In this study, we demonstrated it is possible to improve HCW influenza immunization rates in a network of LTC facilities served by a single LTC pharmacy. Facilities participating in the RISE program were able to reach the primary goal of 60%, almost two thirds reached the secondary goal of 80% or better, and 20% reached the new Healthy People 2020 goal. The rates demonstrated here are some of the highest reported for a network of independent LTC facilities using a voluntary approach. The impact of this program is significant, affecting over 2400 HCW and over 1800 LTC residents.
By having the LTC pharmacy oversee and administer the program, we were able standardized the emphasis on HCW influenza immunizations across all facilities. In addition, we believe we were able to overcome some of the issues related to staff turnover and competing demands on staff attention. In prior work, we found that despite educational interventions and centralization of immunization policies at the facility level, we were unable to achieve national immunization goals.32
High staff turnover is a pervasive issue in LTC and is linked to lower quality of care.33
When turnover is high, consistent application of facility policies may suffer. This may be particularly true with influenza immunization as nursing staff frequently view immunization as a personal choice rather than as an organizational evidence-based intervention.40
In contrast, LTC facilities do not typically change their LTC pharmacy provider annually and so enjoy a stable presence. Administering the immunization program via the LTC pharmacy should result in a more consistent effort across years. Our current findings support this, and in addition correlate with immunization programs using pharmacists in acute care settings.41
We believe the structure of the RISE program contributed to its success. The RISE program makes use of a LTC pharmacy network serving multiple different facilities, a model consistent with most LTC facilities across the country. The RISE program is structured similarly to that described by Babcock and co-workers at their health system.42
In that study, a representative from each facility in the health system participated in a system-wide council that planned and coordinated education, policies and procedures relating to HCW immunizations. Use of a central steering group promotes coordination across sites. Our study is unique in that not all of the participating facilities were part of the same health system and thus were individually managed.
Our program has several limitations. First, all facilities participating in the RISE program were non-profit organizations which limits generalizability. Participating facilities had to transfer oversight of the immunization program to the LTC pharmacy. This may not be possible for some chain facilities in which immunization policies are standardized centrally. In such facilities, it may not be possible to gain the necessary permission to shift location of immunization policies to the LTC pharmacy. Secondly, the RISE program requires significant ongoing efforts to ensure sustainability. While the number of steering group meetings were reduced over time to just one per year, the RISE program still relies heavily on the efforts of each facility’s leadership and champions. Thirdly, we did not track immunization rates for volunteers, physicians, or contracted non-employees. Immunization of these groups is a significant challenge to most LTC facilities. Fortunately, these groups represent only a fraction of the total HCW population of the facilities. Lastly, the RISE program is a voluntary program. While all facilities currently utilize declination forms for HCW declining influenza immunization, no facility imposes any form of disciplinary action for noncompliance, and no facility requires non-immunized HCW to wear masks during the active influenza season. Mandatory immunization programs have been associated with substantially higher HCW immunization rates, and there are strong ethical arguments for their use.42-45
Several organizations including AMDA now advocate for mandatory immunization programs.46
As shown in , there appears to be a plateau occurring in HCW immunization rates for this group of facilities. We believe it is unlikely that most facilities will be able to reach the Healthy People 2020 HCW immunization goal of 90%.
Strengths of our program include the use of standardized declination forms, immunization policies, data collection tools, and importantly, a standard definition of HCW immunization rate. We also provided evidence-based educational materials, an email communication process, and performance feedback.
In summary, we show that through collaborative efforts, LTC facilities sharing a common pharmacy provider can improve their HCW immunization rates. By having the LTC pharmacy oversee and administer the HCW immunization program, it may be possible to reduce the negative impact of high staff turnover in these settings. While nearly two thirds of the facilities reached 80% or better, only 3 exceeded 90% despite detailed, iterative efforts. If we hope to reach the 90% Healthy People 2020 goal, facilities may need to consider exploring mandatory programs.