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A summary of presentations from the weekly Summit partner webinars

Immunize Weekly Summary: July 25, 2024

CMS’ Commitment to Improving Nursing Home Quality and Safety Through the Quality Improvement Organizations – Colleen Frey, RN, MSN, CPHQ, Division Director; and Angel Davis, MBA, MS, BSN, RN, Deputy Division Director, Division of Community and Population Health (DCPH), Quality Improvement & Innovation Group, Centers for Medicare & Medicaid Services
Announcements

CMS’ Commitment to Improving Nursing Home Quality and Safety Through the Quality Improvement Organizations – Colleen Frey, RN, MSN, CPHQ, Division Director; and Angel Davis, MBA, MS, BSN, RN, Deputy Division Director, Division of Community and Population Health (DCPH), Quality Improvement & Innovation Group, Centers for Medicare & Medicaid Services

Colleen Frey, RN, MSN, CPHQ, and Angel Davis, MBA, MS, BSN, RN, gave updates about CMS’ commitment to improving nursing home quality and safety.

SLIDES ARE NOT AVAILABLE FOR THIS PRESENTATION

CMS Authorities and Programs
Although the Quality Improvement Program is the focus of this presentation, CMS has many authorities and programs:

Medicaid and Medicare Coordination
Clinical Standards
Quality & Safety Oversight
Quality & Public Reporting
Payment
Coverage
Program Integrity
Value-Based Incentive Models
Quality Improvement: Quality Improvement & Innovation Programs (Beneficiary and Family Centered Care [BFCC[-QIOs and Quality Innovation Network [QIN[-QIOs, Indian Health Service, End Stage Renal Disease Networks)

Quality Improvement Program
The quality improvement work through the CMS Division of Community and Population Health is done directly with the nursing home. This work is purposely separated from enforcement groups that perform surveys. The QIN-QIOs work in a nursing home, for example, is separate from any survey work that occurs there, although there is one exception: if the QIN-QIO found something egregious or life-threatening, it would be reported. The only time CMS uses the survey group is to determine whether there are trends in citations and, if so, to use those trends to drive the development of quality improvement programs.

When the QIN-QIOs go into nursing homes, it is at no cost to the nursing home, it is a federally funded program, and what is done in partnership with the nursing home is not shared with the survey group.

CMS has another program that works in hospitals: one group that works in the American Indian and Alaska Native Health services, another group that works in end-stage renal disease and the dialysis networks, and a beneficiary and family-centered care group that provides direct assistance to Medicare beneficiaries.

CMS Levers for Change
The CMS levers for change are in place to support the goal of providing the highest quality, best value, and patient-centered care within a resilient system framework. There are four main levers for change.

Scopes of Work
There are 12 regions in the current scope of work and each QIN-QIO has one of those regions across the country. The current scope of work is ending on November 7, 2024, so this is an interesting time to introduce a focus on immunization work, especially in partnership with the National Adult and Influenza Immunization Summit, as the approach to this work will be changing.

In the next scope of work, which will last for 5 years…

There will be 7 regions, instead of 12.
Work will be performed for all providers in the area (i.e., hospitals, outpatient providers, nursing homes, the kidney network) to help with care coordination.
The QIN-QIO contractors will be required to do an assessment of the region with the goals of understanding local programs, eliminating duplication of efforts, and fostering collaboration – with the QIO in a supporting role to local programs, where justified.

Notably, the current scope of work began just months before the COVID-19 pandemic hit, so rapid shifts toward the use of real-time information to provide infection control assistance was necessary. CMS looked at National Healthcare Safety Network (NHSN) data daily and sent strike teams from the QIN-QIO in response to COVID-19 outbreaks. Those teams helped secure personal protective equipment and ensured that staff had good infection control techniques. NHSN data was also used for COVID-19 vaccinations and, later, for boosters. There is a referral every other week for nursing homes that are experiencing low rates of vaccinations for COVID-19.

