Clear Impact logo

P008: Division of Health Improvement/Health Certification Licensing and Oversight

P008: Percent of New Mexico's nursing home population who have received or who have been screened for pneumococcal immunizations

Current Value

70.9%

2017

Definition

Line Bar

Story Behind the Curve

  • The U.S. Centers for Disease Control and Prevention Healthy People 2020 national target for pneumococcal vaccination rate in long term care and nursing homes is 90.0%. Pneumococcal disease is caused by Streptococcus pneumoniae bacteria (pneumococcus). Pneumococcal infections can be the cause of numerous illnesses, one being pneumonia (infection of the lungs).
  • Pneumonia highly affects adults 65 and older, and is one of the most common illnesses in nursing homes, due to its ability to spread through the air in a community setting. Getting the proper vaccine can protect older adults against 23 types of pneumococcal bacteria, leading to improved health and wellness, and a higher quality of life.  By decreasing the number of nursing home residents that get pneumonia, the number of hospital admissions and associated treatment costs are lowered.
  • In FY17, the percent of vaccinations among nursing home residents was 70.9%. Information is tracked through the Minimum Data Set (MDS). The Division of Health Improvement (DHI) is working toward better and more accurate use of the MDS records in nursing homes.
  • Surveyors investigate onsite to ensure residents are offered and/or administered pneumococcal vaccination during annual surveys. 
  • DHI collaborates with multiple partners to implement strategies to increase pneumococcal vaccination rates for nursing home residents. 

Partners

  • HealthInsight
  • New Mexico Health Care Association (NMHCA)
  • NMDOH Epidemiology and Response Division
  • NMDOH Public Health Division
  • Nursing homes
  • DHI surveyors

What Works

The following are associated with modest improvements in immunization rates:

  • Overseeing nursing home compliance with vaccination requirements.  
  • Collecting, tracking, and analyzing data, identifying trends, and sharing concerns with NMHCA and nursing homes.
  • Collaborating with NMDOH Epidemiology and Response Division, NMDOH Public Health Division, HealthInsight, and the NMHCA to identify and implement strategies emphasizing the importance of encouraging nursing homes residents get vaccinated.
  • Collaborating with the NMDOH Chief Medical Officer, Epidemiology and Response Division, and Public Health Division to identify and implement strategies to inform physicians on the importance of immunizations for nursing home residents.
  • Clinical reminders and education.
  • Patient outreach with personal contact.
  • Sending a letter to nursing homes from the DHI Director emphasizing the importance of immunizations and encouraging them to get their residents immunized.
  • Cited deficiencies assist in compliance in offering and/or administration of pneumococcal vaccination.

Strategy

  • Collaborate with NMDOH Epidemiology and Response Division, NMDOH Public Health Division, HealthInsight, and the NMHCA to identify and implement strategies to support nursing homes to encourage residents to get immunized.
  • Direct communication with NMDOH facility administrators.
  • Conducting compliance surveys to identify deficient areas of practice to improve compliance with Centers for Medicare and Medicaid Services (CMS) vaccination requirements.

Action Plan

  • Q1:
    • DHI Director and NMDOH Secretary will approve and submit a letter to the New Mexico Health Care Association emphasizing the need for nursing home resident immunization. Completed.
    • Continue to meet with the NMDOH Chief Medical Officer, Epidemiology and Response Division, and Public Health Division to identify and implement strategies to inform physicians on the importance of immunizations for nursing home residents. Completed.
  • Q2:
    • Continue to explore use of Civil Monetary Penalty (CMP) funds to implement strategies to do education and outreach to increase vaccination. Completed.
    • Collaborate with HealthInsight’s on data tracking and continued vaccination education and outreach.  Completed.
    • Division of Health Improvement Director issued a state wide letter to all Nursing Homes encouraging them to have all residents and vaccinated against Pneumococcal. Completed.
      In October and November 2017, the State Agency met with HealthInsights and New Mexico Healthcare Association encouraging residents to receive Pneumococcal vaccination and discussed HealthInsight and facility tracking of Pneumococcal vaccinations.  Completed.
    • Long-Term Care surveyors continue to enforce regulations related to offering and/or providing Pneumococcal vaccinations to residents during the re-certification Nursing Home annual surveys.  Completed.
    • MDS Coordinator continues to provide education and support to encourage accurate MDS coding related to immunizations. Completed.
  • Q3:
    • Report immunization data to Nursing Home Association at statewide meeting. Completed.
    • Review and approve CMP project that supports increased immunization compliance. Completed.
    • Long Term Care surveyors continue to enforce regulations related to offering and/or providing Pneumococcal vaccinations to residents during the re-certification Nursing Home annual surveys.  Completed.
  • Q4:
    • Continue tracking and monitoring effectiveness of the action plan and reporting results to NMHCA and partners. Completed.

FY18 Annual Progress Summary

  • To improve the immunization rate, DHI collaborates with NMDOH Epidemiology Response Division, Public Health Division, HealthInsight NM, and the New Mexico Health Care Association to identify and implement strategies to support nursing homes in encouraging residents to get immunized.
  • DHI was successful in recruiting a new Minimum Data Set coordinator.

Clear Impact Suite is an easy-to-use, web-based software platform that helps your staff collaborate with external stakeholders and community partners by utilizing the combination of data collection, performance reporting, and program planning.

Scorecard Container Measure Action Actual Value Target Value Tag S A m/d/yy m/d/yyyy