By Rose Hoban
A few days ago, Jay Smith and his wife, Yolanda, loaded up his wheelchair in the car and went down to the state Division of Motor Vehicles office near his Raleigh home to surrender his license.
“You can’t do it by mail, you have to go there,” Jay Smith said. “It’s like 3 months to get an appointment.”
Smith, 57, was diagnosed with amyotrophic lateral sclerosis, known more commonly as ALS or Lou Gehrig’s disease, in December and he’s had rapid loss of ability. By the time his appointment rolled around, he could barely transfer from his car to a wheelchair to go into the building.
“I made it, and it was the last thing I could do,” he said.
Smith and his wife reckon getting him out to receive a COVID vaccine will be even harder, as it’s getting more difficult for him to get in and out of a wheelchair. They could go through a drive-thru clinic, but he hasn’t been able to get an appointment. He also worries about leaving home to drive and then wait in line, where it might be challenging for him to, say, use a bathroom if he needed it.
“There are people who are worse off than me,” Jay Smith said. “They have to take the power wheelchair with them because they cannot be transferred onto a traditional wheelchair without an issue, maybe they have to be inside special medical transport.”
So, he is hoping for someone to come into the house to give him his shot.
Jay Smith is one of thousands of North Carolinians who are homebound for one reason or another. It could be a disability, it could be advanced age, or a developmental or intellectual disability, but these folks constitute some of the hardest people in the state to reach with vaccinations. And even though we’ve all been told to stay home for our safety for the past year, homebound people often require help from caregivers – both professionals and family – who come in and out of the house, increasing their risk of infection.
Getting these vulnerable people vaccinated is vital, said Charlene Wong, the chief policy officer for COVID-19 at the state Department of Health and Human Services. Research has found that people with disabilities have had some of the highest mortality from COVID this year.
Wong estimates there are anywhere between 15,000 and 100,000 homebound people like Smith who cannot get out to a pharmacy, clinic or mass vaccination site.
Instead, someone will have to come to them.
Rural advantage
“A lot of the employees that work here, they actually know the people in the county,” said Kimberly Irvine, the director of human services in Yadkin County.
Yadkin has fewer than 40,000 people, Irvine said, with about 7,700 people over the age of 65. She said only about 10 percent of those folks needed someone to go out to them to give a vaccine.
The smaller numbers have made it a little easier.
“It’s not a lot of people,” she said. “This is a community where you have mothers, grandparents, generations that live here.”
That’s made it easier to check everyone off a list compiled by talking to every kind of care provider.
Nonetheless, there were challenges. For one, the older senior population, those over 75 for the most part, didn’t have the computer savvy to sign up online for a vaccine, so Irvine’s people did what they could to get the word out.
“Senior centers, the churches, through our websites, through mailings, through the newspapers, through robocalls, all kinds of different ways, we let them know that we did have the ability to be able to come and vaccinate,” she said.
For weeks, Irvine has been sending out teams to people’s homes. She estimates that only about 10 percent – or 750 – of the county’s over-65 population were homebound and needed that extra help.
Sometimes they get a hand from a family member.
“We don’t normally have drive-thru clinics, but for those people who can get transportation to one of our clinic sites… we will give them a little bit of special treatment in that they wouldn’t have to come in like everyone else does,” she said. Instead, someone goes out back to give the vaccine to grandma sitting in a passenger seat.
Far flung
In eastern North Carolina, a team of employees and students from East Carolina University has been traveling to remote churches, homes and senior centers to give shots.
Paul Shackelford, a physician from the medical faculty, has been leading teams of volunteers to get out to those last mile vaccine recipients.
Shackelford will pile a group of volunteers into a van and they’ll head out to a remote church to vaccinate a half dozen people. He likened it to mission work.
On another occasion, coordinating with the Pitt County Health Department, Shackelford and his volunteers were able to assemble people from several group homes at a recreation center where they gave about 75 vaccines.
Want Dr. Shackelford’s team to come to your part of Eastern North Carolina? You can reach him here.
“I had one team member to start out with us and came back and said, ‘You know, I just don’t think this is very efficient,’” Shackelford said.
But that’s what it’ll take to get out to far flung folks who wouldn’t have access otherwise, including farm workers, he said.
“I’m assuming that this kind of stuff’s going on all over the state,” Shackelford said. “Like out in the west, central and the north and south and everybody’s working hard.”
In an even more remote part of eastern North Carolina, Albemarle Regional Health Services, Director R. Battle Betts said they use GPS mapping to plan the most efficient routes between people’s houses in an area stretching over eight counties and more than 3,100 square miles.
His teams have been using the Moderna vaccine, which only requires freezing temperatures, not the super cold temperatures needed to preserve Pfizer/ BioNtech vaccines. It takes an hour to thaw a 10-dose Moderna vial, then the vaccine powder gets mixed with saline and a six hour clock starts.
Betts said nurses travel with a cooler and ice.
“Depending on how accurately you can get your mapping, you can literally have another vial thawing while you’re out making the rounds,” he said. “Of course, then a six-hour clock starts on that vial.”
The Albemarle teams have been able to get vaccines out to somewhere between 1,000 and 1,500 people who are homebound, Betts said.
Part of the way they’ve been able to reach homebound folks is by partnering with the Meals-on-Wheels program.
“We’re utilizing our transit buses,” he said. “We can literally take a warm meal and a shot to somebody.”
Having those regular visitors also helped overcome the logistics associated with a two-dose vaccine.
“Hopefully they’re getting a meal on a regular basis and so then we can just step up and put those people back into the home for the second shot in 28 days,” Betts said.
More people, more logistics, more delays
In many parts of the state, though, vaccine providers have waited on the rollout of the one-shot Johnson & Johnson vaccine to make a “one and done” visit to homebound patients.
In Mecklenburg County, health department officials put a special request form on their county website for people needing a home visit.
In the first week after announcing the program on March 11, health department Medical Director Meg Sullivan said they had more than 300 requests.
“The team has been reviewing these requests and making plans to begin administering vaccines likely in early- to mid-April, depending on the supply of the Johnson & Johnson vaccine that we receive,” she said.
Wong, from DHHS, said federal authorities are aware of the need to get to some of these remote places and hard-to-reach people. The department added people with intellectual and developmental disabilities to the Group 1 vaccine group only recently after pressure from disability advocates.
“We made some changes based on their feedback which was, which was really valuable,” she said. “For example, recently, adding in group one people receiving long term care for more than 30 days including home and community based services for persons with I/DD, private duty nursing, personal care services and home health and hospice.”
She said the state has asked for help from the federal program to partner with pharmacies and the federal vaccine allocation program for community health centers.
“What we’re hearing from them is that they’re going to really be encouraging more mobile units be stood up within those programs, which should hopefully also be well positioned to do vaccinations for homebound individuals,” Wong said.
She said these efforts would gain speed as more Johnson & Johnson vaccine gets released to the states.
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There are a lot of home based primary care providers that go into these people’s homes every month that have been completely overlooked in this process. Just like with the flu vaccines, pharmacies won’t allow these providers to obtain the vaccines from them to administer to their own customers who can’t get out and providers aren’t getting included in the administration process unless you are connected to a big medical center. We are the missing link in this story.