Definition
A standing order is a written order stipulating that all persons meeting certain criteria (i.e., age or underlying medical condition) should be vaccinated, thus eliminating the need for individual physician’s orders for each patient.

Advantage
Standing orders are the most consistently effective method for increasing adult vaccination rates and the easiest to implement.

Disadvantage
Standing orders only reach patients already contacting the health care system.

Settings
Appropriate settings for this strategy include private practice, managed care, hospitals including ERs, and long-term care facilities.

Implementation Steps
The physician:

1. Decides on the criteria that will be used to indicate patient eligibility for vaccination and for specific vaccines.
2. Writes the standing order (see Sample).
3. Meets with staff to discuss implementation of the standing order strategy.
4. Monitors vaccination rates.

To see a sample, click here.

Additional examples of standing orders are provided on the Immunization Action Coalition website: http://www.immunize.org/standingorders/

Measurement
To measure the effectiveness of the strategy, you can use either of these two approaches:

1. Compare vaccination rates pre- and post-implementation of the strategy.
2. Set a goal (for example, 75% of persons 65 and older will receive influenza vaccine) prior to implementing the strategy and track vaccination rates resulting from the intervention.

Methods for tracking rates include:

• For the computerized office, determine what proportion of persons on the list were billed for the vaccine. Or access the Comprehensive Clinic Assessment Software Application (CoCASA) program developed to assess adult immunization rates. http://www.cdc.gov/vaccines/programs/cocasa/default.htm
• For the non-computerized office, conducting a manual record review on a daily or weekly basis. For guidelines, see Conducting a baseline assessment
• For influenza, the vaccination rate can be tabulated at the end of the vaccination season.
• In a very large practice, a sampling method could be used to determine an estimate of the proportion of at-risk persons vaccinated.

Effectiveness
Standing orders are the most consistently effective means for increasing vaccination rates. One hospital study (Crouse, 1994) demonstrated that 40% of inpatients were vaccinated against influenza in hospitals using standing orders compared to 10% of patients in hospitals utilizing physician education only.

When standing orders for influenza and pneumococcal vaccination of persons 65 and older were implemented in an emergency room, 50% of patients eligible for influenza and 58% of persons eligible for pneumococcal vaccines were vaccinated (Rodriguez, 1993). In nursing homes, 90% of patients in homes with standing orders were vaccinated against influenza compared to 57% of patients in homes that required a consent form for vaccination (Patriarca, 1985).

Margolis (1988) found that use of standing orders in an outpatient clinic resulted in 81% of patients being offered influenza vaccine compared to 29% in a control group.Another study (Klein, 1986) in an outpatient setting resulted in 78% of eligible patients being vaccinated against pneumococcal disease compared to 0% in a control group.

For Reference, click here.

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Definition
The computer can print a list of possible reminders that appear on a patient’s record. The software can be programmed to determine the dates that certain preventive procedures are due or past due and then print computer-generated reminder messages, usually overnight, for patients with visits scheduled for the next day.

Advantages
Computerized record reminders can be effective, efficient, and inexpensive once the computerized system is in place. Provider reminder strategies are so effective they have been demonstrated to improve rates both alone and in combination with other strategies.

Disadvantages
Computerized record reminders only reach patients scheduled for office visits and may be less effective in fee-for-service practices since the cost of vaccination may be a barrier for the patient.

Settings
Computerized record reminders are appropriate for private practices, managed care, hospitals, and long-term care facilities.

Implementation Steps

1. Design or identify a computerized reminder system that meets the needs of the practice.

2. Train professional staff on how to use computerized reminders.

To see a sample, click here.

Measurement
To measure the effectiveness of the strategy, you can use either of these two approaches:

1. Compare vaccination rates pre- and post-implementation of the strategy.
2. Set a goal (for example, 75% of persons 65 and older will receive influenza vaccine) prior to implementing the strategy and track vaccination rates resulting from the intervention.

