A small, hospital-based skilled nursing facility (SNF) was referred by the Centers for Medicare & Medicaid Services (CMS) to Alliant Health Solutions (Alliant), a CMS Quality Innovation Network-Quality Improvement Organization (QIN-QIO), for assistance with increasing its resident COVID-19 booster rate. The QIN-QIO conducted a root-cause analysis (RCA) and helped the SNF use the Plan-Do-Study-Act (PDSA) method to create an action plan to address the barriers uncovered by the RCA. This led to 100 percent of residents receiving a COVID-19 booster vaccine, a 68.5 percent increase from when the facility was first referred to the QIN-QIO and the last report to the National Healthcare Safety Network (NHSN) database in October 2022.

Constantly Starting from Scratch

Achieving and maintaining a high resident COVID-19 booster rate in a skilled nursing population is often very difficult. On average, a typical resident spends 30-90 days in a SNF which leads to almost 100 percent turnover within a 90-day period. This means the SNF needs to continually evaluate its COVID-19 resident vaccination/booster status to ensure a high rate of compliance with current guidance.

Using Root-Cause Analysis and PDSA to Drive Improvement

In addition to having a high turnover population, Alliant learned through performing an RCA that vaccine hesitancy was contributing to the facility’s low resident COVID-19 booster rate. This could be attributed to the facility 1) having a short-stay population that was hesitant because they knew they would be transitioning to another level of care; and 2) offering a booster from a different manufacturer than the residents’ primary series which they likely received in another health care setting.

To help the facility identify a strategy for addressing these challenges, Alliant provided a PDSA cycle template. The template helped the facility think through these challenges, choose a goal and develop an action plan with the specific steps they needed to take to achieve their goal. The facility chose to focus on educating staff about vaccine hesitancy and about all aspects of the COVID-19 booster including benefits of the booster dose and the safety and efficacy of mixing vaccines developed by different manufacturers. The facility’s action plan included the following steps:

• Ensure the facility’s leadership team has information about vaccine efficacy and effectiveness over time to address hesitancy among residents and families.
• Implement team huddles to ensure the leadership team shares information and facts about the vaccine and booster with front line staff.
• Ensure educational flyers are visible to residents and families.

Alliant provided a link to its Give the BOOST a Shot website landing page to help the facility put its action plan into place. The landing page includes a library of resources intended to help nursing homes improve their resident COVID-19 booster rate. These include how to use motivational interviewing to increase COVID-19 vaccinations, links to frequently asked questions about booster doses (including mixing and matching manufacturers), educational flyers and links to past and upcoming educational events. To date, there have been 15,498 visits to the landing page and 8,199 resource downloads.  The site also features a “Take 5 Minutes for COVID Education” section that includes five-minute videos on topics such as overcoming refusals, how to stay up-to-date with trusted sources and impacting booster uptake for short stay residents. To date, there have been 2,267 views of this content.

In addition to providing these specific resources to the SNF, Alliant also offers weekly educational events (averaging 61 attendees) to all nursing homes in its region. These events are followed by office hours (averaging 58 attendees) that allow for a deeper dive into the questions and challenges facing nursing homes as they work to increase their resident COVID-19 booster rate. These sessions are supplemented by the QIN-QIO’s Booster Bulletin, a monthly newsletter distributed to more than 6,700 contacts that includes links to updated guidance, best practices and additional resources and education.

Keys to Success

Alliant’s success helping the SNF achieve a 100 percent resident COVID-19 booster rate can be replicated by taking the following steps:

1. Look past the obvious. High resident turnover is inherent to SNFs. Through a RCA, Alliant was able to identify additional challenges that were preventing the facility from increasing its resident COVID-19 booster rate.
2. Create a one-stop shop for resources. Alliant’s Give the BOOST a Shot website landing page hosts all the resources the SNF needed to kickstart their action plan.

All nursing homes in the region served by Alliant that were referred to the QIN-QIO for assistance between January 9 and October 2, 2022, saw a 19.1 percent net increase in resident vaccination/booster rates as compared to nursing homes in the region that were not referred to the QIN-QIO for assistance. In addition, the percentage of fully vaccinated and boosted residents in nursing homes in the region that were referred to the QIN-QIO for assistance, increased by 32 percent, compared to fully vaccinated and boosted residents in nursing homes not referred to the QIN-QIO, which increased by only 10 percent.

Alliant Health Solutions’ Regional Nursing Home Resident COVID-19 Vaccination/Booster Rates Including Referrals from January 9 through October 2, 2022.

The graph compares vaccination rates of CMS-referred facilities (orange) with never-referred facilities (blue) and only includes referrals made between January 9 and October 2, 2022. Never-referred facilities did not meet initial criteria for booster referral because CMS focused on facilities with significantly lower rates.

This material was prepared by The Bizzell Group (Bizzell), the Data Validation and Administrative (DVA) contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. 12SOW/Bizzell/DVA-1146-07/18/2023