INFLUENZA VACCINATION FOR SENIORS

Access and Awareness: Dedicated Flu Clinics and Member Outreach

In the United States, influenza and pneumococal infections are, together, the sixth leading cause of death for older adults. Approximately 20,000 high-risk Americans die each year from influenza-related illnesses. Immunizations are reported to prevent up to 70% of hospitalizations and 85% of deaths from influenza-related pneumonia. Along with a statewide cooperative initiative aimed at immunizing seniors, this health plan implemented an initiative to remove barriers to influenza immunization.

The targeted population for this initiative consisted of the plan's Medicare membership. The performance measure used was the percentage of members who had received an influenza vaccination during the reporting year. Data were collected from claims from private physicians' offices and encounters for the plan's staff model centers. The plan looked for the presence of the influenza vaccination code (CPT-4 code 90724) in these data. The 1995 data showed a baseline performance of 36.3%.

Two benchmarks were used: the national average of 43.2% and the regional average of 48.9%. The plan set as its performance goal a 60% annual influenza immunization rate of the population older than 65 years. This was based on the goal in Healthy People 2000.

Using fishbone diagrams, the quality improvement team was able to identify the key barriers that needed to be overcome. The most important were:

• Access/inconvenience
• Limited patient awareness of the importance of annual vaccination
• Incomplete data

A survey performed by the statewide cooperative project emphasized the importance of reminders. Of the seniors surveyed, 78% stated that receiving a reminder for their annual shot was important.

The literature demonstrated that flu clinics and direct mail outreach had been used to successfully immunize this population. Armed with this information, the plan set out to overcome the barriers to immunization for its population.

PRE-INTERVENTION RESEARCH It's important to have a good understanding of the issue before dedicating resources to any quality improvement effort. Here, the plan not only performed a root cause analysis but was able to draw upon survey and literature information directly applicable to its initiative.

The plan of action was designed to address each of the identified key barriers.

In its first year of interventions, the plan concentrated on the barrier of access. It established free flu vaccination clinics in convenient locations and advertised their availability. (Sample fliers are included in QP Tool .) No appointments were needed, and plan members received their immunizations free of charge. Clinics were set up in the plan's staff model centers and in local malls and stores. Volunteers from plan staff were used to man the clinics. Preparations for the clinics included obtaining a standing order for flu vaccination from physicians at the staff model centers (included in QP Tool ).

During the intervention, the plan found that it was difficult to capture immunization data from the different sites. Before the interventions were put into place, both clinical and nonclinical staff members were unaware of the steps they needed to take to ensure that the vaccination information was captured. Often, there was no accountability for the process or simply no process in place. The plan found that the front-line clerical staff who managed many of the processes for the clinics were particularly helpful in suggesting changes that brought more patients in for vaccinations and helped capture vaccination data. When members used the clinics at which their primary care physicians (PCPs) were based, their vaccinations were entered on their charts at the clinic; otherwise, the information was logged and sent to the members' PCPs. (The log sheet is included in QP Tool .)

DATA CAPTURE Although improving performance measures by enhancing data capture is not actually improving care, attention to data issues is critical to any improvement effort. The use of suggestions from front-line personnel here is noteworthy. Nevertheless, for procedures such as influenza immunizations, members may well get their shots somewhere else in the community, and the data may not be captured accurately.

To publicize the clinics, the plan sent letters to the targeted population in both Spanish and English. Information highlighted the need for annual vaccination and the locations and dates of the free clinics. Information was also provided in a member newsletter article. Although the focus of the intervention was the Medicare population, the plan notified employer groups of the clinics.

The plan also used educational materials developed by the statewide cooperative project. (Copies of the letters and articles used are included in QP Tool .)

Remeasurement, based on 1996 data, showed a rate of 61.7%. This increase was not only substantial, but the plan had met is performance goal in a single year.

Based on its success, the plan continued its interventions for a second year. It continued to address all three of the main barriers identified at the start of the initiative.

The plan concentrated on a strong fall publicity campaign for its now annual flu clinics and on identifying high-risk members. The plan used member newsletter articles, direct mailings to all seniors, notifications to employer groups, and general advertisement of the vaccination clinics.

Operations of the flu clinic were enhanced by identifying a responsible coordinator at each staff model center.

The plan also identified high-risk members from within the Medicare population for special attention. These high-risk members were identified by searching encounter and claims data for the presence of diabetes, chronic obstructive pulmonary disease (COPD), heart disease, and renal disease. These high-risk members were sent reminders that stressed the need for annual vaccination to avoid the higher risks these members would encounter if they contracted the flu.

By repeating and continuously improving its strong interventions, the plan hopes not only to duplicate its excellent rate of immunization, but to improve on it.