cdc-rfa-ip15-1503.pdf

Centers for Disease Control and Prevention

National Center for Immunization and Respiratory Diseases

Improving Adult Immunization Rates through Partnerships with Providers and National Organizations

CDC-RFA-IP15-1503

Application Due Date: 07/06/2015

Improving Adult Immunization Rates through Partnerships with Providers and National Organizations

CDC-RFA-IP15-1503

TABLE OF CONTENTS

Part I. Overview Information

Federal Agency NameA.

Funding Opportunity TitleB.

Announcement TypeC.

Agency Funding Opportunity NumberD.

Catalog of Federal Domestic Assistance (CFDA) NumberE.

Dates F.

Executive Summary G.

Part II. Full Text

Funding Opportunity Description A.

Award Information B.

Eligibility Information C.

Required Registrations D.

Review and Selection Process E.

Award Administration Information F.

Agency Contacts G.

Other Information H.

Glossary I.

Part I. Overview Information Applicants must go to the synopsis page of this announcement at www.grants.gov and click on the "Send Me Change Notifications Emails" link to ensure they receive notifications of any changes to CDC-RFA-IP15-1503. Applicants also must provide an e-mail address to www.grants.gov to receive notifications of changes.

A. Federal Agency Name:

Centers for Disease Control and Prevention (CDC) B. Funding Opportunity Title:

Improving Adult Immunization Rates through Partnerships with Providers and National Organizations C. Announcement Type: New - Type 1 This announcement is only for non-research domestic activities supported by CDC. If research is proposed, the application will not be considered Research for this purpose is defined at http://www.cdc. gov/od/ science/ integrity/ docs/cdc- policy- distinguishing- public- health- research-nonresearch. pdf.

D. Agency Funding Opportunity Number:

CDC-RFA-IP15-1503

E. Catalog of Federal Domestic Assistance (CFDA) Number:

93.268 F. Dates:

1. Due Date for Letter of Intent (LOI): N/A

2. Due Date for Applications: 07/06/2015, 11:59 p.m. U.S. Eastern Standard Time, at www.grants.gov.

3. Date for Informational Conference Call: N/A

G. Executive Summary:

1. Summary Paragraph:

The purpose of this cooperative agreement is to develop and implement programs designed to increase adult immunization rates, using the principles of the Standards for Adult Immunization Practice. The Standards are a call to action to healthcare providers to develop new approaches in the way they immunize their adult patients.

Applicants will propose a plan that will demonstrate:

1. ASSESSMENT: Increased number of healthcare providers who routinely assess vaccination status of their adult patients at every clinical encounter.

2. RECOMMEND: Stronger immunization recommendations that providers make to their patients.

3. GIVE VACCINE OR REFER OUT: Improvements in immunization systems at point of care (e.g. use of immunization information systems (IIS) or electronic health records changes in patient care procedures.)

4. DOCUMENT: Increased number of providers who document immunizations in IIS Applicants will propose a workplan designed to increase adult immunization rates. The proposed package of activities should combine elements of 1. Quality improvement, 2. Clinician education, and 3. Changes in adult patient care procedures.

In the first phase of the project, the Demonstration Phase, the activities will focus on a target group of healthcare providers, and help them to improve their immunization services for a group of real patients. In the second phase of the project, the Dissemination Phase, efforts will focus on implementing effective models among a wider national audience of healthcare providers.

The FOA seeks efforts that demonstrate successful models of technical packages, defined by Frieden as "a selected group of related interventions, that together, will achieve and sustain synergistic improvements" in immunization rates.Evidence-based strategies for increasing immunization rates are outlined in The Guide to Community Preventive Services and other reputable science-driven sources. New approaches are needed for selecting, combining and implementing the most effective impact-driven set of activities for increasing adult immunization rates.

a. Eligible Applicants: Open Competition

b. FOA Type: Cooperative Agreement

c. Approximate Number of Awards: 4

d. Total Project Period Funding: $4,000,000

e. Average One Year Award Amount: $250,000

f. Number of Years of Award: 4

g. Estimated Award Date: 08/01/2015

h. Cost Sharing and / or Matching Requirements: N

Part II. Full Text A. Funding Opportunity Description http://foa.grantsolutions.gov/announcementmodule/www.grants.gov http://foa.grantsolutions.gov/announcementmodule/www.grants.gov http://www.cdc.gov/od/science/integrity/docs/cdc-policy-distinguishing-public-health-research-nonresearch.pdf http://www.cdc.gov/od/science/integrity/docs/cdc-policy-distinguishing-public-health-research-nonresearch.pdf http://www.grants.gov

1. Background

a. Overview

Adult vaccination rates are well below the national Healthy People 2020 goals and racial and ethnic disparities in vaccination coverage rates among adults are substantial. Improvement in adult vaccination is needed to reduce the health consequences of vaccine-preventable diseases among adults.

