CMS removes vaccination roadblocks for flu and pneumonia, but will it help?

Agencies still need to look closely at how they address vaccinations

At the beginning of this year’s flu vaccination season, the Centers for Medicare & Medicaid Services (CMS) changed the rules for flu and pneumonia vaccinations. Prior to Oct. 2 of this year, each vaccination administered to a home health patient had to be accompanied by an order from the patient’s physician. Now, the Conditions of Participation allow for standing orders to be developed and used for both vaccines.

Even without the use of standing orders, however, the CMS change indicates a need for home health agencies to look closely at how they are addressing vaccinations and to ask themselves if a more formalized approach to flu and pneumonia vaccinations is needed to ensure quality patient care.

With the change coming at the beginning of flu vaccination season for most home health agencies, there was little or no time to implement standing orders, but agency representatives interviewed by Hospital Home Health say that even with the change in regulation, they probably still will contact physicians on a case-by-case basis for their patients.

"We don’t want to cut the physician out of the process of caring for the patient," explains Jill Bodamer, RN, BSN, quality improvement and education coordinator for Chesapeake Potomac Home Health Agency in Hughesville, MD. "We also prefer to rely upon the physician’s records regarding any adverse reactions from previous vaccinations rather than our patients’ recollections," she adds.

"The only time we might rely upon a standing order would be for ongoing home health aide clients who may only see their physician once each year," says Janet Van Buskirk, branch manager of Preferred Home Health in Lafayette, IN.

Standing orders are common for community flu vaccination programs, but there is the concern that taking the decision away from the patient’s physician can harm the referring physician-agency relationship, Bodamer points out.

With or without the use of standing orders, home health agencies can play a critical part in protecting elderly against the complications of flu and pneumonia, says William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University Medical Center in Nashville, TN.

"Home health nurses can remind physicians that flu shots can be given in the home and make sure that all patients who are at risk for flu or pneumonia can be immunized without having to leave their homes," he says. Vaccinations in the home are attractive to home health patients and their caregivers because it eliminates a trip to the doctor and protects them against illness, he adds.

"We also vaccinate the spouse or family caregiver at the same time," points out Shirley M. Stevens, RN-C, clinical manager for Washington County Hospital Home Health Care in Hagers-town, MD. "This way, we can make sure that the caregiver doesn’t become ill and unable to help the patient," she explains.

As home health managers evaluate their approach to vaccinations, they need to remember to address the pneumonia vaccine, Schaffner says.

According to the CDC, an estimated 40,000 deaths annually in the United States can be attributed to pneumococcal infection, and immunization of high-risk persons could reduce this number to half.1

Because the pneumonia vaccine doesn’t get the public attention that an annual flu vaccine does, it may not be seen as critical to patients and their caregivers, Schaffner adds.

Both the pneumonia and the flu vaccines are covered by CMS, Schaffner says. Although the reimbursement represents a break-even proposition for most agencies, it’s important to note that these vaccines can prevent hospitalizations, complications from the illnesses, and spread of illness to your own staff, he points out.

Protect staff and patients

Even if all home health agencies don’t choose to use standing orders for flu and pneumonia vaccinations, the option of using them will make it easier for home health agencies to formalize their vaccination programs, says Libby Chinnes, RN, BSN, CIC, infection control consultant for IC Solutions in Mount Pleasant, SC.

"Standing orders can be an immense timesaver for the nurse administering the vaccine, and it also reduces pressure on physician time," she says. Any policy that includes standing orders also should include an option for a physician to override standing orders for particular patients, she adds.

When setting up a flu or pneumonia vaccination program, make sure you protect your own employees first, Chinnes says.

Agencies should provide the flu vaccine free to employees and make it convenient for them to get their shot, she says. "You want to make sure you have staff [who] won’t catch the flu from patients and won’t spread the flu to patients," she points out.

If you choose to use standing orders, have a physician-approved policy that allows for administration of the flu and pneumonia vaccines upon admission, if appropriate, Chinnes says.

The policy also should specify that the nurse will assess contraindications and educate the patient as to the benefits and potential complications of the vaccination, she adds. The assessment form then can be adjusted to include questions about the need for vaccinations and to gather information that might indicate contraindications, she says.

