to seek reimbursement for 
vaccinating Medicare beneficiaries.  Roster billing eliminates the need for nursing homes to 
submit individual bills for vaccinating residents by allowing homes to instead submit a roster 
of Medicare beneficiaries who received vaccines.  Over time, HCFA has continued to facilitate 
billing procedures by expanding roster billing to include pneumococcal vaccine, dropping daily 
minimum thresholds for roster billing, and allowing standing orders for vaccinations. 
Medicare carriers, fiscal intermediaries, and PROs have worked with nursing homes to teach 
and encourage them to use roster billing.  In addition, HCFA has worked with industry 
partners such as the American Health Care Association and the American Association of 
Homes and Services for the Aging to publish an annual fact sheet on influenza and 
pneumococcal billing procedures that is tailored for nursing homes. 
HCFA could increase use of the PROs, fiscal intermediaries, and carriers to 
teach nursing homes about Medicare roster billing. 
We recognize the amount of outreach that HCFA and its agents have done to encourage 
nursing homes to use roster billing.  Yet, more work may be required in this area, particularly 
in light of the recent implementation of Medicares prospective payment system for nursing 
homes.  Under this system, HCFA may wish to consider increasing its use of PROs, fiscal 
intermediaries, and carriers to teach nursing homes about roster billing and what impact 
prospective payment has on their ability to bill Medicare for vaccinations.  To make the most 
effective use of its resources, HCFA could use billing or other data to identify and focus 
efforts on nursing homes that have the most difficulty billing Medicare. 
4. Enhancing Education About Vaccine Safety and Efficacy. 
HCFA and CDC have conducted several educational activities focused on increasing influenza 
and pneumococcal vaccination in nursing homes.  For example, in 1997, they jointly published 
a one-page Special Alert for Nursing Homes, stressing the safety of influenza and 
pneumococcal vaccines and urging nursing homes to make them available to Medicare 
beneficiaries.  HCFA distributed this bulletin to all nursing homes in the country along with an 
annual fact sheet on billing Medicare for vaccinations.  CDC recently completed work on a 
comprehensive handbook for nursing home vaccination that will provide nursing homes with 
information on vaccine guidelines, vaccination programs, and simplified Medicare billing, 
among other things..  In addition, Medicare PROs are involved in several projects focused on 
improving vaccination coverage in nursing homes, including their new effort to promote the 
use of standing orders for vaccination in nursing homes. 
15 
Nursing Home Vaccination  OEI-01-99-00010  HCFA and CDC could use the Minimum Data Set to identify and reach out to 
nursing homes with low vaccination rates. 
Provided HCFA chose to use the MDS to collect vaccination data, it and CDC could use 
these data to identify and assist nursing homes whose vaccination rates lag behind the Healthy 
People objective.  HCFA could distribute nursing home-level data on vaccination coverage to 
its regional vaccination coordinators and Medicare PROs.  CDC could distribute the data to 
its vast network of field offices and State and local public health offices.  This would allow 
officials in the field to identify nursing homes with low vaccination rates and engage them on 
an individual, proactive basis.  This hands-on approach would complement HCFA and CDCs 
broader activities by focusing efforts on lagging homes for which passive education may not 
be enough.  In addition, this approach would leverage the expertise of their field staff, who are 
familiar with local nursing homes and the populations they serve, as well as the educational 
barriers nursing homes face. 
16 
Nursing Home Vaccination  OEI-01-99-00010  C O M M E N T S  O N  T H E  D R A F T  
R E P O R T  
We received comments on the draft report from the Health Care Financing Administration 
(HCFA), the Centers for Disease Control and Prevention (CDC), and the Health and Human 
Services Assistant Secretary for Program Evaluation (ASPE).  We include the complete text of 
the comments in Appendix B. 
Comments from HCFA and ASPE 
The HCFA and ASPE concurred with the opportunities for improvement we identified.  In its 
comments, HCFA outlined its plans for adding vaccination to the MDS, for increasing the use 
of Medicare contractors and PROs to teach nursing homes about Medicare roster billing, and 
for using MDS data to target education.  Regarding mandating that nursing homes assess 
residents for vaccinations upon admission, HCFA outlined efforts it and its contractors are 
taking to persuade nursing homes to integrate vaccination into the admission process. 
