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A summary of presentations from the weekly Summit partner webinars

February 1, 2024 – The latest Summit Summary

Frontline Staff Survey Findings from AMDA’s Moving Needles – Elizabeth Sobczyk (AMDA)
The Specialist’s Role in Immunization: Driving Immunization for High-Risk Patients with Chronic Illness – Helen Burstin (CMSS)
Questions
Announcements

Frontline Staff Survey Findings from AMDA’s Moving Needles – Elizabeth Sobczyk (AMDA)

Elizabeth Sobczyk, MSW, MPH, AMDA, The Society for Post-Acute and Long-Term Care Medicine, Inc., gave a presentation AMDA’s “Moving Needles” multi-year project to improve adult immunizations in post-acute and long-term care (PALTC).

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The Society for Post-Acute and Long-Term Care Medicine, Inc. (AMDA) Project GoalsMaking routine adult immunizations a standard of care for post-acute and long-term care residents (PALTC)

Making routine adult immunizations an expectation for employees
Main components
- Focus on frontline staff survey and training
- Help neutralize conversations based on results of staff survey

Timeline of 5-year cooperative agreement

Began in 2021 and end date is 2026
Currently in round two of quality improvement pilot
Working toward change package in curriculum production to train healthcare staff about immunizations
Working on economic and workflow analysis

Frontline Staff Survey Findings

Survey Goals

Survey to understand:
- What types of information they are receiving/would like to receive
- Trusted sources for vaccine information
- Preferred modalities, sources, and formats for professional development
Findings used to develop training module for frontline staff and for supervisors

Survey Distribution and Analysis

Paper survey in Spanish and English at three facilities in Ohio, Colorado, and Connecticut
Online survey in Spanish and English shared via email to National Automated Clearinghouse Association (NACHA) members
Respondents offered $15 gift card to Amazon or Walmart
Offered $300 honorarium to facilities distributing paper surveys
Had 200 respondents from paper surveys and email surveys from NACHA members
- Excluded online responses that were duplicates or not valid
- Excluded respondents not working in PALTC
Analyzed 145 paper surveys and 55 online surveys
Only 2 responses in Spanish
155 responses to an open-ended question: “Imagine you manage staff vaccination for a LTC facility. How would you go about it?”

About Survey Respondents

Of 200 respondents (many worked in more that one setting)
- 90% worked in nursing homes
- 14% worked in assisted living
- 13% worked in home health
- 15% worked in other LTC settings
Most respondents were CNA’s, nursing staff, and front office staff

Respondents’ Beliefs about Immunization: Benefits

Main benefits
- Preventing spread of illness
- Reducing severity of illness
Open-ended responses brought up most frequently
- Protecting self, family, others
- Protecting residents and coworkers, (slightly more for protecting residents)

Respondents’ Beliefs about Immunization: Concerns

Respondents were split on how well vaccines offer protection
- About a third don’t feel protected after getting vaccinated
- Large percentage that either strongly agree or strongly disagree that they feel protected after vaccination
Most talked about concerns are side effects, unknown long-term effects, and limited effectiveness of vaccines

Respondents’ Views on Vaccination for LTC Workers

About half agreed that getting vaccinated was a responsibility for LTC workers
Half felt LTC staff vaccination requirements were reasonable
Around 40% viewed vaccination as a personal decision that does not impact their work. Don’t feel like vaccination is the way to protect the residents.
Most open-ended responses focused on personal choice
Open-ended responses showed nuanced views on vaccination for LTC staff
- Younger staff more often showed support for personal choice—decreased by age group
- Comments supporting staff vaccine requirements were low (8–12%)—did not vary by age or race
To protect residents, respondents suggested masking, testing, separating unvaccinated staff from most vulnerable patients

Desired Vaccine Information

Respondents wanted balanced information (pros and cons of vaccination)
- Who does the vaccine help?
- How much does the vaccine help?
- What are the side effects, long term effects?
- What are the ingredients?
- What are the employees’ rights?
Many say they want to leave the decision up to the employee
Most trusted sources are healthcare providers: doctor or pharmacist, followed by government agencies, and co-workers