The purpose of this cooperative agreement is to develop and implement programs designed to increase adult immunization rates, using the principles of the Standards for Adult Immunization Practice. Barriers that exist for improving vaccination rates in adults include limited patient awareness of the need for vaccines as an adult, shortcomings in procedures for incorporating adult immunizations into routine patient care structure, and documentation of adult immunizations, including limited use of immunization information systems (IIS) by adult vaccine providers. The Standards address a number of current issues in adult immunization, including: • Missed opportunities because many healthcare professionals are not routinely assessing vaccination status. • Different challenges for improving adult immunization rates, in contrast to pediatric immunization. Adult patients have multiple providers and multiple insurance/reimbursement scenarios. Clinical decision making around needed adult vaccination can sometimes be more complex and often requires a more advanced use of IIS or electronic health records. • Reducing immunization rate disparities will depend on making immunization a standardized, routine and efficient service for all adult patients To address barriers and reduce missed opportunities, the Standards for Adult Immunization Practice were approved by the National Vaccine Advisory Committee in 2013 and were published in Public Health Reports in February 2014. The Standards for Adult Immunization Practice call on healthcare providers to develop new approaches to assess, recommend, give and document immunizations. In the first phase of the project, the Demonstration Phase, the activities will focus on a target group of healthcare providers, and help them to improve their immunization services for a group of real patients. In the second phase of the project, the Dissemination Phase, efforts will focus on implementing effective models among a wider national audience of healthcare providers. Applicants should be national organizations representing a significant membership of healthcare providers who are licensed to immunize, such as primary or specialist physicians, nurses, or pharmacists. They must demonstrate reach into both the clinical setting on a local level, as well as the capacity for making impact on a national level. As noted by Williams et al, “Successful vac¬cination programs combine 1) education of potential vaccine recipients and publicity to promote vaccination, 2) increased access to vaccination services in health care settings, and 3) use of practices shown to improve vaccination coverage, including reminder-recall systems, efforts to remove administrative and financial barriers to vaccination, use of standing order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members. Health care provider recom¬mendations for vaccination are associated with patients’ receipt of vaccines. Routine assessment of adult patient vaccination needs, recommendation, and offer of needed vaccinations for adults should be incorporated into routine clinical care of adults. “ Source: http://www.cdc .gov/Mmwr/preview/mmwrhtml/mm6404a6.htm Evidence-based strategies for increasing immunization rates have been previously identified in the Guide to Community Preventive Services and other reputable science-driven sources. However, new approaches are needed for selecting, combining and implementing the most effective impact-driven strategies to increase adult immunization rates. This funding opportunity is designed to bring about new approaches to the provision of adult immunization services. The FOA seeks efforts that demonstrate successful models of the “technical package”, as defined by CDC Director Thomas Frieden as “a selected group of related interventions, that together, will achieve and sustain synergistic improvements in a specific risk factor or disease outcome.” Source: http://www.ncbi.nlm.nih.gov/pubmed/24228653

b. Statutory Authorities

This program is authorized under section 317(k)(1) of the Public Health Service Act [42 US. C. 247b(k)(1)]. Under this statutory authority, for-profit entities are not eligible.

c. Healthy People 2020

Measurable outcomes of the program will be in alignment with Healthy People 2020 goals for immunization and infectious disease. Source: http ://www.healthypeople.gov/ These include but are not limited to specific objectives: (IID-1) Reduce, eliminate, or maintain elimination of cases of vaccine-preventable diseases Influenza Vaccination Goals for Adults IID-12.12 Increase the percentage of adults aged 18 and older who are vaccinated annually against seasonal influenza IID-12.13 Increase the percentage of health care personnel who are vaccinated annually against seasonal influenza IID-12.14 (Developmental) Increase the percentage of pregnant women who are vaccinated annually against seasonal influenza Hepatitis B Vaccination Goals for Adults IID-15 (Developmental) Increase hepatitis B vaccine coverage among high-risk populations IID-15.1 (Developmental) Increase hepatitis B vaccine coverage among long-term hemodialysis patients IID-15.2 (Developmental) Increase hepatitis B vaccine coverage among men who have sex with men IID-15.3 Increase hepatitis B vaccine coverage among health care personnel IID-15.4 (Developmental) Increase hepatitis B vaccine coverage among injection drug users Pneumococcal Vaccination Goals for Adults IID-13 Increase the percentage of adults who are vaccinated against pneumococcal disease IID-13.1 Increase the percentage of noninstitutionalized adults aged 65 years and older who are vaccinated against pneumococcal disease IID-13.2 Increase the percentage of noninstitutionalized high-risk adults aged 18 to 64 years who are vaccinated against pneumococcal disease IID-13.3 Increase the percentage of institutionalized adults (persons aged 18 years and older in long-term or nursing homes) who are vaccinated against pneumococcal disease Zoster Vaccination Goals for Adults IID-14 Increase the percentage of adults who are vaccinated against zoster (shingles) In addition, HP2020’s Health Communication and Health Information Technology objectives point to importance of using the internet and social media. These include: (HC/HIT-8) Increase the proportion of quality, health-related websites and (HC/HIT-13) (Developmental) increase social marketing in health promotion and disease prevention. Source: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topic Id=23

d. Other National Public Health Priorities and Strategies http://www.cdc.gov/Mmwr/preview/mmwrhtml/mm6404a6.htm http://www.cdc.gov/Mmwr/preview/mmwrhtml/mm6404a6.htm http://www.ncbi.nlm.nih.gov/pubmed/24228653 http://www.healthypeople.gov/ http://www.healthypeople.gov/ http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=23 http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=23

