While mass vaccination is crucial to ending the COVID-19 pandemic, plans to distribute vaccines say little about how shots will be delivered to the country's two million homebound residents.
Dr. Christopher Stark, a chief clinical officer at Landmark Health — a home health care provider operating in 17 states including Pennsylvania — notes that older age and chronic conditions often put homebound patients at higher risk of contracting a serious case of COVID-19. “They’re the sickest of the sick,” he said. “These are the patients that will die from COVID-19.”
While these patients may be unable to leave their homes, they face potential exposure through visits and deliveries. “Yes, they’re at home, but nurses come in, families come in and they get deliveries, so there’s a lot of ways they can wind up getting COVID,” Stark said.
How Pennsylvania’s homebound residents get vaccines is largely still being sorted out, and logistics fall primarily on home healthcare companies or the individuals themselves.
Pennsylvania on Tuesday expanded eligibility for the vaccine in Phase 1A to people over age 65 and to younger individuals with serious conditions, though the state’s plan doesn’t specify how homebound patients will receive vaccine doses. Department of Health Deputy Press Secretary Maggi Barton wrote in an email to PublicSource that residents with a healthcare provider that isn’t enrolled for vaccine distribution “may need to travel to obtain the vaccine.” A map of enrolled providers can be found on Pennsylvania’s COVID-19 dashboard.
“We are working with the Department of Aging and its Area Agencies on Aging to ensure that those who cannot leave their homes can be vaccinated," Barton wrote.
Amie Downs, the communications director for Allegheny County, wrote in a Jan. 6 email that care coordination for homebound patients isn’t typically a responsibility of public health departments. Instead, home health agencies are the ones who would make plans with patients for vaccination. Downs noted that “the Allegheny County Health Department would defer to those medical professionals that provide care to those individuals to make determinations on when and if a vaccine is appropriate.”
Since the beginning of the pandemic, Stark and his team at Landmark Health have worked harder to address patient needs, checking up on them with assessments to ensure they have access to food and necessary medication. But even under normal circumstances, providing quality home health care access can be difficult. Necessary medical equipment is often in short supply, and in some cases, not covered by insurance.
The decentralized nature of home care means that physicians and other healthcare workers aren’t able to treat the same number of patients over a period of time as they would in a hospital or doctor's office. Because many doctors derive portions of their income from their productivity, home care can be less profitable for some.
These types of infrastructure challenges can result in some homebound patients receiving delayed care, or not receiving it at all.
Stark also worries about vaccine misinformation. “To try and stop them from falling through the cracks,” he said, “we’re partnering with primary care providers and community members that they trust to help them overcome any fears.”
Stark’s concerns speak to another challenge in coordinating vaccinations for the homebound. In order for these patients to even indicate interest in receiving the vaccine, they first have to be on home care provider’s radar. If they’re not, they might not have access to a shot.
A more complicated vaccine
Bringing vaccines to homebound patients isn’t a new idea.
Many organizations associated with home care for seniors provide in-home flu shots every year. But the COVID-19 vaccine may not be able to easily employ these same pipelines.
Dr. Donald B. Middleton, the vice president of family medicine at UPMC St. Margaret, noted that flu vaccines are easier to distribute because they’re already so accessible. “They’re universally available,” he said. “You can get them at almost any pharmacy, and often even churches or workplaces.”
Middleton doesn’t think that level of availability will exist for the COVID-19 vaccine. Beyond the early production limitations associated with any new technology, he says that the cold storage temperatures and multiple doses required for the new vaccine will be particularly challenging for home health care to accommodate. After determining which of their patients wants to receive the vaccine, providers would have to set up a careful delivery schedule that allows vaccines to thaw as needed to ensure each patient receives a viable dose. Then, Middleton says, they’d have to keep records of each first dose in order to repeat this same process for the second one.
The Pfizer-BioNTech vaccine must be stored at a temperature between -80 and -60 degrees Celsius. Before injection, however, the vaccine needs to reach room temperature, which can be done by thawing the vaccine either in a refrigerator or at room temperature. If thawed in the refrigerator, the vaccine remains potent for another five days. But if thawed at room temperature, the vaccine only remains potent for two hours.
The Moderna vaccine is slightly more manageable, stored between -25 and -15 degrees Celsius. It can also be thawed in the refrigerator and remains viable for 30 days. Once a vial is thawed and punctured, the Moderna vaccine remains viable for six hours.
Because of the challenges associated with maintaining proper temperatures, Middleton said that the timing of vaccine injections is a bigger concern than transporting them. If patients want to receive the vaccine at home, health care workers will have to logistically plan the thawing process, minute by minute, in order to deliver a potent vaccine to each patient. Some companies, like Johnson & Johnson and Novavax, have developed vaccines that can be stored in normal refrigerators, but these vaccines have yet to be approved by the FDA.
Instead of bringing the vaccine directly to patients at home, some health officials think reinforcing transportation for homebound populations to get to a pharmacy could be another good approach. Cindy Vunovich, the vice president of clinical integration for AHN Healthcare at Home, says she’s staying “open-minded” about potential options. “We have a pretty robust chain of individuals going into people’s homes,” she said. “But I definitely would not close the door to any kind of mass transport opportunity for vaccination.”
Vunovich noted that AHN continues to follow vaccine distribution guidelines provided by the state and federal government. She wrote in an email that AHN remains open “to exploring all options for helping our patients.”
Dr. Bruce Y. Lee, a professor of health policy and management at the City University of New York and former associate professor of medicine and biomedical informatics at the University of Pittsburgh, agrees that bringing the vaccine to homebound patients might require multiple solutions.
“Ideally what would happen is you take a map with population density and use care patterns data to identify who would probably need some type of assistance to get vaccinated,” he said. For those in a denser Pittsburgh area like Shadyside, timing in-home vaccine appointments might be easier. But in rural areas, where the distance between patients is greater, providing transportation to a pharmacy or hospital for the vaccine might make more sense.
Lee worries that the federal government’s lack of cohesive logistical planning and communication to states on such matters so far might prolong the pandemic, especially for these more susceptible populations.
“I think the dialogue around vaccination can be off when it comes to the most vulnerable people in our population,” he said. “It can be more like this is a nice or compassionate thing to do, but it’s not just that — it’s the smart thing to do.”
Persistent problems with vaccine distribution to vulnerable populations become problems for everyone, Lee said. He argues that we should worry less about distribution to wealthy people or those who work white collar office jobs, instead emphasizing vaccinations for those who often slip through the cracks. “As long as the virus is spreading somewhere, then everyone’s at risk,” he said. “Society is only as strong as its weakest link.”
This story was fact-checked by Amanda Su.
Sophie Burkholder began reporting this story as a PublicSource editorial intern. She is a freelance reporter now and can be reached at firstname.lastname@example.org.