Staying at home has never been so vital for older Americans and those with compromised health. After nine months of the coronavirus pandemic, sheltering in place is still the most effective protection against Covid-19 for many older adults, and likely will be until an effective vaccine helps stop the pandemic.
The virus has taken an enormous toll on our nation’s older adults. They account for 16% of the U.S. population but 80% of Covid-19 deaths, somewhat higher than their share of deaths from all causes over the same period (75%).
Covid-19 has crystallized for many the challenges that homebound older adults face when it comes to access to care. At least 2 million people ages 65 and older are permanently homebound and millions more cannot easily get to a doctor’s office. While telemedicine has exploded and living room couches have become the new exam table, virtual medicine cannot deliver vaccines — a challenge that we hope will need solving sooner rather than later.
We believe that the home should be a focal point in the effort to eradicate the virus. Bringing vaccines to the home also gives providers another opportunity to visualize the management of their patients’ chronic diseases and intervene accordingly.
The mobilization to develop a Covid-19 vaccine is the medical Manhattan Project of our time, but success is not guaranteed. Unfortunately, history is not replete with examples of rapid vaccine development or vaccine adoption for emerging viral diseases. Although HIV was identified in 1984, an effective vaccine against it still has not emerged. And while influenza has been amenable to more rapid vaccine development, the annual adult adoption rate hovers around 45%. Against that backdrop, Operation Warp Speed has set a goal for distribution of 300 million doses of approved Covid-19 vaccines by the middle of 2021.
Several trials have shown evidence of multiple components of immunity and multiple Phase 3 randomized controlled trials are now underway. But once a vaccine is approved, many people will be asking, “How can I get it?”
Without serious planning, it could take a year for a Covid-19 vaccine to reach the majority of Americans. Social determinants of health — age, race, income, geography, education, mobility, and access to health care — will complicate the challenge of providing it to everyone effectively. News that the vaccine may require two rounds of injections may make distribution even more complex and limit the rate of adoption.
These challenges must be addressed before a vaccine arrives by putting into place strategies to gain the trust of the public and reach essential adherence rates, which is needed to bring good health to all, including vulnerable and underserved populations. To that end, the home setting should be included in vaccine distribution planning.
Here are three actions that can be taken today to begin that process.
Establish the right criteria for allocation. A society is only as healthy as its most vulnerable populations. Equitable distribution of a Covid-19 vaccine begins by protecting those at greatest risk for exposure to the virus — health care workers, first responders, and the like — as well as those who would be most endangered by infection, such as people who are homebound or living in long-term care facilities, those with chronic illnesses, and those over age 65.
The National Academies of Sciences, Engineering, and Medicine, which have been charged by the National Institutes of Health and the Centers for Disease Control and Prevention to create prioritization plans for equitable vaccine distribution, released a draft framework on Sept. 1. Organizations that provide home-based care should work with these agencies to ensure that in-home delivery is part of the solution for the nation’s homebound older populations. As providers of in-home care, our two organizations have already started to develop the necessary capabilities to assist in this effort and are using this year’s flu season to prepare for it.
Use flu season as a dress rehearsal. Vaccines are fragile. Taking them on the road requires solving issues of reliable transportation, secure packing and shipping, stable cold chain storage, and other distribution demands. Most home-based health care providers stopped delivering vaccines at home years ago for those very reasons. To solve the challenges and scale for national home-based coverage, biopharma companies — which are expanding vaccine production — should partner with national shipping companies and distribution locations.
This year’s seasonal flu vaccine is an opportunity for a dress rehearsal to launch and refine the home-based vaccination model at scale. Distributing the flu vaccine at home would be both a public health benefit — getting ahead of a “twindemic” — and an essential trial run for the forthcoming Covid-19 vaccine initiative.
Use the professionals patients already trust. People don’t want strangers coming into their living rooms, even ones bringing life-protecting vaccines. But according to the American Academy of Home Care Medicine, there are currently 16,000 home-health care providers who see patients in their homes. They are a good place to start. These providers are not strangers to the patients and families they visit. Harnessing the power of in-home practitioners that Medicare enrollees and homebound people trust will be essential for quality care and achieving a high level of adherence. Mobilizing the small practices and large organizations that have experience delivering care in the home would overcome the logistical challenge of scaling implementation for national coverage.
The distribution of a Covid-19 vaccine provides the U.S. health care system with a unique opportunity. The home can be a private, safe, and confidential location in which clinicians who people know and trust can help achieve the national distribution necessary to eradicate Covid-19. Not only can we create a better way to protect all Americans from the pandemic, but in doing so we can take a major step in the direction of bringing health care into the home, breaking down barriers to good health and making the house call a new normal for the 21st century.
Thomas Lally is a specialist in internal medicine and population health for high-complexity patients and the founder and CEO of Bloom Healthcare. Marc Rothman is a specialist in geriatrics, palliative medicine, and disaster preparedness, and is the chief medical officer of Signify Health.