This FOA aligns and supports other relevant national strategies: Standards for Adult Immunization Practice: This FOA aims to develop models of Standards Implementation and demonstrate the practicalities of improved immunization assessment, service delivery, documentation and referral.

Source: http://www.cdc.gov/vaccines/hcp/patient-ed/adults/for-practice/standards/index.html Community Preventive Services Task Force This FOA direct applicants to propose evidence-based interventions, drawing on the Community Preventive Services Task Force findings. Among the relevant evidence-based intervention identified in the Community Guide: Reminder-recall. Standing orders Provider Assessment and Feedback Use of IIS Health systems interventions Multi-component interventions, rather than stand-alone unilateral activities While evidence-based interventions have been identified, new approaches are needed in the selection, combination and implementation of a set of interventions that results in immunization rate increases. Source: http://www.thecommunityguide.org/vaccines/vpd-jphpm-recs-IIS.pdf HHS Action Plan to Reduce Racial and Ethnic Health Disparities This plan calls on HHS agencies to work to promote integrated approaches, evidence-based programs and best practices to reduce health disparities. A number of adult immunization disparities persist and may be worsening. This project aims to develop small models on the practice or community level that ensure standardized and routine provision of immunization services across all demographic categories of adult patients.

Source: http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&;lvlid=33&;ID=285 The “Pathway to Leadership” report, and the now emerging National Adult Immunization Plan. The Pathway to Leadership report was approved by the National Vaccine Advisory Committee on June 14, 2011. A new national adult immunization plan is emerging, under the leadership of the National Vaccine Program Office. To date, these national plans have developed recommendations for establishing a comprehensive, sustainable, national adult immunization program to ensure adults are up-to-date on their recommended immunizations. Among the recommendations targeting healthcare providers, these national plans call for:

Education of providers on quality improvement/quality assurance activities Education of providers on standards of care and immunization practice Improving and expanding immunization information systems for adult vaccinations Source: http://www.publichealthreports.org/issueopen.cfm ?articleID=2762 National Adult and Influenza Immunization Summit The National Adult and Influenza Immunization Summit (NAIIS) is dedicated to addressing and resolving adult and influenza immunization issues. A key priority for the Summit is the implementation of the Standards of Adult Immunization Practice The NAIIS now consists of over 400 partners, representing more than 100 public and private organizations. Summit participants include a wide range of stakeholders from the healthcare industry, public health and private medical sectors, vaccine manufacturers and distributors and consumers. Source: www. izsummitpartners.org

e. Relevant Work

CDC’s National Center for Immunization and Respiratory Diseases is focused on reducing death and disability from vaccine-preventable diseases.

Raising adult immunization rates and reducing disparities are important imperatives. NCIRD works on a number of fronts to increase adult immunization rates, including through the mechanisms of the National Adult and Influenza Immunization Summit and through the Standards for Adult Immunization Practice.

2. CDC Project Description

a. Approach

Activities of National

Association/Professional Society

Short term Outcomes Among

TARGETED HEALTHCARE

PROVIDERS

Intermediate Outcomes

AMONG

National Audience of Healthcare Providers

In This Category

Long-term Outcomes

AMONG

All HEALTHCARE

PROVIDERS

in this Category

Activities of National Association/Professional Society

In Demonstration Phase ONE:

Review, select, and implement relevant activities helping their

TARGETED HEALTHCARE

PROVIDERS improve the immunization rates of their adult patients.

Document, analyze and collate practices and successes among Targeted Healthcare Providers

In Dissemination Phase TWO:

In Demonstration Phase ONE

TARGETED HEALTHCARE

PROVIDERS will take actions to improve immunization rates among their adult patients, resulting in these outcomes:

- Increased documentation of the vaccination assessment in patient charts, as a routine practice

- Increased or improved provider recommendations

- Improved provision of immunization services at point of care, as measured through quality improvement activities

- Changes in (adult) patient care procedures to ensure appropriate immunization assessment, recommendation and/or documentation.

Includes changes in immunization referral procedures, where appropriate.

-Evidence of collaboration and immunization data exchange among multiple categories of providers who share a defined pool of adult patients.

-Increased number of providers documenting adult immunizations in state

Among the defined NATIONAL

AUDIENCE OF HEALTHCARE

PROVIDERS

The vaccination assessment becomes a routine and integral part of healthcare visits of adult patients Adult patients are aware of the vaccines that are recommended for them, because of their provider’s recommendation.

