The Impact of Influenza on Elderly Residents
Vaccination Recommendations for LTCFs
Tool: Influenza Vaccination: Fiction vs. Fact
Preparing for Seasonal Flu
How to Recognize Signs and Symptoms of Influenza in the Elderly When the Virus is Circulating in the Community
Guidelines for Managing an Influenza Outbreak
Influenza Outbreak Control Checklist and Healthy Hands Campaign
Sample Letter to Families of Residents in the Event of an Influenza Outbreak
Sample Call Script for Notifying Family Members
Sample Press Release to Inform Media of a Flu Outbreak
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This handout provides tips to stay healthy, promotes proper antibiotic use and encourages
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There are a number of state and federal agencies, provider organizations and consumer groups that advocate and effectuate policy related to funding, licensure and consumer protection.
Department of Health and Human Services (HHS) - is the United States Government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. The department includes more than 300 programs such as health and social science research, preventing disease, including immunization services, Medicare (health insurance for elderly and disabled Americans) and Medicaid (health insurance for low-income people), and services for older Americans.
Centers for Medicare & Medicaid Services (CMS) - CMS administers the Medicare and Medicaid programs which provide health care to almost one in every three Americans. Medicare provides health insurance for more than 44.6 million elderly and disabled Americans. Medicaid, a joint federal-state program, provides health coverage for some 50 million low-income persons, including 24 million children, and nursing home coverage for low-income elderly. CMS also administers the State Children's Health Insurance Program that covers more than 4.4 million children.
Open Door Forums - "Open Door Forums" provide an opportunity for live dialogue between CMS and the provider community at large, in order to understand and help find solutions to contemporary program issues. The Skilled Nursing Facilities / Long-Term Care Open Door Forum (ODF) addresses the concerns and issues of the Medicare SNF, the Medicaid NF, and the nursing home industry generally.
Centers for Disease Control and Prevention (CDC) - Working with states and other partners, CDC provides a system of health surveillance to monitor and prevent disease outbreaks (including bioterrorism), implement disease prevention strategies, and maintain national health statistics. It provides for immunization services, workplace safety, and environmental disease prevention.
Administration on Aging (AOA) - AOA supports a nationwide aging network, providing services to the elderly, especially to enable them to remain independent. Supports some 240 million meals for the elderly each year, including home-delivered "meals on wheels." Helps provide transportation and at-
home services. It supports ombudsman services for elderly, and provides policy leadership on aging issues.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) - An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 15,000 health care organizations and programs in the United States in order to improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations
The California Department of Aging (CDA) - Administers programs that serve older adults, adults with disabilities, family caregivers, and residents in long-term care facilities throughout the State. The Department administers funds allocated under the federal Old Americans Act, the Older Californians Act, and through the Medi-Cal program. The department contracts with the network of Area Agencies on Aging. The area agencies directly manage a wide array of federal and state-funded services that help older adults find employment, support older and disabled individuals to live as independently as possible in the community, promote healthy aging and community involvement, and assist family members in their vital care giving role. CDA also contracts directly with agencies that operate the Multipurpose Senior Services Program through the Medi-Cal Home and Community-Based Waiver for the elderly, and certifies Adult Day Health Care centers for the Medi-Cal program.
California Department of Public Health (CDPH) - Health care facilities in California are licensed, regulated, inspected, and/or certified by a number of public and private agencies at the state and federal levels, including the California Department of Public Health (CDPH) Licensing and Certification Program (L&C) and the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services (CMS). These agencies have separate, yet sometimes overlapping, -- jurisdictions. L&C is responsible for ensuring health care facilities comply with state laws and regulations. In addition, L&C cooperates with CMS to ensure that facilities accepting Medicare and Medi-Cal (in California, Medicaid is referred to as Medi-Cal) payments meet federal requirements. L&C also oversees the certification of nurse assistants, home health aides, hemodialysis technicians, and the licensing of nursing home administrators.
Office of Statewide Health Planning and Development (OSHPD) - One of 13 departments within the California Health and Human Services Agency. OSHPD administers programs which endeavor to implement the vision of
"Equitable Healthcare Accessibility for California."
California Department of Social Services (CDSS), Community Care Licensing Division – CCLD Provides oversight and enforcement for more than 85,000 licensed facilities statewide serving such clients as children, parents and the elderly. Those facilities include Adult and Elderly Facilities, Adult Day
Programs, Adult Residential Facilities, Residential Care Facilities for the Elderly (RCFE), and Continuing Care Retirement Communities (CCRCs).
California Conference of Local Health Officers (CCLHO) - Provides a state/local forum for the discussion of significant health issues in order to develop recommendations for appropriate health policy. Its various program committees consider technical and policy issues in communicable disease control and prevention, health promotion and chronic disease prevention, environmental health, emergency/disaster/terrorism preparedness, and health surveillance and data.
