Ensuring COVID-19 Vaccine Access for Homebound Older Adults

Mary Stevenson is worried. Her mother, Ann, is in her 90s, has dementia, is frail and has difficulties walking. Mary and a home health aide provide her round-the-clock care. Ann has not been vaccinated for COVID-19 even though her level of care is essentially the same as provided to patients in a skilled nursing facility. The only options to get Ann vaccinated involve taking her to a vaccination site, which is not realistic given her overall health and immobility. Mary lives in fear that she or the others who care for her mother will expose her to the virus with a potentially tragic outcome.

More and more people are facing Mary’s dilemma. One would assume that by now we would have vaccinated most if not all older adults whose age, health, and frailty make them the most vulnerable. But for at least 2 million older adults who cannot leave their homes, access to the vaccine has been challenging or impossible. While it is often assumed that those who require round-the-clock care reside in nursing homes, in fact, the majority of such older adults live in the community and are cared for by family members, friends, and home care and elder services agencies.

Solving this problem is not easy given the size and characteristics of the population and the barriers to access. A complicating factor is that the roles of various governmental agencies and non-governmental organizations in ensuring access to the COVID-19 vaccine are unclear. And when states are under pressure to vaccinate the largest number of people in the shortest amount of time, the slower pace of vaccinating the homebound one at a time becomes less of a priority.

Trust for America’s Health has hosted two convenings with the White House Vaccine Coordinator, senior leaders from the Centers for Disease Control and Prevention (CDC) and the Administration for Community Living, which funds aging services programs throughout the nation, and state and local public health officials, home-visiting health care providers, such as the Visiting Nurse Association, elder services organizations and national associations representing local and state frontline providers.ⁱ Using lessons gathered at these sessions, we outline below how government can best meet the urgent vaccination need among homebound older adults.

Most states and cities don’t have a straightforward way of identifying residents who are unable to travel to vaccination sites. However, given that care is provided for many homebound individuals through health care, aging service, or social service agencies, Medicare and state Medicaid programs may be able to determine which of their patients are homebound. Medicare-certified home health agencies and Medicare-reimbursed home-based medical care physicians and providers already know and care for many of these patients—and could administer the vaccines. The hundreds of thousands of home visits made by health aides through these entities every day should be leveraged to help homebound people get the COVID-19 vaccine.

State and cities also need to determine how to cover the costs of vaccinating the homebound. Neither the Centers for Medicare and Medicaid Services (CMS) nor private payers have established reimbursement rates to cover these costs. Frontline providers who are eager to begin the process of vaccinating the homebound have begun to identify the costs that need to be covered. But the codes that insurers have provided for vaccine administration are designed for office visits rather than home care settings where additional time is spent on travel, family discussions, and post-vaccination observation.

If insurance reimbursement is not adjusted to meet the shortfall, state and local health departments could utilize federal funding, from the December 2020 relief package and the recently passed $1.9 trillion American Rescue Plan, to secure vaccines and contract with those clinicians and organizations currently serving the homebound population so they can provide the vaccinations.

The Seattle-King County Public Health Department (PHSKC) has been a trailblazer in vaccinating their homebound population. PHSKC leaders have systematically gathered information on the population and plan to reach them through coordinated planning with both governmental and non-governmental entities. A central multiple-language helpline for homebound older adults or their caregivers is being created to give this population an alternative to online scheduling apps.

Another model effort has been implemented by the Veterans Administration Home Based Primary Care program, which provides home care services to more than 34,000 veterans. As of mid-March, 60 percent of homebound veterans had received at least one vaccination. The program’s success was based on their existing connection to the vets, as well as personalized outreach, educational efforts, and unrushed care. Each vaccinator, for example, visited no more than six homes per day.

The CDC has provided helpful guidance for vaccinating the homebound that policymakers, insurers, and providers can consult as they develop vaccination plans for this population. It points out the necessity of estimating the number of doses needed for the homebound, providing information in multiple formats, ensuring vaccine safety (including temperature control), and scheduling carefully. It emphasizes the need for skilled clinicians to do the in-home vaccination administration, namely those who can do the appropriate screening, post-vaccination observation, and recognition and treatment of anaphylaxis, if needed.

There is a growing consensus among those serving these populations that the homebound will only be vaccinated if they are prioritized at the federal, state, and local levels as has been the case with patients in skilled nursing facilities who have similar health conditions. That would require four key steps: 1) identifying the population, 2) securing the needed vaccines, 3) contracting with the organizations that can provide the home visits to administer the vaccines, and 4) covering their costs. Such an effort would require coordination between the federal government, including the CDC and CMS, and state and local health agencies. If executed efficiently, a process to vaccinate the homebound population could be completed in as little 60 days.

John Auerbach is the President and CEO of Trust for America’s Health (TFAH). Megan Wolfe is a Senior Policy Development Manager at TFAH and directs its Age-Friendly Public Health Systems initiative.

NOTES

ⁱ The John A. Hartford and Cambia Foundations funded the convenings.