Providers improve their delivery of immunization services, including referral protocols Adult vaccinations are documented in state immunization info registries and in electronic health records A greater degree of collaboration and communication among multiple healthcare providers is achieved, especially in use of immunization information systems.

Other providers nationally adopt best practices for implementing the Standards for Adult Immunization Practice.

Providers routinely assess vaccination status at every healthcare visit.

Providers make strong immunization recommendations to their patients.

Adult patients are up-to-date on their recommended vaccinations.

Adult immunizations are documented in immunization information systems.

Multiple categories of health care providers collaborate and communicate to exchange information on vaccination status of adult patients.

Increased vaccination uptake and coverage rates http://www.cdc.gov/vaccines/hcp/patient-ed/adults/for-practice/standards/index.html http://www.thecommunityguide.org/vaccines/vpd-jphpm-recs-IIS.pdf http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=285 http://www.publichealthreports.org/issueopen.cfm?articleID=2762 http://www.publichealthreports.org/issueopen.cfm?articleID=2762

Disseminate and promote best practices/ successes nationally to NATIONAL AUDIENCE of

HEALTHCARE PROVIDERS

and immunization community immunization registries. .

In Dissemination Phase TWO

AMONG NATIONAL AUDIENCE OF

HEALTHCARE PROVIDERS-

The grantee will generate these short-term outcomes:

- Creation of products/models/tools for a

NATIONAL AUDIENCE OF

HEALTHCARE PROVIDERS that will enable them to improve the immunization rates of their adult patients.

- Verification that the products/models/tools will contribute to improved immunization rates

- Dissemination and promotion of best practices/successes to NATIONAL

AUDIENCE OF HEATLHCARE

PROVIDERS

i. Purpose

Increasing adult immunization rates is a compelling public health problem. The burden of vaccine-preventable diseases is substantial, and largely unnecessary.

The purpose of the cooperative agreement is to develop and implement programs designed to increase adult immunization rates. The aim is to bring about measurable improvements in the routine assessment of vaccination status, the strong provider recommendation, documentation of immunizations, and in measures of immunization service delivery.

This funding opportunity is designed to bring about new approaches to the provision of adult immunization services and to demonstrate successful models leading to immunization rate improvements.

ii. Outcomes

The logic model for this project identifies short, mid and long-term outcomes. Overall, the long-term outcome is an increased number of adult patients who are up-to-date on the vaccines recommended to them by the Advisory Committee on Immunization Practice.

Grantees are expected to show progress on all the short-term outcomes during the project period. They can propose activities that will demonstrate progress in mid or longer term outcomes, as outlined in the logic model for this project.

In Demonstration Phase ONE, TARGETED HEATLHCARE PROVIDERS will take actions to improve immunization rates among their adult patients, resulting in these outcomes:

- Increased documentation of the vaccination assessment in patient charts, as a routine practice

- Increased or improved provider recommendations

- Improved provision of immunization services at point of care, as measured through quality improvement activities

- Changes in (adult) patient care procedures to ensure appropriate immunization assessment, recommendation and/or documentation. Includes changes in immunization referral procedures, where appropriate.

- Changes in immunization documentation procedures so that multiple categories of providers document and exchange immunization information about their patients.

- Increased number of providers documenting adult immunizations in state immunization registries.

In Dissemination Phase TWO, AMONG NATIONAL AUDIENCE OF HEATLHCARE PROVIDERS- The grantee will generate these short-term outcomes:

- Creation of products/models/tools for a NATIONAL AUDIENCE OF HEATLHCARE PROVIDERS that will enable them to improve the immunization rates of their adult patients.

- Verification that the products/models/tools will contribute to improved immunization rates

- Dissemination and promotion of best practices/successes to NATIONAL AUDIENCE OF HEATLHCARE PROVIDERS

iii. Strategies and Activities

The applicant will propose a combination of activities, hereafter referred to as the technical package. The technical package should propose the most cost-efficient, impact-driven set of activities in these areas: 1. Quality improvement; 2. Clinician education and outreach and 3. Changes in (adult) patient care procedures to ensure appropriate immunization assessment, recommendation and/or documentation.

This technical package of activities should be designed to specifically and efficiently achieve project period outcomes. The technical package of activities should reflect a ground-breaking approach, one that could be replicated and make a significant national impact on adult immunization rates.

In order to select and combine strategies and activities for this project, the Standards for Adult Immunization Practice can be used as a tool for identifying missed opportunities, and other opportunities to improve immunization services. As such, the proposed strategies and activities should be based on a planning process that asks these questions:

1. How can we make the vaccination assessment more routine?

2. How can we ensure that providers make strong immunization recommendations to their adult patients?

3. How can we streamline or improve immunization services as measured through quality improvement?

4. How can we better document immunization in IIS and ensure that all of a patient’s healthcare providers have access to that information?