Respondents’ Preferences for Training

Preference for training is a paid staffing service (30–60 minutes) provided by the facility/direct supervisor
Some support for pre-recorded videos, webinars, or written materials
Half more likely to participate if receive certificate or credit

Key Take-Aways

Respondents are motivated to protect themselves and others from illness
- About half accept vaccination as a responsibility for LTC staff
Confidence in protection through vaccination is low
Many think vaccination should be a personal decision
Want balanced information to make own health decisions
Want information from supervisors, healthcare providers, and government agencies for training
- Prefer something less than one hour
- Prefer training that’s paid and in-service

Staff In-Service Modules

Frontline staff module
- In-service directly being developed based on the results of the survey findings
“Train the trainer” module also in development

Other Projects

Cost benefit analysis
- Direct link between resident vaccine rates, hospitalization 5-star ratings, and reimbursement
- Survey going out in spring
Two documents on EHR/IIS interoperability
- Will be posted up on the website soon
- Encourage better connectivity between facilities and IIS for better history and documentation of immunization between public health and SNFs

For more, see: www.movingneedles.org

Questions? Contact: Elizabeth Sobczyk esobczyk@paltc.org

The Specialist’s Role in Immunization: Driving Immunization for High-Risk Patients with Chronic Illness – Helen Burstin (CMSS)

Helen Burstin, MD, MPH, CEO, Council of Medical Specialty Societies (CMSS), gave a presentation on the specialist’s role in immunization: driving immunization for high-risk patients with chronic illnesses.

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Council of Medical Specialty Societies’ (CMSS) Mission

Mission is to advance the expertise and the collective voice of specialty societies in support of physicians and the patients they serve.
Think about how to advance healthcare for both physicians and patients

CDC Standards for Adult Immunization Practice (SAIP)

The Standards the case that during every clinical encounter, clinicians should be assessing for immunization and strongly recommending when possible
The usual practice has been assuming that primary care doctors will take care of recommending immunizations

Specialty Societies Advancing Adult Immunization (SSAAI) Project Overview

Five-year cooperative agreement between CDC and CMSS
Thinking about how to promote adult vaccination for high-risk patients with underlying chronic illnesses who may not be seeing a primary care clinician
Involves specialties caring for patients with COPD, asthma, diabetes, heart disease, cancer, and chronic kidney disease, as well as older adults, and in occupational health settings

SSAAI Advances Adult Immunization Practice in Specialty Settings by:

Engaging health systems to test interventions in specialty settings
Finding the best practices to improve vaccination practices, assessment, recommendation, administration, referral, and documentation
Trying to align the specialty side of educational offerings, policies, and guidelines to the Standards for Adult Immunization Practice
Working with all 50+ societies to learn what they are doing around vaccination

Participating Health Systems

7 specialty society partner organizations recruited 45 healthcare systems
Criteria for recruitment included:
- Capacity to collect and report on data needed around immunizations
- Focus on the specific high risk populations
- Diversity of provider/patient mix
Finished recruitment in September 2023
Covers 81 practice sites with reach across U.S. (over 30 states included)

Participating Health Systems: Testing what Works

Health systems are implementing quality improvement (QI) interventions to test strategies to improve adoption of SAIP in practice
Initially focused on COVID-19 and flu
Will expand to other vaccinations in 2024
QI interventions will fall into 10 categories
Most of the health systems are in QI 1 or 2: working on clinical workflow and vaccine assessment
Health systems will report process and outcomes data into a centralized data platform

SSAAI Data Platform Aggregates Health System Process and Outcomes Data

Data platform aggregates in terms of both the actual measures of COVID-19 and flu vaccine uptake, as well as additional measures proposed in 2024
Can provide back to the health systems the most detailed information to build on their QI interventions

Health System QI Interventions Will Generate On-the-Ground Learning about How to Adopt SAIP in Specialty Settings