California Association of Public Authorities for IHSS (CAPA) - A non-profit association comprised of the IHSS Public Authorities in California created to provide proactive leadership to improve the IHSS program in California. There are 56 Public Authority IHSS agencies throughout California’s 58 counties and they serve more than 400,749 consumers and 420,215 caregivers.
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California Association of Health Facilities (CAHF) - A non-profit professional association for long-term care providers. CAHF's membership is comprised of more than 1,400 licensed nonprofit and proprietary health facilities serving a wide spectrum of needs in a variety of settings.
Aging Services of California - (formerly California Association of Homes and Services for the Aging) - Represents more than 400 nonprofit providers of senior living and care – including affordable housing, continuing care retirement communities, assisted living, skilled nursing, and home- and community-based care.
California Association of Long Term Care Medicine (CALTCM) – An organization made up of long term care physicians and other long term care professionals that focuses on individualized medical care, a team approach, and the integration of medical science with personalized care.
California Assisted Living Association (CALA) - Represents over 400 Assisted Living communities. Members range from small independently operated communities to large multi-national organizations, and from providers that cater to an active lifestyle, to those that specialize in caring for residents with dementia.
California Association of Adult Day Services (CAADS) - A non-profit statewide association to support the development of adult day services as an alternative to institutional care. CAADS members include providers, local government, case managers, consultants, vendors, and others interested in supporting the mission of the organization.
California Association for Health Services at Home (CAHSAH) - represents more than 556 members and 850 offices that are direct providers of health and supportive services and products in the home. Members include Medicare-certified home health agencies, licensed home health agencies, hospices, private duty organizations, home medical equipment providers, home infusion pharmacy providers, and interdisciplinary professional services.
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Pharmacy Foundation of California - A non-profit corporation with a newly-established mission to serve the pharmacy-related needs of the California public by collaborating with government agencies, public and private foundations, and educational institutions to conduct research, education and information dissemination.
California Pharmacists Association (CPhA) - Represents pharmacy professionals from all practice settings. Its mission is to promote, expand and defend the profession of pharmacy and the role of pharmacists in California.
California Medical Association (CMA) – represents physicians based on the type of practice they are in—solo/small group; medium; large and very large group; academic; hospital-based; or government employed. CMA has more than 35,000 members in all modes of practice and specialties.
Network of Ethnic Physician Organizations (NEPO) – with the support of the CMA Foundation, the Network, comprised of over 40 ethnic physician organizations is engaged in policy advocacy and provides a resource to link ethnic physicians with community and patient groups to address critical health issues.
California Senior Legislature - A volunteer body whose primary mission is to gather ideas for legislation at the state and federal levels, craft the ideas into formal proposals, prioritize the proposals, present them to members of the Legislature or the Congress, and advocate for laws implementing the ideas.
California Advocates for Nursing Home Reform (CANHR) - A nonprofit advocacy organization dedicated to improving the choices, care and quality of life for California’s long term care consumers.
Older Women’s League - A nonprofit membership organization organized to achieve economic and social equity for older women, to improve their image and status, and to provide for mutual support. Through research, education and advocacy activities, OWL chapters and at-large members throughout the United States address the economic, social and health problems women face as they become older.
California Nurses Association (CNA) – along with its national arm, the National Nurses Organizing Committee, presently has 80,000 members in 50 states, representing nurses at scores of hospitals, clinics, and home health agencies. Since 2000, more than 19,000 RNs at 50 hospitals have elected to affiliate with CNA.
SEIU California State Council – Represents over 700,000 members in California, with more than 2 million members nationwide. SEIU members include homecare (IHSS) providers, nurses, human service and developmental disability workers and hospital and health professionals, and nursing home workers.
Vaccination in Skilled Nursing Facilities
Influenza vaccination is the cornerstone for influenza prevention. Influenza vaccine effectiveness varies in older adults. However, influenza vaccination is still effective at preventing severe illness, secondary complications and death. Studies have shown that nursing homes with high rates of vaccinated residents and staff have fewer outbreaks of influenza than nursing homes with lower vaccination rates.
(See “Influenza in the Nursing Home,” American Family Physician, January 1, 2004.)
In other words, vaccinations of nursing home residents and staff can significantly decrease rates of
hospitalization, pneumonia and related mortality. The Federal Government requires that all nursing homes
serving Medicare and Medicaid patients provide the vaccine to all residents if they would like to be
vaccinated. CDC researchers report that, nationally, not all residents of nursing homes receive influenza vaccinations even though Medicare has fully covered immunization costs for influenza since 1993 (Gorina, Kelly, Lubitz et al., 2008). In 2004, only 63.7 percent of residents of nursing homes received the influenza vaccine in the previous year. In other words, older adults covered by Medicare Part B pay no coinsurance or deductible for their flu shot, as long as they receive it from a Medicare provider. Vaccinations administered in long-term care facilities are covered under the Medicare Part B. Program. Current law also requires the facility to obtain informed consent for the immunization services from the resident or legally authorized guardian.
