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Archived Service Delivery Profile:

Nurse-Led Telephone Outreach More Than Doubles Pneumococcal Vaccination Rates for At-Risk Individuals


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Snapshot

Summary

Kaiser Permanente Georgia proactively contacts at-risk individuals to encourage those who have not received a vaccination or cancer screening to schedule an appointment for one. The program initially used nurses to call individuals in need of a pneumococcal vaccine; now automated systems contact those in need of an influenza vaccine (with pneumococcal vaccines being promoted once the patient comes in for an appointment), mammography, or Pap smear. The nurse-led program more than doubled pneumococcal vaccination rates; data from the 2008 flu season suggests that the automated system significantly increased influenza vaccination rates.

Evidence Rating (What is this?)

Strong: The evidence consists of an RCT of 6,106 individuals that compared pneumococcal vaccination rates among those receiving nurse outreach with rates in a comparable set of individuals who did not receive a call. Additional evidence includes comparisons of influenza vaccination rates before and after implementation of the automated outreach system.
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Developing Organizations

Centers for Disease Control and Prevention; Kaiser Permanente-Georgia
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Date First Implemented

2004

Problem Addressed

Influenza and pneumonia cause hundreds of thousands of hospitalizations and tens of thousands of deaths each year. Effective vaccines exist, but are underutilized, especially in certain high-risk groups, including the elderly and ethnic and racial minorities. Written reminders to those in need of a vaccination tend to yield low response rates.
  • Many hospitalizations and deaths: A 2004 study found that more than 200,000 people are hospitalized each year for respiratory and heart conditions and illnesses associated with influenza virus infections, and that this figure has generally been increasing over time.1 The U.S. Centers for Disease Control and Prevention (CDC) estimates that more than 36,000 flu-related deaths occur each year.2 Common pneumococcal diseases—including pneumonia, bacteremia, and meningitis—kill approximately 4,800 people each year.3
  • Effective vaccines available: Vaccines (administered annually for the flu and once every 5 years for pneumococcal diseases) can be highly effective in preventing the conditions, and in reducing the risk of hospitalization or death from them. Vaccinations are especially important in high-risk populations, such as those over the age of 65 years old and younger individuals with chronic diseases or other risk factors.
    • Flu vaccine: The effectiveness of the flu vaccine varies from year to year, but in those years when vaccine and virus strains are well matched, it can reduce the risk of flu by 70 to 90 percent in healthy adults. Although less effective in warding off the flu in elderly persons and very young children, the vaccine can still prevent serious complications in these groups. In fact, the vaccine is 30 to 70 percent effective in preventing hospitalization in the elderly not living in chronic care facilities, and among those living in nursing homes, it is 50 to 60 percent effective in preventing hospitalization or pneumonia and 80 percent effective in preventing death from the flu.4
    • Pneumococcal vaccine: The pneumococcal vaccine is 60 to 80 percent effective in preventing pneumococcal disease in targeted populations.5 Antibiotics have historically been highly effective in treating pneumococcal disease, but growing resistance to these drugs has limited their usefulness, making vaccination of high-risk groups even more important.
  • But underutilized: Vaccination rates remain too low, especially among certain racial and ethnic groups. For influenza, vaccination rates reached 70 percent in 2004 (up from 30.1 percent in 1989), but well below the nationwide goal of 90 percent. Influenza vaccination rates among certain at-risk populations, including adults aged 50 to 64 years old, health care workers, adults living in a household with a high-risk individual, and pregnant women, still fall well short of Healthy People 2000 and Healthy People 2010 goals. Influenza vaccination rates for minority groups remain below those for non-Hispanic whites in all targeted adult populations.6 With respect to pneumococcal vaccines, the National Health Interview Survey found that 57 percent of high-risk, non-Hispanic whites and 31 percent of high-risk, non-Hispanic blacks are current on their vaccination.
  • Written reminders generally ineffective: The traditional approach of sending written reminders to those in need of a vaccine or screening typically yields low response rates; Kaiser Permanente Georgia, for example, has found that written reminders for mammography screening yield response rates in the 1 to 2 percent range.

What They Did

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Description of the Innovative Activity

