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Influenza Vaccination of Nursing Home/ Skilled Nursing Facility Residents

CBE ID
0432
1.4 Project
National Voluntary Consensus Standards for Influenza and Pneumococcal Immunizations
Endorsement Status
Endorsement Removed
1.1 New or Maintenance
Maintenance
Previous Endorsement Cycle
Fall 2010
Is Under Review
No
1.3 Measure Description

Percent of nursing home/ skilled nursing facility residents given the influenza vaccination during the flu season.

    • 1.14 Numerator

      The number of residents in the denominator who meet any of the following criteria for the most recently completed influenza season (October 1 through March 31):
      (1) received the influenza vaccine within or outside the facility during the flu season (computed separately); or
      (2) were offered and declined the vaccination (computed separately); or
      (3) were determined to be ineligible due to medical contraindication(s) (computed separately) (i.e., anaphylactic hypersensitivity to eggs or other component(s) of the vaccine, history of Guillain-Barré syndrome within 6 weeks after a previous influenza vaccination, bone marrow transplant within past 6 months).

    • 1.15 Denominator

      The measure will be stratified by resident population. Rates will be reported separately for the long-stay (chronic care) and short-stay (post-acute care) populations.

      Denominator Statement for Chronic Care (Long-Stay) Residents
      All residents in the chronic care influenza vaccination sample with a valid MDS target record (any assessment or discharge tracking form) during the influenza vaccination reporting period (October 1 through June 30).

      Chronic Care Influenza Vaccination Sample Definition
      The chronic care influenza vaccination sample includes residents meeting any of the following three conditions indicating a non-PPS stay during the season:

      (1) resident has a non-PPS assessment during the influenza season (October 1 through March 31); or
      (2) resident has a discharge tracking form during the season and the prior MDS record was a non-PPS assessment within 100 days prior to discharge; or
      (3) resident had a stay with days during the season and was discharged prior to completion of an initial assessment. (Note that the discharge can be after the flu season end.)

      Denominator Statement for Post-Acute Care (Short-Stay) Residents
      All residents in the post-acute care influenza vaccination sample with a valid MDS target record (any assessment or discharge) in the influenza vaccination reporting period (October 1 through June 30).

      Post-Acute Care Influenza Vaccination Sample Definition
      The post-acute care influenza vaccination sample includes residents meeting either of the following conditions:

      (1) resident has a PPS assessment during the influenza season; or
      (2) resident has a PPS assessment before the season with the next record being a discharge during the season


      Denominator Statement for Post-Acute Care (Short-Stay) Residents
      All residents in the post-acute care influenza vaccination sample with a valid MDS target record (any assessment or discharge) in the influenza vaccination reporting period (October 1 through June 30).
      Post-Acute Care Influenza Vaccination Sample Definition
      The post-acute care influenza vaccination sample includes residents meeting either of the following conditions:
      (1) resident has a PPS assessment during the influenza season; or
      (2) resident has a PPS assessment before the season with the next record being a discharge during the season.

    • Exclusions

      Resident-Level Exclusions
      Residents satisfying any of the following conditions on the selected target assessment or discharge are excluded from the denominator:

      (1) The resident was not in the facility during the influenza season.

      Note: Residents are not excluded if either or both of the influenza vaccine items (W2a and W2b) have dash (-) values indicating inability to determine.

      Facility-Level Exclusions
      Facilities with small sample sizes are excluded from public reporting of the influenza vaccination measure.

      Chronic Care Facility-Level Exclusions
      Facilities are excluded if either of the following is true:

      (1) the chronic care influenza vaccination sample includes fewer than 30 residents; or
      (2) the facility has fewer than 30 non-PPS quarterly assessments (AA8a = 05) for the entire facility for the year ending with the last day of the last completed influenza season (March 31).

      Post-Acute Care Facility-Level Exclusions
      Facilities are excluded if either of the following is true:

      (1) the post-acute care influenza vaccination sample includes fewer than 20 residents; or
      (2) the facility is excluded if there are no 5-day PPS assessments (AA8b = 1) for the entire facility for the year ending with the last day of the influenza season (March 31)

    • Most Recent Endorsement Activity
      Measure Retired and Endorsement Removed National Voluntary Consensus Standards for Influenza and Pneumococcal Immunizations
      Initial Endorsement
      Last Updated
      Removal Date
    • Steward
      Centers for Medicare & Medicaid Services
      Steward Organization POC Email
      [email protected]