When possible, applicants should use evidence-based strategies as identified by the Community Guide. Applicants may propose strategies and activities to achieve project outcomes that are not described in the Community Guide, but they must then describe the rationale for developing and evaluating new strategies or practice-based interventions. While many evidence-based strategies have been identified, new approaches are needed for selecting, combining and implementing the most effective impact-driven set of activities for increasing adult immunization rates. Whenever possible, work plans should demonstrate ways to make systems changes through more automatic or electronic methodologies, (e.g. tracking immunization rate increases using chart pulls generated from electronic health records, rather than manual chart pulls.)

In Demonstration Phase ONE: In the first phase of the project, efforts will focus on building a successful effective model of adult immunization standards implementation among a smaller target group.

The strategies and activities for the Demonstration Phase are: Review, select, and implement a technical package of activities helping TARGETED HEALTHCARE PROVIDERS improve the immunization rates of their adult patients. Document, analyze and collate practices and successes among Targeted Healthcare Providers In Dissemination Phase TWO: In the second phase of the project, efforts will focus on implementing the national adult immunization standards among a national-level audience of healthcare providers, as targeted by the applicant.

The strategies and activities for the Dissemination Phase of the project are: Disseminate and promote best practices/ successes nationally to NATIONAL AUDIENCE of HEALTHCARE PROVIDERS Applicants should carefully define the target group, both for the first and second phase of the project. They should provide information about the population of adult patients whose immunization rates will be tracked over time in the Demonstration Phase One. They should also carefully define the products, models or tools they will develop for a national audience of healthcare providers in the Dissemination Phase of the project. This could be a model or products such as websites, learning collaboratives, resources, toolkits, examples of patient care protocol changes, peer-to-peer approaches, “how-to” type roadmaps. The applicant must demonstrate how they will verify that such products will be useful to healthcare providers and contribute to improved immunization rates. The application should demonstrate a historical understanding of the models or products that have been previously been developed in order to make the case that the technical package they are now proposing will make a significant contribution to the current adult immunization landscape.

Applicants should propose strategies in the areas of quality improvement, clinician education and outreach; and changes in adult patient care procedures. However, applicants are not required to stratify project activities into these three discrete areas, since they sometimes overlap.

Quality Improvement Activities: Examples might be:

• Use of software/electronic health records or other electronic methodology for tracking and using adult immunization rates • Use of quality improvement project requirements or metrics tracking to strengthen adult immunization rates. • Learning collaboratives or other coaching methodologies • P-D-S-A approaches : (Plan-Do-Study-Act) • Use of office champions or immunization champions tasked to strengthening team approaches • Use of prompts • Better use of information technologies for tracking and improving immunization rates. • Better monitoring of rate changes through run charts or other tools, along with continuous feedback to practice staff Clinician Education and Outreach Activities: Examples might be: • Review, select, and implement relevant activities with the healthcare providers in your constituency/membership that aim to increase adult vaccination rates. • Support and actively facilitate activities such as peer-to-peer training (utilizing CDC tools and CME courses) at clinician conferences grand rounds, or through webinars or other online or in-person education opportunities. • Assess and evaluate change in knowledge, attitudes, and behaviors. • Disseminate to healthcare professionals the practical tools and/or information that will help them to better deliver adult immunization services, including how they assess, recommend and document vaccinations. • Utilize professional clinical mechanisms such as websites, newsletters, professional mailings, and other print and/or electronic media to help promote adult vaccination and ensure that clinicians make strong recommendations and stay up-to-date on current recommendations, their own state or local chapter immunization rates, and national goals for vaccination levels.

Changes in Adult Patient Care Procedures Examples might be:

• Procedures that make immunization assessment of adult patients more routine and efficient • Procedures than ensure a patient receives a strong immunization recommendation from relevant clinical staff. • Job descriptions or job tasks that are rewritten to improve immunization services

• Documentation of immunization is entered in electronic health records and/or statewide immunization information systems • New standing order protocols are put in place • Reminder-recall systems are put in place or upgraded. • Electronic health record systems are adapted to improve adult immunization assessment, recommendation or documentation • Improved methods of communication among multiple categories of healthcare providers, particularly sharing of immunization documentation. • Staff are assigned to monitor quality improvement following changes in patient care procedures, to monitor and assure improvements in service delivery

1.Collaborations

a. With CDC-funded programs:

Applicants must describe intentions to collaborate with CDC to improve technical and program guidance and evaluation.

b. With organizations external to CDC:

Applicants are required to collaborate with external partners that have a role in achieving the FOA outcomes and proposed activities

2. Target Populations

Through the efforts of healthcare providers, this FOA is designed by ensure adult patients are up-to-date on their recommended vaccinations. There are three main target groups of the project, and the parameters are described below.

Applicants should propose activities in two phases: Firstly, in the Demonstration Phase, they should propose activities that demonstrate measurable improvement in the clinical practice setting on a local or regional level targeting real patients and real providers. For the Demonstration Phase, the applicant should define a TARGET GROUP of HEALTHCARE PROVIDERS, and a TARGET GROUP of Adult Patients.

