Immunization: Strategies That Work
Private Practice Strategies
Pulsifer Medical Associates, Rochester, NY
CDC's Basic Strategy
Pulsifer Medical Associates is a group of seven internists and a physician assistant.
Two internists are infection control consultants for Rochester's Genesee Hospital, and one
is a gastro-enterologist. The group serves about 20,000 patients. Sixty percent are HMO
members who select Pulsifer physicians as their primary care physicians; two percent are
Medicaid patients; the rest are a combination of Medicare and private insurance patients.
Practice partner Geoffrey Morris, MD, described the adult immunization strategies of his
practice for us.
(Note: See CDC recommendations on the next page for a comprehensive basic strategy for
Places a health maintenance sheet in the front of every patient's
chart. Influenza, pneumococcal, tetanus-diphtheria, MMR, and hepatitis B are checkoff
items on the sheet. (Note: CDC also recommends that varicella be a checkoff item.)
Identifies high-risk patients and patients age 65 or older when charts
are pulled and reviewed the night before appointments. When patients check in during
influenza season, staff asks if they have been immunized, and if not, staff gives
immunizations via standing orders. Each physician within the group handles pneumococcal
Accepts walk-ins for influenza vaccine without arranging an office
visit, unless needed. Never makes patients wait for influenza immunizations.
Recognizes the power of physician advice in the physician-patient
relationship and encourages undecided patients to receive immunizations. For influenza,
Dr. Morris emphasizes that HE gets influenza immunizations and that there are no
significant side effects to influenza immunization. He also points out that influenza can
be a deadly disease for seniors or those with chronic medical problems.
Places informational posters in the waiting room.
Uses self-stick labels printed with vaccine batch numbers as a
time-saver. Labels are applied to patient charts and initialed when patients are
Targets school teachers and health care workers.
Participated in a pilot study several years ago to increase influenza
immunization levels. The study was organized by the Monroe County health department and
Marc LaForce, MD, of Genesee Hospital. Placed posters and pamphlets provided by the county
for patient education in the waiting room during influenza season. Pulsifer physicians
competed with each other to immunize the most high-risk patients during influenza season.
"Scores" were tracked on a graph displayed in the office.
Continued to use posters and graphs after the study was completed,
since they were successful.
Time in training medical assistants to prioritize patient flow during influenza season.
Vaccine ordering time. Billing time. "Paperwork is minimal," according to Dr.
Morris. The group accepts Medicare assignment for influenza and pneumococcal
immunizations. Local HMOs do not require a co-pay for influenza immunizations.The county
health department provides posters for free.
Barriers are few, since the entire community supports adult immunizations, and patients
frequently initiate immunizations. Computer-based records, rather than paper-based records
would facilitate the identification of patients who are high-risk and 65 or older for
During the pilot study, influenza immunization levels approached 90%. Dr. Morris
estimates that they currently immunize 80% of patients who are high-risk and age 65 or
older against influenza.
CDC Recommends this Basic
- Establish changes in office systems among physician and non-physician personnel to
prompt and support activities which enhance delivery of vaccination services (motivation
plans, intake procedures, cues, standing orders, feedback)
- Identify all patients in the practice with indications for vaccination by reviews of
office records and patient histories
- Display vaccination goals and chart progress (e.g., wall posters/graphs) so all staff
can share in your success
- Set up opportunities to offer vaccination services to patients during scheduled office
visits for other purposes and special vaccination clinics (e.g. influenza walk-in
clinics)--use standing order systems
- Use physician and patient reminder systems (chart stickers, computer prompts, call-back
- Establish Continuous Quality Improvement systems.