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    Homebound, but not hopeless

    Many frail and elderly people can’t get out to get a COVID-19 vaccine. So teaching hospitals are packing up shots and giving them to patients right in their own homes.

    Gail and Robert Pursel of Millville, Pennsylvania, receive their COVID-19 vaccines, thanks to Geisinger’s in-home health care service.
    Gail and Robert Pursel of Millville, Pennsylvania, received their COVID-19 vaccines in January without having to handle a difficult trip out, thanks to Geisinger’s in-home health care service.
    Courtesy: Geisinger

    In January, Joan Pennington lost part of her leg to amputation following a nasty infection she likely picked up in a swimming pool. After that, most outings for the 73-year-old Connecticut resident required an ambulance. Receiving the COVID-19 vaccine seemed quite the reach.

    Then, in late February, Pennington got the shot right in her house. That was thanks to Hartford HealthCare at Home, which is part of Hartford HealthCare, a statewide network of clinics and teaching hospitals that includes Hartford Hospital.

    “I was thrilled,” says the former copy machine company administrator of the vaccine she received. “I just can’t say how much I appreciate it. I haven’t seen my grandchildren in a year except for one outdoor visit. I cannot wait to hug them.”

    In the United States, as many as 4 million adults are completely or mostly homebound. They are generally older and tend to have more than one complex health condition, such as cancer, diabetes, lung disease, heart failure, or cognitive issues. They often rely heavily on caregivers, and they’re more likely to become seriously ill or even die if infected with the coronavirus.

    That stark reality has sent leaders scrambling to figure out how to get this vulnerable population vaccinated. Along with public health offices, fire departments, and even National Guard units, teaching hospitals are stepping up to inoculate thousands of homebound patients.

    “Weeks before vaccines arrived here, I had already approached our health system’s leadership,” notes Laurie St. John, RN, MSN, vice president of Hartford HealthCare at Home, which serves more than 4,000 Connecticut residents. “I immediately felt a responsibility to our patients.”

    Such efforts require complex logistics, starting with special cooler bags for storing the vaccines and a bit of mapping magic to ensure that opened vials get to patients’ homes within the required time limits.

    “I was thrilled. I just can’t say how much I appreciate it. I haven’t seen my grandchildren in a year except for one outdoor visit. I cannot wait to hug them.”

    Joan Pennington
    Hartford HealthCare at Home patient

    Still, those involved say they are delighted to do it.

    “I remember driving out with the vaccines on the first day and feeling super excited,” says Won Lee, MD, who runs the inoculation effort for the Geriatrics Home Care Program, which treats older and homebound patients of Boston Medical Center. “But I got very emotional driving near the home of a patient who had recently died from COVID. Part of me was thinking, ‘Gosh, if she’d only been vaccinated two months ago, maybe things would be different now,’” she adds. “So many of our patients have died, and we’ve seen so much suffering.”

    Inside — and often invisible

    The definition of “homebound” is pretty straightforward. It covers people who never or rarely go out, either because they need help from another person or equipment to leave or because doing so would harm their health. But life as a homebound person is far from simple.

    “These are very sick people. Over 95% of our patients have more than five medical conditions,” notes Mia Yang, MD, director of the Wake Forest Baptist House Call Program, which provides in-home primary and urgent care to more than 200 patients of Wake Forest Baptist Health, an academic medical center based in Winston-Salem, North Carolina. “Sometimes, they have heart or lung conditions that make them so short of breath they can barely walk.”

    Gail Pursel, who often relies on a home oxygen machine, recently received the Pfizer vaccine from Geisinger at Home, a program that treats 5,000 elderly patients and is part of Geisinger, an integrated health care system in Pennsylvania. The 72-year-old says simply, “I think [COVID-19] is not something I would live through getting.”

    Some homebound patients rarely get out of bed. “We have folks who cannot leave the house except on a stretcher,” Lee explains. “Some live in housing that poses real challenges to people with mobility issues, such as three flights of stairs. Getting out for a vaccine would be a whole event and potentially traumatic.”

    Kevin Barboza, a clinical social worker, cares for his parents, both of whom are in their mid-90s and have dementia. “They would not have understood why I was bringing them out of the house and making them wait in a line,” says Barboza, who lives in Boston. “But they’re so used to Dr. Lee coming that they did very well with getting the vaccine.”

    “These are very sick people. Over 95% of our patients have more than five medical conditions.”

    Mia Yang, MD
    Director of Wake Forest Baptist Health’s House Call Program

    The Commonwealth Fund reports that homebound individuals are more likely to be from lower-income and African American backgrounds and to be unmarried and less educated. They often rely heavily on health aides or family members, which means they can't always adhere to social distancing measures.

    “Although these patients are not exposed to a whole lot of people, they depend a great deal on those they are in contact with,” Yang explains. “That’s not something people think about very often. Generally, homebound people are not thought of much from a policy and community perspective.”

