A comprehensive influenza campaign in a managed care setting

PII: SO264-410X(98)00138-8

Vaccine, Vol. 16, No. 18, pp. 1718-1721, 1998 0 1998 Published by Elsevier Science Ltd. All rights reserved Printed in Great Britain 0264-410X/98 $iQ+O.OO

ELSEVIER

A comprehensive influenza campaign in a managed care setting Dave C. Pearson*& Lisa A. Jackson?, Beverley Wagener” Sarver”

and Laurie

Group Health Cooperative, a large, membership-governed, stafs model health maintenance organization (HMO), has designed a comprehensive influenza campaign for identifying, recruiting and vaccinating enrollees at increased risk for injluenza-related complications. The Cooperative’s Centre for Health Promotion is responsible for the overall planning, implementation and evaluation of the influenza campaign. The model for delivering influenza immunizations has been designed to build on the strengths and capabilities of a staff model HMO with sophisticated automated information systems. The model permits area medical centres (AMCs) and physicians to use the materials and intervention strategies generated by the Centre for Health Promotion, while at the same time allowing them flexibility to design and use their own intervention strategies to increase compliance. More importantly, the model reduces resource requirements on AMCs and physicians to plan and maintain internal immunization efforts. Recommendations for improving the influenza campaign are discussed. 0 1998 Published by Elsevier Science Ltd. All rights reserved Keywords: Influenza

immunization

campaign;

managed

care; organizational

responsibilities

INFLUENZA CAMPAIGN COMPONENTS Group Health Cooperative (GHC) is a large, membership-governed, staff model health maintenance organization (HMO) that was established in 1947. GHC serves more than 680000 members in Washington State, with some 395000 members in the immediate Puget Sound area. Comprehensive care is delivered in the Puget Sound region through GHC’s own facilities, including 30 area medical centres (AMCs), six specialty centres, two hospitals and a skilled nursing facility. GHC provides primary, specialty, hospital, home health and inpatient skilled nursing care on a prepaid basis. Group Health Cooperative became an affiliate of Kaiser Permanente in 1997. The population served by GHC is demographically similar to that in the surrounding area by race, age and sex distribution. Approximately 90% of GHC members are Caucasian, 4% are African-American and 4% are Asian/Pacific Islander. Income is similar to the standard metropolitan statistical ara, although fewer GHC members have very high levels of income and the percentage of low-income individuals is similar.

*Centre for Health Promotion, Group Health Cooperative of Puget Sound, 1730 Minor Avenue, Suite 1520, Seattle, Washington 98101, IUSA. tCentre for Health Studies, Group Health Cooperative of Puget Sound, 1730 Minor Avenue, Suite 1520, Seattle, Washington 98101, USA. *Author to whom all correspondence should be addressed. Tel: 001 206 287 4391; Fax: 001 206 287 4287.

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The influenza campaign has five major components: centralized planning and coordination, publicity, education, recruitment and special immunization clinics. The Centre for Health Promotion has primary responsibility for the first four components of the campaign: centralized planning, coordination and evaluation, publicity, education and identification and recruitment. Area medical centres and physicians have primary responsibility for coordinating and staffing immunization clinics (Table 1). Centralized

planning

and coordination

The design of the overall campaign, coordination of campaign activities and ongoing evaluation of the campaign, is the responsibility of the Centre for Health Promotion. The initial campaign was designed in 1983, and since that time many modifications have been made to improve the delivery of the campaign, including procedures for identifying high-risk groups, refining media messages and offering more opportunities for enrollees to be immunized. Publicity

The publicity component was developed to provide consistent messages throughout the delivery system to enrollees and providers about the need for the delivery of immunizations. Articles and announcements appear in GHC’s internal newsletters, Internet web page,

Influenza campaign: D.C. Pearson et al. Table 1

Key components

Campaign

and organization

components

Centralized

planning

Publicity

Education Identification

Immunization

and recruitment

responsibilities

for the influenza campaign

Centre for health promotion Responsible for overall design, implementation and evaluation of campaign Develop all media materials (newsletters and articles for enrollee magazine, internal and external commmunication and posters) Design and distribute all educational materials, pamphlets Design algorithm for identifying highrisk enrollees, provide names of enrollees to AMCs and physicians. Generate all recruitment mailings to enrollees, identify non-compliant enrollees for 2nd mailing