Quantitative Successes in Nursing Homes

12 QIN-QIOs collaborating with nursing homes across all U.S. states and territories
14,500+ nursing homes involved
2,598 local and large group learning events hosted by QIN-QIOs, with 207,783 nursing home attendees participating
12,059 nursing homes completed CMS-sponsored training, and 2,078 nursing homes with 75% or more staff trained
14,030 nursing homes received 1:1 QIO support for infection control, including on site assessment of the infection control program
7,095 nursing homes received 1:1 QIO support for vaccine and booster uptake, including support such as teaching motivational interviewing techniques (specifically for COVID-19) and working to increase uptake of influenza and pneumococcal vaccines, too

Priority Areas for Nursing Home Assistance
The priority areas support four goals:

Reduce COVID-19 infections, including vaccine and booster uptake activities
Provide infection prevention training
Increase patient safety with a focus on reduction of harm
Increase the quality-of-care transitions

The QIN-QIOs are committed to offering responsive and adaptive assistance to nursing homes nationwide, including those with low vaccination rates, high infection rates, and high staff turnover, among other challenges.

Success Stories
Success Story #1: Vaccine Uptake – Increased COVID-19 Booster Rates and Setting Up Vaccine Clinics
CMS identified an urban nursing home with low booster coverage rates. The QIO conducted a root-cause analysis and determined that vaccine hesitancy was the cause of the low rate. The QIO selected motivational interviewing to increase resident COVID-19 booster rates. The QIO then taught the facility the motivational interviewing method, including providing a conversation guide and encouraging staff to practice the SHARE model. Finally, the QIN-QIO created an award program for nursing homes with a booster coverage rate of 80% or higher, including press packages, names in a winners’ announcement, and a digital badge for promotion on their website. Based on the interventions suggested by the QIN-QIO, this nursing home was able to increase the resident COVID-19 bivalent booster rate by 53.9%.

Success Story #2: Using Data to Improve Patient Safety in Nursing Homes
CMS identified a rural nursing home with low resident vaccination rates. The QIO determined that access to vaccines was a main contributing factor. The QIO developed an Immunization toolkit, including steps to partner with community organizations; a Friends and Family Vaccine Clinic toolkit, including logistics checklists, press releases, and sample letters, forms, and flyers; and they also partnered with the State Department of Health to schedule the initial onsite clinic, using the process as a model for the nursing home. After receiving assistance and support from the QIO, this nursing home increased its resident COVID-19 bivalent booster rate by 75.5%.

Success Story #3: Using Data to Improve Patient Safety in Nursing Homes
In one QIO region, readmission rates and emergency department visits were higher than the established target and higher than the average rates for all QIOs combined. The QIO analysis revealed sepsis as the primary diagnosis for readmissions and emergency department visits. The QIO used a Sprint cycle for improvement, allowing for a greater impact in a shorter time. The QIO implemented onsite training and tailored resources, including frontline staff resources (i.e., wallet cards, an early warning tool), clinical staff resources (i.e., an SBAR [Situation, Background, Assessment, Recommendation] communication sheet, a sepsis algorithm for adults), and resident and family resources (i.e., a guide to understanding sepsis, and a stoplight tool). Outcomes in this region included hospital readmission rates that remained steady (further analysis is being conducted to mitigate other contributing factors to readmission), but emergency department visits were reduced by 60% in a 3-month period.

QUESTIONS & ANSWERS

Q: Where can we access the link to the conversation guide in the first success story?
Angel Davis (CMS): The Conversation Guide is available at https://comagine.org/resource/2069.

Q: As you move forward, in the next 5 years, where do the other vaccines come in — such as RSV, influenza, pneumococcal – for long-term care?
Colleen Frey (CMS): Vaccines continue to be a very important part of the work that we do. We are going even further this time. When we were looking at chronic diseases, we were mostly managing them in the 12^th scope of work; in the 13^th scope of work, we are really focusing on prevention. Of course, vaccines are a huge part of prevention activities for folks that have chronic diseases. And we decided that, based on our lessons learned with the public health emergency, that we can’t just say we’re only working on these vaccines. So we’ve left it open. RSV has been emerging for a few years now, but there’s more emphasis on getting the RSV vaccine. So our group of vaccines will continue to be the COVID-19 team boosters as they come out, influenza, pneumococcal, and RSV. But again, we are leaving the contract open for other emerging diseases where a new vaccine may be developed. One of the examples that we did in the 12^th scope was when monkeypox came around. We quickly got a vaccine out there for monkeypox and made sure the right population got vaccinated for it. And it seemed like it quickly arrested the spread of the disease. So, we want to make sure that if any new diseases come up and there are vaccines for those diseases, that we have a vehicle to promote those, as well.

