HHA offers preventive care for flu, pneumonia
HHA offers preventive care for flu, pneumonia
Program protects clients, caregivers, staff
Most often, home health agencies must be in a reactive mode, responding to patients’ symptoms or changes in conditions. But one Wisconsin agency has undertaken a full-scale proactive effort to immunize its clients — and others — against influenza and pneumonia.
The result: Ministry Home Care of Marshfield, WI, has an 80% flu vaccination rate, says Dorothy Flees, MSN, RN-CS, quality improvement and staff education coordinator.
"I often hear in home care that we’re primarily here to do acute and chronic care, and we have so little opportunity to do preventive care," Flees says. "This is really one avenue where, as a home care provider, we could do preventive care."
Ministry Home Care carefully tracks participation in the immunization program, and refines it each year to serve new populations and better understand the factors driving patients’ decisions to get vaccinated. One vital piece of the program is reimbursement, Flees says, noting that Medicare Part B covers both influenza and pneumococcal vaccines in home care.
Ministry Home Care’s immunization program began in 1996, when it was a single-site agency. Now Ministry has grown to a corporation that includes three home health agencies — Saint Joseph’s Hospital Home Health in Marshfield, Sacred Heart-Saint Mary’s Home Health and Hospice in Rhinelander, and Saint Michael’s Home Health Center in Stevens Point — and two hospice agencies.
Fall 1999 was the first flu season in which the flu and pneumonia immunizations were offered at all of the agencies.
"It’s been kind of interesting trying to look at data from a small number of staff compared to a whole corporation," Flees says.
Infection tracking leads to program
The Atlanta-based Centers for Disease Control and Prevention (CDC) has targeted a number of groups as being at high risk for complications from influenza (see box, p. 88). Among them are those ages 50 and older, those with chronic medical conditions such as cardiovascular disorders or diabetes, and people taking immunosuppressant drugs — in short, a large part of the home health population.
Healthy People 2000, a federally led national health initiative, has set a goal of having 90% of all people ages 65 and older get flu and pneumonia vaccinations by 2010.
Flees says the impetus for Ministry’s immunization program came from data collected on pneumonia in the agency’s elderly population. She says the agency wanted to know more than simply how many cases were out there.
"We tried to pin down some of the causes to that. When did they occur, whether it was the typical flu season of October to March, or were they more physical-type pneumonias from swallowing disorders and so on," she says. "As a result of that program we thought we really should try to perfect a preventative program."
Physician OK required
Prior to the immunization program, Ministry’s nurses simply administered vaccinations when physicians ordered them. They still wait for physicians’ orders, even though they’re only required for pneumococcal vaccines. Flu vaccines technically can be administered without an order, Flees says. "We don’t just go ahead and give the flu vaccine because the patient requests it. We still call the physician and say, So-and-so would like to have a flu vaccine; is that OK with you?’ and then we go ahead and give the vaccine."
Flu shots are offered to all of the agency’s adult population, Flees says. Previously, Ministry Home Care had refrained from attempting to vaccinate children because they required a different vaccine formula. Those patients were instead referred to their physicians to be vaccinated.
She says this past flu season was the first time the agency was offered a vaccine that would have worked for younger patients."We really went with the recommendations that are out there for the influenza vaccine — any person because of age or underlying medical condition who is at increased risk for complications of influenza."
Although both flu and pneumonia vaccines are offered, participation in the pneumonia program is much lower — 13% to 20%, as opposed to the 80% who get the flu shot. Flees says the difference is due to different criteria for who gets the pneumococcal vaccine. Here’s how the program works:
At the start of the flu season — basically, whenever the agency gets its yearly supply of the flu vaccine — nurses are told to begin asking patients if they want to receive vaccinations.
The nurses carry tracking reports that note the name of each patient, where he or she received a vaccination (at a home health agency, physician’s office, clinic, or other program), or the reason the patient gave for not getting vaccinated.
Flees says those who refuse the shots tend to fall into a few main groups:
• Patients who don’t think they’re at risk for flu or pneumonia. "They say, I never had the flu; so why would I want to have a shot?’ They think they’re not at risk," Flees says. She adds that nurses bring along education sheets from CDC that explain the rationale for getting immunized.
• Patients who fear they’ll get the flu from the shot, or are worried about other side effects.
"Some people had [the flu vaccine] back in the days when the vaccines were first given and they recall becoming quite ill," Flees says. "Or they don’t want the muscle soreness or they don’t like some of the side effects they get from the flu vaccine."