Secondly, in the Dissemination Phase, they should propose activities that make a national impact on national audience of healthcare providers. For the Dissemination Phase, the applicant should define a NATIONAL AUDIENCE of HEALTH CARE PROVIDERS These definitions should include rationale for defining the populations, estimated cost of reaching the target populations, and how selection of these groups will contribute to making an impact on a national level. For each of the respective target populations, the applicant should present cost estimates in reaching these individuals, in order to demonstrate value and reach of their proposed project.

This FOA provides gives general parameters about the three target groups. It is the applicant’s job to further refine and specify the definitions of their selected target groups General Parameters for Defining “TARGETED HEALTHCARE PROVIDERS”: The applicant defines their targeted group of healthcare providers, typically a smaller subset of their large national membership. This group is the target of the project interventions in Phase One, the Demonstration phase. These TARGETED HEALTHCARE PROVIDERS must be clinicians licensed to administer vaccines and they must serve a population of real adult patients on a local-level or large-systems level clinical setting. They could be nurses, general physicians, specialist physicians, pharmacists, medical assistants, physician assistants, or possibly teams of providers. The applicant should explain per capita costs designated to reach this group.

General Parameters for Defining TARGET GROUP of ADULT PATIENTS: “The applicant should define the TARGET GROUP of ADULT PATIENTS, as those who receive care from the TARGETED HEATLHCARE PROVIDERS. In defining the TARGET GROUP of ADULT PATIENTS, the applicant should describe how immunization rates will be determined at baseline and the post-intervention points. The applicant should explain per capita costs designated to reach this group. If relevant, the applicant may document evidence of disparate immunization rates and include actions in their work plan to reduce such immunization rates disparities.

General Parameters for Defining the NATIONAL AUDIENCE OF HEALTHCARE PROVIDERS: This is the national level audience of healthcare providers targeted for Phase Two, the Dissemination Phase. It could be defined as the full membership of the national organization. The applicant should demonstrate why this group should be targeted and its potential for making a national impact on adult immunization rates. The applicant should also explain their organizational capacity for influencing, educating and/or bringing about behavior change in this group. The applicant will explain how effective model/tools/resources will be used by the NATIONAL AUDIENCE of HEALTHCARE PROVIDERS. The applicant should describe how they will ensure the project’s dissemination plan will be utilized by NATIONAL AUDIENCE of HEALTHCARE PROVIDERS. In defining the NATIONAL AUDIENCE OF HEATLHCARE PROVIDERS the applicant should explain per capita costs of reaching the individual healthcare provider in this group. It may discuss other measures for measuring evidence of change in knowledge of behavior. Definition of ALL HEALTHCARE PROVIDERS: In the logic model for this project, the long-term outcomes aim to make an impact on all healthcare providers. The applicant is not required to specify a definition of all immunizing healthcare providers, but they may explain how their applicant-defined target groups of this project could have influence or impact on other healthcare providers

a. Inclusion

Low adult immunization rates are characterized by disparities associated with race, ethnicity, income, insurance coverage and other factors.

Reducing immunization disparities will depend on making immunization a routine standardized service for all patients. Improved office-based practices that standardize and routinize immunizations could significantly impact Healthy People 2020 goals by increasing vaccine uptake among all groups. Rigorous implementation of the Standards for Adult Immunization Standards would help reduce corresponding racial and ethnic disparities. The applicant can provide data to document any relevant disparate immunization rates among their adult patients and identify the most promising interventions at hand for reducing such disparities.

iv. Funding Strategy (for multi-component FOAs only)

Not applicable.

b. Evaluation and Performance Measurement

i. CDC Evaluation and Performance Measurement Strategy

The CDC Strategy for monitoring and evaluating program and awardee performance will include several activities, spanning both process and outcome evaluation and will be consistent with the logic model and approach presented earlier. CDC will monitor process and outcome measures of progress throughout the course of the project. Evaluation of the project should align with the project’s short-term outcomes.

At the start of the project, CDC and the awardee will review the project work plan and evaluation strategy, ensuring process and outcome measures are concrete and achievable, and represent the best use of funding. The focus is on the SIX outcomes in the Demonstration Phase and THREE outcomes in the Dissemination Phase. Project modifications may occur, if merited. Awardees will submit further details or revisions to their Awardee Evaluation and Performance Management Plan six months following the award date.

CDC’s evaluation and performance measurement strategy will be to ensure the applicants’ proposed outcome and process measures are consistent with the purpose of the funding announcement opportunity. Applicants are directed to propose outcome and process measures that will demonstrate achievement relevant to these evaluation questions:

Evaluation Questions for Demonstration Phase Outcome Number 1: Increased documentation of the vaccination assessment in patient charts, as a routine practice Was there an increase in the routine vaccination assessment, as measured through documentation in patient records? Were new technologies or procedures utilized to streamline the vaccine assessment? Did healthcare provider use immunization information systems to prospectively screen or forecast for vaccination needs? Did multiple categories of providers communicate to determine vaccination status, appropriate intervals or medical conditions that impact vaccination decision-making? (* E.g. Pharmacists and primary care providers ). Were state-based IIS used prospectively to check on patients’ immunization status?

