TMF Quality Innovation Network, a Centers for Medicare & Medicaid Services (CMS) Quality Innovation Network-Quality Improvement Organization (QIN-QIO), helped a nursing home improve resident COVID-19 booster rates from 16.9 percent at time of referral on January 9, 2022, to 100 percent by April 24, 2022, through customized one-on-one technical assistance.

Root Cause Analysis Reveals Staff Turnover and Resident Vaccine Hesitancy

TMF worked closely with the facility to do a root cause analysis (RCA) using a Fishbone diagram tool to help the facility gain a deeper understanding of challenges and barriers to critical issues such as booster adoption. By the time customized assistance began in February 2022, the resident booster rates had increased to 44.8 percent.

Through the RCA, TMF learned the nursing home had experienced leadership turnover of both their Director of Nursing and Administrator. In addition, there was a statewide shortage of certified nursing assistants (CNAs). Due to this leadership turnover and staffing shortages, it was difficult for the facility to focus on holding frequent vaccine clinics and improving resident booster rates. TMF also found that vaccine hesitancy was a barrier to booster acceptance among nursing home residents and their families.

Resources for Staff Hiring and Retention, Weekly Vaccine Clinics

TMF worked closely with the facility throughout the leadership turnover and moved forward with a plan to facilitate more frequent vaccine clinics. They provided web-based articles and resources on staff hiring and retention on their web page, Consistent Assignment & Staff Turnover. Additionally, TMF provided a COVID-19 Vaccine Checklist to the facility to help them plan and organize weekly vaccine clinics. By assisting the nursing home to establish a process to identify vaccine and booster status upon admissions, the new weekly vaccine clinics increased access for all residents in need of a booster.

Education to Address Resident and Family Vaccine and Booster Hesitancy

TMF also focused on education of residents and their families to address vaccine and booster hesitancy. Two of the most effective tools used were a CDC poster, Protect Your Loved Ones by Getting a COVID-19 Booster, and an infographic created by TMF, Who Stays Well After Direct Exposure to COVID-19? The nursing home reported that nursing home residents and their families found the infographic particularly compelling, as it clearly shows the significant reduction in illness and death for those who have received the booster compared to those who are unvaccinated or who are vaccinated but not boosted. Residents could see that while they might get COVID-19 after getting the booster, they were unlikely to get as sick or to die. The nursing home found that including this infographic in its admission materials also helped boost vaccine and booster rates among new residents.

Residents and their families were updated regularly on county positivity rates. In addition to educational resources, TMF facilitated one-on-one meetings with residents and their families to answer questions about the booster and to reinforce educational materials. Through these individual meetings and interventions, TMF formed relationships which supported significant improvement in resident booster rates at the facility.

Webinars, Office Hours, COVID-19 Resource Library

Throughout this time, TMF continued to host weekly webinars and office hours for staff on the topic of infection prevention and control as well as vaccinations and boosters, and to host an extensive library of COVID-19 and other resources for nursing homes to use in both resident and staff education.

A 100 Percent Resident Booster Rate

Through customized interventions to address nursing home leadership and staff turnover, and to provide educational resources and one-on-one support to address COVID-19 vaccination and booster hesitancy, TMF helped this nursing home increase the resident booster rate by 83.1 percent since time of referral, and to maintain a continued 100 percent booster rate as of May 17, 2022, with 59 residents eligible and boosted.

TMF Assistance Improves Resident Vaccination/Booster Rates at Referred Facilities

More broadly, all nursing homes in the four-state and two-territory region served by TMF that were referred to the QIN-QIO for assistance between January 9, 2022, and May 15, 2022, saw a net 22.7 percent increase in resident vaccination/booster rates as compared to nursing homes in that region that were not referred for assistance. In addition, the percentage of fully vaccinated and boosted residents in TMF’s four-state and two-territory region referred to the QIN-QIO for assistance increased by 33 percent as compared to fully vaccinated and boosted residents in nursing homes not referred to the QIN-QIO which increased only 6 percent.

TMF’s Regional Nursing Home Resident COVID-19 Vaccination/Booster Rates Including Referrals from January 9, 2022, through May 15, 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 May 15, 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-1125-07/18/2023