Kaiser Permanente Georgia proactively contacts at-risk individuals to encourage those who have not received a vaccination to schedule an appointment for one. The program initially used nurses to call individuals in need of a pneumococcal vaccine; now an automated system contacts those in need of an influenza vaccine (with pneumococcal vaccines being promoted once the patient comes in for an appointment). A similar automated approach is used to contact those due for a mammogram or Pap smear. Key elements of the program are described below:
  • Target population: During the pilot study, researchers used administrative databases to identify all members who had not received a pneumococcal vaccination who were either over the age of 65 years old or over the age of 18 years old with a chronic condition. Identified individuals received a letter providing background information on the vaccination and encouraging them to schedule an appointment or respond if they had already been vaccinated. Today, staff use an electronic registry (automatically uploaded from the electronic medical record) to identify at-risk individuals who do not appear to have received an influenza vaccination.
  • Outreach by telephone: During the pilot, nurses trained in pneumococcal vaccination indications and contraindications called at-risk individuals. The protocol allowed nurses to call patients up to four times, if there was no response. Today, an automated system with interactive voice response based on built-in protocols has replaced the nurse-led outreach, targeting those in need of an influenza vaccination (the pneumococcal vaccine is discussed once a patient comes into the clinic). Each September (just before the start of the flu season), the system attempts to contact all 22,000 high-risk members in Kaiser Permanente Georgia. Key steps during the outreach process are described below:
    • Inquiring about vaccination status: The nurse or automated system inquires about current vaccination status, because some individuals may have received a vaccination at a non-Kaiser facility. In these situations, the information can be entered into the patient’s record.
    • Educating individuals: At-risk members receive educational information on the risks of the relevant disease (pneumococcal disease during the initial nurse-led pilot study; influenza with the automated system), and the potential of the vaccines to dramatically reduce those risks.
    • Encouraging individuals to get a vaccination: Unvaccinated individuals are reminded that vaccines are a covered benefit through Kaiser with no required copayment or other out-of-pocket expenses. During the pilot, nurses used a list of responses to frequently asked questions to address any concerns about the vaccine and to encourage individuals to schedule an appointment for one. The automated system provides similar information through interactive voice response based on built-in protocols. At the end if the automated call, the system asks the at-risk member if he or she would like to be transferred to a health coach. For those who say no, the system encourages them to contact their primary care provider to schedule a flu shot. Those who say yes are transferred to a health coach who provides information on upcoming flu clinic hours (which are held 4 weeks a year). Members can also ask the health coach to schedule a flu shot appointment for a specific time, or to arrange to receive the vaccination in conjunction with an upcoming appointment with their primary care provider.
  • Similar automated system for select cancer screenings: A similar interactive voice response system is used to contact women due for a mammogram or Pap smear. An electronic registry screens members to identify those who appear to be in need of the test. An automated system calls each individual; those reached receive education on the importance of the screening test, and are given the option at the end of the call to transfer to the Kaiser call center to schedule a screening. In March/April 2009, the system proactively contacted 25,000 women who met the established criteria.

Context of the Innovation

Kaiser Foundation Health Plan of Georgia, a subsidiary of Kaiser Permanente, provides health care to more than 250,000 members at 12 hospitals and medical facilities in the Atlanta region. The CDC is the primary Federal agency responsible for conducting research to support public health in the United States. The CDC was responsible for designing and reviewing the initial nurse-led pilot study, while Kaiser provided the study data. Kaiser implemented the automated system on its own. Both the initial pilot program and the automated system represent a continuation of a movement within Kaiser Permanente away from the traditional approach of sending written reminders to those in need of a vaccination or screening test. Response rates on traditional mailings tend to be quite low (1 to 2 percent), while the response to automated telephone calls, e-mail reminders, and other systems that "reach people where they are" tend to be much higher (15 to 40 percent), giving these approaches the potential to be more efficient and effective.

Did It Work?

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Results

A randomized controlled trial (RCT) found that the nurse-led program more than doubled pneumococcal vaccination rates. Data from 2008 suggest that the automated system significantly improved influenza vaccination rates.
  • Significantly increased pneumococcal vaccination rates: Those contacted by phone were 2.3 times more likely to be vaccinated for pneumococcal diseases than was a control group of similar individuals not receiving a call. (The difference in vaccination rates was even higher among unvaccinated persons actually reached by telephone.) Among those with one or more chronic illnesses, 16 percent of those receiving the outreach call were vaccinated, compared with 6 percent in the control group. Among the elderly, 17 percent of those receiving the call were vaccinated, compared with 8 percent in the control group. Although non-Hispanic blacks were less likely than non-Hispanic whites to have been previously vaccinated, the intervention achieved similar improvements in both groups.
  • Higher influenza vaccination rates: The influenza vaccination rate for the target population of adult members with chronic conditions in 2008 (the first year of the automated system) was 46.5 percent, up from 36 percent in 2007 and 39 percent in 2006.

Evidence Rating (What is this?)

Strong: The evidence consists of an RCT of 6,106 individuals that compared pneumococcal vaccination rates among those receiving nurse outreach with rates in a comparable set of individuals who did not receive a call. Additional evidence includes comparisons of influenza vaccination rates before and after implementation of the automated outreach system.

How They Did It

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Planning and Development Process

Key steps in the planning and development process for the pilot study included the following:
  • Creating an outreach plan: The outreach plan addressed issues such as how many times the nurses or automated system should attempt to reach individuals, what time of day to place the call, and other logistical concerns.
  • Training nurses: For the initial pilot study, nurses received a 2-hour training session on indications and contraindications for the pneumococcal vaccine. Most nurses were already fairly knowledgeable about the topic due to past training sessions they had attended.
  • Creating a script for nurses: For the pilot study, Kaiser developed a script and a list of responses to frequently asked questions about the pneumococcal vaccine. These materials assisted nurses in their efforts to clearly explain the importance of the vaccine.
  • Screening and hiring a vendor, developing call script: Kaiser evaluated several vendors before choosing a company (Eliza) to develop the interactive voice response system. The vendor provided a generic script that was customized by Kaiser to the target audience.
  • Coordinating with health coaches, call center: Periodic conversations occur between the program leader and managers of the health coach program and/or call center to alert them to the schedule for upcoming automated calls. Such coordination helps to ensure that adequate resources (e.g., staffing, phone lines) are available to serve members who wish to speak to a live person after the automated call.

