Vaccinations for the 12 million people estimated to be in hospice care or who are homebound because of health issues have been “localized, scattered, and limited,” Bill Dombi, president of the National Association for Home Care & Hospice, tells Verywell. “You’re not likely going to have them stand in line for hours at a convention center waiting for their vaccine,” he says.
Dombi says that vaccinating homebound patients may have been overlooked until now because it is not an easy problem to solve. In addition, he says homebound patients may have been thought to have a lower risk of both contracting and spreading COVID-19. However, their caregivers generally spend time outside the home, and risk contracting the virus and transmitting it to homebound patients.
A Monumental Task
Dombi and other homebound care experts know it’s a monumental job to transport and administer vaccines—especially the freeze-then-thaw Moderna and Pfizer versions—to people in their homes. They are frustrated, says Dombi, that the CDC “bypassed public health to connect nursing homes and long-term care pharmacies for vaccine administration” but didn’t do anything similar for homebound patients.
The CDC did issue guidance on vaccinating homebound patients on February 11 in response to requests from advocates, noting that the situation “presents unique challenges to ensure the appropriate vaccine storage temperatures, handling, and administration to ensure safe and effective vaccination.”
The CDC does a good job of outlining—but not solving—the complexity in its guidance, including:
Avoid wasting vaccines by estimating the number of doses needed as accurately as possible. [Map] out travel plans to ensure vaccine is utilized within the approved timeframes for use, factoring in pre-vaccination preparation time and post-vaccination observation time. Ensure readiness to maintain, monitor, and report the temperature of vaccine from the time the vaccine is taken out of a clinic facility, during transportation, and up to the time that vaccine is administered. Prepare the injection in a designated, clean medication preparation area that is not adjacent to potential sources of contamination. Have at least three doses of epinephrine on hand when administering vaccines (in the rare case of a severe allergic reaction).
Updated Guidance Needed
The CDC guidance “is really helpful [but] needs to be updated based on the Johnson & Johnson approval,” says a spokesperson for LeadingAge, which represents 5,000 nonprofit aging services providers. This includes the Visiting Nurse Association, which has some member agencies that have been administering COVID-19 vaccines for homebound patients. The Johnson & Johnson vaccine, authorized for use on February 27 and several weeks after the CDC issued its guidance for homebound patients, needs only refrigerator storing. It does not need to be thawed and is given as a single shot, unlike the Pfizer and Moderna vaccines.
Medicare and Medicaid, which cover the health costs of many homebound patients, need to consider higher payment for vaccine administration outside a mass vaccination site. “The administration fees are great if you are cycling through people rapidly at a large site,” the spokesperson tells Verywell. “However, the current [payment] codes do not remotely cover the costs of sending out a staff person to a home, administering the vaccine, staying to be sure there is no adverse reaction, travel between sites, etc.”
Who Is Taking Initiative For Home-Based Vaccinations?
Any examples of homebound vaccine administration are largely self-started by intrepid caregivers, hospitals with established home care programs, and a bit of innovation by at least one health department.
Stamford Hospital in Connecticut, Wake Forest Baptist Hospital in North Carolina, and the Boston Medical Center, for example, have all been vaccinating the homebound patients they currently take care of, as well as caregivers if there is sufficient vaccine supply.
“There is not currently a scheme for distribution specifically for homebound adults,” the LeadingAge spokesperson says. “For providers doing it, they [have] to negotiate for doses with their state, county, or local public health department/partners; it varies by state and there is not currently a system.”
Under its House Call Program for homebound, hospice, and some recently-released patients, Wake Forest Baptist Hospital sends two staff members—a geriatrics provider and a community pharmacy resident—to administer the vaccine, monitor for reactions, and schedule the second dose. They select patients by looking through their House Call lists “to see which [patients] are bedbound or have extreme difficulty leaving the home,” Mia Yang, MD, medical director of Wake Forest Baptist Health, tells Verywell.
Georges Benjamin, MD, executive director of the American Public Health Association, tells Verywell that until there’s a coordinated system in communities, in order to get a homebound patient vaccinated, the starting point is talking to your primary care provider.
That’s what Nancy Hemenway of Fairfax County, Virginia, did in order to have her adult daughter, who is immunocompromised, get her shot. “[Our doctor] called our health department early in the process to alert them to the risk it would be for her to have to go someplace like the government’s center in Fairfax to get a vaccination,” Hemenway tells Verywell. “The Fairfax County health department arranged for EMTs to give her the vaccination…they also vaccinated me.”
In New York State, the health department launched a small pilot program this week in the city of Yonkers, just north of Manhattan, with Ro, a health technology firm, for the many complex tasks involved in vaccinating homebound patients.
The way Ro is coordinating the shots speaks volumes about the complexity. The company, which is administering Moderna vaccines supplied by the state, is maintaining an online scheduling website for people who are eligible. The company can handle the coordination because it already has a pharmacy division which is managing vaccine inventory and distribution, as well as an in-home care division that is coordinating and dispatching vaccinators and sending real-time alerts to patients and caregivers, which is likely to cut down on vaccine spoilage and waste.
Waiting for the White House
The White House did announce a new community vaccination initiative on March 3—the Vaccine Community Connectors pilot initiative—which targets two million at-risk seniors and is supported by health insurance providers. But it appears to address other important equity issues rather than homebound ones.
Access solutions announced so far include mobile clinics in neighborhoods and paid-for ride shares to vaccination sites, which don’t address the needs of people at risk if they leave their homes to get the vaccine.
While Dombi says he is “agnostic” about which vaccine should be used, other homebound care experts hope the one-dose Johnson & Johnson vaccine is prioritized. “It will make the process easier in part because, unlike the Pfizer and Moderna vaccines, it can be returned to the fridge if someone decides at the last minute that they don’t want it,” Wake Forest’s Yang tells Verywell.
But at least for now, the White House is holding firm that the Johnson & Johnson vaccine will not be allocated to special populations.
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