She says nurses explain that shots might cause a sort of "mini-flu" — a low-grade fever, some arm soreness — but not the full-blown illness.
• Patients with physical barriers to vaccination, such as an allergy or an ailment that makes it a bad time to get vaccinated. While it’s important to explain to patients why the vaccinations are a good idea, ultimately the decision is up to the patient. "It’s like anything else; you can try to get them to buy into it, you can educate, but you also have to respect their refusal," Flees says.
Normally, vaccinations are offered from October to December. In addition to making a sweep of current patients, the agency also offers it to new patients who begin care during the immunization season. A separate form similar to the tracking form is placed in the patient’s file at admission. (See tracking form and admission immunization record, inserted in this issue.) It too, keeps track of where the patient might have gotten vaccinated or what reason he or she gave for refusing.
Outreach to others
As the program has matured, Ministry Home Care has begun offering shots to other at-risk populations. The first group targeted — at their own request — was at-home caregivers.
"For the first two years, we chose to only offer [vaccinations] to our patients," Flees says. "Then we had requests out there from spouses who sometimes are as homebound as patients."
Now, nurses offer the shots to the client and anyone else in the home. Next, the corporation offered shots to its own employees and began branching out to the community at large, holding some clinics at local churches and grocery stores.
"We didn’t want to duplicate services somebody else is offering," Flees says. "We didn’t want to compete with them. We wanted to be part of the continuum of care in the community, looking for places where we could fill a gap."
The tracking forms help identify those gaps, since they show where patients might be receiving vaccinations outside of home health. Those receiving shots who are not home health clients are billed for the service either through their own insurance or by cash.
Flees eventually hopes to expand the program even further, setting up at large companies to make it easy for workers to get vaccinated. Agencies can be limited by the amount of vaccine they receive.
At Ministry, the first priority is the patients, then their caregivers. While providing shots for employees is important, Flees says they are more likely to have other outlets for getting vaccinated.
Tracking flu shot success
The agency did not keep track of the number of patients vaccinated prior to 1996, so Flees says she has no way of knowing how high participation was before the program began. But in the first year, flu vaccination participation was pegged at 61%, which includes patients vaccinated by home health nurses, as well as those who received their shots through some other source.
In 1997 and 1998, the rate was 80%, which Flees says actually tracked quite closely the rate of vaccinations communitywide. "We feel pretty fortunate to have hit that 80% acceptance rate," she says, attributing it in part to a greater awareness in a community with a large medical facility.
So far, there’s no data showing whether the vaccination program has actually resulted in fewer flu cases among the clients who got the shots. Flees does hope to gather that data in the future, though. "I guess that’s our dream for next year," she says.
Flees notes that even with high participation, agencies may have some years where flu rates aren’t affected, since those creating the vaccine are guessing at which strain will be most prevalent that year. "That doesn’t mean you aren’t going to get the flu from some other strain that’s out there — it’s not a cure-all."
She says that one of the most cumbersome aspects of the vaccination program is the process to track it, requiring nurses to fill out forms with more and more detailed information. Every year, she refines those forms. Most recently, she added another category for patients who discontinue home care after the first few visits.
"We couldn’t get caseload numbers to match the amount of information that came back from the staff," she says. "We learned that we didn’t have anything on the form to say that this person was no longer seen after the day we started this flu vaccine, so [we] lost those numbers."
Flees says agencies have to decide how much information they need to gather. "We want to collect a lot of information so that we can make our program the best that it can be. It’s really according to the perspective you want to take. If you simply want to give the vaccine and promote it as a healthy measure of preventative care, that’s pretty simple.
"But you’ve still got to battle how you’re going to get reimbursed. What is the success of the program? Is it cost-effective? We’re trying to collect information to be able to tell that, to look at the difference that this made." Here are Flees’ other tips to agencies beginning an immunization program:
• Start early. Flees says an agency needs two to three months’ advance work to put a program in place. "Starting in September is too late," she warns.
• Consider patient/client outcomes and benefits with each step of the process.
• Debrief at the end of each flu season. What worked? What didn’t? Were there missed opportunities? What are things that could be changed for next year?
Flees says she has no doubts that Ministry’s program is improving patient health. "This is a patient outcome-oriented initiative," she says. "The way I look at it, you can’t go wrong by doing it. You can only improve the quality of life and cut costs by doing something preventative."
• Dorothy Flees, Quality Improvement and Staff Education Coordinator, Ministry Home Care, 611 St. Joseph Ave., Marshfield, WI 54449. Telephone: (715) 389-3866. Fax: (715) 387-9950. E-mail: [email protected].
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