Resources Used and Skills Needed

  • Staffing: During the pilot study, each nurse made 75 to 100 calls per day, although many of these calls did not successfully reach the intended target. The automated system requires no additional staff, although the managers of health coaches and/or call center staff must be made aware of when the automated calls are being made, so that appropriate staffing exists to handle those who wish to speak with someone.
  • Costs: During the pilot study, the cost of nurse staff time for calls was $41,520.50, or $147.35 per additional member vaccinated. Adoption of the automated system using interactive voice response has reduced this cost significantly, as each connected call costs less than first-class postage for a letter.
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Funding Sources

Centers for Disease Control and Prevention
The CDC provided a grant to the Kaiser Foundation Research Institute to fund the pilot study. Kaiser Permanente funds the automated programs.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Establish a need: Internal analysis of current vaccination or screening rates can be used to help establish the need for the program and “sell” the idea to organizational leaders.
  • Create system to identify at-risk, unvaccinated individuals: An electronic health record, registry, and/or administrative database can be an inexpensive means of identifying at-risk individuals in need of a vaccination or screening test. Such systems may not cover network physicians (i.e., those under contract with the health plan or system), leaving claims data as the only option.
  • Consider timing of calls: Develop a plan for when to reach individuals, including the appropriate time of year and the time of day when they are most likely to be home to receive a call. Kaiser, for example, generally does not place calls during the summer months, except for employer groups dominated by teachers (i.e., school systems), who tend to be most reachable and receptive during the summer. (As a health plan, Kaiser has this type of information; not all organizations will.) In addition, Kaiser tries to reach elderly patients during the day, but younger individuals at night (because they typically work during the day).
  • Develop rules/systems to avoid too many calls: If automated calls are being used for a variety of purposes, rules should be developed to avoid inundating individuals with a series of calls over a short period of time. At Kaiser, automated systems are used for other purposes as well (e.g., to alert members when a prescription is ready at the pharmacy), creating the potential for overload. To avoid this problem, Kaiser sets up priorities, with some calls being delayed as necessary. In addition, the first sentence of any script should clearly indicate the intent of the call, as this helps to reduce the number of hang-ups.
  • Customize script to population: As noted, scripts may work with some populations but not with others. As a result, each script should be customized to the demographics of the population being targeted.

Sustaining This Innovation

  • Monitor and report results: Measure and report on the program's impact, as sharing success can help to maintain program momentum. Many organizations might find it convenient to track and report HEDIS® (Healthcare Effectiveness Data and Information Set) measures.
  • Track call response rates and tweak system accordingly: Kaiser's vendor tracks very detailed data related to how many people complete the call, where in the script they most commonly drop off, etc. Kaiser and the vendor then work to address any problem areas. For example, Kaiser initially used a "light-hearted" script in one of its cancer outreach programs, only to find that it did not work well in Georgia (even though it had in the Pacific Northwest).
  • Track reasons for not being vaccinated or screened: This list can help in developing persuasive responses that nurses or health coaches can use when asked difficult questions.
  • Considering covering cost of vaccinations or screenings: As a health plan, Kaiser covers vaccinations and screenings with little or no out-of-pocket costs for the member. Organizations that do not offer such coverage should consider the need for other strategies to reduce the costs for at-risk individuals to receive these needed services.

More Information

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References/Related Articles

Winston CA, Mims AD, Leatherwood KA. Increasing pneumococcal vaccination in managed care through telephone outreach. Am J Manag Care. 2007;13(10):581-8. [PubMed]

Footnotes

1 Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA. 2004;292(11):1333-40. [PubMed]
2 Centers for Disease Control and Prevention. Questions and answers estimating seasonal influenza-associated deaths in the United States: CDC confirms variability of flu. 2011. Available at: http://www.cdc.gov/flu/about/disease/us_flu-related_deaths.htm
3 National Foundation for Infectious Diseases. Pneumococcal disease. 2006. Available at: http://www.nfid.org/pneumococcal/
4 Centers for Disease Control and Prevention. Questions and answers vaccine effectiveness: how well does the seasonal flu vaccine work? 2011. Available at: http://www.cdc.gov/flu/about/qa/vaccineeffect.htm
5 Immunization Action Coalition. Ask the Experts: Pneumococcal polysaccharide vaccine (PSV). November 2010. Available at: http://www.immunize.org/askexperts/experts_ppv.asp
6 Lu P, Bridges CB, Euler GL, et al. Influenza vaccination of recommended adult populations, U.S., 1989–2005. Vaccine. 2008;6(14):1786-93. Epub 2008 Feb 14. [PubMed]
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Original publication: April 28, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 31, 2011.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 26, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.