    In fact, homebound individuals often suffer from social isolation, which is linked to serious health risks, such as heart disease and stroke. The ability to safely see friends and family is one of the many benefits of vaccination for homebound patients, experts note.

    “I have one patient who has only been waving to her nephew through the window,” Lee says. “Although she lives with her sister, she was anxious to reconnect with him. They hadn’t been letting anyone in, including me. But when I said, ‘I’m bringing the vaccine,’ they let me come in.”

    Clocks, maps, and coolers

    Teaching hospitals’ at-home health care programs range from reaching 200 patients in one city to more than a thousand across a vast region. But COVID-19 vaccination requires complex logistics for all of them.

    Generally, once vials are open — depending on the vaccine and temperatures — a two- or six-hour clock ticks down until they need to be used or tossed. Most programs aim to inoculate between five and 10 patients in that window, taking into account travel time plus 15 to 30 minutes to monitor each patient for possible side effects. (Guidelines for the Moderna vaccine recently expanded that clock to 12 hours, which will ease the distribution pressure for teams using it.)

    Tight time limits have led to some nail-biting moments. “A few weeks ago, I had to go pretty far up in the mountains, and it was snowing,” notes Natalie O’Connor, RN, of Hartford HealthCare. “One road hadn’t been plowed at all, but I got through. Another day, my patients weren’t so close together, and I started thinking, ‘Oh my God, am I going to make it?’ But I got it done in five hours and 15 minutes.”

    “We’re using special mapping software to cluster patients and create efficient routes. Then we have backup plans that will ensure that all of the vaccine gets used if there’s a last-minute change.”

    Karen Abrashkin, MD
    Medical director of Northwell Health’s House Calls program

    Karen Abrashkin, MD, medical director of Northwell Health’s House Calls program — part of Northwell Health, which includes several teaching hospitals on Long Island, and in Queens and Manhattan — and her team have spent hours planning how to vaccinate approximately 1,000 patients.

    “We’re using special mapping software to cluster patients and create efficient routes,” says Abrashkin, whose effort launched on March 10. “Then we have backup plans that will ensure that all of the vaccine gets used if there’s a last-minute change. For example, we’ll quickly contact other nearby patients if it turns out someone on the original list can’t get vaccinated.”

    For some vaccinators, timing issues now have a new twist. “We had been using Moderna, and then we recently added the Johnson & Johnson vaccine, which lasts six hours — but only if you keep it cold enough. So, we need thermometers in our cooler bags, and if the temperature goes up, we’ll suddenly need to adjust to being down to two hours,” Lee explains.

    “We also need color-coded bags to make clear which is Moderna and which is Johnson & Johnson. That’s a whole other layer of complexity,” she notes. Her program also recently got a bit more intense when it added caregivers to its list of vaccine recipients.

    Lee also coordinates the involvement of medical students, and she greatly appreciates being able to bring them along. “Our fourth-year geriatrics students always join us for home care. Now, it’s definitely helpful to have another medical individual with me in case something happens, like an allergic reaction to the vaccine.”

    St. John is grateful that her logistical issues are eased by her parent institution. “We’re very fortunate to be part of Hartford HealthCare since they have resources like staff to contact all these patients to see if they want the vaccine.”

    Since the team started vaccinating homebound patients on Feb. 6, it has inoculated more than 300 people, which has entailed some nurses working weekends. But St. John has more than a thousand patients she’d still like to reach. “We only have so many staff available, unfortunately,” she says. “I wish we could go even faster.”

    Gaining from giving

    Providers who hit the road to deliver vaccines find the work tremendously rewarding.

    “One patient burst into tears after getting vaccinated,” recalls O’Connor. “She said, ‘If you hadn’t come here, there’s no way I would have been able to get out by myself. I have nobody to take me.’ So she’s crying, and I start crying.”

    Although it’s gratifying to inoculate anyone, Yang says she’s particularly relieved to help protect some of society’s most vulnerable members. She worries about the unique issues that her patients might face if they wind up hospitalized from COVID-19.

    “I have one patient who had to be hospitalized. She has pretty severe dementia and doesn’t speak English, and she depends a lot on her son, who couldn’t come to the hospital. It was a very traumatizing experience for both of them,” Yang recalls. “I feel like it’s a privilege to deliver this liquid gold to patients.” In fact, she notes, her whole team is volunteering their time to support inoculation efforts.

    Students involved with at-home vaccinations also greatly value the experience. For fourth-year Boston University School of Medicine student Ali Siddiqui, it was his first time administering a vaccine. He appreciated the opportunity to learn the skill, but he says the chance to see patients in their home environments was most rewarding.

    “There are things you just can’t see when you treat a patient in the hospital,” he says. “You might miss how they struggle to open a medication package or get around their apartment. But there are other things you don’t always consider too. Everyone has a different life story — they have hobbies, families — and you can really see that so clearly when you’re inside their home.”