Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

APRIL 2000 

OEI-01-99-00010 

Nursing Home Vaccination: 

Reaching Healthy People Goals 
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 
EXECUTIVE SUMMARY 

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. 

Nursing Home Vaccination 1 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 

Nursing Home Vaccination 2 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 

Medicare’s 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. 

Nursing Home Vaccination 3 OEI-01-99-00010 
TABLE OF CONTENTS 

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

Nursing Home Vaccination 4 OEI-01-99-00010 
INTRODUCTION 

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. 

Nursing Home Vaccination 5 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 

Nursing Home Vaccination 6 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 State’s 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 President’s Council on Integrity and Efficiency. 

Nursing Home Vaccination 7 OEI-01-99-00010 
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. 

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 resident’s vaccination history and allergies becomes more 

difficult. Physicians can forget to assess residents for vaccination and to write orders for 

vaccines. Getting the resident’s or his/her family’s 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 resident’s 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 resident’s 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 

Nursing Home Vaccination 8 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 

Montana’s nursing homes exceed the Healthy People 2000 objective for influenza 

vaccination but lag in pneumococcal vaccination and vaccination of nursing home staff. 

Nursing Home Vaccination 9 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 State’s 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 selfreported 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 State’s 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 State’s behalf. 

Nursing Home Vaccination 10 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 Louisiana’s 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 resident’s 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 State’s 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 State’s 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. 

Nursing Home Vaccination 11 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 State’s vaccine purchase successful. 

Nursing Home Vaccination 12 OEI-01-99-00010 
OPPORTUNITIES FOR 

IMPROVEMENT 

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, CDC’s 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. 

Nursing Home Vaccination 13 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. HCFA’s 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 indepth 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 resident’s 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 

Nursing Home Vaccination 14 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 Medicare’s 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. 

Nursing Home Vaccination 15 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 CDC’s 

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. 

Nursing Home Vaccination 16 OEI-01-99-00010 
COMMENTS ON THE DRAFT 

REPORT 

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 

resident’s or family’s consent to vaccination, to document vaccination history, and to get 

physician’s 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. 

Nursing Home Vaccination 17 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 State’s 

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 

Nursing Home Vaccination 18 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 State’s 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 State’s 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 State’s 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 Program’s 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 

Nursing Home Vaccination 19 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 State’s 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 Program’s 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 State’s 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 Department’s survey data in their educational efforts. 

Nursing Home Vaccination 20 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 State’s 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. 

Nursing Home Vaccination 21 OEI-01-99-00010 
APPENDIX A 

Nursing home staff we spoke with said their facilities have had little difficulty complying with 

the State’s 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 resident’s 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 CDC’s 

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 State’s survey and certification process which, 

until recently, was conducted by the Board of Health’s 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 mandate’s 

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. 

Nursing Home Vaccination 22 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 State’s 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 Oklahoma’s 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. 

Nursing Home Vaccination 23 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 State’s 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 Louisiana’s 

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 resident’s 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. 

Nursing Home Vaccination 24 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 

Nursing Home Vaccination 25 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 State’s 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 State’s 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. 

Nursing Home Vaccination 26 OEI-01-99-00010 
APPENDIX B 

Comments on the Draft Report

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APPENDIX B 

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APPENDIX B 

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APPENDIX B 

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Nursing Home Vaccination 33 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. 

Nursing Home Vaccination 34 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, CDC’s 

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 LongTerm Care Facilities,”: 349 - 355. 

Nursing Home Vaccination 35 OEI-01-99-00010 
APPENDIX C 

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. 

Nursing Home Vaccination 36 OEI-01-99-00010