Overall trying to generate on the ground learning for the 45 health systems and the 7 specialty societies
CMSS monitoring and analyzing from data coming in to learn across all project participants to identify best practices

Examples of Current QI Interventions

Validating vaccine data in EHR and cross-walking with the state IIS
Barriers to documenting vaccine status in EHR
Adding immunization assessment and documentation to standard rooming protocols
Training anyone involved in the workflow to engage with patients who are vaccine hesitant
Developing educational toolkits
Collaborating with state Medicaid agencies to identify the patients who have lower vaccination rates

Insights from Specialty Practices’ Experience

Specialists’ role in adult immunization
- Understand the value of vaccination to the patient populations
- Not sure if it’s their role to recommend vaccination
- Not clear where they fit in to recommend
Barriers to addressing adult immunization in specialty settings
- Time constraints
- Patients with severe illness may be vaccine hesitant
- Lack of standard practices and protocols because doesn’t fit into their workflow
- Reimbursement
- Logistics to carrying, storing, and administering vaccines

QI Interventions Informing Society Educational Offerings Examples

Participating societies have developed new and updated sources to align to SAIP
Educational materials for patients and providers

CMSS Developing Resources to Support All Members in Advancing Adult Immunization

CMSS developing resources that are relevant across all specialties to support physicians and care teams in implementing SAIP
Resources focused on barriers to adopting SAIP
CMSS and society resources are available at The CMSS Learning Center, a new Learning Management System launched in December 2023

Featured Resource: Vaccine Coding Toolkit

At-a-glance resource for physicians and staff about coding for vaccine counseling and administration
Includes tips for coding success and case studies
Adapted from a resource developed by American Association of Clinical Endocrinology
To be released February 2024

Featured Resource: Conversational Receptiveness e-Learning Modules

New resource to support clinicians talking with patients who have vaccine hesitancy
In development by Dr. Julia Minson, Harvard University based on years of research on conversational receptiveness and the psychology of disagreement
Series of 10–15 minute modules featuring case studies and knowledge checks
To be released in March or April 2024

Featured Resource: EHR Navigation Tools

Product of a CMSS-led Data Mapping Workgroup of 11 participating health systems working to develop solutions for leveraging EHRs to make sure there’s a place to assess and document immunization status
Some health systems use multiple vendors
Workgroup output will include:
- Practical insights that can be shared with EHRs around clinician user experience and organization approach
- Technical insights to identify data sources and how to query the EHRs to give the health systems and practices information at their fingertips

Questions? Contact Helen Burstin at: hburstin@cmss.org

Questions

Q: Both of you talked about some important data and tools that you have developed as part of these projects. Will these be publicly available to the broader vaccine provider community?

Helen Burstin (CMSS): Everything is publicly available. They will be open to anyone who would like to use them.

Elizabeth Sobczyk (AMDA): Our training and other tools will also be available on the website movingneedles.org, which is in the middle of getting a lot of updates with new materials and reports. You’re welcome to e-mail us directly at movingneedles@paltc.org and we can send you the training piece directly.

Q: Will any of the tools be available in Spanish or other languages?

Elizabeth Sobczyk (AMDA): We have not done the training in Spanish. If there is a strong need for that, please reach out and let us know so we can adjust. We offered the survey in Spanish and only had two responses, so it seemed like the primary interest in need was in English language. We can look at translation services and we have a group that can do that for us.

Helen Burstin (CMSS): I don’t know that we have any in Spanish yet, but it’s certainly an issue. As you could see by their list of health systems, there are some there that are heavily Latino in the in California area, so we’ll do everything we can to make sure materials are available in Spanish where needed.

Q: Where does it say what locations or health systems are participating? Is there anything in the Washington DC area?

Helen Burstin (CMSS): It can be a little hard to track because if you look at some of the big national areas like DC, for example, there’s so many different sites. With that map that I shared, we can see if we can put a bit more detail on there.