However, it agreed that if these efforts are unsuccessful, it could consider making vaccination 
a mandatory Condition of Participation for nursing homes.  We are pleased that HCFA has 
agreed to take action in each of the areas we identified. 
In addition, HCFA and ASPE recommended that we clarify that nursing homes should offer 
residents the influenza vaccine during the flu season as well as upon admission.  In response, 
we made minor changes to the language in our report.  However, we continue to stress the 
importance of the admission process to vaccination.  This is by no means meant to preclude 
addressing vaccination more frequently.  However, admission is the optimal time to get the 
residents or familys consent to vaccination, to document vaccination history, and to get 
physicians orders  regardless of whether it occurs during the flu season.  Assessing new 
residents upon admission can ensure that these items are in place when it is time for nursing 
homes to carry out their seasonal influenza vaccination programs. 
Finally, ASPE recommended that we discuss Medicare coverage rules, how Medicare 
determines vaccine reimbursement, and the adequacy of reimbursement, among other things. 
While we agree that these are important issues that warrant further study, they fall outside of 
the scope of this inquiry. 
Comments from CDC 
In its comments, CDC recommended that we give more prominence to integrating vaccination 
into the admission process, vaccination of nursing home staff, and using consultant 
pharmacists, among other things.  Based on these and a separate set of technical comments 
from CDC, we strengthened language related to integrating vaccination into the admission 
process, referenced ACIP recommendations for vaccination of nursing home staff, and 
clarified language throughout the report. 
17 
Nursing Home Vaccination  OEI-01-99-00010  APPENDIX A 
Measurement Initiatives

Overview 
Measurement initiatives are efforts to measure vaccination rates and learn about vaccination issues 
in nursing homes.  They can tell States which nursing homes are reaching vaccination goals and 
give insights into barriers and to best practices for vaccination.  Public health agencies and nursing 
home oversight bodies can use this information to guide action aimed at enhancing vaccination 
rates.  For example, States may create educational programs for nursing home staff and residents 
or focus on vaccination procedures during their annual certification surveys of nursing homes. 
Several potential problems may weaken the usefulness of measurement initiatives.  Because 
measurement usually takes the form of a survey, poor survey design or poor response rates can 
generate unreliable data.  Second, even with good data, measurement initiatives have limited 
impact when States fail to use the data they collect to take action to increase vaccination rates. 
Massachusetts 
Description 
Since 1996, Massachusetts has conducted an annual Pneumonia Survey of nursing homes. 
The State began the initiative after its Division of Health Care Financing and Policy identified 
pneumonia as the top diagnosis of nursing home residents admitted to hospitals.  The States 
survey collects data that include the numbers of residents and staff who received 
pneumococcal and influenza vaccines, reasons for resident refusal of vaccines, and residents 
who were transferred to the hospital with pneumonia.  The purpose of the survey is to collect 
data that the State can use to target education aimed at increasing vaccination coverage and 
reducing resident admissions to hospitals due to pneumonia.  In addition to its survey, the 
State also has a vaccine purchase initiative that provides influenza and pneumococcal vaccines 
to nursing homes. 
Experience 
After receiving only 31 out of 100 surveys the first year of its initiative, the State held a 
feedback meeting with respondent nursing homes to redesign its survey.  The next year, the 
State mailed a revised survey to over 500 nursing homes in Massachusetts.  It followed up on 
the survey by sending field nurses to pick up completed surveys in person and do a quality 
check of the survey responses with nursing home staff.19  The State implemented this process 
fairly easily, since it already sent field nurses to nursing homes to perform audits of Medicaid 
data.  Using this method, the State increased its response rate to about 95 percent and 
enhanced the quality of the responses.  In 1998, the State added questions to its survey and 
18 
Nursing Home Vaccination  OEI-01-99-00010  APPENDIX A 
repeated this approach. 
