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Nursing Interventions Increase Influenza Vaccination Quality Measures for Home Telehealth Patients


Author Information
doi: 10.1097/NCQ.0000000000000577


Home telehealth (HT) nursing was recognized by the American Academy of Ambulatory Care Nursing as a subspecialty in 1997.1 HT nursing standards of practice incorporate care coordination among providers and community resources. Evidence-based disease management protocols guide patient care provided during telephone and video visits initiated by home telehealth care coordinators (HTCCs). In addition, patients are instructed on the use of interactive communication platforms on cellular devices, computers, and tablets. This enables them to transmit personal data from connected devices like blood pressure cuffs, scales, and blood glucose meters and engage in remote monitoring.2 The program offers timely, efficient, and equitable access to care, and an enduring patient-centric partnership. HTCCs reduce the effect of disease burden and complications by providing ongoing access to health information and resources. They inspire and empower patients to practice healthy behaviors and participate in activities that culminate in self-management of acute and chronic conditions in their home.

In 2005, the San Francisco Veterans Administration (SFVA) launched an HT program following the success of a 3-year pilot in the southern United States. This outpatient service was designed to offer chronic condition management, reduce inpatient, emergency department, and unscheduled clinic visits, and avoid nursing home placement.3.4 The mobilization of technology resources and ongoing telephone support for high-risk patients represent foundational elements in this comprehensive approach to care.

The chronic care model was adopted by HT programs as a multiprong strategy to (1) enhance interprofessional relationships, (2) increase access to community services, (3) promote evidence-based decision-making, and (4) infuse information technology resources into patient care.5 The effectiveness of the model is demonstrated through compliance with therapy, promotion of healthy behaviors, and improvement in measurable quality outcomes.6,7 Additionally, this model shifts reactive, costly and urgent care needs of patients to coordinated, proactive, patient-centric care. To ensure this blueprint for success, HTCCs communicate regularly with Patient-Aligned Care Teams through data-rich progress summaries and “view alerts” ensuring communication of time-sensitive clinical updates using the SFVA Computerized Patient Record System.

The SFVA HT program has approximately 770 enrolled Veterans, with each HTCC managing a fluctuating panel of 85 outpatients. Program outcomes are submitted quarterly to local and regional quality departments. These include census, peer review of documentation accuracy, remote monitoring nonresponder rates exceeding 3 days, and patient satisfaction results. Preventive health measures such as influenza vaccination rates are not evaluated as a quality metric.


The purpose of this study was to determine whether newly developed HT clinical and technology interventions can improve vaccination rates among Veterans. Feasibility and ease of adoption of practices were discussed among team members with agreements made regarding implementation.

Vaccinations prevent influenza illness and reduce outpatient visits, hospitalizations, and intensive care unit admissions.8.9 In an effort to reduce influenza-associated morbidity and mortality, Healthy People 2030 proposes a vaccination target of 70% of noninstitutionalized persons aged 6 months.10 Influenza immunity impacts the prevalence of symptoms like fever, cough, dyspnea, sore throat, headache, chills, and fatigue, which are similar to those manifested by individuals suspected of coronavirus disease-2019 (COVID-19) infection.11 This differentiation is critical for health care workers engaged in preliminary screening of symptomatic individuals.

Flu vaccine interventions

Technology intervention

Continuous automated 2-way messaging using remote patient monitoring was transmitted from September 17, 2020, to October 1, 2020, and October 11, 2020, to October 25, 2020. This virtual flu campaign timeline was selected in accordance with seasonal recommendations for vaccination.8 Messages provided the following information:

The VA is offering flu Vaccines at all locations. Veterans can also get a flu vaccine at a local Walgreen's with a pharmacy, at no cost to you. Please contact the VA Community Care Office for other contracted providers offering flu vaccines in your area by calling 877-881-7618.

Patients were prompted to respond to a question asking whether they received a flu vaccine anywhere other than the Veterans Administration (VA) or Walgreens pharmacy. Walgreens can update influenza immunization information in the Veteran's personal health record through a health information exchange program. A yes response triggered an alert to the HTCC prompting Veteran contact to update the immunization record indicating receipt of a flu vaccine outside the VA.