See the CMSS Learning Center website for more information: https://learn.cmss.org.

Q; We recently did a survey with our state’s (Vermont) skilled nursing facilities (SNF) and received some responses about caregivers refusing on behalf of family members with dementia or residents receiving palliative care. Would the Conversational Receptiveness e-learning modules be a good resource fit for these providers for having those conversations? Or are there other resources you might suggest?

Elizabeth Sobczyk (AMDA): I think there’s a lot of information in there about that. We started with why long-term care workers in particular are at high risk, and then what vaccines are recommended for residents and what vaccines are recommended for staff. We then added some frequently asked questions or more information about the side effects in those components. I think that could be taken and tailored. It’s more geared toward staff than residents and family members, but you could certainly use the information that’s there. We have other things that we could provide depending on where exactly the needs are. So, please reach out to our e-mail address (movingneedles@paltc.org) and we’d be happy to find some better materials. I think it’s also worth talking through consent processes as well. There are things like renewable consent documents and assent versus consent conversations with residents that are worth having to try to minimize the administrative impact that some of that whole process might have.

Helen Burstin (CMSS): I think as the conversational receptive tools roll out, we’ll share them broadly. They can really be used for a whole variety of different approaches, including the questionnaires.

Carolyn Bridges (Immunize.org): I’m very excited to see those videos when they come out. One thing that I didn’t hear either of you mention is provider fatigue. We’ve heard so much about this and maybe they’re so fatigued that they don’t even want to talk about vaccines in some settings. Did you find that this was a current barrier, and are you seeing any changes as we’re coming out of the pandemic?

Elizabeth Sobczyk (AMDA): Yes, there’s a lot of fatigue. Our setting is a little bit different in terms of the traditional provider fatigue. I would say the challenges are that the staff are fatigued from hearing about this and from being told that they have to get the COVID-19 vaccine. We talked with our facilities in the pilots about developing peer champions and a lot of them said we don’t have anyone who can be a peer champion for COVID-19, which I think is sad but a reality of where things are right now. So yes, I think we’ve heard a lot of discussin about fatigue since commercialization of COVID-19 vaccine. There are a lot of additional access components that are really challenging, includingskilled nursing facilities-related vaccine billing and vaccine billing for pharmacies and facilities and what Medicare allows for Part B vaccines: COVID-19, flu, and pneumonia. With the residents, there hasn’t been that same level of mental fatigue, but we’re seeing a lot of access challenges now that are making it harder. I think less so on the resident side regarding fatigue, except for the mental fatigue with increased access barriers. And there are increased vaccine access barriers for the staff in addition to the fatigue.

Helen Burstin (CMSS): I’ll mention that one of our challenges has been that some specialties never ask about vaccination. It’s adding something to their plate when they are already incredibly busy. You have to get through with these really sick patients in 15–20 minute visits, and so that’s been the beauty of thinking outside the box in terms of QI interventions. It’s been really interesting to watch, for example, American College of Cardiology, which has largely been using virtual practices and trying to see if there are ways outside of the usual visit. What could you do in a virtual visit that you’re checking in for to really do some of this work? I’m really excited they’re being very creative about trying to get around either “I don’t think this is in my role” or “I don’t have time to do this,” and frankly when they asked cardiologists about this initially the feeling was, “no, I’m just not going to do it. I don’t have time.” And their response was, “I’ll do it if somebody else will help me or if it’s built into electronic systems,” which I thought was an interesting insight. That’s exactly what their work now is. It’s trying to understand how you can build it into the electronic system so that it makes sense and it works, but doesn’t overburden providers.