Methods for tracking rates include:

• For the computerized office, determine what proportion of persons on the list were billed for the vaccine. Or access the Comprehensive Clinic Assessment Software Application (CoCASA) program developed to assess adult immunization rates. http://www.cdc.gov/vaccines/programs/cocasa/default.htm
• For the non-computerized office, conducting a manual record review on a daily or weekly basis. For guidelines, see Conducting a baseline assessment
• For influenza, the vaccination rate can be tabulated at the end of the vaccination season.
• In a very large practice, a sampling method could be used to determine an estimate of the proportion of at-risk persons vaccinated.

Effectiveness
Computerized chart reminders can be very effective. In one practice, pneumococcal vaccination rates of high-risk persons increased from 29% before implementation to 86% following implementation of computerized chart reminders (Payne, 1995).

For Reference, click here.

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Definition
Chart reminders can be as simple as a colorful sticker on the chart or can be a comprehensive checklist of preventive services including vaccinations. Reminders to physicians that patient vaccinations are due or overdue should be prominently placed in the chart. Reminders that require some type of acknowledgment, even a simple checkmark by the physician, are more effective.

Advantages
Chart reminders are inexpensive and efficient. Reviewing health maintenance inventories with patients requires less than 4 minutes and can become part of the physician’s routine. Provider reminder strategies are so effective they have been demonstrated to improve rates both alone and in combination with other strategies.

Disadvantages
Chart reminders only reach patients scheduled for office visits. Chart reminders may be more effective in managed care organizations as compared with fee-for-service practices since cost to the patient may be a barrier to vaccination.

Settings
Private practice, managed care, hospitals, and long-term care facilities are appropriate settings for chart reminders.

Implementation Steps

1. Design or identify a chart reminder to use (see Sample).

2. Make copies to be inserted into all appropriate patient records.

3. Assign a staff person to place the reminders in a prominent place in the chart.

To see a sample, click here.

Measurement
To measure the effectiveness of the strategy, you can use either of these two approaches:

1. Compare vaccination rates pre- and post-implementation of the strategy.
2. Set a goal (for example, 75% of persons 65 and older will receive influenza vaccine) prior to implementing the strategy and track vaccination rates resulting from the intervention.

Methods for tracking rates include:

• For the computerized office, determine what proportion of persons on the list were billed for the vaccine. Or access the Comprehensive Clinic Assessment Software Application (CoCASA) program developed to assess adult immunization rates. http://www.cdc.gov/vaccines/programs/cocasa/default.htm
• For the non-computerized office, conducting a manual record review on a daily or weekly basis. For guidelines, see Conducting a baseline assessment
• For influenza, the vaccination rate can be tabulated at the end of the vaccination season.
• In a very large practice, a sampling method could be used to determine an estimate of the proportion of at-risk persons vaccinated.

Effectiveness
When tetanus and pneumococcal vaccinations were included in a health maintenance inventory sheet, 19.8% and 14.6% of adults were vaccinated against tetanus and pneumococcal disease respectively, compared with 3.2% and 1.6% in the year preceding use of the health maintenance inventory sheets (Rodney, 1983). In another study (Davidson, 1984), influenza vaccination rates increased from 18% before use of a health maintenance flow sheet to 40% with use of the health maintenance flow sheet.

For Reference, click here.

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Definition
Provider assessment and feedback involves retrospectively evaluating the performance of providers in delivering one or more vaccinations to a client population and then reviewing their assessment data with providers.

Performance feedback as used in this program focuses on benchmarking, i.e., comparing performance to a goal or standard and is usually implemented in private practice or managed care settings. But keep in mind, assessment of vaccination coverage and feedback to providers in hospitals and long-term care facilities has been shown to be effective in improving vaccination coverage rates in those institutions.

Incentives/benchmarking: An effective incentive for many physicians is comparing their vaccination rates for a particular patient population to a goal or standard. Such assessment provides feedback on the physicians’ performance. Some practices encourage friendly competition among physicians, which creates an additional incentive to increase vaccination rates.