Prior to the start of the flu season, a new note template was created by a clinical application coordinator to enable HTCCs to record seasonal influenza vaccine given elsewhere, or patient educated on the need for receiving influenza immunization either at VA or outside facility. Standardized templated documentation triggers completion of an electronic health record (EHR) clinical reminder. This was the first time that HTCCs updated this quality measure.

Clinical intervention

HTCCs reviewed vaccination plans with patients with open influenza clinical reminders beginning in January 2021. Missing information was reconciled during a telephone visit using the new note template. When patients offered no plans for vaccination, tailored education was provided to address concerns about influenza and its effects, false beliefs, and complications associated with infection in individuals living with chronic health conditions.12 Multiple studies indicate that the advice of a health professional can lead to better vaccine compliance.12–14


Influenza vaccination rates are an integral component of VA quality outcomes. Vaccines are provided free of charge on all VA campuses. An intranet website offering Electronic Quality Measurement (eQM) reporting is compiled weekly by the VA Office of Analytics and Performance Integration, providing data sets that enable flu vaccination benchmarking with public and private health care sectors. The National Committee for Quality Assurance provides the VA health care system with access to Quality Compass data, which includes the Healthcare Effectiveness Data and Information Set (HEDIS) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.15,16 This information is published on the Centers for Medicare & Medicaid Services (CMS) Hospital Compare public website, and since 2016 includes performance measures associated with VA hospitals.17 Facilities can compare their performance with other VA and non-VA facilities.18–21


Design and study setting

This was a concurrent cohort study design in which a pre- and postintervention analysis was conducted to assess effectiveness of nurse-led clinical and technology interventions on influenza vaccination rates. Veteran EHRs were examined over 2 flu seasons. Interventions were introduced as part of a novel practice change. During the 2019 to 2020 flu season, HT patients received usual care provided by outpatient clinic teams, which incorporated vaccination administration during face-to-face visits. During the 2020 to 2021 flu season, HT patients received usual care and new interventions provided by HTCCs.


This was a convenience sample of all Veterans continuously enrolled in the SFVA HT program from September 17, 2019, to March 15, 2021.

Screening and selection

Study patients represent 1 of 3 categories of care. A Non-Institutional Care (NIC) Veteran designation requires 1 of the following: (1) dependencies in at least 3 activities of daily living (ADL); (2) behavior or cognitive problems; or (3) life expectancy of less than 6 months. Alternatively, the patient may have 2 or more ADL deficits and 2 of the following: (1) deficits in 3 or more instrumental ADL (meal preparation, grocery shopping); (2) 75 years or older; (3) living alone in the community; or (4) 12 or more clinic visits in the past year.

Non-Institutional Care Low Responder Veterans meet the same criteria for NIC but also require technology patient participation guidelines of 70% response over 3 consecutive months.

Chronic care management patients have a diagnosis of 1 or more chronic illnesses (eg, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and diabetes) requiring nursing case management, monitoring, and intervention.

Data collection

To ensure vaccination data were collected accurately, a board-certified informatics nurse reviewed vaccination documentation for all patients for both flu seasons. Veterans were contacted by HT staff to update vaccination information for the 2020 to 2021 flu season when data were reported missing by the nurse informaticist. Nurse informaticians can support nursing care quality and the benefit derived from this partnership is demonstrated through the success of this study.

Standardized electronic patient-level data and narrative notes were reviewed. Data included (1) sociodemographic data (age, gender, primary care clinic location); (2) date of vaccination for the 2019 to 2020 flu season and 2020 to 2021 pre- and postintervention; (3) location of vaccination site; and (5) date of enrollment in HT. Qualitative data for Veterans that indicated no vaccine in the postintervention period were collected through telephone visits. Unvaccinated Veterans were asked why they did not get a vaccine during the 2020 to 2021 flu season.

Data analysis

Descriptive statistics were applied to describe sex, age, location of vaccination site, and vaccination status for 2 consecutive flu seasons with an in-depth examination of postintervention results. Qualitative data collected during telephone interviews indicating declination reason in the postintervention phase were grouped based on similarity in response. Vaccination rates reported in eQM across Veterans Health Administration (VHA) entities (local, regional, and national) were also compared.