Amy Parker Fiebelkorn (Team Lead, Partnership and Health eEuity Branch in Immunization Services Division at CDC): It has been so fun being part of both projects and seeing the many layers that you all are addressing with the provider surveys and the resident surveys, understanding the issues with the EHR and the IIS, and helping these different groups incorporate adult immunizations into the workflow. I think you all touched on really key points and findings that you’ve learned so far, but I think it’s also really exciting that you have a massive amount of data coming in. Elizabeth already has data from the initial pilot sites and what that looked like when they implemented the QI interventions in those first ten sites. And Helen with all the work that you’re doing in these 45 systems, you’ve hired out a data management company to help ensure that the data are consistent, and that it’s in a format that you can look at across all these different sites and find out which interventions are working and layer on to those interventions so that other sites can pull that data and learn from that. I just don’t think there’s anything out there on adult immunization in health systems and in long term care settings that have the amount of data that you both in each of your different projects will be pulling in. So, as exciting as the information is that you both shared today, there’s so much more to come and it’s really just incredible to see how the whole thought process from specialists as well as from these long term care providers can be shifted so that they learn that this is a responsibility that they want to take on and be able to offer adult immunizations in their interactions with their patients and residents.

Helen Burstin (CMSS): I’ll also point out that one of the groups is not like the other, which is the association of occupational and environmental health physicians, and so a lot of their interventions I think will be very broadly applicable and we’re happy to share that. What’s the role of the employer in terms of factory based or employer based immunization? A little different than the others because they’re not in traditional settings but I think we’ll also learn so much as we already have from them so far. They’re going beyond the usual suspects and immunizations to think more broadly about hepatitis, for example, and the things that are going to be directly relevant to work for their workers.

Elizabeth Sobczyk (AMDA): Just to add on what we’ve discovered in the process, is that as much work as we’ve done on collecting the data, there’s still a really big gap in the long-term care community in having systems that do that automatically. So, we had to step back and start foundationally. Some of our second-round pilot sites are still struggling with those pieces and a lot of it is a manual process. We’ve got a COVID-19 and flu excel spreadsheet. We’ve got some for pneumococcal, but there’s virtually nothing for Tdap and shingles on the resident side. Staff is even harder because it’s through employee tracking systems. If it’s not mandated, no one is collecting that information. So, there are a lot of components in long-term care that have not had the same attention that other populations have had in the past. We’re putting together what that data poll looks like when you don’t necessarily have a system that already supports being able to grab that data. So, even more foundational than what one might originally have thought you would have access to, but we’ve had to step back and spend a lot more time on the data collection piece than we thought we would.

Q: Can you remind us what the current requirements are for CMS in terms of reporting immunizations in LTCF?

Elizabeth Sobczyk (AMDA): I think there are a couple of components to that. The requirement in skilled nursing long-term care right now is a COVID-19 vaccine can be offered to residents and to staff. That could be that a facility helps their staff find it off site, but the requirement isn’t that you vaccinate in the regulations for skilled nursing facilities. This is specifically for skilled nursing because assisted living is governed at the state level. Independent living and home- and community-based services are governed through different sets of regulations, so just for skilled nursing there’s a requirement to offer COVID-19 vaccination separately. Then there are quality metrics around COVID-19 and flu. I believe sometimes pneumococcal, as well. I think primarily COVID-19 and flu. NHSN has reporting on other vaccines so I know that’s not a straightforward answer to your question but it’s nuanced in terms of what’s required in terms of the clinical quality of care and then what has to be reported through different mechanisms.

Q: Are these quality measures in place for adult immunizations helpful or not helpful? How are those being utilized? What are your thoughts about whether those are helpful to these providers?

Helen Burstin (CMSS): I think they’re helpful. They’re often at a fairly high aggregated level though so you only ultimately learn about whether a shot was given, and I think what we’re really trying to figure out is all those steps along that pathway of what does it take for somebody to engage in that discussion even recommend it refer somebody even if they’re not administering in their office. So, I think we want to get all those different steps along the pathway. They don’t cover as many of the immunizations that I think we’re really trying to talk about here. We’ve driven Amy crazy with questions about how do we count the number of COVID-19 vaccinations, for example, and how do we handle pneumococcal vaccination. It’s so complex. A big challenge is just ensuring we’re collecting the data in the right bite size elements so that at the end of the day we can try to assess and understand where the improvement opportunities are. So, it’s data collected for different purposes that’s oftentimes assessing the quality of a health plan as opposed to understanding here what an individual practice clinician or health system can really engage in.

