ACOEM Application: CMSS/CDC Funding Opportunity - Employers

ACOEM Application: CMSS/CDC Funding Opportunity - Large Employers

Improving Adult Immunization Rates for COVID-19, Influenza, and Routine Adult Vaccinations through Partnerships and Medical Subspecialty Professional Societies and the Long-Term Care Professional Society
Month Day Year
Date
Name of organization: *
Organization TIN: *
Headquarter address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
ACOEM member overseeing the project: *

First Name Last Name Suffix
Email: *
example@example.com
Please upload CV of ACOEM member. *

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Individual completing the application: *

First Name Last Name Suffix
Email: *
example@example.com
Does your company have onsite workplace clinics (either operated by your company or by an outside healthcare organization)? *

Yes No
If yes, how many?
What are the average overall number of patient/worker visits per year? *
What are the demographics of the patients/workers that you serve? *
What is the percentage of the patient population residing in a rural area (if known)?
What is the percentage of the patient population residing in an area designated as a Medically Underserved Population (MUP) (if known)?
Do your clinics treat nonwork-related medical issues or just work-related issues such as preplacement or surveillance exams and workers' compensation? *
Do you use an Electronic Health Record (EHR)? *

Yes No
If yes, what EHR do you use?
Are vaccinations administered in your clinics? *

Yes No
If yes, which vaccines do you administer? (check all that apply)

COVID-19 Influenza Pneumococcal Shingles (Zoster) Human papillomavirus (HPV) Measles, mumps, rubella (MMR) Chickenpox (Varicella) Meningococcal Hepatitis A Hepatitis B Tdap or Td booster Vaccinia Rabies Travel-related vaccines Other occupational vaccines
Does your EHR include both vaccination status and vaccinations administered at visits? *

Yes No
Does your clinic staff have access to the Immunization Information Systems (IIS) in the jurisdictions where you operate? *

Yes No
Do you report immunizations administered in your clinics to the city or state IIS? *

Yes No
Do you agree to hire a full-time project coordinator as a requirement of accepting the award (also project manager, quality manager, or equivalent) to fulfill project requirements and related activities? *

Yes No
Do you agree to submit relevant quality data, including vaccination status, provider recommendations to receive vaccines, vaccine administration, and other activities as requested by the CDC or American College of Occupational and Environmental Medicine (ACOEM) during the Project? *

Yes No

Upload a description of your work plan. The work plan should include:

As part of the award associated with this application, all practices/health systems will be required to engage in performance improvement activities related to vaccination awareness, vaccine activity, and/or addressing vaccine hesitancy within your practice/health system. Please describe your aims and proposed approaches.
A description of your proposed pilot program/potential strategies in the first year to improve the delivery of care/increase vaccination rates among adults or workers in occupational health clinics or workers in your organization (starting with COVID-19 and influenza vaccines).
A description on how immunization rates will be determined at baseline and post-intervention points.
A description of your practice/health system’s experience with promoting routine vaccines among your providers, including clinical quality improvement initiatives implemented and provider response.
A description of your practice/health system’s experience with promoting vaccines within your patient population, including improving vaccine awareness, vaccine activity, and/or addressing vaccine hesitancy.
Include a chart identifying a 4-year plan for the number of covered individuals each year and scope of immunizations covered (see example below).

Table X. Anticipated Enrollment

Use a table to show the anticipated enrollment in each of the 4 project years. (Please provide an estimate as we recognize that circumstances may change over time.)

	Number of sites	Participants		Vaccines	Worker Groups
	Number of sites	New	Follow-up*	Vaccines	Worker Groups
Year 1
Year 2
Year 3
Year 4

*Follow-up = enrolled in previous years

Please upload your work plan. *

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Please review Appendices 1-3 which list the CMSS recommended structural elements, data quality issues and recommended data outcome and process measures to submit. We realize that each employer may not be able to meet or choose to meet all the required items.
Which of these structural elements or data quality issues will you be able to meet? *
Which of the data outcome measures or process measures will you be able to measure or provide? (check all that apply) *

Number and percent of patients or employees who have documented vaccine assessment in their record Number of provider-made or employer-based recommendations about vaccination; frequency of provider or employer recommendations Number and percent of providers’ or employer recommendations that resulted in immunization Number of eligible patients counseled by clinical team Number of eligible patients refusing vaccination Number of patients referred to another site for vaccination (e.g., pharmacy) Number of immunizations administered at another site captured in patient record Frequency (stronger way or more routine way) and quality of the provider or employer recommendations through patient or worker assessments/surveys Number and percent of healthcare providers in employer's network using EHR and/or IIS to screen or forecast vaccination needs Number and types of new technologies or procedures utilized to streamline the vaccine assessment Changes in adult patient care or employer procedures to ensure appropriate immunization assessment, recommendation, vaccine offers and/or documentation Number and types of improvements to employer, provider, or referral systems/procedures Changes in how immunizations are documented in IIS or EHRs Number of patient or worker records in IIS Number of new users in IIS Number and types of exchange of immunization information among multiple categories of providers or across employer Number and percent of patients or workers reporting access to their own immunization records
Will your employer be able to provide ACOEM a monthly report which assesses and measures changes to monitor progress? *

Yes No
If you are not planning on providing monthly reports, how often would you plan to report progress to ACOEM?
Please upload your budget with justification.
Budget with justification *

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If applicable, upload documentation of your organization's Federal Negotiated Indirect Cost Rate.

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It is crucial that leadership of the practices/health systems support team members’ participation in the program. This includes a commitment of leadership to the improvement project(s) and willingness to dedicate resources and protect participants’ time. To demonstrate this commitment, please upload a letter of support from a c-suite representative of the employer (e.g., Chief Executive Officer, Chief Medical Officer, Chief Quality Officer, Chief Nursing Officer). *

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To the best of my knowledge, my health system is not applying with another professional society to participate in the CDC Improving Adult Immunization Rates for COVID-19, Influenza, and Routine Adult Vaccinations Project. *

Yes No
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ACOEM Application: CMSS/CDC Funding Opportunity - Large Employers