Q: Considering the partnership with the State Department of Health-hosted clinic, do you have any idea who paid for that vaccine? Billing for nursing home residents and staff continues to have some challenges, and we’re looking for any partnership opportunities to expand access that we may not have thought of yet.
Colleen Frey (CMS): In that success story, we were fortunate that it took place during the public health emergency. So it was at no cost to the nursing homes and to the health department and pharmacy. We have a different model now. So, what I can share with you is Will Harris, from the Office of the CMS Administrator, did a couple of sessions with the QIN-QIOs on how to bill for those vaccines. I believe, in at least some states, if the Health Department holds the vaccine clinic, the Health Department provides the vaccines. It’s a little bit of a different story when the vaccines are being administered in the nursing homes. But that’s another resource that we can send to you: the payment guides for who does billing for the vaccines, whether it’s the facility or the facility pharmacy, and how and when.

Q: Where can we find those vaccine rate improvement resources? Is the “A Friends and Family Vaccine Clinic Toolkit” available? Basically, there is a lot of interest from the summit partners to get access to those resources and toolkits.
Colleen Frey (CMS): [We can get a list of resources and toolkits to you.] I’m also going make a plug for QIOProgram.org. It is a website that has many resources. And the other thing that will be helpful for the nursing home participants is that you can find your QIO on there, too. If you have not been in contact or had an encounter with your QIO, their information is out there so that you’re able to contact them, as well. But many of these resources are on QIOProgram.org.

Q: Will required weekly NHS and vaccine coverage reporting expand from COVID-19 for staff and residents?
Colleen Frey (CMS): I’m not aware that it’s going to be extended. We have made our case to the CDC, because it has been so helpful in managing various outbreaks. And if flu and RSV get added to that, that would be really wonderful. Because then we’d have that real time resource to be able to give information to the facilities.

Q: Considering that Medicare has accepted the adult composite measure, which on the Medicare core set covers flu, pneumococcal, hepatitis B, and Tdap, is CMS going to be thinking about using that adult composite measure at all?
Colleen Frey (CMS): We’re in procurement, so I can’t give you a lot of details about what the next contract looks like. But what I can say is that we’ve tried, as much as possible, to align our requirements for the QIN-QIOs, and work with the providers, nursing homes, and hospitals to what already exists for value-based purchasing with other CMS quality programs. I can tell you that we’ve tried to align as much as possible.
Carolyn Bridges (Immunize): It’s flu, pneumococcal, Tdap, and Zoster – not hepatitis B, and it also does not include COVID-19, which is something that we should probably be talking about.
L.J Tan (Immunize): I think it’s interesting to recognize that the AMGA has a national campaign called The Rise to Immunize program that started with the adult immunization status measure. And this year, they decided to continue to perform on additional adult vaccines. And they added COVID-19 and RSV, as well as hepatitis B, so they’re measuring themselves on seven vaccines, which is where we would like to get to.

Q: Focusing on healthcare providers, the CNAs and the nursing aides working in long-term care facilities: their immunization coverage rates across vaccines are [concerning]; for example, COVID-19 remains challenging and, as they are potential role models to their patients, what is the focus on the CMS for the next 5 years on trying to get them vaccinated. Also notable, people in that population tend to hold multiple jobs and, therefore, are uninsured because they have three part-time jobs.
Colleen Frey (CMS): We will have to get back with you on payment for that. I can’t answer it right now, because I just don’t know the particulars. But, as far as just trying to encourage the CNAs to become vaccinated again, it’s using those motivational interviewing techniques, talking to them about how they’re protecting their patients and also protecting their families. When they leave the facility, they go home to their families. And so that’s been a lot of the emphasis with that group, but we’ll have to find out about reimbursement, because it’s a really good question. We’ll get back to you on that.

Q: Regarding your three success stories, how scalable are these projects, for example the one in the Pacific Northwest with the motivational interviewing, which seems like a high intensity project?
Colleen Frey (CMS): Something like motivational interviewing techniques can be highly scalable, because, especially for those of us in healthcare, you always train the trainers right? Also, some of the programs that we’ve had for the nursing homes are webinars or presentations, and motivational interviewing techniques. In some cases, they’ll provide training modules and motivational interviewing techniques. We used a lot of CDC’s Project Firstline for infection control, and some of those modules deal a little bit with that, too: why you want to get vaccinated, why you want to use PPE, why you want to have good hand hygiene techniques. So, I think something like that is scalable. Some of those rapid response projects are a little tougher because you must be on site. And there are so many people. We use data to see the facilities that are in most need, such as the small number of facilities they worked with on the sepsis project. It was truly alarming because they had the highest sepsis rates in the country and something had to be done, so they did on-site work. So, it really depends on the work that they’re doing. We have a new piece of the sepsis project rolling out for this year, which includes on-site work with 211 nursing homes that have some of the highest rates, identified through CMS claims data. We could look at data and say, these are the guys who are having the biggest struggle. But we also had a second face to that, with just the general education program and providing resources across the country to whomever wanted to participate. There are pieces of things that can be scalable, too.