One highly effective method of performance feedback uses posters to track the number of patients vaccinated. (See Sample under Implementation Steps).

Advantages
Through the use of competition, performance feedback strategies increase physician compliance with vaccination recommendations. There is immediate feedback on each physician’s performance. This strategy is easy to implement, is minimally disruptive of office activity, and provides built-in evaluation. Each doctor can use his own approach for bringing patients into the office for vaccination (e.g., telephone reminders, informational brochures, personal encouragement). Overall this strategy offers a good way to motivate physicians.

Disadvantages
It takes time to train staff and implement this strategy. However, less time is needed for evaluation since the poster is the actual evaluation tool. Another disadvantage is that it can be difficult to continually track vaccination rates.

Settings
Private practice and managed care are appropriate settings for performance feedback.

Implementation Steps

1. Enumerate number of eligible patients (denominator).

2. Generate lists of patient names if necessary.

3. Create or adopt target-based poster on which to track number of patients vaccinated (see Sample).

4. Hold meetings with staff and doctors to explain the graphic, i.e., a denominator-based tracking system.

5. At the end of each week, physicians and their staff should record all vaccinations being tracked (for example, all influenza vaccinations given to at-risk patients), tabulate the cumulative weekly total, and calculate the percentage of the target population vaccinated.

6. Graph this percentage on the poster. (Reports of vaccinations received outside the office should not be included unless the patient has documentation.)

To view a sample, click here.

Measurement

The poster itself is an ongoing evaluation tool. For example, at the end of the influenza vaccination season, the percent of patients vaccinated is the measure of success.

Effectiveness
In one study (Buffington, 1991), the percentage of eligible patients vaccinated against influenza at that practice office was 50%, compared to 34% in a control group that did not used the target- based approach. An additional 16% were vaccinated in public clinics, bringing the total percent of patients vaccinated to 66% among patients whose physicians used the target-based approach (6% higher than the Healthy People 2000 goal) compared with 50% among control physicians. One physician in this study vaccinated 79% of his patients.

Another study (Kouides, 1993) offered small financial incentives for physicians vaccinating 70% and 85% of their eligible patients. Physicians in the incentive group vaccinated 73% of their eligible patients compared to 56% of eligible patients in a control practice.

For Reference, click here.

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Definition
Home visits involve providing face-to-face services to clients in their homes. These services can include education about vaccine-preventable diseases and vaccines, assessment of need for or referral to vaccination services, and delivery of vaccinations. Home-visiting interventions can also involve telephone or mail reminders.

Advantages
Home visits are efficient if existing home health care delivery services are used. This strategy may help increase service delivery to lower income and other disadvantaged persons.

Disadvantages
Home visits require increased staff time, expense, and possible training requirements, particularly if implemented solely for vaccination services. Clients may lack records, or recall, of previous immunizations.

Settings
Private practice and managed care are appropriate settings for implementing a home visit strategy.

Implementation Steps

1. Determine if your practice has a relationship with home health services for your clients.

2. Meet with home health staff to discuss implementation of strategies to improve vaccination.

3. Develop appropriate protocols for home visit vaccination services.

4. Implement vaccination protocols.

5. Monitor increased vaccination rates.

To view a sample, click here.

Measurement
To measure the effectiveness of the strategy, you can use either of these two approaches:

1. Compare vaccination rates pre- and post-implementation of the strategy.
2. Set a goal (for example, 75% of persons 65 and older will receive influenza vaccine) prior to implementing the strategy and track vaccination rates resulting from the intervention.

Methods for tracking rates include:

• For the computerized office, determine what proportion of persons on the list were billed for the vaccine. Or access the Comprehensive Clinic Assessment Software Application (CoCASA) program developed to assess adult immunization rates. http://www.cdc.gov/vaccines/programs/cocasa/default.htm
• For the non-computerized office, conducting a manual record review on a daily or weekly basis. For guidelines, see Conducting a baseline assessment
• For influenza, the vaccination rate can be tabulated at the end of the vaccination season.
• In a very large practice, a sampling method could be used to determine an estimate of the proportion of at-risk persons vaccinated.

