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Vaccinating Homebound Patients Is an Uphill Battle


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The suspension of the Johnson & Johnson vaccine has made inoculation efforts against COVID-19 more complicated for one of the most vulnerable groups – homebound patients.

There are about 2 million to 4 million homebound patients in the United States, according to a webinar from the Trust for America’s Health, which was broadcast in March. But many of these individuals have not been vaccinated yet because of logistical challenges.

Some homebound COVID-19 immunization programs are administering Moderna and Pfizer vaccines to their patients, but many state, city, and local homebound vaccinations administered the Johnson & Johnson vaccine after it was cleared for use by the Food and Drug Administration in February 2021. The efficacy of the one-shot vaccine, as well as it being easier to store and ship than the Moderna and Pfizer vaccines made getting it to homebound patients less challenging.

“With Pfizer and Moderna, transportation is a challenge because the temperature demands and the fragility of [messenger] RNA–based vaccines,” Brent Feorene, executive director of the American Academy of Home Care Medicine, said in an interview. That’s why [the Johnson & Johnson] vaccine held such promise – it’s less fragile, [can be stored in] higher temperatures, and was a one shot.”

Other hurdles to getting homebound patients vaccinated have been in place prior to the suspension of the Johnson & Johnson vaccine.

Many Roadblocks to Vaccination

Although many homebound patients can’t readily go out into the community and be exposed to the COVID-19 virus themselves, they are dependent on caregivers and family members who do go out into the community.

“Their friends, family, neighbors, home health aides, and other kinds of health care workers come into the home,” Shawn Amer, clinical program director at Central Ohio Primary Care in Columbus, said in an interview. “Even though they’re not out and circulating in the public in the ways that you or I might, they are still at risk of contracting COVID themselves and can still spread it to others. So it’s really still important to think about the patients that need to be vaccinated in the home.”

The higher costs of getting homebound patients vaccinated is an additional hurdle to getting these vulnerable individuals protected by COVID-19 shots.

There have also been reports of organizations that administer the vaccines – which are free for patients because the federal government is paying for them – not being paid enough by Medicare to cover staff time and efforts to vaccinate patients in their homes, Kaiser Health News reported. According to the Centers for Medicare & Medicaid Services, they pay $40 for the administration of a single-dose COVID-19 vaccine and, for COVID-19 vaccines requiring multiple doses, Medicare pays approximately $40 for each dose in the series. These rates were implemented after March 15. Before that date, the rates were even lower, with the Medicare reimbursement rates for initial doses of COVID-19 vaccines being $16.94 and final doses being $28.39.

William Dombi, president of the National Association for Home Care & Hospice, told Kaiser Health News that the actual cost of these homebound visits are closer to $150 or $160.

“The reimbursement for the injection is pretty minimal,” Mr. Feorene said. “So unless you’re a larger organization and able to have staff to deploy some of your smaller practices, just couldn’t afford to do it.”

Many homebound patients have also been unable to get the lifesaving shots because of logistical roadblocks and many practices not being able to do home visits.

“I think that initially when the [Centers for Disease Control and Prevention] came out with vaccine guidance for medical providers, they offered no guidance for in-home medical providers and we had to go back and ask for that, which they did produce,” Mr. Feorene said. “And we’re grateful for that. But I think just this general understanding that there is a population of folks that are [limited to their home], that they do receive medical care and other care in the home, and that we have to remember that the medical providers who provide care in the home are also primary care providers.”

Furthermore, trying to navigate or find programs delivering vaccines to the homebound can be difficult depending on where a patient lives.

While some programs have been launched on the country or city level – the New York Fire Department launched a pilot program to bring the Johnson & Johnson vaccine to homebound seniors – other programs have been spearheaded by hospital networks like Northwell and Mount Sinai. However, many of these hospital networks only reach out to people who already have a relationship with the hospital.

“A lot of the decisions and resources [surrounding the distribution of COVID-19 vaccines] are local or dependent on local resourcing,” Ms. Amer said.

She added that identifying homebound patients and reaching out to them could be difficult and can contribute to the logistics and time involved in setting patients up for the vaccine.

“Reaching some of these patients is difficult,” Ms. Amer noted. “Sometimes the best way to reach them or get a hold of them is through their caregiver. And so do you have the right phone number? Do you have the right name?”

Overcoming the Challenges

With the absence of a national plan targeting homebound patients, many local initiatives were launched in an effort to do just that. Local fire department paramedics have been going door to door to administer the COVID-19 vaccine in cities like Chicago, New York, and Miami. However, the suspension of the Johnson & Johnson vaccine led to a suspension of New York’s in-home vaccination program.

Health systems like Mount Sinai vaccinated approximately 530 people through the Mount Sinai Visiting Doctors Program, including patients and their caregivers, according to Peter Gliatto, MD, associate director of the Mount Sinai Visiting Doctors Program. When the Johnson & Johnson vaccine was suspended, the program was already about to wrap up its vaccination drive, he noted.

“In different cities, townships, and jurisdictions, different health departments and different provider groups are approaching [the distribution of the COVID-19 vaccine] slightly differently,” Ms. Amer said. “So a lot of the decisions and the resources are dependent upon local resources.”

People who live in rural areas present a unique challenge, but Mr. Feorene said reaching out to local emergency medical services or the local health departments can provide some insight on what their town is doing to vaccinate homebound patients.

“I think understanding what a [public health department] is doing would be the very first place to start,” Mr. Feorene said in an interview.

If a patient is bedridden and is mobile enough to sit in a car, Mr. Feorene also recommends finding out if there are vaccine fairs “within a reasonable driving distance.”

Homebound vaccination programs that utilized the Johnson & Johnson vaccine will have a more difficult time vaccinating patients if they decide to switch over to Moderna or Pfizer, said Ms. Amer, whose practice launched a pilot of a COVID-19 homebound vaccination program in March with Johnson & Johnson vaccines and is considering using other vaccine alternatives.

“Without using the Johnson & Johnson vaccine the logistics become a little bit more difficult because now instead of sending a provider to a home once, you’re doing it twice,” Ms. Amer said. “So it’s double the effort and I think it makes it extra difficult to get to these homebound patients.”

However, Ms. Amer said continuing this mission is necessary for public health.

“Even if it’s going to take longer to vaccinate these homebound patients, we still have it make an effort. So much of the country’s vaccine efforts have been focused on getting as many shots and as many arms as quickly as possible. And that is definitely super important for public health,” she said.

The experts interviewed in this article have disclosed no relevant financial relationships.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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