Using the survey, the State learned where vaccination rates lagged and where to target 
educational efforts.  For example, it learned from its survey that, in 1997, 82 percent of 
nursing home residents in the State received an influenza vaccination.  However, it also 
learned that pneumococcal vaccination and vaccination of nursing home staff trail far behind 
that of influenza.  Preliminary data from the 1998 survey shows that rates are climbing, but 
still have room for improvement.  The State plans to use these data to design educational 
programs for nursing homes and to challenge those with low vaccination rates to improve. 
Nursing home representatives we spoke with found the survey was effective at raising 
awareness of the importance of vaccination and fostering collegial relations with the State. 
They also said that the States field nurses were helpful because they could provide feedback 
based on what they had seen in other facilities.  In fact, the nursing home representatives we 
spoke with said that more comparative data would be useful as a benchmark of their 
performance.  However, they also find that the States survey effort fails to address what they 
feel remains a major barrier to vaccination  resident and staff misperceptions about the 
influenza and pneumococcal vaccines. 
Montana 
Description 
To track vaccination in nursing homes, the Immunization Program of Montana Department of 
Public Health and Human Services conducted a series of vaccination surveys.  Officials at the 
Immunization Program began the initiative in 1991 as a telephone survey of 15 nursing homes. 
Later, they developed a short written survey, which they mailed to all nursing homes in 1994, 
1996, and 1998.  The survey collected data on resident and staff vaccination levels as well as 
data on vaccination policies.  Program officials are using the survey data to guide their efforts 
to increase vaccination coverage in nursing homes. 
Experience 
Officials at the Immunization Program report that their survey has been successful at gathering 
useful data on nursing home vaccination.  Through persistent telephone follow-up of 
unresponsive nursing homes, program officials have maintained a response rate of just under 
70 percent of the States nursing homes for the past three surveys.  In addition, a recent 
survey conducted by the local Medicare PRO generated vaccination data that corroborated 
the results of the Immunization Programs survey. 
Immunization Program officials use the survey data to assess progress on reaching the 
Healthy People 2000 vaccination objectives and to guide educational strategies.  For 
19 
Nursing Home Vaccination  OEI-01-99-00010  APPENDIX A 
example, in 1998, data revealed that nursing homes exceeded the Healthy People 2000 
objective by vaccinating 92 percent of the States residents against influenza, while 
pneumococcal vaccination trailed behind at 71 percent.  However, the data also revealed that 
nursing homes with standing orders for pneumococcal vaccine had higher vaccination rates. 
Armed with this information, program officials now recommend that nursing homes use 
standing orders for pneumococcal vaccine as a way of increasing their vaccination rates. 
Program officials are including this and similar expertise in a vaccination training manual for 
the Immunization Programs field nurses to use when they visit nursing homes.  Yet despite 
these strides, officials report that competing priorities and reduced funding threaten to 
discontinue their adult immunization program. 
Illinois 
Description 
In 1993, officials at the Illinois Department of Public Health began surveying nursing homes in 
response to outbreaks of flu-like illness in nursing homes.  During follow-up calls to nursing 
homes where outbreaks occurred, Department officials learned that many nursing homes 
lacked standard written vaccination policies.  In response, they designed a survey to collect 
vaccination data and to increase nursing homes awareness of strategies that prevent influenza 
and pneumococcal disease.  The survey collects data on nursing homes vaccination coverage, 
policies for staff and resident vaccination, and Medicare billing activity. 
Experience 
Department officials report mixed success in carrying out their survey initiative.  While their 
1998 survey achieved a 67 response rate and piqued interest from nursing homes, officials say 
that vague responses from nursing homes have undermined the usefulness of some survey 
questions.  For example, where the survey asks for the numbers of residents who have 
received vaccines, many homes answered all or most, thus preventing officials from 
calculating reliable coverage estimates.  Officials would like to follow-up with nursing homes 
to validate the survey data, but staffing constraints prevent them from doing so. 
Despite these problems, Department officials do their best to make use of the survey data by 
sharing it with stakeholders who can use it to promote vaccination.  For example, officials 
share aggregate survey data with the States survey and certification agency, who use it to 
draw attention to the importance of vaccination during on-site visits to nursing homes.  The 
Department also shares data with the Illinois Adult Immunization Coalition, of which it is a 
founding member.  The coalition includes the Medicare PRO and Part B carrier, nursing home 
trade associations, and the HCFA regional office, among others.  Coalition partners frequently 
reference the Departments survey data in their educational efforts. 
