January 2024
February 01, 2024

TMF QIN’s Persistence and Focus on Partnership Helps Nursing Home Increase its Resident COVID-19 Vaccination Rate to 100 Percent

In January 2023, a large metro-area facility in Texas was referred by the Centers for Medicare & Medicaid Services (CMS) to TMF Quality Innovation Network (TMF QIN), a Quality Innovation Network-Quality Improvement Organization (QIN-QIO), to increase nursing home resident COVID-19 vaccinations. To make improvements, the 90-bed facility needed additional support and resources. By leveraging the expertise of TMF QIN, the facility increased its rate from 33.33 to 100 percent as reported to the National Healthcare Safety Network (NHSN) database in September 2023.

TMF QIN has a successful record of providing nursing homes in its region with access to on-going support, training, and education. In this specific case, significant turnover at the facility made it difficult to contact the appropriate member of the leadership team. TMF QIN remained persistent, however, and was able to reach the facility’s regional nurse consultant. Together, TMF QIN and the consultant acted as partners to increase the facility’s staff and resident COVID-19 bivalent vaccination rates.

To understand the challenges the facility was facing and the opportunities for improvement, TMF QIN conducted a root-cause analysis (RCA). As part of their RCA, TMF QIN had multiple conversations with the regional nurse consultant over the phone and via email. These discussions shed light on the significance of the facility’s staff turnover in both leadership and clinical positions. The impact of staffing fluctuations led to gaps in the transition of information, operations and procedures. The remaining facility staff was spread thin, which contributed to immunization resources, education and best practices falling through the cracks and resulting in a decline in the administration of COVID-19 vaccines.

The Importance of Accessing Data

In addition to uncovering inconsistencies in vaccination education and processes, TMF QIN discovered that the facility’s new staff did not have access to National Healthcare Safety Network (NHSN) data. This information is critical for establishing and verifying resident and staff immunization status. Assisting in obtaining NHSN access was one of the first positive impacts of the partnership between the facility’s leadership and the TMF QIN. Simply having access to accurate immunization data opened the door to continued improvements in staff and resident vaccination rates.

Defining Up to Date

Another challenge the RCA revealed was misinformation about the definition of being up to date with COVID-19 vaccinations. To help clarify this information and educate facility staff, TMF QIN provided What is Up to Date? Understanding the Centers for Disease Control and Prevention (CDC) definitions of "up to date" for the COVID-19 vaccine (Please note: this link is updated regularly with current guidance). This resource was used by the facility as training for staff and information was shared with residents and their families. To help clarify up-to-date terminology in NHSN, TMF QIN also shared Vaccination Status: Surveillance Definition Change for Long-Term Care Facilities assisting the nursing home to understand the change in definition for up to date. Having a clear, ongoing understanding of what the CDC defines as Up to Date is critical to the continued success for the facility.  At the time TMF QIN delivered these resources, the facility was focusing was on the bivalent vaccine. However, the same strategies are applicable to the 2023-24 vaccine.

Supporting Vaccination Access

In addition to confusion about the definition of being up to date, the facility’s access to the vaccine was inconsistent. This led to a decline in immunizations for staff and residents and contributed to the facility’s low vaccination rates. To address this challenge, TMF QIN worked with the facility’s regional nurse consultant and the on-site pharmacy to schedule and establish a cadence of quarterly vaccination clinics.

Providing Resources for Continued Success

To ensure the facility’s continued success, TMF QIN recommended the facility initiate a standard practice to educate new hires and provide information about COVID-19 and other immunizations to residents and their families at admission. In addition, TMF recommended the facility implement quarterly care plan education and vaccine offerings for residents, their families, and representatives.

To promote vaccine clinics, TMF QIN-QIO also provided the following seasonal flyers:

Keys to Success 

TMF QIN’s success can be replicated by taking the following steps:

  1. Remain persistent in your efforts to reach key nursing home staff.
  2. Ensure nursing home staff have access to NHSN data.
  3. Adapt the delivery of tools and training based on the facility’s specific needs.
Infographic of three Keys to Success






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-1272-1/04/2024. 

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