Effectiveness
Home visits have been found to modestly increase vaccination and counseling for vaccination. Nicholson et al. (1987) documented a higher influenza vaccination rate of 20.4% among older persons immobile at home with a specific vaccination program, compared to similar persons with no specified vaccination program, in the United Kingdom.

Black et al. (1993) demonstrated an increased rate of offering influenza vaccine with a targeted influenza vaccine promotion in homebound patients (42.2% vs. 18.2%). However, vaccination rates were similar (56%) in the intervention and control groups.

For Reference, click here.

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Definition
To implement this reminder/recall strategy, medical staff either call the patient or send a postcard/letter reminding the patient that a vaccination is due (reminder) or overdue (recall) and offer the patient the opportunity to schedule an appointment.

Advantages
Phone contact ensures that the message is understood and provides the opportunity to schedule an appointment. Mailed/telephone reminders reach patients who may otherwise not have scheduled visits. It is an easy strategy to implement, requiring minimal staff time.

When used on a regular basis, a reminder/recall strategy is an excellent way to increase vaccination rates. For a stable population that is literate, a mailed reminder often works well. For a less literate population, a telephoned reminder may be effective.

Disadvantages
Mailed/telephoned reminders rely on patients to schedule and keep appointments. A reminder/recall strategy is not useful in practices with high patient turnover or with a population that changes residences frequently. Some practices may need bilingual reminders.

Generating the list of patients who should receive reminders may also be difficult (e.g., in practices without computerized records). If baseline vaccination rates are high, the incremental increase in vaccination rates attained may not be worth the time and effort invested.

Settings
Private practice and managed care are appropriate settings for mailed/telephoned reminders.

Implementation Steps

1. Determine selection criteria (i.e., age and/or diagnosis).

2. Generate a list of patients to be reminded (manually or via computerized billing or medical records).

3. Review list to remove the names of patients who have died, transferred their care to another provider, entered a long-term care facility, left the practice/area, or received vaccinations.

4. Develop reminder (see Sample).

5. Send reminders or place calls (6 calls a day, 5 days a week for eight weeks = 240 patients contacted).

6. Schedule appointments.

To see a sample, click here.

Measurement
To measure the effectiveness of the strategy, you can use either of these two approaches:

1. Compare vaccination rates pre- and post-implementation of the strategy.
2. Set a goal (for example, 75% of persons 65 and older will receive influenza vaccine) prior to implementing the strategy and track vaccination rates resulting from the intervention.

Methods for tracking rates include:

• For the computerized office, determine what proportion of persons on the list were billed for the vaccine. Or access the Comprehensive Clinic Assessment Software Application (CoCASA) program developed to assess adult immunization rates. http://www.cdc.gov/vaccines/programs/cocasa/default.htm
• For the non-computerized office, conducting a manual record review on a daily or weekly basis. For guidelines, see Conducting a baseline assessment
• For influenza, the vaccination rate can be tabulated at the end of the vaccination season.
• In a very large practice, a sampling method could be used to determine an estimate of the proportion of at-risk persons vaccinated.

Effectiveness
Mailed and telephoned reminders are similar in effectiveness (McDowell, 1986; Brimberry, 1988); effectiveness of both decreases as baseline vaccination rates increase.

McDowell (1986) found that telephoned reminders resulted in 37% of persons receiving influenza vaccine compared with 9.8% in a randomized control group.

Mailed reminders have resulted in a 20% increase in pneumococcal vaccination rates. Postcards personalized with the patient’s name and/or the doctor’s signature and postcards with information regarding the importance of vaccination are more effective than generic postcards.

For Reference, click here.

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Definition
Expanding access can include 1) reducing the distance patients must travel to receive vaccination services, 2) increasing, or making more convenient, the hours during which vaccination services are provided, 3) delivering vaccinations in settings previously not used, and/or 4) reducing administrative barriers to vaccination (e.g., drop-in clinics or express lane vaccination services).