20 
Nursing Home Vaccination  OEI-01-99-00010  APPENDIX A 
Mandate Initiatives

Overview 
Mandate initiatives are laws or regulations that require nursing homes to offer vaccines to all 
residents.  They offer States the most sweeping and direct way of addressing influenza and 
pneumococcal vaccination in nursing homes.  States can fold vaccination mandates into standards 
that nursing homes must meet for State licensure, such as those for infection control.  They can 
assess compliance with mandates on an ongoing basis by reviewing nursing home policy, 
residents vaccination records, and other information during annual licensure and certification 
surveys.  States can enforce mandates by imposing fines on noncompliant nursing homes or 
ordering them to submit plans for improving their vaccination programs. 
However, vaccination mandates do not guarantee that homes will achieve high vaccination rates. 
Vaccination mandates can lose effectiveness if States fail to assess nursing homes compliance or 
fail to take action against those who are noncompliant.  In addition, misperceptions about 
vaccination among nursing home residents can lead to high refusal rates for vaccines  thus 
undermining even the most well-enforced mandate. 
New Jersey 
Description 
New Jersey administrative code mandates nursing homes to offer every new resident influenza 
and pneumococcal vaccines upon admission.  In addition, it requires nursing homes to offer 
influenza vaccine to all existing residents during flu season.  The State created its mandate in 
1998 as part of a broad vaccination campaign designed to ensure that at least 80 percent of 
seniors receive the opportunity to get vaccinations.20  The States Long Term Care 
Assessment and Survey unit enforces the vaccination mandate by checking nursing homes 
policies, procedures, and vaccination rates during the infection control portion of its annual 
licensure surveys. 
Experience 
State officials are pleased with their efforts but believe they must do more than simply 
mandate that nursing homes offer vaccines to residents.  While citing nursing homes high 
compliance and low number of disease outbreaks as evidence that their approach to 
vaccination is working, officials also concede that vaccination rates still fall short of their 
goals.  State officials believe that high numbers of resident refusals of vaccines are holding 
nursing homes influenza vaccination rates to between 70 percent and 80 percent and 
pneumococcal vaccination rates to around 40 percent.  They would like to address this 
problem by supplementing their mandate with a program to educate nursing home residents, 
their families, and personal physicians about the importance of vaccination. 
21 
Nursing Home Vaccination  OEI-01-99-00010  APPENDIX A 
Nursing home staff we spoke with said their facilities have had little difficulty complying with 
the States vaccination mandates.  To meet the pneumococcal vaccination requirement, they 
established a program that uses admission orders to assess every admission for pneumococcal 
vaccination and document acceptance or refusal of vaccines in each residents vaccination 
record.  To meet the influenza requirement, they set up a seasonal vaccination program that 
assesses all existing residents for influenza vaccination by November 30th and every new 
admission until February 1st. 
Delaware 
Description 
Since 1990, Delaware State Board of Health regulations have required nursing homes to 
document influenza and pneumococcal vaccination for every resident, as indicated by CDCs 
Advisory Committee on Immunization Practices (ACIP).  Officials at the Board of Health 
wrote the regulations to supplement their educational efforts on vaccination safety and 
efficacy.  The mandate is enforced through the States survey and certification process which, 
until recently, was conducted by the Board of Healths Office of Health Facility Licensing and 
Certification.21 
Experience 
Citing full compliance with the mandate, officials at the Board of Health believe that the 
mandate has been successful in large part because of work done early on in the mandates 
development.  For example, prior to publishing final regulations for the mandate, they held 
public hearings to seek input and buy-in from the public, nursing homes, and physicians. 
Perhaps more importantly, they also started a program to provide free influenza and 
pneumococcal vaccines to nursing homes, which continued until Medicare began paying for 
influenza vaccine in 1993.  Finally, officials also attribute success to detailed enforcement of 
the mandate after it was enacted, which put nursing homes on notice that the Board of Health 
took the mandate seriously. 
