CMS-CDC Immunization Standing Orders Program (SOP) Project: Nursing Home Immunization Practices and Barriers to SOPs in 12 States L McKibben, A Shefer,

CMS-CDC Immunization Standing Orders Program (SOP) Project:

Nursing Home Immunization

Practices and Barriers to SOPs in 12 States

L McKibben, A Shefer, H Roberts, P Stange, J Krider, D Bratzler

APHA 129th Annual Meeting, Oct. 23, 2001

Atlanta, GA

SOP Project Background

Healthy People 2010 Goals for influenza and pneumococcal vaccinations are 90% for all persons > 65 years old, including nursing home residents

Nation did not reach HP 2000 goals of 80% for these immunizations in nursing home residents

Advisory Committee on Immunization Practices endorsed evidence-based standing orders programs (MMWR 49:RR-1,3/2000)

Influenza and Pneumococcal Vaccinations, Nursing Homes,

United States, 1995, 1999*

63 66

81

24

38

63

0102030405060708090

Flu Vaccine PneumococcalVaccine

1995

1999

1999 w/ounknown

*CDC unpublished data, National Nursing Home Survey

1999 Baseline Objectives of the SOP Project

To assess:

Current & planned immunization program types

Perceived barriers to SOPsNeed for training resourcesCapacities to track immunizations

Methods

Self-administered, 2-page questionnaire:4-6 responses on current and planned program types9 responses for SOP barriers for each vaccine8 responses for training needs2 responses for tracking practices

Mailed July 1999 to all Medicare or Medicaid certified nursing homes in 7 intervention & 5 control states

Overall response rate of 77%

Response Rates: Intervention States

PRO

Jurisdictions

TOTAL # of NURSING HOMES

# RETURNED RATE (%)

FL 725 521 72%

MA 502 423 84%

MN 416 389 94%

KY 256 190 74%

NM 74 65 89%

ID 73 58 80%

DC 19 15 79%

Totals 2065 1661 80%

Note: 2 states (HI & MT) used alternate surveys

Response Rates – 5 Control States

PRO

Jurisdictions

TOTAL # of NURSING HOMES

# RETURNED

RATE (%)

OH 1008 689 68%

PA 766 598 78%

WI 413 340 82%

SC 158 121 77%

NV 51 38 75%

Totals 2396 1786 75%

Immunization Program Types

Preprinted Admission Orders (PPAO): Standardized Forms included in admission

package for personal physician signature; may address future as well as current vaccination needs. May require periodic updating.

Standing Orders (SOP): Institutional policy authorizes appropriate

nursing staff to immunize residents by institution- or medical director-approved protocol w/out need for written or verbal order from personal physician.

Immunization Program Types

Physician reminders and education: Procedures in place for educating and/or

reminding physicians and residents on importance of I&P vaccines. May include stickers on charts, letters to physicians’ offices, posters, etc. Procedures require physician order for each immunization.

No formal procedures in place: Residents are immunized upon request and/or

upon personal physician’s individual discretion. Physician’s orders are required for each immunization.

Types of Program, Baseline 1999

Intervention States, N = 1,598 *

Program Types

Flu program % Pneumococcal program %

PPAO 56% 41%

SOP 9% 7%

Reminder/

Educ

29% 28%

None 6% 24%

No response <1% <1%

* 1,598 represents complete survey & OSCAR data

% Plan to Change Y2000 Programs,

Intervention States, N = 1,598

5% to change flu program (n=73) 39 of these plan to change to PPAO23 of these plan to change to SOP

9% to change pneumo program (n=144) 62 of these plan to change to PPAO32 of these plan to change to SOP

Type of Program, Baseline 1999

Control States, N = 1,772 *

Program Types

Flu program

%

Pneumococcal

program

%PPAO 46% 31%

SOP 8% 7%

Reminder/

Educ38% 30%

None 8% 32%

No response <1% <1%

* 1,772 represents complete survey & OSCAR data

% Plan to Change Y2000 Programs, Control States, N = 1,772

6% to change flu program (n = 104)56 planning to change to PPAO24 planning to change to SOP

10% to change pneumo program ( n= 181) 81 planning to change to PPAO26 planning to change to SOP

Barriers to SOPs: Flu Vaccination,

Intervention States, N=1,598

Barriers Frequency % of Total

No legal authority 891 54%

Need to educ MDs 862 52%

No Advantage 679 41%

Liability 668 40%

Inappropriate 430 26%

Staff turnover 334 20%

Cost 271 16%

Reimbursement 263 16%

Lack of Support 124 7%

Barriers to SOPs: Pneumococcal Vax,




Need to educ. MDs 869 52%

Liability 653 39%

No advantage 637 38%



Cost 285 17%


Lack of support 132 8%

Barriers to SOPs: Flu Vaccination,

Control States, N=1,772



Need to educ. MDs 909 51%

No Advantage 759 43%

Liability 675 38%



Cost 266 15%


Lack of Support 159 9%

Barriers to SOPs: Pneumococcal Vax,




Need to Edu. MDs 902 51%No advantage 717 40%

Liability 663 37%



Cost 271 15%


Lack of support 157 9%

Training Topics Needed,


Training Topic Materials for staff On-site training

Model policy 59% 30%Billing procedures 42% 24%Influenza vaccine 50% 26%Pneumococcal vaccine