clinics

primary care clinic newsletters, and VIEW, a bimonthly magazine sent to all enrollees. Internal newsletters remind and encourage medical staff, nurses, and other health care providers to talk to enrollees about the importance of immunizations. Each fall, VIEW publishes an article on influenza which addresses current facts and recommendations for influenza immunization. Included in all publicity efforts is a telephone number - a central resource line - to respond to enrollees’ and providers’ questions. While general publicity about the campaign is centralized in the Centre for Health Promotion, each of the AMCs can and often do develop their own local publicity campaigns to improve recruitment and vaccine coverage levels. As an example, one of the AMCs (Olympia Clinic) offers a ‘special senior night’ at their clinic. The senior night serves dual purposes. One is to sponsor a senior health fair providing on-site expertise from a nutritionist, a diabetic clinician, a cardiac nurse clinician, a see and hear centre representative and a physical therapist. The second purpose is to immunize seniors for influenza. At the senior night, one of the local high schools volunteers to play ‘big band music’ for enrollees. The success of the senior night even has resulted in other AMCs offering similar events. Education

To augment the publicity effort an educational, selfhelp pamphlet, ‘Colds, Flu and You: A Guide to Taking Care of Yourself at Home’ was developed. This pamphlet is made available to enrollees and distributed throughout the AMCs. The brochure provides information on colds and influenza and promotes self-care skills with the goal of reducing visits and calls to medical centres. Pharmacies at each of the AMCs also provide influenza information to enrollees picking up or refilling medications in the form of a ‘tear-off sheet’ (About the Influenzu Vaccine). Clinic staff at each of the clinics also play a vital role in educating enrollees about the importance of being immunized for influenza. While enrollees are at the clinics, staff members remind enrollees about the upcoming influenza campaign. Clinic staff distribute posters throughout AMCs and provider offices

Area medical centres

Coordinate local publicity with coop-wide efforts

Physicians

efforts

Coordinate local education efforts with plan-wide efforts Review list of high-risk enrollees

Offer immunization clinics during regular business hours

Review list of hgih-risk enrollees

Sign standing orders

reminding patients about the time and location upcoming immunization clinics.

Identification

of

and recruitment

Consistent with national recommendations all seniors (age 65 and above) are targeted for the influenza campaign’. Enrollees are identified through computerized enrollment files located at a central registry. Adults and children with chronic disorders of the pulmonary or cardiovascular systems or chronic metabolic diseases are also targeted. To identify these chronically ill adults and children, the Immunization Subcommittee of the Committee on Prevention has established an internal review group, consisting of pharmacists, primary care provides and infectious disease experts to design a system which identifies enrollees with chronic disorders associated with increase risk for influenza-related complications. This system combines information from a variety of automated patient data registries. The pharmacy system is the primary means of identifying enrollees receiving one or more drugs associated with increased risk for influenza related complications. To identify other enrollees who may be at increased risk for influenza-related complications, but who arc not receiving drug prescriptions associated with chronic disorders, information from the Diabetes Clinical Roadmap System and the Heart Care Roadmap System is accessed. In addition, recent receipt of a pneumococcal vaccine is included as high-risk criteria. As a final method to assure accuracy of the identihcation process, AMC clinical staff (physicians, physician assistants and nurses) review generated names of chronically ill enrollees and make final recommcndations to add or remove enrollees to be targeted (Table I, columns 3 and 4). Before the influenza season begins, the Centre for Health Promotion, through the use of computerized enrollment tiles and in combination with the identification procedures described above, generates a list of all high-risk enrollees targeted for the influenza campaign. With the use of computerized mailing labels, each high-risk enrollee receives a postcard from their

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Influenza campaign: D.C. Pearson et al. primary clinic with information about the upcoming influenza season, informing them that a safe, effective vaccine is available and that medical staff recommends immunization (except for those with contraindications). The postcard identifies dates, times, and locations of the influenza clinics and indicates that no appointment is necessary for an influenza vaccination. At the end of January, all seniors who have not received an influenza vaccination (assessed through the automated immunization system) are mailed a postcard reminder stating ‘Your GHC physician strongly recommends this vaccine’ and requests them to come in to be immunized. This postcard also invites non-compliant enrollees to call the senior resource line to let us know if they have received a flu shot at another facility not affiliated with GHC. This allows immunization status for enrollees to be updated. In addition, non-compliant enrollees are given the option to have their name removed from the targeted list of high-risk enrollees if they do not wish to receive recruitment mailings for the next influenza campaign. Clinic teams responsible for those enrollees are notified. Follow-up with these enrollees may take place to assess reasons for declining further recruitment efforts, e.g. allergies, negative attitudes about immunizations or misinformation. To assess compliance with GHC’s immunization guidelines, information on all immunizations, including influenza, exists in both the written medical record and the Automated Immunization System (A1S)‘,3. The AIS was implemented in March 1991 at Group Health Cooperative of Puget Sound. This computerized system provides a mechanism for recording ‘on-line’ information on every immunization, including date of immunization, manufacturer and lot number, site of administration, and identity of the individual performing the immunization. The immunization database was developed on an IBM 3090 mainframe to allow it to be accessed throughout GHC through terminals in every clinic and emergency department. A mainframe program was written for each of the following: (a) to allow entry of immunizations; (b) to change immunization entries; (c) to create a complete listing of all immunizations and changes for each patient; and (d) to create a summary reflecting correct entries for a patient. At the area medical centre level, multiple computers are available to physicians, nurses and other staff and are linked by a clinic-based local area network (LAN) and file server. Individual immunization status can be accessed via this system and compared to current immunization guidelines that are accessible in the guidline warehouse portion of the system. Immunization

