A 200 bed long- and short-term care facility 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 improving its resident COVID-19 bivalent booster rate. Through one-on-one coaching and targeted resources, Alliant helped the facility achieve a 42.65 percent increase in its resident COVID-19 bivalent booster rate from the time the QIN-QIO made its initial outreach to the nursing home in January 2023 and the last report to the National Healthcare Safety Network (NHSN) in June 2023.

Root Cause Analysis Reveals Several Challenges
Upon receiving the referral from CMS, Alliant conducted a root cause analysis to determine the reason for the nursing home’s low resident COVID-19 bivalent booster rate. The analysis revealed several challenges: 1) A lack of vaccine confidence and hesitancy among residents as well as concerns about the safety and efficacy of the vaccine; 2) Some residents having received only one of the two required doses of the primary series making them ineligible to receive the bivalent booster; 3) Lack of understanding among staff about NHSN data entry leading to inaccurate reporting; and 4) An email firewall which was blocking messages from Alliant team members.

Alliant quickly resolved the firewall issue through real-time communication with one of the facility’s two infection preventionists (IPs) to ensure nursing home staff had access to Alliant’s resources and education. The QIN-QIO also worked with the IPs to clarify the correct NHSN data entry format and definitions, provided NHSN reference documents such as key terms related to COVID-19 vaccination and the up to date vaccination status definition and followed up if data entry issues persisted.

Addressing Vaccine Ineligibility
To help the facility ensure residents who were ineligible for the bivalent vaccine completed their primary series, Alliant provided guidance from NHSN that included flow charts on how to get up-to-date. The guidance included a timeline on how soon the bivalent booster could be given following the second dose in the primary series. The QIN-QIO also met with the facility monthly to discuss the number of residents who remained ineligible to help address any concerns or challenges.

Coaching Infection Preventionists to Boost Residents Confidence and Reduce Hesitancy 
Hesitancy among residents stemmed from concerns about 1) Receiving too many vaccines; and 2) The vaccine’s safety following the administration of a bivalent booster to a resident who then developed chest pains. Despite confirmation from a physician that these pains were unrelated to the vaccine, no additional side effects were documented and there was no need for a higher level of care, these concerns persisted. To help nursing home staff address residents’ hesitancy, Alliant provided coaching to the facility’s IPs using Motivational Interviewing (MI) techniques and provided MI resources. These included the Centers for Disease Control and Prevention’s (CDC) Talking with Patients about COVID-19 Vaccination and Alliant’s Using Motivational Interviewing to Increase COVID-19 Vaccinations. In addition, the QIN-QIO offered its Take 5 Videos, including Take 5: Overcoming Refusals, a five-minute video highlighting strategies to mitigate vaccine refusals. 

Targeted Resources Help IPs Educate Residents
Alliant also provided several resources to help address residents’ concerns about safety. These included Frequently Asked Questions About Updated COVID-19 Vaccines, the CDC’s Myths and Facts about COVID-19 Vaccines, Alliant’s Bivalent Myths and Facts and Alliant’s Bite Sized Learning on COVID-19 Vaccination. The combination of coaching and resources provided to the facility was intended to empower the IPs to speak confidently about the vaccine and answer any questions from residents.

Due to staffing challenges at the facility, the IPs were assigned to patient care. This offers an opportunity for the IPs to educate residents one-on-one in addition to their regular responsibility of offering and administering the bivalent vaccine to residents. To help staff take advantage of this opportunity, Alliant provided an Immunization Trivia Kit for Seniors. The kit is intended to engage residents, provide education and dispel misinformation about the vaccine through interactive activities such as team trivia, daily trivia and newsletter trivia. Although the content is focused primarily on COVID vaccines, there also are questions about other vaccines in the recommended schedule for this age group including shingles, pneumonia and flu.

Keys to Success
Alliant’s success can be replicated by taking the following steps:

1. Use root cause analysis to quickly identify barriers and challenges.
2. Quickly address small barriers to allow time for tackling more difficult challenges.
3. Provide customized resources and education based on identified barriers and challenges.

Regional Impact of Alliant’s Assistance
Per the NHSN weekly report dated September 3, 2023, the percentage of residents who are up to date in nursing homes that received assistance from Alliant increased by 7.7 percent as compared to the average change in resident vaccination across all nursing homes in Alliant’s region.

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-1195-09/18/2023.