At Preferred Home Health, every patient is asked if a flu or pneumonia vaccination has been received, Van Buskirk says.

"If the patient indicates that there has been no vaccination, the nurse contacts the physician and asks for a verbal order to administer the vaccination," she says. A copy of the order is sent to the physician for signature after the verbal order is received, she adds.

By calling the physician, Van Buskirk’s staff has a chance to verify that no vaccinations have been given. Although the use of standing orders means that you have to rely upon the patient’s memory, there is little risk in revaccinating a patient, Chinnes says.

"Of course, the flu vaccine is recommended each year because different strains of influenza predominate each year," she says.

"With pneumococcal vaccine, studies have shown that the risk beyond self-limited local reactions was minimal for a second dose given two to five years after the primary dose and did not contraindicate revaccination with pneumococcal vaccine in the recommended high-risk groups," she says.2

Determine safeguards

One issue that needs to be addressed is whether the home health nurse can vaccinate a patient who never has received a flu shot.

"We cannot be the first to administer a flu shot because we don’t know if the patients will have a reaction, even after we’ve assessed them for contraindications," Bodamer says. For this reason, patients who never have had a flu shot must go to the physician’s office for the first vaccination, she adds.

"We will give first-time injections, but we make sure the nurse stays at least 15 minutes after the injection to observe potential complications," Van Buskirk says. "The order we request from the physician not only includes the vaccine but also epinephrine if needed," she adds.

Not all home health agencies include the administration of epinephrine if needed on the orders they receive from a physician, but Van Buskirk says that it is essential that nurses have the supplies and authority they need to address complications.

"It’s a matter of patient safety," she adds.

Make sure you also have uniform paperwork, educational flyers, consent forms, and a log for billing purposes, Stevens suggests.

This makes it easy for nurses to administer the vaccines from year to year, because they don’t have to relearn the process, she explains.

"Our flu vaccination is always successful, with most of our patients vaccinated each year," says Stevens. Her nurses, she says, exhibit responsible enthusiasm for the effort. "The first of October, all of the nurses come by my office wanting to know if the vaccine has arrived."

[For more information about flu and pneumonia immunization programs, contact:

  • Jill Bodamer, RN, BSN, Quality Improvement and Education Coordinator, Chesapeake Potomac Home Health Agency, 7627 Leonardtown Road, Hughesville, MD 20637. Telephone: (301) 274-9000, ext. 116.
  • Janet Van Buskirk, Branch Manager, Preferred Home Health Care, 3540 Coleman Court, Lafayette, IN 47905. Telephone: (765) 449-4848.
  • William Schaffner, MD, Chairman, Department of Preventive Medicine, Vanderbilt University Medical Center. E-mail:
  • Shirley M. Stevens, RN-C, Clinical Manager, Washington County Hospital Home Health Care, 1799 Howell Road, Hagerstown, MD 21740. Telephone: (301) 766-7800.
  • Libby Chinnes, RN, BSN, CIC, Infection Control Consultant, IC Solutions, 524 Crowfield Land, Mount Pleasant, SC 29464. Telephone: (843) 849-6027. E-mail:
  • Susan R. McCarter, RN, Community Educator, Diversified Home Health Services, 809 Gleneagles Court, Towson, MD 21286. Telephone: (410) 823-0880. Fax: (410) 823-2552. E-mail:]


1. 67 Fed Reg 61,809 (Oct. 2, 2002).

2. Centers for Disease Control and Prevention. Use of standing orders programs to increase adult vaccination rates. MMWR 2000; 49:15-26.

Immunization Resource

Delmarva Foundation, 9240 Centreville Road, Easton, MD 21601. Telephone: (410) 822-0697. Web site:

The Delmarva Foundation developed a flu and pneumonia vaccination project in 2001 for home health agencies in Maryland. While the toolkit has not been updated this year, the information still is accurate and helpful to agencies that are starting up a program. Access the toolkit at It contains sample policies, consent forms, standing orders, educational material for nurses and patients, billing education, and strategies.