This group of strategies has been very effective in increasing immunization rates when combined with other strategies, such as patient reminder/recall notices, and is strongly recommended as part of a multicomponent intervention.

Advantages
Expanding access is an efficient strategy to implement and is clearly effective when combined with other strategies. In addition, this strategy may increase access to services for those not already in the health care system and may help increase service delivery to lower income and other disadvantaged persons.

Disadvantages
Expanding access requires increased staff time and can be expensive to implement. Additionally, new clients may lack records, or recall, of previous immunizations.

Settings
Private practice, managed care, and hospitals are appropriate settings for expanding access interventions.

Implementation Steps

1. Determine which access barriers are the most important for your patients.

2. Meet with staff to discuss implementation of strategies to improve access.

3. Develop appropriate materials to advertise the clinic’s expanded access activity. For example, advertising can be done through mailings, posters, or a health care plan’s newsletter.

4. Implement strategies.

5. Monitor increased vaccination rates in comparison to resources expended.

To view a sample, click here.

Measurement
To measure the effectiveness of the strategy, you can use either of these two approaches:

1. Compare vaccination rates pre- and post-implementation of the strategy.
2. Set a goal (for example, 75% of persons 65 and older will receive influenza vaccine) prior to implementing the strategy and track vaccination rates resulting from the intervention.

Methods for tracking rates include:

• For the computerized office, determine what proportion of persons on the list were billed for the vaccine. Or access the Comprehensive Clinic Assessment Software Application (CoCASA) program developed to assess adult immunization rates. http://www.cdc.gov/vaccines/programs/cocasa/default.htm
• For the non-computerized office, conducting a manual record review on a daily or weekly basis. For guidelines, see Conducting a baseline assessment
• For influenza, the vaccination rate can be tabulated at the end of the vaccination season.
• In a very large practice, a sampling method could be used to determine an estimate of the proportion of at-risk persons vaccinated.

Effectiveness
Expanding access is effective in increasing vaccination levels in adults. Nicholson et al. (1987) found that special immunization clinics increased influenza vaccination rates from 18.5% to 25.6% in older persons in the United Kingdom.

Lukasik et al. (1987) demonstrated that availability of influenza vaccination anytime during usual office hours, in combination with a telephone reminder, increased the vaccination rate to 50.8%, compared to a 26.8% rate of informing patients about the vaccine who were already in the office.

For Reference, click here.

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Definition
Patients coming in for a scheduled appointment are handed an information sheet to review in the practice waiting room, prior to hospital discharge, or upon admission to a long-term care facility.

For instance, during influenza season, the receptionist would give all patients an information sheet on the need for influenza and pneumococcal vaccines in certain persons. The patient could be instructed to mark whether they fall into any of the risk groups, read the information, and then check whether or not they wish to receive the vaccines.

The physician could then quickly review the handout, answer any questions, and administer (or have the nurse administer) the indicated vaccines.

It is also effective to include in the handout a statement that vaccination will be administered as part of the patient’s routine care that day, unless the patient signs the sheet to indicate refusal.

Advantages
Educational materials are inexpensive and easy to implement, requiring minimal staff time. Patients can ask questions and receive feedback. These materials do not require generating a patient list.

Disadvantages
Educational materials only reach patients already in contact with health care providers. Written materials are not useful in practices serving a low literacy patient population, however, video and audio resources can sometimes be used. Some patients in the practice may need bilingual information sheets.

Settings
Private practice, managed care, hospitals, and long-term care facilities are appropriate settings for disseminating educational materials to patients.

Implementation Steps

1. Create or identify an appropriate patient information sheet or use the Vaccine Information Statement (VIS). (See Sample).

2. Assign a staff person to distribute the information sheet or VIS.

To view a sample, click here.

Measurement
To measure the effectiveness of the strategy, you can use either of these two approaches:

1. Compare vaccination rates pre- and post-implementation of the strategy.
2. Set a goal (for example, 75% of persons 65 and older will receive influenza vaccine) prior to implementing the strategy and track vaccination rates resulting from the intervention.

