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Adult Immunization: Strategies That Work
Managed Care Strategies
Harvard Pilgrim Health Care, Massachusetts

Resources Required
CDC's Basic Strategy

The Health Centers Division of Massachusetts' Harvard Pilgrim Health Care serves 300,000 patients in the metropolitan Boston area. Harvard Pilgrim began its Influenza Immunization Program in 1976, in response to the public demand for swine flu vaccine.

The program has evolved since its inception. The ongoing management and enhancement of the Influenza Immunization Program has been coordinated for the past 10 years by Information *Technologist Lindy Alves, RRA, Program Coordinator Leslie Van Raalte, NP, and Infection Control Officer Basil Fine, MD. Recently, responsibility for coordination of the program was transferred to Ralph Blair, MD, Infection Control Officer for the Health Centers Division.


Searches through records for codes signifying diagnoses in the high-risk categories of chronic cardiac disease, chronic respiratory disease, chronic renal disease, diabetes, and immunosuppression, as well as patients aged 65 and over. Sends a list of high-risk and elderly patients to the primary care physicians. Primary care physicians review the charts of those listed and may or may not exclude patients who do not have high-risk conditions.

Sends direct mailing to the remaining listed patients notifying them of special influenza vaccination sessions, the benefits of influenza vaccination, and that the program is FREE!

Establishes "flu lines" at all locations to respond to any telephone questions regarding appointments, cost, etc.

Appoints an influenza coordinator for each center. The coordinator is responsible for clinical support and promotional materials distribution.

Arranges for special group immunization sessions and adjusts staffing to permit those who call about influenza immunization to come in at certain hours each day. Walk-ins are never refused.

Generates two reminder lists during the influenza season for the primary care physician of all unimmunized high-risk patients.

Prints a separate reminder lead sheet to the record for the clinician to see at any visit if high-risk or elderly patient is still not immunized.

Tracks statistics on clinician and Health Center immunization rates, patient refusals, high-risk populations, and immunization rates of non-high-risk patients for future program management.

Notifies the department chief of individual and departmental immunization performance rates at the end of the influenza season.


Responded to member requests for influenza vaccinations in 1976 by developing a centralized approach to immunizations.

Sent notices to primary care providers announcing group immunization sessions for swine flu immunizations.

Sent a mailing to patients aged over 65 promoting group immunization sessions for swine flu immunizations.

Revised the strategies continuously until the current program evolved.

Resources Required


  • Local influenza coordinator - most are registered nurses, but some are office managers/supervisors
  • RNs and LPNs - to give immunizations
  • Medical support staff - to staff the special sessions to assist with patient flow, including consent forms, influenza vaccine information, bandage strips, and an information sheet saying what a patient can expect after immunization.


  • Collateral - includes posters, flyers, pharmacy bag stuffers, mailer and mailing to approximately 60,000 members
  • Overhead - staffing, building operations, equipment (syringes, bandage strips, copying)
  • Information Technologist's and Coordinators' time.

There were no real barriers to implementation, as Harvard Pilgrim realizes that prevention both preserves health and cuts costs.

Harvard Pilgrim's Influenza Program goal was to increase adult immunization rates in patients 65 and older and in high-risk patients younger than 65. In 1989, national benchmarks were 33% in the elderly, improving to 53% in 1993 (MMWR, 45:5, 9). Currently, immunization rates in the Health Centers Division reach almost 80% in elderly patients who visit a health center during the influenza season. Results for high-risk patients under age 65 are less accurate due to incomplete editing of the high-risk lists by physicians.

According to Leslie Van Raalte, the influenza immunization program "has become an integral part of our practice and gives us an immediate return on our investment."

CDC Recommends this Basic Strategy:

  • Establish system-wide policies encouraging optimal vaccination practices--involve all key departments and staff
  • Identify all patients needing vaccination and offer services
  • Use physician and patient reminder systems and standing orders
  • Establish Continuous Quality Improvement systems.

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This page last modified on August 2, 2001


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