Q: How do the QIN-QIOs use the minimum data set to assess the vaccination coverage rates among the residents? And what systems is CMS using to monitor vaccine rates and coverage?
Colleen Frey (CMS): Oh, that’s a technical question. The main way we track COVID-19 vaccines is through NHSN, because it’s very real time. We use the Minimum Data Set (MDS) and claims data for influenza and pneumococcal tracking. There are a lot of issues, especially with using claims data. For example, was it entered correctly so that it shows up on the claims data? And we know that the data is at least 90 days behind, so there’s a lag. But that’s what we have right now. We have been encouraging the QIOs to reach out to their state health information exchanges and immunization registries to get information from there. Some states have been better and more cooperative than others. And some states have better systems for sharing that data with others. We will continue to look at the various ways to use technology to get the data faster. But right now, unfortunately for flu and pneumococcal, it lags for a little bit. We have to just do general activities again. If there’s a flu outbreak, we’ll put the resources there and then use that claims data to drive practices, even though it’s a little bit behind.
L.J Tan (Immunize): You measure what you treasure, right? So, might COVID-19, Zoster, and Tdap be added to the MDS?
Colleen Frey (CMS): We always love hearing this because it’s not a decision that Angel and I – or our team – makes, but we have contacts. So we can say, “Hey, have you considered…? Here’s why you need to….” We try to do that when we can, so we’ll take that back for sure.

Q: Regarding hospital discharges to long-term care facilities and readmission rates, if there was a comprehensive vaccination prevention program, do you think that might be one of those factors that could have brought down the readmission rates? Were you able to look at the impact of some of the other vaccines, or lack of vaccinations, on readmission?
Colleen Frey (CMS): Certainly, we’re going to be focusing more on preventive care in the next contract. But having good vaccination rates, whether it’s for flu or pneumococcal pneumonia or COVID-19 or RSV, if you’re vaccinated, generally even if you get the illness, the illness is less severe, so would be much more likely not to require hospitalization. Some of the impact data we saw was that for nursing homes that worked with the QIN-QIOs on COVID-19 reduction, there was about 25% fewer hospitalizations among the residents than nursing homes that did not work with the QIN-QIO. So, we did see the illness was less severe and, of course, then generally less hospitalization. So, certainly having the residents be immunized, if you can get it to 100, is really going to protect everybody, and it should reduce readmissions or hospitalization.

Q: In these studies, in the three examples you provided – especially that first one, when COVID-19 vaccination rates went back up – did you see any collateral positive impact on acceptance of other vaccines, like flu?
Colleen Frey (CMS): Here’s what we were really worried about, and what we saw that wasn’t positive: We’ve noticed the immunization rates for influenza in the nursing homes in the past three seasons has dropped. So, there’s a concern that the overall climate around COVID-19 vaccines is spreading. So we’re working very hard, obviously, on some of the strategies that the nursing homes have done that are not optimal. For example, it is easier to co-administer flu and COVID-19 vaccines; like, when I go get my vaccines, I get both of them, one in each arm, at the same time. However, what the nursing homes have done is unbundle their flu vaccination campaign from the COVID-19 vaccination campaign, so they’re taking care of the flu vaccines first to encourage folks. The other concern that is expressed is if you get both of them and you have a slight reaction to the COVID-19 vaccine, then in the resident or family’s head, it’s the reaction to the flu vaccine, so now they don’t want it. So, we actually saw the converse, unfortunately, in most cases as we look at the data. That’s been one of the areas where we’re really focusing. Where we have been successful, though, with COVID-19 vaccine, we have been successful with other vaccine campaigns, too.

Announcements

The latest agenda for the National Adult Influenza Immunization Summit meeting that will be held immediately after the National Immunization Conference in Atlanta, Georgia, on August 15-16, 2024 is up on the summit website: www.izsummitpartners.org. The keynote speaker is Kathleen Hall Jamieson, a distinguished professor at the Annenberg School of Communications at the University of Pennsylvania, who has done a lot of work on vaccine hesitancy and vaccine confidence and the impact on public health.
The slides from this meeting’s presentation (July 25, 2024) are not available.