Evaluation Questions for Demonstration Phase Outcome Number 2: Increased or improved provider recommendations Were the immunization recommendations that providers make to their patients improved? Were the immunization recommendations made in a stronger way or in a more routine way? Were the procedures for making immunization recommendations improved or made more efficient? Did changes occur in the clinic set-up or patient flow procedures that resulted in a strong provider recommendation? Can a stronger provider recommendation be demonstrated through changes in patient care procedures either, before, during or after the office visit? Can stronger provider recommendations be demonstrated by an increase in immunization rates?

Evaluation Questions for Demonstration Phase Outcome Number 3: Improved provision of immunization services at point of care, as measured through quality improvement activities Were improvements in adult immunization services achieved? Did immunization rates increase among the adult patients targeted? Did quality improvement efforts result in increased immunization rates? If immunization rates did not increase, were the resulting lessons learned acted upon? Did referral procedures improve? If relevant, were disparities in immunization rates detectable? Could disparities be monitored and/or addressed through these quality improvement activities?

Evaluation Questions for Demonstration Phase Outcome Number 4: Changes in (adult) patient care procedures to ensure appropriate immunization assessment, recommendation and/or documentation. Includes changes in immunization referral procedures, where appropriate. Were there changes in (adult) patient care procedures to ensure appropriate immunization assessment, recommendation and/or documentation? Were new or improved systems of referral put in place? Were new procedures put in place either before, during or after the patient encounter? Did new patient care procedures result in increases in adult immunization rates?

Evaluation Questions for Demonstration Phase Outcome Number 5: Evidence of collaboration and immunization data exchange among multiple categories of providers who share a defined pool of adult patients. Were there improvements in how immunizations are documented in immunization information systems (IIS) or in electronic health records? Was there an increase in the exchange of immunization information among multiple categories of providers? Did providers use IIS or EHR data to help them forecast vaccine needs or ensure appropriate minimum intervals between vaccine doses? Did patients have greater access to their personal immunization record? Did multiple categories of healthcare provider work together to streamline immunization assessment, documentation, and/or recommendation of immunization? Did other collaborations among multiple categories of providers result in increased immunization rates of their shared patients, through improvements in vaccine ordering, inventory or forecasting procedures?

Evaluation Questions for Demonstration Phase Outcome Number 6: Increased number of providers documenting adult immunizations in state immunization registries. Was there an increased number of providers documenting adult immunizations in state immunization registries? Was there an increased number of patient records in the immunization registry? Was there an increased number of (adult) providers who registered as new users in their state IIS? Did different categories of healthcare providers share patient information about a shared pool of patients? Did patients have better access to their own immunization records? Was there evidence of greater reliance on state immunization registries?

Evaluation Questions for Dissemination Phase Outcome Number 1:

Creation of products/models/tools for a NATIONAL AUDIENCE OF HEALTHCARE PROVIDERS that will enable them to improve the immunization rates of their adult patients. Did the project identify and develop useful national-level products to increase adult immunization rates?

If the project is developing a model of change, is it clear what the model consists of, and why it will be used by healthcare providers? Does the definition of the national-level products reflect an expert understanding of the landscape of adult immunization? Does the definition of the national-level products demonstrate expert knowledge of the state of the art and of the successes and failures to date in the field of immunization?

Evaluation Questions for Dissemination Phase Outcome Number 2: Verification that the products/models/tools will contribute to improved immunization rates Did the project evaluate the effectiveness or utility of their national-level products? Will healthcare providers perceive the national-level products as helpful to them? Did the project demonstrate that the national-level products will be used or have been used by a national-level audience of healthcare providers? Did the project demonstrate that use of the national-level products contribute to improved immunization rates?

Evaluation Questions for Dissemination Phase Outcome Number 3: Dissemination and promotion of best practices/successes to NATIONAL AUDIENCE OF HEALTHCARE PROVIDERS Did the project disseminate their national-level products to their national target audience? Did the project demonstrate use of the national-level products among their target audience? Did the project demonstrate changes in knowledge or behavior of their target audience?

Potential Process Measures: Phase One: Strategy: Review, select, and implement relevant activities helping their TARGETED HEALTHCARE PROVIDERS improve the immunization rates of their adult patients. Measure: Existence of inventory of relevant activities that have been selected through formal review and take into account the needs of the service area?

Strategy: Document, analyze and collate practices and successes among Targeted Healthcare Providers Measure: Existence of inventory of best practices and successes extracted from the experience of the targeted providers.