Despite success with their vaccination mandate, officials identified enhancements that would 
have made for a smoother implementation of the mandate.  In-service training for nursing 
homes would have taught nursing home staff about the importance of vaccination, details of 
the regulation that established the mandate, and how to set up vaccination programs to aid 
compliance with the mandate.  Training surveyors on how to examine vaccination records and 
developing standardized vaccination logs for nursing homes would have streamlined the 
survey process, which was initially slow and awkward. 
22 
Nursing Home Vaccination  OEI-01-99-00010  APPENDIX A 
Purchase Initiatives

Overview 
Purchase initiatives are programs where States provide free vaccines to nursing homes.  Because 
they enable nursing homes to provide influenza and pneumococcal vaccines to all residents 
regardless of their insurance coverage, vaccine purchase initiatives can dramatically increase 
access to vaccines.  Also, by aggregating the vaccine needs of an entire States nursing homes into 
one vaccine order, States remove the burden of ordering vaccines and negotiate stronger, more 
reliable purchasing agreements with vaccine manufacturers.  Finally, although seasonal purchases 
of influenza vaccine are the centerpiece of purchase initiatives, vaccine purchases may also include 
pneumococcal and other vaccines on a year-round basis. 
States face two problems that may undermine the effectiveness of vaccine purchase initiatives. 
First, even with free vaccines, nursing homes may elect not to participate in the initiative. 
Although vaccine purchases remove the burden of purchasing and seeking reimbursement for 
vaccines, they may do little to ease the workload and financial burden associated with 
administering vaccines  which in the case of influenza vaccine is nearly as high as the cost of the 
vaccine itself.  Second, resident refusals of vaccination due to concerns about vaccine safety and 
efficacy can negate the impact of open access to vaccines created by vaccine purchases. 
Oklahoma 
Description 
Since 1991, the Oklahoma Department of Health has worked to increase access to vaccines by 
providing free influenza vaccine to nursing homes.  Department officials initially decided to 
purchase vaccines for nursing homes because Medicare did not pay for the influenza vaccine. 
Without free vaccines, officials felt that Oklahomas nursing homes would not vaccinate their 
residents.  Although Medicare began paying for influenza vaccine in 1993, the Department has 
continued to purchase vaccines for nursing homes.  In fact, it is working to expand its 
purchase to include pneumococcal vaccine, even though it, too, is covered by Medicare. 
Department officials say that their program remains a vital source of vaccines because only 
half of Oklahoma nursing homes bill Medicare for services and, of those, few find that 
Medicare reimbursement makes it worthwhile to vaccinate their residents. 
Experience 
Officials at the Department of Health report that their vaccine purchase has made major 
inroads to protecting nursing home residents from influenza.  Yet, they cite continual funding 
shortages as a major hurdle to further success.  For example, in 1998, the State was unable to 
provide influenza vaccine to about 15 percent of facilities due to funding limitations. 
23 
Nursing Home Vaccination  OEI-01-99-00010  APPENDIX A 
Department officials project that their new pneumococcal vaccine program may fail to meet 
demand as well.  To remedy the situation, they are developing a program to recoup vaccine 
costs by billing Medicare for doses given to Medicare-eligible nursing home residents. 
However, Department officials report difficulty getting homes to send in the billing 
information that is required for Medicare reimbursement.  To overcome this problem, officials 
plan to hire a contractor to provide technical assistance to nursing homes and to bill Medicare 
on the States behalf. 
Louisiana 
Description 
The Immunization Program at the Louisiana Department of Health and Hospitals works to 
remove financial barriers to vaccination by providing free influenza vaccine to nursing homes. 
The program began in 1984 when the State legislature started setting aside Medicaid funds to 
purchase influenza vaccines for Medicaid recipients and residents of nursing homes.  In 1999, 
the Immunization Program got funding from the Department of Health and Hospitals to 
provide pneumococcal vaccine with the stipulation that it recoup the expense of the vaccine 
by billing Medicare. 
