November 2022
July 18, 2023

TMF’s Persistence Helps Nursing Home Increase its Resident COVID-19 Booster Rate by More Than 50 Percent

A small nursing home in a Midwest suburb struggling to increase its resident COVID-19 booster rate was referred by The Centers for Medicare & Medicaid Services (CMS) to TMF, a CMS Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for assistance. With TMF’s help, the nursing home demonstrated a 53.5 percent increase in its resident COVID-19 booster rate from when it was first referred to the QIN-QIO and the last report to the National Healthcare Safety Network (NHSN) database in October 2022.

Navigating a Gatekeeper

TMF quickly learned that supporting the facility would be a challenge. The QIN-QIO had one meeting with the facility’s Administrator and Director of Nursing but was told the nursing home’s corporate Director of Education (DOE) would be TMF’s only point of contact. Initially, the DOE only wanted to work with one member of TMF’s team. That team member learned the facility was facing staffing challenges and vaccine hesitancy among residents. However, the DOE was very adamant that the nursing home was already addressing those issues and was aware of the areas in which the facility needed to improve.

Guiding the Development of a Quality Improvement Initiative (QII) Plan

To help get to the root of the facility’s challenges, TMF talked the DOE through creating a QII Plan. The QIN-QIO provided a plan template that includes both the 5 Whys approach and a Fishbone Diagram to determine the root-cause of the facility’s low resident COVID-19 booster rate. The DOE chose the 5 Whys approach and, according to TMF, efficiently and effectively identified that many staff had not completed the CMS Targeted COVID-19 Training for Nursing Homes (targeted training) and needed additional infection control education.

As a next step, TMF helped the DOE develop an outcomes tracking table that outlined the steps the facility should take to provide infection control education and have all staff complete the targeted training. These steps included having discussions about resident exposure due to increased family visits, reviewing CMS infection control guidance, adhering to the core principles of infection prevention and taking a person-centered approach to caring for the facility’s residents. The DOE also developed educational activities for staff built upon the targeted training using a platform called RELIAS. These efforts led to 100 percent of nursing home staff completing the targeted training.

Providing Education About COVID-19 Boosters

In addition to helping the DOE ensure all nursing home staff received infection prevention training, TMF shared CMS guidance on staff vaccinations and provided education on the importance of resident COVID-19 booster vaccinations. This included:

  • Sharing a COVID-19 Toolkit for Nursing Homes that features vaccination guidance (page three);
  • Explaining how and when to offer boosters;
  • Suggesting the facility routinely re-offer boosters during Minimum Data Set (MDS) assessments and resident care planning; and
  • Suggesting the facility offer boosters concurrently with the flu vaccine during flu season.

To supplement this one-on-one support, TMF also hosts weekly Office Hours sessions and presents weekly during the state’s Infection Control and Assistance Program (ICAP) meetings. On average, 60 participants attend Offices Hours sessions, though some topics garner even higher numbers of attendees; ICAP meetings attract more than 200 participants. The DOE routinely participated in both these meetings. TMF also shared with the DOE its Resource Library which houses more than 2,000 educational tools, materials, videos and links. These include recordings and handouts from Office Hours sessions (that average 400 clicks), links to infection prevention signs and infographics (example currently has 652 clicks) for posting in facilities and strategies for implementing Motivational Interviewing (currently has 526 clicks) to mitigate vaccine hesitancy.

Keys to Success

TMF’s success helping the nursing home achieve a more than 50 percent increase in its resident COVID-19 booster rate can be replicated by taking the following steps:

TMF Key's to success

All nursing homes in the region served by TMF that were referred to the QIN-QIO for assistance between January 9 and October 2, 2022, saw a 16.2 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 25 percent, compared to fully vaccinated and boosted residents in nursing homes not referred to the QIN-QIO, which increased by only nine percent.

TMF’s 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.


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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-1108-07/18/23

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