Phase Two: Strategy: Disseminate and promote best practices/ successes nationally to NATIONAL AUDIENCE of HEALTHCARE PROVIDERS and immunization community Measure: Existence of a dissemination and promotion plan that uses appropriate channels to reach the national audiences.

ii. Applicant Evaluation and Performance Measurement Plan

Applicants must provide an initial evaluation and performance measurement plan to show how they will identify progress in implementing activities in their program strategies and achieving their selected outcomes. Applicants will already have described measurable objectives in the work plan referenced above. In this section, they will refine those into performance measures and add details of any additional evaluation to be completed.

Applicants should also:

+ Describe how the target population will be engaged in the evaluation and performance measurement planning process;

+ Describe potentially available data sources and feasibility of collecting appropriate evaluation and performance data;

+ Describe how evaluation findings will be used for continuous program/ quality improvement; and + Describe how evaluation and performance measurement will contribute to development of the evidence base for improving immunization rates and enhancing disease prevention.

Here is guidance for the applicant as they develop their evaluation and performance measurement plan. This guidance provide examples of possible outcomes.

Demonstration Phase Outcomes:

In the Demonstration Phase, the applicant will propose working with a target group of healthcare providers in order to improve immunization rates of a target group of adult patients. The outcomes they plan to accomplish will largely depend on how they define these target groups of both patients and providers. Applicants are encouraged to neither over-estimate nor under-estimate what they can accomplish. Process measure likely will focus on such factors as: patient encounters, services rendered, distribution numbers to national-level of healthcare providers, number of providers educated or participating in other type of interventions. Outcome measures are more likely to demonstrate system change and be sustainable or permanent accomplishments.

Demonstration Phase Outcome: Increased documentation of the vaccination assessment in patient charts, as a routine practice Was there an increase in the routine vaccination assessment, as measured through documentation in patient records? Were new technologies or procedures utilized to streamline the vaccine assessment? Did healthcare provider use immunization information systems to prospectively screen or forecast for vaccination needs? Did multiple categories of providers communicate to determine vaccination status, appropriate intervals or medical conditions that impact vaccination decision-making? (* E.g. Pharmacists and primary care providers ). Were state-based IIS used prospectively to check on patients’ immunization status?

Demonstration Phase Outcome: Increased or improved provider recommendations Were the immunization recommendations that providers make to their patients improved? Were the immunization recommendations made in a stronger way or in a more routine way? Were the procedures for making immunization recommendations improved or made more efficient? Did changes occur in the clinic set-up or patient flow procedures that resulted in a strong provider recommendation? Can a stronger provider recommendation be demonstrated through changes in patient care procedures either, before, during or after the office visit? Can stronger provider recommendations be demonstrated by an increase in immunization rates?

Demonstration Phase Outcome: Improved provision of immunization services at point of care, as measured through quality improvement activities Were improvements in adult immunization services achieved? Did immunization rates increase among the adult patients targeted? Did quality improvement efforts result in increased immunization rates? If immunization rates did not increase, were the resulting lessons learned acted upon?

Did referral procedures improve?ý If relevant, were disparities in immunization rates detectable? Could disparities be monitored and/or addressed through these quality improvement activities?

Demonstration Phase Outcome: Changes in (adult) patient care procedures to ensure appropriate immunization assessment, recommendation and/or documentation. Includes changes in immunization referral procedures, where appropriate.

Were there changes in (adult) patient care procedures to ensure appropriate immunization assessment, recommendation and/or documentation?

Were new or improved systems of referral put in place? Were new procedures put in place either before, during or after the patient encounter? Did new patient care procedures result in increases in adult immunization rates?

Demonstration Phase Outcome: Evidence of collaboration and immunization data exchange among multiple categories of providers who share a defined pool of adult patients.

Were there improvements in how immunizations are documented in immunization information systems (IIS) or in electronic health records? Was there an increase in the exchange of immunization information among multiple categories of providers? Did providers use IIS or EHR data to help them forecast vaccine needs or ensure appropriate minimum intervals between vaccine doses? Did patients have greater access to their personal immunization record? Did multiple categories of healthcare provider work together to streamline immunization assessment, documentation, and/or recommendation of immunization? Did other collaborations among multiple categories of providers result in increased immunization rates of their shared patients, through improvements in vaccine ordering, inventory or forecasting procedures?

Demonstration Phase Outcome: Increased number of providers documenting adult immunizations in state immunization registries.

Was there an increased number of providers documenting adult immunizations in state immunization registries? Was there an increased number of patient records in the immunization registry? Was there an increased number of (adult) providers who registered as new users in their state IIS?

Did different categories of healthcare providers share patient information about a shared pool of patients? Did patients have better access to their own immunization records? Was there evidence of greater reliance on state immunization registries?

DISSEMINATION PHASE OUTCOMES

Successful outcomes in the Dissemination Phase Two of the project will depend on the products/model/tools/resources that are developed, hereafter referred to as the "national-level products."

What the applicant develops and disseminates is applicant-defined. National-level products should be designed to make national impact.

National-level products could be some combination of…