55% 29%

Process/software for tracking

53% 35%

Training Topics Needed,


Training Topic Materials for staff On-site training

Model policy 54% 23%

Billing procedures 37% 17%

Influenza vaccine 43% 18%

Pneumococcal vaccine

49% 21%

Process/software for tracking

46% 28%

Consistent Place to Record Vaccinations,


Consistent place used: N (%)

For influenza vaccine 1364 (85%)

For pneumococcal vaccine 1235 (77%)

For Neither 151 (9%)

Don’t Know 43 (3%)

Centralized Tracking of Vaccinations,

Intervention States, N=1598

Centralized tracking: N (%)

For Influenza vaccine 824 (52%)

For Pneumococcal vaccine 719 (45%)



* Computer or Log book

Consistent Place to Record Vaccinations,


Consistent Place used: N (%)





Centralized Tracking of Vaccinations,

Control States, N=1772

Centralized tracking N (%)





* Computer or Log book

Summary I

SOPs are underutilized Few NHs planning to change program types

More likely to change to PPAO>SOP Vaccine history documented in consistent

place in the resident’s chart Many facilities need centralized tracking Barriers to SOPs:

Legal & regulatory issuesNeed for physician education

Characteristics of Nursing Homes Associated with Influenza Vaccine

SOPs and other program types

Exploratory analysis of SOP baseline survey & selected nursing home variables from OSCAR*.

* CMS administrative database used in annual certification process.

Characteristics of Nursing Homes by State Type

Characteristic Intervention % Control %

multiple-owned facility (chain)

61% 50%

provider category :

Long, SNF Health Agency, NH Rehab

Hospital

41%

54%

4%

1%

38%

46%

9%

7%

bed size:

Large (>120) Medium (51-120) Small (<50)

44%

45%

11%

41%

48%

12%

1999 Influenza Immunization Program, by Provider Category,

Intervention States

Provider Category

Type of Program

SNF

n=650

Unskilled

n=873

Rehab

n=65

Hospital

n=16

PPAO 63% 53% 25% 44%

SOP 12% 6% 6% 6%

Reminder/Educ 21% 35% 32% 31%

None 4% 6% 37% 19%

Unknown <1% <1% 0 0

Total 100% 100% 100% 100%

P value

<.01

<.01

<.01

<.01

Bivariate Analysis: Co-variates

Certification Status Both (89%), Medicare

(6.5%), Medicaid (4%)

Provider-based Administered by

hospital (10%) or by provider (90%)

Multi-facility organization Chain or independent

Provider category4 types: Long, SNF;

Health Agency, NH; Rehab; Hospital

Facility size < or > 50 beds

Certification Status & Program Types

Program type vs

No Program

Pearson Chi-Square test for association

P-value

SOP vs None 58.46 < 0.0001

PPAO vs None 214.60 < 0.0001

Reminder/Educ vs None

96.64 < 0.0001

Chain Affiliation & Program Types

Program type vs

No Program

Chi-Square test for association

P-value

SOP vs None 3.32 0.0684

PPAO vs None 0.23 0.6353


0.01 0.9234

Provider-based & Program Types

Program type vs

No Program


P-value

SOP vs None 30.11 < 0.0001

PPAO vs None 158.93 < 0.0001


87.87 < 0.0001

Provider Category & Program Types

Program type vs

No Program


P-value

SOP vs None 63.76 < 0.0001

PPAO vs None 215.29 < 0.0001


98.87 < 0.0001

Facility Size & Program Types

Program type vs

No Program


P-value

SOP vs None 31.36 < 0.0001

PPAO vs None 110.99 < 0.0001


79.77 < 0.0001

Polytomous Logistic Regression*:Best 2 Models

Facility size; Multi-facility Org; Certification StatusP value = 0.7344 (higher p-value indicates best

model)

Facility size; Multi-facility Org; Cerification status; Provider based; Provider-based*Certification statusP value = 0.2937

*CATMOD in SAS v8

Best Model: Coefficient Estimates

**p<.01

PPAO vs None

SOP vs None


Intercept 1.0681** -0.5901** 0.8762**

Fac size (L) 0.4646** 0.3311** 0.4737**

Chain (yes) -0.0994 -0.2807** -0.1141

Certification (both)

0.8732** 0.8693** 0.6073**

Certification (Medicaid)

0.2500 0.0975 0.0391

Summary II: Influenza Vaccine Programs

Larger facilities (> 50 beds) more likely to have organized programs (all 3 types) for influenza vaccine

Chain facilities less likely to be using SOPs

Certification status (Both) has large effects on all 3 program types

Conclusions: Quality Improvement Opportunities for Intervention PROs

Promote centralized tracking of vaccinations Promote SOPs for pneumococcal vaccine Address legal authorities for SOPs Provide education materials, especially

model policies (ACIP); physician education about the benefits of SOPs; advantages of SOPs

Promote SOPs to chains Promote SOPs to small facilities ? Convert other program types to SOPs

Documents

CMS-CDC Immunization Standing Orders Program (SOP) Project: Nursing Home Immunization Practices and Barriers to SOPs in 12 States L McKibben, A Shefer,