Vaccination Rates of Health Care Workers and Family Members
Vaccination of health care workers and family members can also prevent the spread of infection to long-term care residents. Despite the availability of safe and effective vaccines, many susceptible adults are not being immunized.
The CDC recommends that persons who live with or care for persons at high risk (for example, health care workers and individuals within a household who have frequent contact with persons at high risk and who can transmit influenza to those persons at high risk) receive annual influenza vaccinations.
CMS conditions of participation for nursing facilities (42 CFR 483.65) require nursing facilities to establish and maintain an infection control program designed to prevent the development and transmission of disease and infection. The Occupational Safety and Health Administration (OSHA) strongly supports the CDC guidelines for immunization of health care workers. However, in California, no requirement exists to do more than make the vaccine available. In California, there is no requirement that nursing home staff be vaccinated against seasonal influenza.
As of July 1, 2007, JCAHO requires that all staff of LTC facilities be offered the influenza vaccine. Also in July 2007, the CDC’s Advisory Committee on Immunization Practices (ACIP) recommended vaccination of all healthcare workers and that healthcare administrators consider vaccination coverage levels as a measure of patient safety quality programs and that administrators obtain signed declinations from workers who opt out of seasonal influenza vaccination for reasons other than medical contraindications.
A law passed in California in 2005 permits, but does not require, standing orders for residents of skilled nursing facilities age 50 and older to receive the influenza vaccination. No standing orders are in force in California, however, for vaccination of skilled nursing personnel. All that is allowed in California is the
encouragement of skilled nursing facilities to make a “concerted” effort to ensure the annual vaccination of their staff, beginning in October each year. Efforts to require standing orders for the vaccination of skilled nursing personnel for influenza and pneumococcal disease have been opposed by CAHF citing their low Medicare and Medicaid reimbursement rates and the increased vaccination costs. To date, their arguments have won out in the California legislature.
Beyond Immunization – Practicing Good Hygiene
While vaccination is critical for flu prevention among older adults, some people who receive the vaccination will still get influenza. Practicing good hygiene can help people avoid catching or spreading the flu. This includes frequent hand washing, covering the nose and mouth when coughing or sneezing, followed up by hand washing. Those who are well should stay away, when possible, from those who are sick.
Healthcare providers, older adults, and family members and friends of older adults should be educated in these common sense flu prevention measures.
Outbreak Management in Skilled Nursing Facilities
Seasonal influenza can be expected in communities between mid-October and April each year.
Most skilled nursing facilities in California do not have a timely, effective mechanism to track the
spread of seasonal influenza in their community. A good source of information to monitor flu activity is the FluSTAR web site, www.fluSTAR.com. This website offers real-time surveillance for tracking flu, identifies influenza outbreaks at the regional (and national) level and reports weekly data from multiple sources.
A seasonal influenza outbreak is defined in the Seasonal Influenza Guidance distributed by the California Department of Public Health as two or more cases of acute respiratory infection (with or without fever) occurring within 48 to 72 hours. An outbreak is a sudden increase in the number of cases of acute respiratory infection over the normal background rate or when any resident tests positive for influenza virus.
Communication about influenza outbreaks in the community is an important feature in curbing the spread of the disease. Long-term care facilities and nursing homes should consider contacting families of residents (via letters and phone calls) in the event of an influenza outbreak regarding restriction of visitation, flu shots and hand washing.
Skilled Nursing Facilities must document per the physicians (regarding influenza vaccinations for residents) that patients were offered/refused and, or received their vaccinations. The percentage of residents who receive the vaccine is reported as a federally required Quality Measure at ( www.medicare.gov/NHCompare), Nursing Home Compare.
CDPH sends annual guidance to facilities on managing flu (www.cdph.ca.gov) Recommendations for the Prevention, Detection, and Control of Influenza in California Long-Term Care Facilities, November 13, 2007). www.medicare.gov/NHCompare . Yearly, the CDC also provides a health advisory on influenza antiviral use.
Information and toolkits to assist acute care and long-term care health care facilities immunize healthcare workers are available at the California Adult Immunization Coalition website at http://immunizecaadults.org.
Title 17, California Code of Regulations (Local County Health Officer Reporting) requires that every health care provider, knowing of or in attendance on a case or suspected case of any of the diseases or conditions listed (including influenza), to report to the local health officer for the jurisdiction where the patient resides. The administrator of a facility who knows of or suspects an outbreak of disease within the facility shall establish and be responsible for administrative procedures to assure that reports are made to the local officer.
American Lung Association
Find a Flu Clinic
Maxim Health Systems
Flu Shot Locator