Methods for tracking rates include:

• For the computerized office, determine what proportion of persons on the list were billed for the vaccine. Or access the Comprehensive Clinic Assessment Software Application (CoCASA) program developed to assess adult immunization rates. http://www.cdc.gov/vaccines/programs/cocasa/default.htm
• For the non-computerized office, conducting a manual record review on a daily or weekly basis. For guidelines, see Conducting a baseline assessment.
• For influenza, the vaccination rate can be tabulated at the end of the vaccination season.
• In a very large practice, a sampling method could be used to determine an estimate of the proportion of at-risk persons vaccinated.

Effectiveness
When implemented as a pre-discharge measure in a hospital, pneumococcal and influenza vaccination rates were 75% and 78% respectively, compared to 0% of patients not given an informational handout (Bloom, 1988). This method has also been used to effectively increase tetanus toxoid administration (Cates, 1990).

For Reference, click here.

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Definition
Personal health records (PHRs) are issued to patients (either given to patients at the time of a visit or mailed) and contain a preventive care schedule, including recommended times to receive vaccinations.

Advantages
Personal health records empower patients and encourage them to be proactive in their own health care. This strategy can be combined with other preventive health measures, such as cancer screening, to increase the usefulness of the PHR. Several types of PHRs are available, such as a one-page sheet or a wallet–size card (See Sample under Implementation Steps). In addition to being simple and inexpensive to implement, PHRs provide patients with a record of the preventive services they’ve received should they move or change providers.

Disadvantages
Personal health records require patients to take the initiative to schedule and keep appointments and to remember to bring their PHR with them for the clinic visit. This strategy also requires providers to encourage and promote use to the PHR to their patients.

For this strategy to be effective, the patient needs to be moderately literate; non-English speaking patients may need to have the PHR translated into their language. This is not a good strategy to use in populations with historically low compliance rates.

If vaccination rates are already relatively high in the practice, the incremental increase in vaccination rates attained may not be worth the time and effort invested.

Settings
Private practice and managed care are appropriate settings for personal health records.

Implementation Steps

1. Create or adapt a personal health record.

2. Decide on a distribution plan (mail or distribute in the office).

3. If distributing in the office, appoint a person (receptionist, nurse, doctor) to distribute the PHR to patients and explain its use. If mailing, generate a list of eligible patients (usually based on age) from computerized medical records, computerized billing records, or manually from medical records.

To view a sample, click here.

To view a wallet card: http://www.immunize.org/adultizcards/index.htm

Measurement
To measure the effectiveness of the strategy, you can use either of these two approaches:

1. Compare vaccination rates pre- and post-implementation of the strategy.
2. Set a goal (for example, 75% of persons 65 and older will receive influenza vaccine) prior to implementing the strategy and track vaccination rates resulting from the intervention.

Methods for tracking rates include:

• For the computerized office, determine what proportion of persons on the list were billed for the vaccine. Or access the Comprehensive Clinic Assessment Software Application (CoCASA) program developed to assess adult immunization rates. http://www.cdc.gov/vaccines/programs/cocasa/default.htm
• For the non-computerized office, conducting a manual record review on a daily or weekly basis. For guidelines, see Conducting a baseline assessment.
• For influenza, the vaccination rate can be tabulated at the end of the vaccination season.
• In a very large practice, a sampling method could be used to determine an estimate of the proportion of at-risk persons vaccinated.

Effectiveness
In one study (Dickey and Petitti, 1992), pneumococcal vaccination rates increased to 20.5% among patients with PHRs compared to 4.8% of patients not given a PHR. Td rates were 12.5% among patients with PHRs compared to 5% in the control group.

The effectiveness may hinge on the physician’s attitude toward the PHR and receptiveness to patient-initiated care. Effectiveness will be maximized when physicians encourage the patients to take initiative, and physicians are willing and able to provide the requested services.

For Reference, click here.

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