Needs Assessment

Identifying Stakeholders

A large primary care facility located in South Florida was selected for the program. The stakeholders associated with this office consist of a medical director, an internal medicine physician, and two advanced nurse practitioners. The medical director graduated from medical school in 1999 and performed his residency in family practice. The internal medicine physician graduated medical school seven years ago, and he cares for patients in Broward county clinic twice a week. He sees approximately 20 patients each day that he works. The ARNPs are certified in family practice, and they each tend to approximately 15 patients each day. Both ARNPs are familiar with and work for the medical director and internal medicine physician.

Assessing the Environment

In addition to the stakeholders, the facility’s personnel includes an office manager and two medical and support staff members. Along with the clinical care staff, the facility employs an office manager who is responsible for managing daily operations and the operating budget. The office manager also keeps the facility up to date regarding practice policies and manages the staff’s growth and development. The medical and support assistants job description includes authorizations, checking in and checking out patients, verifying insurance, maintaining medical records, answering phones, and scheduling appointments. Assessing an organizational structure requires deconstructing the environment and viewing it with an open-system perspective that analyses its socio-psychological, organizational, and ecological structures (Hogg, Rowan, Russell, Geneau, & Muldoon, 2007). With a Gap Analysis (See Appendix A for practical use of the Gap Analysis), we can see the primary care facility has a steady influx of patients; however, we need to identify the type of patients. Because the problem that will be addressed will be the low rates of vaccinations in the adult 65 years and older population, the GAP analysis will assist this DNP student in explaining why a particular health action for adults who are 65 years and older requires educational programs for clinicians, pharmacists, and the community. 

Hogg et al. (2008) has noted that the current trend allows clinicians to focus on people rather than disease. With the overall goal of increasing immunization rates for adults over 65 years of age, it is predictable that a screening tool may have some benefits, but there is an underwhelming concern for this particular demographic. While a comprehensive screening tool can be developed, the success may rely on ARNPs because both are able to administer immunizations. The SWOT analysis reveals (See Appendix B for practical use of the SWOT analysis) that the facilities strength lies in its workers, but its weaknesses suggest a lack of awareness programs within the facility and the older adult community. 

Hard Core Data

The target population for this project will be adults 65 years and older. In 2013, the Centers for Disease Control and Prevention recommended that adults 65 years of age and older receive the standard dose IIV or the high-dose IIV ("Immunization schedules," n.p.).  In addition, according to The American Geriatrics Society, the elderly population should receive the following vaccinations: 

• Influenza† 1 dose annually

• Pneumococcal polysaccharide 1 dose

• Zoster 1 dose

• Tetanus, diphtheria (Td)† Td booster every 10 years

Healthcare providers now share responsibility for putting these guidelines and recommendations into practice because there are new Advisory Committee on Immunization Practices (ACIP) and new vaccines approved regularly. With the identification of the need for improved administration of older adult immunizations, there is evidence of need to increase the rate of immunization at the patients scheduled office visit with their primary care provider. 

To determine the outcome, this project will measure performance based on CDC Healthy People 2020 Objectives and reduce invasive pneumococcal infections in adults 65 and older to the proposed goal of 31%.  Essentially, this project anticipates that a vaccination protocol will increase the rate of immunizations for the targeted population and in turn reduce the contraction of infectious disease

The project site has supplies ordered every month, and the supply of immunizations has been maintained to meet the needs of the patients without interruption of supplies. There is unlimited accessibility to printer and printer supplies. 

A letter of support from the medical director (See Appendix C) related to the importance of this timely capstone is included.

Problem Statement

It is a common misconception that vaccinations are only meant for young children and infants; however, the CDC (2011) asserts that people of all ages should continue to receive vaccines in order to reduce diseases that are preventable and decrease morbidity and mortality. Specifically, adults over 65 years of age are in the most need of routine immunizations.  For example, Sokos (2005) has noted that “Case-fatality rates for pneumococcal pneumonia, bacteremia, and meningitis are 6%, 20%, and 30%, respectively, and may be significantly higher in the elderly” (p. 369). 

Because of the “new ACIP recommendations for the use of many vaccines in adults, providers of adult health care now share a greater responsibility for putting those recommendations into practice” (CDC, 2013. p. 320). It seemed that this particular population did not have any education to draw upon based on the limited research. Nevertheless, vaccinations for older adults often are a cost effective approach because it decreases the amount of people who may require hospital care. Often those who are not immunized end up contracting or developing illnesses that require emergency or hospital care.

Therefore, it seems that problem is both a content issue and a context issue. While adults over 65+ may not realize immunizations will provide protection from common ailments turning into something serious, physicians and nurse practitioners may be unaware that patients over 65 are not current on their immunizations; however, it is a problem that can be easily solved with a primary care appointment to administer vaccinations based on the elderly adult’s primary care history. 

Developing the Strategy

The primary instrument for this project will be a screening questionnaire developed by using the CDC guidelines written in English and Spanish at a 6th grade education level for easy understanding. While the instrument may have to be in other languages based on patients who may come from other countries, research must be conducted to determine the predominant foreign language. The screening tool (questionnaire) will be later developed using evidence base guidelines and CDC. Office staff will be able to assist participants who experience trouble understanding the screening tool.  

The participants will be the patients of the practice who fit the inclusion criteria who will be seen by one of the providers at scheduled appointments. Office staff will remind patients that Medicare covers Influenza vaccine; PPSV is covered by Medicare Part B; and the Varicella vaccine is covered by Medicare Part D; however, Medicare will not cover Tetanus nor diphtheria immunizations. 

The screening tool will also be developed into a brochure for patients. They can choose to read it while waiting for their appointment, or they will be encouraged to offer brochures to their friends or family. The problem at hand requires awareness, so providing other ways in which to pass on the information is a vital component to this program’s success. 

Case Representative

A 67 year old patient arrives to the facility for his/her primary care appointment. After the patient is signed in, medical assistants will ask the patient to fill out the questionnaire (screening tool). The patient mentions in the questionnaire that they have contact with their grandchildren or great-grandchildren. The patient does not remember the last time they were immunized, and the primary health care facility does not have any background for the patient’s immunization history. 

Based on the patient’s screening, it appears that he/she is eligible for the vaccines, so an immunization will be offered, after the patient is educated about the benefits of receiving the vaccinations. The eligible patients that receive vaccinations will be entered into the electronic database and compared to the eligible patients before vaccination protocol initiated. The clinical outcomes may determine that eligible individuals who after vaccination protocol initiated were more likely to get the recommended immunizations. 

(Appendix A and B omitted for preview. Available via download)

References

Centers for Disease Control and Prevention. (2011). General recommendations on immunizations. MMWR Recommendations and Reports, 60(2), 3-60. Retrieved from http://www.cdc.gov/

Centers for Disease Control and Prevention. (2013). Recommended adult immunization schedule—United States - 2013 [PDF]. United States.

Hogg, W., Rowan, M., Russell, G., Geneau, R., & Muldoon, L. (2007). Framework for primary care organizations: The importance of a structural domain. International Journal for Quality in Health Care, 20(5), 308-313. doi: 10.1093/intqhc/mzm054

Immunization schedules. (2013, January 29). Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html

Sokos, D. R. (2005). Pharmacists’ role in increasing pneumococcal and influenza vaccination. American Journal of Health-System Pharmacy, 62.