Experience 
Citing a 90 percent vaccination rate, officials at the Immunization Program say that their 
influenza initiative is working well.  In fact, because their program has consistently provided 
free influenza vaccine for nearly 15 years, officials say that there are no financial barriers to 
getting the vaccine, which has led vaccination to become standard procedure at Louisianas 
nursing homes.  Recently, officials began working with the local Medicare PRO to teach 
nursing homes how to bill Medicare for vaccination.  This would further reduce financial 
barriers to vaccination by allowing nursing homes to be paid for their effort administering 
vaccinations.  Billing Medicare would also enable the Immunization Program to recoup the 
cost of vaccines that it provides to Medicare beneficiaries in nursing homes.  However, 
despite the financial incentive for nursing homes, officials report problems getting them to 
provide information that Medicare requires for reimbursement, such as each residents name, 
address, Medicare number, date of birth, signature, and the date the vaccination was given. 
This difficulty with billing for influenza vaccine has prompted Immunization Program officials 
to delay offering pneumococcal vaccine to nursing homes.  Officials are concerned that they 
will be unable to recoup the expense of the vaccine, as directed by the Department of Health 
and Hospitals.  Moreover, officials say that Medicare reimbursement for pneumococcal 
vaccine was recently reduced and, even if nursing homes did turn in adequate billing 
information, it may not be enough for them to continue the pneumococcal initiative. 
24 
Nursing Home Vaccination  OEI-01-99-00010  APPENDIX A 
Educational Initiatives

Overview 
Educational initiatives are programs designed to educate nursing home residents, staff, physicians, 
residents families, and others about vaccines and vaccine-preventable illnesses.  Through 
education about the safety and efficacy of vaccines as well as the severity of the illnesses they 
prevent, educational initiatives seek to increase demand for vaccines.  For nursing home staff and 
physicians, education reinforces the importance of vaccinating nursing home residents and keeps 
them informed of the latest guidelines for vaccine usage, such as those from the ACIP.  For 
nursing home residents and their families, education addresses common misperceptions and fears 
that can undermine residents willingness to accept potentially life-saving vaccines. 
There are several potential problems that can limit the effectiveness of educational initiatives.  If 
States do not have an adequate understanding of where the vaccination process is breaking down, 
they may target education toward the wrong audience.  Second, even well-targeted education can 
be ignored if not presented in an engaging manner and on a level of detail that is appropriate for 
its intended audience. 
New York 
Description 
Since the late 1970s, officials at the New York State Department of Health have informed 
nursing homes about vaccination by mailing them an annual influenza information packet. 
When State officials began their initiative, they decided that, rather than spending the majority 
of the influenza season investigating outbreaks, they would instead try to prevent them 
through education.  To that end, they developed an information packet to raise awareness of 
influenza and to help nursing homes in their vaccination efforts.  The packet includes 
information on the benefits and safety of vaccination, vaccine administration guidelines, 
vaccine ordering, and record-keeping.  State officials mailed similar packets about 
pneumococcal disease in 1993 following a well-publicized pneumococcal outbreak and in 
1997 to announce changes in ACIP guidelines for pneumococcal vaccine. 
Experience 
State officials have accomplished annual mass distribution of their information packet, but face 
challenges that limit the effectiveness of their efforts.  As part of a wider adult vaccination 
project, they copy and distribute the packet to several health care settings, including about 
250 hospitals, 550 assisted living facilities, and 650 nursing homes.  State officials, though, are 
unsure of who at the nursing home receives the packet, if they are using it, or are finding it 
useful.  State officials say they would like to conduct in-person follow-up 
25 
Nursing Home Vaccination  OEI-01-99-00010  APPENDIX A 
with nursing homes, but have other responsibilities that demand their time and resources. 
Ironically, outbreaks of influenza  which the States educational program aims to prevent  
provide officials with the best opportunity to educate nursing homes about vaccination, since 
they must go on-site to investigate each outbreak. 
Nursing home representatives we spoke with said that the States informational mailings are 
useful, but also suggested ways that the educational campaign could be improved.  They 
praised the packet for serving as an annual reminder and technical resource, but also said that 
the State should do more to target nursing home residents, their families, and the residents 
doctors, who can be influential vaccination advocates.  Rather than mailing a standardized 
packet of information to nursing homes, they recommended that the State tailor its education 
to meet the specific needs and level of understanding of different audiences  for example, an 
eye-catching pamphlet for low level nursing home staff or public service announcements for 
residents and their families. 