clinics

The fifth component of the campaign, influenza clinics, are the primary responsibility of the area medical centres and physicians practicing in these centres (see Table 1, columns 2 and 3). AMCs design and hold immunization clinics during a 4-8 week period in the fall. The availability of clinics is advertised through the recruitment postcard (mentioned earlier), which includes a schedule for both day and evening immunizations, and various GHC publications. Information about the immunization clinics is also available on GHC’s web page.

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During this time, some primary care clinics offer immunizations at off-site locations in the community, such as churches and activity centres, to improve access. The Northgate Area Medical Centre completed a community-based assessment and marketing plan to identify strategies to increase immunization compliance among those targeted for the influenza campaign. Results of this plan suggested that improving access (hours of operation) and removing transportation barriers would increase vaccine compliance. The clinic offered off-site influenza immunizations at local community centres and the Woodland Park Zoo, and was able to immunize over 1000 enrollees a day during last year’s flu season.

RESULTS As discussed above, the influenza campaign targets four risk groups: chronically ill seniors; chronically ill adults; chronically ill children and ‘well’ seniors. Among these groups, chronically ill seniors had the highest coverage levels for influenza vaccine during the last flu season. Among that group, 78.5% were vaccinated, while about two-thirds of ‘well’ seniors were vaccinated. Less than half of the chronically ill adults and children were vaccinated during the same flu season.

DISCUSSION We have presented a description of the procedures used to identify, recruit and immunize high-risk groups for the influenza campaign. The model for delivering influenza immunizations has been designed to build on the strengths and capabilities of a staff model HMO with sophisticated automated information systems. The model permits AMCs and physicians to use the materials and intervention strategies generated by the Centre for Health Promotion while at the same time allowing them flexibility to design and use their own intervention strategies to increase compliance. More importantly, the model reduces resource requirements on AMCs and physicians to plan and maintain internal immunization efforts. Results suggest relatively high levels of vaccine coverage for seniors, especially those who are chronically ill. However, compliance levels for seniors have not changed substantially in the past few years in spite of some modest efforts to improve the recruitment procedures (more emphasis on educating providers about the importance of the influenza vaccination and the addition of follow-up reminders). In contrast, there still appears to be room for improvement with coverage levels for high-risk adults and children. Historically, we have spent most of our efforts identifying strategies for boosting coverage levels among seniors4 - for obvious reasons. They are clearly at-risk; they are easy to identify; they tend to have the time to read, absorb and understand education materials; and they utilize AMC (outpatient) services regularly, and therefore are exposed to many more ‘recruitment’ opportunities. In contrast, we have spent much less time developing and identifying recruitment strategies for high-risk adults and children.

Influenza campaign: DC. Pearson et al. We have tested the impact of follow-up postcard reminders to adults and found them much less effective than with our senior population. However, we don’t know if this ineffectiveness is related to, for example, a belief by adult enrollees that they won’t get the flu, that the flu vaccine doesn’t work or that they simply don’t have the time to access immunization services. Finally, we continue to explore ways to improve influenza coverage levels among the senior population group despite any increase in coverage levels in the past few years. While the coverage levels are high, in absolute numbers they represent the largest group of unvaccinated high-risk enrollees. And, in spite of their receptivity to educational messages and medical information, there sti!l appears to be a significant segment of this group that holds on to inaccurate information

about the influenza vaccine such as the vaccine is ineffective or the vaccine can ‘cause’ the flu. REFERENCES CDC. Prevention and control of influenza: recommendations of the advisory committee on immunization practices (ACIP). MMWR 1997 46 (No. W-9). Davis, R.L. et al. Immunization tracking systems: experience of the CDC vaccine safety datalink sites. HMO Practice 1997, 11(l), 13-17. Payne, T. et al. Development and validation of an immunization tracking system in a large health maintenance organization Am J Prevent Med 1993, 9, 96-100. Pearson, D.C. and Thompson, R.S. Evaluation of Group Health Cooperative of Puget Sound’s senior influenza immunization program. Public Health Repoffs 1994, 109, 571-578.

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