Nurse practitioner-managed practices thrive in vaccinating seniors

Vaccination in older adults is an important step in preventive care, particularly as those individuals’ immune responses decline. A new study of two nurse practitioner-managed clinics may hold the key to improving uptake of vaccines in this population.
And while the study occurred in this environment, the clinics employed practices for more than a decade that may help improve compliance across primary care.

In a report titled “Comparison of immunization rates of adults ages 65 years and older managed within two nurse practitioner–owned clinics with national immunization rates,” published in the Journal of the American Association of Nurse Practitioners, researchers reviewed vaccination records for 150 seniors aged 65 and older from two nurse practitioner-managed clinics. Five vaccines were reviewed including tetanus, diphtheria and pertussis; influenza; pneumococcal polysaccharide vaccine 23; pneumococcal conjugate vaccine 13; and the herpes zoster vaccine.

The review revealed that clinics had higher immunization rates than the national average for all five vaccines, with herpes zoster administration exceeding the goals set by the federal Healthy People 2020 initiative.

Wendy L. Wright, FNP, FAANP, FAAN, an adult and family nurse practitioner and lead author of the report, said vaccination compliance among older adults is critical.

“This is a vulnerable population. We must find ways to ensure vaccinations in this group. Medicare does pay for these vaccines, but practices must understand the mechanisms by which the billing needs to be done,” Wright told Medical Economics. “Implementing a comprehensive vaccine strategic plan can significantly increase vaccine rates.”

Next: Impact on older adults

Older adults and vaccinations

Less than half of the 42 million Americans aged 65 and older report being up-to-date on preventive care, according to the report, and this is a problem considering that age group is expected to balloon to 72 million by 2030.

There are numerous barriers that prevent older adults from receiving vaccinations, including limited knowledge of vaccines, failure of healthcare providers to promote those vaccines and lack of access or insurance coverage, according to the report.

Numerous studies indicate that the more than 222,000 U.S. nurse practitioners, two-thirds of which work in primary care, are extremely effective in improving the management of chronic health conditions-better in many cases than physicians. There have been few studies, however, investigating the effectiveness of nurse practitioners in improving vaccination rates.

Nationally, 71.5% of individuals aged 65 and older received the flu vaccine, according to a 2014 U.S. Census Bureau report cited in the paper, and 61.3% reported receiving a pneumococcal vaccination. In comparison, 33% of participants in Wright’s study received all five of the recommended vaccines. Eighty-one percent received Tdap vaccination, above the national overage of 20.1%, 52.8% received the PCV13 vaccine, 76.4% received the PPSV23 vaccine, 77.8% received the seasonal flu vaccine, and 70.3% received the herpes zoster vaccine.

The report attributed the success in those clinics to direct billing to Medicare for Part D vaccines and pre-visit care planning.

At both clinics involved in the review, vaccines were stocked at the clinic and a medical assistant care coordinator reviewed the chart of every patient prior to arrival, documenting individual preventive care needs for the nurse practitioner. Patients needing vaccinations were encouraged to receive them, and reminders were set for future visits when vaccinations were deferred at a particular visit, particularly for influenza vaccines if they were not yet available at the time of the visit.

Next: Lessons for other practices

Lessons for other practices

Wright said setting up an office to bill Medicare Part D is easy, and practices can sign up with various services to bill Part D directly from the office.

“This allows practices to administer and bill Tdap and Zostavax without having to send these individuals to a pharmacy,” Wright said.

Stocking vaccines is also important, as well as checking vaccination needs and offering vaccines at every visit.

“We just can’t wait for well visits,” she said.

Providers should also use presumptive language, she said, clearly stating a recommendation for a particular vaccine when needed. Having an “office champion” who encourages providers to suggest vaccinations can also help keep clinicians on task. Finally, Wright recommends setting reminders for patients who choose not to receive a vaccine at the time of a visit so that it can be addressed during their next appointment.

Wright said she was surprised at the vaccination rates revealed in the study.

“I thought we were actually higher than what the rates showed. This perception is so common,” she said. “If you are not running your rates, you don’t know how you are doing.”

She was also surprised to find that women were less likely to be vaccinated than men.

“This was statistically significant with many of the vaccines,” Wright said. “We need to understand why and tailor our strategies to address any reluctance.”

Wright said she hopes other clinicians will take note of her results and use her report to take a look at their own immunization practices.

“We have a lot of work to do, particularly around the shingles vaccine, to improve our rates,” Wright said. “I would like people to see the strategies that can make a difference and maybe try them at their clinics. I also want the medical community to see the stellar work of nurse practitioners in improving the healthcare of this nation’s older adults.”