As the U.S. healthcare system transitions from volume- to value-based care, the role of healthcare providers will also be transitioning. In a value-based care system, providers focus on efficiency and quality, rather than the quantity of patients they see. Providers will have to think about improving the health of the population as a whole and not just individual patients. There are opportunities to emphasize quality improvement (QI) and practice redesign in ways that could fundamentally improve healthcare in the United States.
SPONSORED BY: Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., has paid for and provided editorial input on this material.
The Triple Aim framework serves as an approach for organizations to successfully improve the health of individuals and populations. According to the Institute for Healthcare Improvement (IHI), the 3 tenets of the Triple Aim are improving the care experience, reducing the per capita cost of healthcare, and improving the health of populations.
To improve the care delivered, healthcare organizations should expand in vision, reach and practice to affect health through population health interventions. One method to help prevent illness is through vaccination. Vaccines have been recognized as one of the 10 great public health achievements of the 20th century by the Centers for Disease Control and Prevention (CDC). For patients achieving immunity, vaccination can help reduce disease burden, disease transmission, and the need for disease-specific therapeutic intervention.
Charles-Edward Amory Winslow, founder of the Yale School of Public Health in New Haven, Connecticut, defined public health many years ago as "the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities and individuals."
This definition can be helpful when thinking about healthcare's modern emphasis on population health management. The goal of population health management is to keep a patient population as healthy as possible. While a portion of population health management focuses on high-risk patients who generate the majority of health costs, another component is systematically addressing the preventive and chronic care needs of every patient. For providers, this means being knowledgeable about the health of all their patients and proactively working to achieved desired health outcomes. The primary focus of medical care has been on tertiary prevention, which is the effort to help avoid or defer the complications of diseases after they have developed. While tertiary prevention strategies, such as disease management, can be quite complex and multi-faceted, vaccination interventions may be achievable due to a few key reasons. Vaccinations typically occur in a single-care setting such as a doctor's office or pharmacy; are one- time or relatively infrequent events (with the exception of multi-dose regimen completion); and rely on patient acceptance, but not significant lifestyle change, such as diet, exercise or medication adherence.
An area of preventive care ripe for improvement is adult vaccination, as vaccination rates among adults remain low for most routinely recommended vaccines, according to the CDC. For example, during the 2014–2015 flu season, the vaccination rates for individuals over the age of 18 was 43.6%, falling well short of the U.S. Department of Health and Human Services (HHS) Healthy People 2020 target goal of 70%.
While influenza seasons can vary in severity, during most seasons people 65 years and older experience the greatest burden of severe influenza disease. For instance, during the 2015–2016 season, individuals ≥ 65 years of age accounted for only 15% of the US population, but they made up 50% of influenza-associated hospitalizations and 64% of pneumonia and influenza deaths. According to the CDC, 63% of this patient population received an influenza vaccination for the 2015–2016 flu season. Low vaccination rates leave a large portion of patients unprotected against a potentially serious virus.
In this evolving healthcare landscape, sustainable systems for vaccinating children, adolescents, and adults are needed. High vaccination rates cannot simply be achieved using one-time or short-term efforts. To create enduring vaccine delivery systems, greater understanding of strategies to increase and maintain high vaccination rates is necessary. A combination of strategies implemented with the goal of maintaining high vaccination rates should be aimed at both providers and the public.
Vaccines: Alignment with quality measure goals
Vaccination is closely aligned with quality goals. A number of organizations develop metrics to measure and evaluate quality, and an even larger number of organizations collect measures for the purpose of evaluating and reporting on the performance of providers. The Medicare Shared Savings Program and the Healthcare Effectiveness Data and Information Set (HE-DIS®), which 90% of private health plans use, are among quality improvement drivers that contain a vaccine component.
Health systems and providers can use evidence-based standards to assess the quality of their vaccination programs. Standards for adult vaccination were approved by the National Vaccine Advisory Committee in 2013 and are supported by the CDC, as well as a number of national medical associations. All healthcare professionals — whether they provide vaccination services or not — should follow these standards to ensure eligible adult patients are vaccinated against potentially serious diseases.
ProMedica, a nonprofit health system serving northwest Ohio and southeast Michigan, is an example of a system that used a team-based approach to vaccination improvement by involving providers across disciplines. Vaccines are promoted throughout the system's physician groups, pharmacies, and clinics. According to Dee Ann Bialecki-Haase, MD, director of medical operations for ProMedica. "[Vaccination] is really about helping to protect the health of the most vulnerable members of our communities, which is where true population health management at a health system level comes in."
"We're really all in this together, to do this and deliver quality care to patients, regardless of where [they are] in our system," said Dr. Bialecki-Haase.
Hospital-wide efforts to improve vaccination rates can be implemented with great success, as evidenced in a study published in Pediatrics in 2015. The study documents a vaccination initiative launched at Children's Hospital of Philadelphia (CHOP).
The CHOP initiative consisted of 5 components:
- Vaccination education for patients' families, including the distribution of handouts on the influenza vaccine in clinic waiting rooms.
- Dissemination of daily lists of patients due for vaccination to frontline providers.
- Use of colored wristbands to alert providers of a patient's vaccination status.
- Integration of vaccine orders into inpatient admission orders.
- Education for providers on patient screening, vaccine ordering and dosing, documentation of vaccine refusal, and contraindications precluding vaccination.
CHOP's vaccination initiative boosted influenza vaccination rates among patients receiving chemotherapy by 20.1% to 64.5% over a 2-year period (2011–2013).
A call to action
Lack of information, as well as misinformation, can cause patients to delay or skip certain vaccines altogether, which may increase their risk for vaccine-preventable diseases.
Hospitals are often pillars in the communities they serve; they are uniquely positioned not only to treat patients for acute health issues, but also to engage and educate community members about health and wellness. Many hospitals and health systems are committed to patient education, including topics such as vaccination.
Administrative commitment is essential for the successful implementation of a vaccination program. Leadership is critical in effective implementation of innovation in organizations, particularly in health care.
According to HHS' National Vaccine Advisory Committee standards published in 2014 in Public Health Reports, keys to successful vaccination initiatives include:
- Emphasizing the importance of vaccination during patient encounters
- Strongly recommending all vaccinations patients need
- Providing recommended vaccines at the time of patient visit
- Ensuring employees are up to date on their own recommended vaccinations
- Implementing systems to integrate vaccine assessment into routine outpatient care
- Educating patients about vaccines using understandable language
- Utilizing vaccination registries
Quality Gaps exist between the number of patients who are recommended to receive vaccinations and those who actually receive them. To see real improvement, initiatives across the healthcare system will be required to achieve increased vaccination rates in adults.