COVID-19 Vaccine Access for Homebound Older Adults Part 3; Some Progress!!

Disclaimer: The purpose of this 3rd “article” is a quick share of my updated understanding of the situation and to continue a dialogue, I recognize that I may be missing something so I hope this post will create some learning opportunities for the author as well as the reader! Here is a link to the 1st post and 2nd post if you missed them!

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Two down, Two million to go!

I’ve made thousands of home visits, and indirectly through my teams I’ve been associated with millions of home visits — I think the two visits I made today will be the most memorable of my career. It just felt so rewarding to get out and provide two homebound seniors their 1st dose of the Moderna COVID-19 vaccine. One of my biggest hopes is that people in the home care community will see that if a simple guy like me can do this, they can too — -this is going to have to be a mass effort. I am so thankful to both Mr. Samuel Ferguson Jr. of Asbury Park, NJ and Ms. Leonora Shippey of Neptune, NJ for being the 1st two home COVID-19 vaccination recipients — they were brave and also generous in allowing us to photograph the visits.

Given how homebound seniors are often underserved and overlooked, and how devastating COVID-19 has been for older people with chronic illness and people of color, it was so powerful to feel useful in helping to turn the corner! It also was special to make these visits on the national holiday celebrating the great civil rights leader Dr. Martin Luther King who was a fierce advocate for improving health equity. Today again reminded me that everyone concerned with issues of health equity and care of vulnerable populations should be major champions of home care. Home visits break down access barriers and take clinicians out of their comfort zone onto the patient’s turf, it shows people they are worth being known and cared for.

Disclaimer #2: While it was great to vaccinate Mr. Ferguson and Ms. Shippey, VNA Health Group is not yet able to offer this service widely, but we are hoping to make progress on this in the coming weeks. For anyone who wants to know why the availability of this service (and also why vaccine availability in general) is slower than hoped for, pls see the hundreds of articles and social media posts that are out there on this topic!

Notes on Logistics

I was able to access vaccine for these two individuals through our affiliation with the Visiting Nurse Association of Central Jersey Community Health Center in Asbury Park, NJ. This Federally Qualified Health Center (FQHC) is a leader and innovator in public health and I am just as proud to work with this clinic as I am for my past work at the world famous Cleveland Clinic. FQHC’s are incredible resources and we should be investing heavily in their continued success. Our home health agencies will likely be able to access a supply of vaccines in the coming weeks, but the Asbury Park FQHC was prepared and prioritized right out of the gate. The two people I visited lived within 5 miles of the health center, but because of their immobility the health center may as well have been a hundred miles away — they needed home visits.

I was able to pick up the two doses of vaccine at the FQHC and complete both home vaccinations and all required observation and documentation in just under two hours. With a bit more experience and process improvement I could see getting one done every 30 to 45 minutes if they live close to a center where the vaccine is stored. I transported the vaccine in prefilled syringes and made sure the vaccine was kept at the appropriate temperature and administered well within the 6 hour window after the vial was 1st punctured. There were several family members present on both visits, and the idea of “family cluster” vaccination that I mentioned on the last blog post could have been ideal. But, for this 1st go round of home vaccination, we decided to keep it simple in terms of scheduling and visit prep. We do not yet have an electronic system for family scheduling, though my team is trying to develop something.

A Note to CMS

Last week I sent in a waiver/flexibility request to CMS regarding home health agencies’ role in COVID-19 vaccination. I haven’t heard anything back yet. I made the request on behalf of our agencies and recommend that others with the same concern go on Medicare’s website and make similar requests — maybe more requests will lead to action. Here is the text of my submission, please feel free to cut and paste:

“Homebound Medicare beneficiaries are often at high risk for COVID-19 infection and associated morbidity and mortality, and many homebound individuals are in high priority populations for COVID-19 vaccination as prioritized by the United States Centers for Disease Control. Given that these individuals are homebound, they may be unable to access COVID-19 vaccination outside of their home. Our home health agencies would like to help provide access to COVID-19 vaccination for homebound Medicare beneficiaries to help protect them from COVID-19 and contribute to ending the pandemic. There are several waivers and or flexibilities that we are requesting:

1. Administration of medications and intramuscular injections may be skilled nursing services under a home health plan of care. And, the Pfizer-BioNTech and Moderna COVID-19 vaccines currently with Emergency Use Authorization are medications administered by intramuscular injection. However, medication injection skilled nursing services are typically covered when they are “reasonable and necessary to treat illness and injury.” In the case of COVID-19 vaccines are typically needed to PREVENT COVID-19 rather to treat illness or injury, and homebound Medicare beneficiaries may be in need of vaccination due to their advanced age alone. We are requesting that you clarify that in the context of the public health emergency, when a physician or appropriate provider orders a home health nurse to perform COVID-19 administration/injection as part of a home health plan of care in order to prevent COVID-19 disease, that this service is in fact a covered service under the Medicare home health benefit irrespective of illness or injury.

2. In order for a homebound Medicare beneficiary to be eligible for skilled nursing services under the home health benefit, these services must be “intermittent” meaning there’s “a medically predictable recurring need for skilled nursing services.” We are asking, for the public health emergency, that you clarify that a single nursing visit and/or series of 2 visits separated by 21–30 days for COVID-19 vaccination (and immediate post-vaccination observation for anaphylaxis) be deemed to be “intermittent” for the purposes of eligibility and payment under the home health benefit.

3. If there are any other regulatory barriers or impediments to a home health agency providing homebound Medicare beneficiaries COVID-19 vaccination, we ask that you review and remove such barriers.”

Dad, Husband, Son, President & CEO, Family Doctor & Geriatrician. Passionate about improving health care and public health. Views are my own!

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