ACOEM Application: CMSS/CDC Funding Opportunity - Health Systems

ACOEM Application: CMSS/CDC Funding Opportunity - Health Systems

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
MonthDayYear
Date
Name of health care system:*
Healthcare TIN*
Headquarter address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ACOEM member overseeing the project:*

First NameLast NameSuffix
Email:*
example@example.com
Please upload CV of ACOEM member only.*

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Individual completing the application:*

First NameLast NameSuffix
Email:*
example@example.com
Does the healthcare system have its own occupational medicine clinics?*

YesNo
If yes, how many?
What is the estimated number of patients/workers that your health system serves per year?*
What are the demographics of the patients/workers that you serve?*
What population/type of workers do you see in the clinics?*
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)?
Does the health care system use an electronic health record (EHR)?*

YesNo
If yes, which EHR is being used?
Does your health system actively use a vaccine module within your EHR?*

YesNo
Do you administer vaccines?*

YesNo
If yes, which vaccines do you administer? (check all that apply)

COVID-19InfluenzaPneumococcalShingles (Zoster)Human papillomavirus (HPV)Measles, mumps, rubella (MMR)Chickenpox (Varicella)MeningococcalHepatitis AHepatitis BTdap or Td boosterVacciniaRabiesTravel-related vaccinesOther occupational vaccines
Does your staff routinely access the Immunization Information Systems (IIS) in your state?*

YesNo
If yes, does your staff access the IIS to see which vaccines have been received?

YesNo
Does your staff input any vaccines given into your state IIS?

YesNo
Does your staff access the IIS for any other purpose?

YesNo
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?*

YesNo
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?*

YesNo

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

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 (starting with COVID-19 and influenza vaccines).
A description on how immunization rates will be determined at baseline and post-intervention points.
Location and description of the clinic or clinics including population served that you will use in year one of this project.
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.
A desciption of your practice/health system’s experience with promoting routine vaccines among your providers, including clinical quality improvement initiatives implemented and provider response.
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.

Include a chart identifying a 3-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 3 project years. (Please provide an estimate as we recognize that circumstances may change over time.)

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

*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 every health system/employer may not be able to meet or choose to meet all of 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 who have documented vaccine assessment in their recordNumber of provider-made recommendations about vaccination; frequency of provider recommendationsNumber and percent of providers’ recommendations that resulted in immunizationNumber of eligible patients counseled by clinical teamNumber of eligible patients refusing vaccinationNumber of patients referred to another site for vaccination (e.g., pharmacy)Number of immunizations administered at another site captured in patient recordFrequency (stronger way or more routine way) and quality of the provider recommendations through patient assessments/surveysNumber and percent of health care providers using EHR and/or IIS to screen or forecast vaccination needsNumber and types of new technologies or procedures utilized to streamline the vaccine assessmentChanges in adult patient care procedures to ensure appropriate immunization assessment, recommendation, vaccine offers and/or documentationNumber and types of improvements to referral systems/proceduresChanges in how immunizations are documented in IIS or EHRsNumber of patient records in IISNumber of new users in IISNumber and types of exchange of immunization information among multiple categories of providersNumber and percent of patients reporting access to their own immunization records
Will your health system be able to provide ACOEM a monthly report which assesses and measures changes to monitor progress?*

YesNo
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 health system (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.*

YesNo
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