26 
Nursing Home Vaccination  OEI-01-99-00010  APPENDIX B 
Comments on the Draft Report

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Nursing Home Vaccination  OEI-01-99-00010  APPENDIX B 
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Nursing Home Vaccination  OEI-01-99-00010  APPENDIX B 
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Nursing Home Vaccination  OEI-01-99-00010  APPENDIX B 
33 
Nursing Home Vaccination  OEI-01-99-00010  APPENDIX C 
Endnotes

1.  J. Pekka Nuotari et al., An Outbreak of Multidrug Resistant Pneumococcal Pneumonia and 
Bacteremia Among Unvaccinated Nursing Home Residents, New England Journal of Medicine 
338 (June 25, 1998) 26: 1861-1868. 
2.  Alan P. Kendal and Peter A. Patriarca (eds.), Options for the Control of Influenza (New York: 
Alan R. Liss, Inc., 1986), 155-168. 
3.  Centers for Disease Prevention and Control, Prevention and Control of Influenza: 
Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR 48 
(April 30, 1999) RR-04: 1-28. 
4.  Centers for Disease Prevention and Control, Prevention of Pneumococcal Disease: 
Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR 46 
(April 4, 1997) RR-8: 17. 
5.  Centers for Disease Prevention and Control, Immunization of Health Care Workers: 
Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the 
Hospital Infection Control Practices Advisory Committee (HICPAC), MMWR 46 (December 26, 
1997) RR-18: 1-42. 
6.  U.S. Department of Health and Human Services, Healthy People 2000 - National Health 
Promotion and Disease Prevention Objectives, PHS 91-50212, September, 1990. 
7.  U.S. Department of Health and Human Services. Healthy People 2010 (Conference Edition, in 
Two Volumes). Washington, DC: January 2000. 
8.  Please see: Centers for Disease Prevention and Control, Outbreaks of Pneumococcal 
Pneumonia Among Unvaccinated Residents in Chronic-Care Facilities -- Massachusetts, October 
1995, Oklahoma, February 1996, and Maryland, May-June 1996, MMWR 46 (January 24, 1997) 
3: 60-62; J. Pekka Nuotari et al., An Outbreak of Multidrug Resistant Pneumococcal Pneumonia 
and Bacteremia Among Unvaccinated Nursing Home Residents, New England Journal of 
Medicine 338 (June 25, 1998) 26: 1861-1868; Kristin L. Nichol, Revaccination of High Risk 
Adults with Pneumococcal Polysaccharide Vaccine, Journal of the American Medical 
Association 281 (January 20, 1999) 3: 280-181. 
9.  S.M. Greby, et al, Influenza and Pneumococcal Vaccination Coverage in Nursing Homes, 
United States, 1995" (abstract).  In: Abstracts from the 32nd National Immunization Conference, 
Atlanta, GA; 32nd National Immunization Conference, 1998. 
34 
Nursing Home Vaccination  OEI-01-99-00010  APPENDIX C 
10.  Ibid. 
11.  Please see:  Centers for Disease Prevention and Control, Recommendations of the Advisory 
Committee on Immunization Practices: Programmatic Strategies to Increase Vaccination Rates  
Assessment and Feedback of Provider-Based Vaccination Coverage Information, MMWR 45 
(March 15, 1996) 10: 219-220; Centers for Disease Prevention and Control, Measles, Mumps, 
and Rubella  Vaccine Use and Strategies for Elimination of Measles, Mumps, and Congenital 
Rubella Syndrome and Control of Mumps: Recommendations of the Advisory Committee on 
Immunization Practices (ACIP), MMWR 47 (May 22, 1998) RR-8: 1-57; National Vaccine 
Program Office, The Measles Epidemic - The Problems, Barriers, and Recommendations, 
Journal of the American Medical Association 266 (September 18, 1991) 11: 1547-1552. 