There were 523 medical records reviewed; 10 patients were excluded due to discharge during the study period or death, resulting in 513 patients in pre-and postintervention groups. Vaccination status, sex, age, and location of vaccination characteristics were compared to determine similarities and differences (see Supplemental Digital Content Table 1, available at: Ninety-seven percent of the cohort was male, and over one-half ages 70 to 79 years. The SFVA main campus serves 44% of Veterans (vaccinated, no vaccine, and no data) in the study. Missing documentation for the 2019 to 2020 flu season impacted the ability to accurately analyze results. This unresolved data led to inconclusive vaccination reporting for consecutive flu seasons at 78.7% and 79.9%. From January to March 2021, all 98 unvaccinated Veterans were contacted by telephone to gather additional information. The most common reason for no vaccine was fear of side effects, and rarely leaving home as a result of the COVID-19 pandemic (see Supplemental Digital Content Table 2, available at:

Vaccination documentation during the 2019 to 2020 flu season was missing completely at random in 10.3% of veteran records and increased to 25.3% for 2020 to 2021 pre-intervention. Data recovery of missing values for the 2020 to 2021 flu season proved successful through telephone encounters and documentation of vaccination status in narrative notes. Documentation accuracy post-intervention increased from 75% to 99% (Table 1).

Table 1. - Flu Season Documentation for Home Telehealth Patientsa
Clinical and Technology Intervention
Outcome 2019 n (%) Before (n = 513) 2020 n (%) After (n = 513) 2020 n (%)
Vaccinated 404 (78.8) 357 (69.6) 41 (79.9)
No vaccine 56 (10.9) 26 (5.1) 99 (19.2)
No data 53 (10.3) 130 (25.3) 5 (1.0)
aFrom CPRS Documentation Recent Immunization Date/Time Stamp, Immunization/Skin Testing Notes.

The VA internal eQM platform provides vaccination rates across all VHA entities. Reported vaccination rates indicate that 25.82% of all SFVA Veterans 19 to 65 years of age and 43.28% of all SFVA Veterans 66 years and older received the influenza vaccine as of March 15, 2021. VHA seasonal targets for these age groups are 50% and 73%, respectively.

When data for SFVA HT patients in the study were reconciled post-intervention, 70.4% of Veterans 19 to 65 years of age were vaccinated, and 81.7% of Veterans 66 years and older received the vaccine. Although the younger age group may be underrepresented in HT, all rates exceed VHA, VISN 21, and SFVA targets for vaccination rates (Table 2).

Table 2. - VHA Primary Care Flu Vaccination Rates by Entity 2020-2021a
Entity Influenza Immunization 19-65 y of Age, % Influenza Immunizations 66 y and Older, %
VHA National 25.46 43.78
VHA V21 26.22 43.58
VHA San Francisco 25.82 43.28
VHA HT (before intervention) 58.0 69.0
VHA HT (after Intervention) 70.4 81.7
Abbreviations: HT, home telehealth; VHA, Veterans Health Administration.
aVHA results obtained from Electronic Quality Measurement performance data on March 15, 2021. VHA Home Telehealth Veterans 19 to 65 years of age, n = 81. VHA Home Telehealth Veterans 66 years and older, n = 432.

The Centers for Disease Control and Prevention (CDC) recommends seasonal vaccination by end of October with continued efforts extending to January or later.22 For all vaccinations given to HT patients during the 2020 to 2021 flu season, the majority (96.8%) were administered based on CDC recommendations, with 28.4% in September, 46.9% in October, 16.6% in November, and 4.9% in December.

CDC reports indicate that, among adults receiving the influenza vaccine, a higher proportion were vaccinated in retail locations and a lower proportion in doctors' offices compared with the 2019 to 2020 season.23 Results are similar for the 410 vaccinated HT Veterans, where 20.7% received vaccinations outside of the VA. Reasons for location differences could not be determined from data collected but could correspond with concerns about contracting COVID-19, particularly in health care settings, and the ability to receive free or low-cost vaccinations in alternative settings. Vaccine convenience is important in reducing flu vaccine hesitancy. This includes physical availability, affordability and willingness to pay, and geographical accessibility.24

Medicare covers 95% of the cost of seasonal influenza and pneumococcal vaccines and many Veterans receive health care coverage through both the VA Healthcare System and by other insurance, such as Medicare or a private health care plan, referred to as dual use.25,26 This benefit may also influence a veteran's selection of where to seek vaccine administration.