Elizabeth Sobczyk (AMDA): Pneumococcal alone, just as a highlight, is so hard in a system that doesn’t already have a robust data collection to begin with. To say have you had PCV13 does that count and then do we want to offer PCV15 or 20? Then where does PPSV23 fall in all of that? What has been shared clinical decision making and what is a routine recommendation? Even though it’s simpler now than it has been in the recent past, it’s still really complicated when you don’t have easy access to a resident history, which is very frequently the case for people who are making transitions of care between hospital settings, ambulatory care settings, and skilled nursing or assisted living facilities. Being able to have access to a good [vaccination] history serves the adult population across all of those settings really well, which speaks to the need for more interoperability and more robustness to support reporting to IIS.

Helen Burstin (CMSS): Absolutely. It’s one of the main reasons we’re working with the EHRs, to really understand how we can best ensure those data are in there. If someone had their first vaccination five years ago, it may not have been in the same health system, and if we can’t connect to the IIS or other sources we may not know what’s happening. It’s critical that we have that full view.

Q: How does the requirement to refer for vaccination elsewhere work if you offer the vaccine through an off-site vendor? We’re hearing that vendors can’t be reimbursed because it’s part of the bundled payment made in the facility and patients have to physically leave the facility for separate payment.

Elizabeth Sobczyk (AMDA): Billing is ridiculously complex for a Part B vaccine. For a resident who is in their Part A stay a facility, they can bill separately for that but it has to be the facility. They use roster billing. Your Part B vaccines can be billed separately outside of the global payment but it has to be from the facility, it can’t be from a pharmacy, for example. I suppose it would be possible for an off-site vendor to come in and bill that as well as a medical provider, but it has to be on that medical site and not that pharmacy site after a resident has transitioned into their long-term care stay and out of their Part A stay. Then the pharmacy can start billing for Part B vaccines. Part D vaccines always have to be billed by the pharmacy and there’s some conversation about whether those get bundled in for your Part A stay patients. There’s a lot of confusion about this so we’ve put together a billing guidance. It’s 3-pages. We can share that with you. Medicare Advantage is an entirely different story, so it’s very complex. The facilities typically are not billing for that Part B vaccine because the roster billing is so complex, which is another reason we think that some of the resident rates are lower than they should be because there’s not an easy mechanism for payment back to the facility and it’s not something that they do routinely when the pharmacy is typically doing a lot of the billing for those and providing the vaccine to the residents in a lot of cases.

Announcements

A special Summit Weekly Update on vaccination of pregnant women will be held on Thursday, February 22 at 3:30 p.m. (ET). This webinar is co-sponsored by the NAIIS and American College of Obstetricians and Gynecologists. Participants will need to register in advance for this webinar. Link to register for the Maternal Immunization: Opportunities and Challenges webinar: https://us06web.zoom.us/webinar/register/WN_Ktn8yKMkRLOFi1USxyIaVw
Please also mark your calendars for the Summit in-person meeting being held August August 15 (full day) and August 16 (half day) in Atlanta, GA. The in-person meeting has been moved to August to accommodate the National Immunization Conference (NIC), which is being held in Atlanta, GA, on August 12–14. The Summit in-person meeting will focus on operationalizing adult immunizations. Stay tuned for further information.
The Summit workshop developed tools to address challenges in providing multiple adult vaccines along with COVID-19, flu, and RSV vaccines. See the Summit’s Operationalizing Adult Immunizations in the 2023 Fall Season and Beyond Workshop web page for the deliverables.
There is a new zoom link for the Summit meetings for 2024. If you do not have the new link, please contact info@izsummitpartners.org.
If you have agenda items you are interested in sharing with the Summit, please tell us and we can add you to an upcoming call as a speaker or panelist. Contact information: info@izsummitpartners.org