11.  Standing orders can play an important role in increasing vaccination.  In fact, CDCs 
Advisory Committee on Immunization Practices recently voted to update its pneumococcal 
vaccine guidelines to include a recommendation that providers use standing orders as a way to 
increase vaccination coverage for pneumococcal disease.  Charles Marwick, New 
Recommendation for Adult Immunization Journal of the American Medical Association, 282 
(December 15, 1999) 23: 2199.  One journal article advises that vaccination should be organized, 
automatic, and planned with physician input, but not necessarily dependent on physicians for 
implementation. Lance C. Peterson and David S. Fedson, Prevention, Management, and 
Control of Influenza in the Institutional Setting, The American Journal of Medicine  82  (June 
19,1987) suppl. 6A: 58-60. 
13.  For more information on organized vaccination programs and vaccination during the 
admission process, please see:  Centers for Disease Prevention and Control, Prevention and 
Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices 
(ACIP).  MMWR 1999;48 (April 30, 1999) RR-4;  American Society of Consultant Pharmacists, 
100% Immunization Campaign Resource Manual, January 1999; Peter A. Patriarca, et. al., 
Prevention and Control of Type A Influenza Infections in Nursing Homes, Annals of Internal 
Medicine 107 (November 1987) 5: 732-740;  Robert J. Buynak and Jonathan M. Evans, 
Influenza in the Nursing Home: Prevention and Treatment, Nursing Home Medicine 4 
(November 1996) 11: 319-324;  Kristin L. Nichol et al., Immunizations in Long-Term Care 
Facilities: Policies and Practice, Journal of the American Geriatrics Society 4 (April 1996) 44: 
349 - 355. 
14.  For more information on the need for uniform data on vaccination, please see:  David S. 
Fedson, Summary of the National Vaccine Advisory Committee Report, Journal of the 
American Medical Association, 272 (October 12, 1994) 14: 1133 - 1137. 
15.  For more information on access to vaccines, please see:  Fedson, Summary of the National 
Vaccine Advisory Committee Report,: 1133 - 1137;  Nichol et al., Immunizations in Long-
Term Care Facilities,: 349 - 355. 
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16.  For more information on education about influenza and pneumococcal vaccines, please see: 
Centers for Disease Prevention and Control, Recommendations of the Advisory Committee on 
Immunization Practices (ACIP),: RR-8;  National Coalition on Adult Immunization, Improving 
Influenza and Pneumococcal Immunization Rates Among High Risk Adults, May 1998; Nuotari 
et al., An Outbreak of Multidrug Resistant Pneumococcal Pneumonia and Bacteremia,: 1861-
1868. 
17.  In fact, fear and misperceptions about vaccination may be on the rise, as evidenced by recent 
controversy about the safety of childhood vaccination.  For more information, please see 
Stephanie Stapleton, "Vaccines Not Immune to Criticism," American Medical News 2 August 
1999, In a Glance section, 1; "Vaccine Benefits Far Outweigh Any Risk," Newspage, 4 August 
1999;  Statement of David Satcher, Assistant Secretary for Health and Surgeon General, 
Department of Health and Human Services, before the Committee on Government Reform, U.S. 
House of Representatives (3 August 1999). 
18.  In addition to information about nursing home resident vaccination, the New York also sends 
information about the potential impact of influenza on residents, the need for vaccination of health 
care workers, information on how to diagnose influenza outbreaks early and institute control 
measures, and how to contact the health department with questions regarding influenza 
prevention and control. 
19.  Massachusetts Division of Medical Assistance has a staff of field nurses who visit nursing 
homes quarterly to collect data for its prospective payment system. 
20.  New Jersey Department of Health and Senior Services (DHSS) may soon make this goal 
more ambitious by raising its target numbers and changing its focus from ensuring that residents 
are offered vaccines to ensuring that residents are vaccinated.  In October, 1999, DHSS released 
for comment a set of public health goals called,  Healthy New Jersey 2010 - A Health Agenda for 
the First Decade of the New Millennium, which, among other things, aims to increase influenza 
and pneumococcal vaccine coverage in nursing homes to 90 percent. 
21.  In March of 1999, the Board of Health transferred responsibility for survey and certification 
of nursing homes to a new division called Long Term Care Residents Protection. 
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