This study demonstrates the effect of novel HT nursing intervention on seasonal vaccination rates through the implementation of clinical and technology interventions. The introduction of the clinical intervention, incorporating tailored education to encourage vaccinations among Veterans, was insignificant in increasing rates. Veterans who declined vaccinations pre-intervention continued to decline during the 2020-2021 flu season. Two-way messaging demonstrated importance in alerting HT staff that vaccinations were received in locations outside of the VA. Veterans seeking to avoid exposure to COVID-19 were provided with new information on locations closer to home where free vaccinations were available. The new note template successfully provided a new opportunity to update vaccination status in the EHR and was successfully adopted by all HT nursing staff.

Although not an original consideration in the study, data missing completely at random were discovered during medical record review. The role of HT staff in recovering missing data using a new note template to update immunization records led to improvements in data analysis for vaccination rates among Veterans. Although the Computerized Patient Record System provides underlying infrastructure for extraction of data within immunization/skin testing notes, the ability to use information effectively requires charting accuracy, a proactive approach to missing data, and use of standardized templates.27,28

Missing data for flu vaccination administration place the VA health system at risk for underreporting immunization data and misleading conclusions about its care delivery system among national agencies and patients evaluating care. This will lead to inaccuracies in Quality Compass HEDIS and HCAHPS survey results collectively published on the CMS Hospital Compare public website. If Veterans continue to seek vaccinations outside of the VA without accurate data capture, erroneous reporting may continue. Efforts to improve unknown vaccination status are necessary in planning quality improvement activities throughout any organization.

HTCCs have a significant influence on patient engagement, decision-making, and perceived benefit of recommended self-management strategies. They effectively tailor recommendations on influenza vaccination to a patient's individual attitudes, beliefs, and intentions when other providers may not be adequately prepared to deal with the complexities of vaccine hesitancy.29

This 2-year study demonstrates that Veterans enrolled in HT have a higher influenza vaccination rate than the overall VA patient population. Vaccination rates are not currently evaluated in VA HT programs but offer a measurable clinical quality outcome worthy of consideration. In addition, HT has a unique ability to engage in vaccination outreach, promote vaccination-seeking behavior, and prevent negative outcomes associated with influenza infection.


The study was conducted during the COVID-19 pandemic, and 2020 to 2021 flu season results may not serve as future predictors of vaccine behavior among Veterans in an HT program. HT patients have one or more chronic conditions or unique care needs that impact their desire to be vaccinated for any disease when vaccines are recommended. Future studies can serve to provide more conclusive information to support current findings.


Efforts to capture accurate vaccination data may be achieved through dedicated outreach support teams trained on techniques to collect and update information. The development of a shared information system where influenza and COVID-19 vaccine providers upload data offers a potential approach. The California Immunization Registry, a comprehensive data sharing system in which providers of health care and other children's services submit aggregated data files, is one such immunization information system.30,31

New studies are warranted to identify behavioral changes associated with vaccination-seeking behavior since the emergence of COVID-19. According to a survey conducted by Dror et al,32 the most significant predictor for acceptance of a COVID-19 vaccine is current influenza vaccination. Accordingly, HT data can determine whether Veterans vaccinated against seasonal influenza have an increased likelihood of COVID-19 vaccine acceptance. Individuals who traditionally decline flu vaccinations may be open to change through education by trusted health care sources. A CDC survey reports that 70% of adults state they are likely to turn to a physician, nurse, or other health care provider for information about the COVID-19 vaccine.33 Vaccination planning for seasonal influenza may be influenced by increased public awareness of the role of vaccines in reducing transmission of COVID-19 infection. Past influenza vaccine practices may not be a reliable indicator of future decision-making.


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influenza vaccination; nursing; outpatients; quality measures; technology; telehealth

Supplemental Digital Content

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