Settings of Care

Join Dr. Tim Farrell, from University of Utah and the VA SLC GRECC and Dr. Mariah Robertson, from Johns Hopkins School of Medicine, as they discuss vaccine access across settings of care. They also discuss community partners and assets for reaching older adults across settings of care as well as, special considerations when planning vaccinations for older adults.

To view a transcript click here then select the transcript tab. 

Transcript

Timothy Farrell, MD, AGSF: [00:00:00] Hello, I'm Dr. Timothy Farrell, Professor of Medicine and Geriatrics Division Associate Chief for Age Friendly Care at University of Utah Health. I'm also a physician investigator at the VA, Salt Lake City GRECC, and it is my pleasure to moderate today's session. We'll be discussing key points from the AGS Older Adult Vaccine Initiative module on Vaccine Access Across Settings of Care, and I am pleased to introduce my colleague, Dr. Mariah Robertson. 

Mariah Robertson, MD, MPH: Thank you so much, Dr. Farrell. It's such an honor to be here with you and to discuss access to vaccines across settings of care today. I am Mariah Robertson. I am an assistant professor of medicine in the Department of Medicine, Division of Geriatric Medicine and Gerontology at Johns Hopkins.

I also serve as Associate Program Director for the Geriatric Medicine Fellowship. And in my clinical and educational roles, I run the educational efforts for our house call [00:01:00] program and am a house call physician who thinks a lot about access and equity for individuals who are not able to access care easily.

Timothy Farrell, MD, AGSF: Well, Dr. Robertson, thanks so much for being here and let's dive right in. I wanna start off by asking you about some of the limitations that exist when vaccines are only offered in hospitals and clinics. And I think many, many of us in health professions and the public typically think of those two locations as sort of the the mainstays of where vaccines can be provided.

Can you comment a little bit on the limitations of thinking about only those two settings and maybe some ways to advocate for populations who have difficulty getting vaccines or, you know, maybe sort of outside of those usual settings of care. 

Mariah Robertson, MD, MPH: Yes, absolutely. You're, you're right in that we often in healthcare think that the best place to deliver care is where we are housed in clinical settings, hospitals, [00:02:00] health, even health departments, which are are traditionally a, an organiz- or a place in the community where people can get access to care, but still do have limitations for several people in our population. In particular, I think a lot about our home bound or home limited older adults, those for whom getting out of the house to go anywhere is impressively challenging and for whom often they have lack of access to primary care.

I also think a lot about individuals who may have transportation challenges at baseline, or individuals who are non-English, speaking for whom coming to a, a practice where there may not be access to resources in their own language, make it challenging and a barrier. And also thinking about less dense areas like rural or remote communities where access to clinical settings like hospitals and clinics is just not as readily available and easy to to get to. Moreover, we have many patients and individuals in our communities who are experiencing [00:03:00] houselessness, who don't have a place that they call home that they live in, and that they're able to use as a touchstone. And also it may not have a medical home from where they would receive care and those individuals who are incarcerated. And I'll talk a bit about that as well in a, in a little bit, I think. But where sometimes access to preventive care is, is disjointed or, or completely not available. 

So those are some areas where in populations where we really do see disparities in access and where we really need to recognize that, that us thinking only in the setting of hospitals and clinics is really limiting us.

Timothy Farrell, MD, AGSF: And Dr. Robinson, is it fair to say that we should be bringing care to people rather than expecting people to come to us for the vaccines? 

Mariah Robertson, MD, MPH: I think that's a very fair statement. In another life before I went to medical school, I was a public health professional, and what we know from the public health world is that making the healthy choice, the preventive choice, the easy choice is really the way we are [00:04:00] successful. And doing that in ways that reach communities and, and leverage community assets really is the best way to engage individuals in their own care and in their health. 

You had asked in your original question a bit about how we do this, and I think we, we know that community assets exist and community organizations exist that are embedded into the various communities I mentioned before, including in rural areas. And I think, you know, using those community assets to our advantage to go to people where they are, to provide these services, these vaccines is really the way to be successful and to build trust and support from communities of older adults in in these settings. 

If it's helpful, I can give some examples.

I think about Area Agencies on Aging, Aging and Disability Resource Centers, for example. Leveraging community organizations that we often use for patients that are not able to get out of their home or who are food insecure, like Meals on [00:05:00] Wheels. And thinking about home healthcare agencies, particularly for our home bound, where they're already coming out to the home to provide services who might also be able to provide vaccinations and other key and important preventive services. You could think about local pharmacies as well as paratransit services as well. 

Timothy Farrell, MD, AGSF: Yeah. Thank you Dr. Robertson. And it strikes me as a geriatrician, I might know about these resources, but I might not think of them as a means by which to deliver vaccination to hard to reach populations. I wonder if, if that may be, you know, sort of a, a twist on sort of a usual way of thinking about the services that are already available for older adults.

Mariah Robertson, MD, MPH: Yes, absolutely. I think what we have learned is that, I think in healthcare, we often think that we hold the key to how we provide health services and preventive services like vaccines. But, but in reality, many different organizations in the community have much more access [00:06:00] to our, our patients than, than we do in many scenarios.

And so using those organizations and recognizing how beneficial it is to leverage them really can help us reach patients. You're right, we are, I think as geriatricians, traditionally very good at understanding what community resources are available to our older adults. But making that connection to think about how we might be creative in using those community organizations to also help provide preventive services like vaccination is, is the key.

Timothy Farrell, MD, AGSF: And it would also seem to me that geriatricians can be leaders to health systems to alert them, if you will, to ways to leverage these existing resources. I, I would imagine that other disciplines and specialties may not be aware of these resources in the first place, let alone the, you know, the opportunity to leverage them for vaccination.

Mariah Robertson, MD, MPH: Absolutely. I wanna, I wanna expand a bit on some of the other ways that we can leverage the community existing community resources [00:07:00] beyond just, you know, I mentioned several agencies and organizations that are providing services, but also I think we have to think broadly about where our patients are, are going in the communities that may not even be adjacent at all to healthcare delivery or food delivery.

I'm thinking about things like faith communities, churches, and places of worship. Speaking about tribal or cultural centers or, or even going to adult day service centers where people are going already and providing these services to them. I think in particular, we've seen success in faith-based communities where we engage pastors in helping address some of the vaccine deliberation and hesitance that might exist, particularly in communities where there have been significant structural factors that, and systemic factors that have raised their distrust in healthcare appropriately. You know, having engaging community leaders really does help break down some of those barriers and address some of that deliberation and hesitance.[00:08:00] 

Also, many really cool initiatives have happened within black barbershops for vaccination. So again, Being creative, thinking about where we can go. That, that there is trust and there is community and, and capitalizing on that in a way that's helping build that trust. 

Timothy Farrell, MD, AGSF: And Dr. Robertson, I think the need to collaborate effectively with other groups, communities, populations is underscored by data. 

Mariah Robertson, MD, MPH: Absolutely. 

Timothy Farrell, MD, AGSF: In terms of how inequities are seen not just with COVID vaccinations, but across all the vaccinations that are important to older adults. Could you comment on sort of the data supporting the approaches that we're discussing here? 

Mariah Robertson, MD, MPH: Yeah, absolutely. You're exactly right. I think COVID has brought this to light in an even more magnified way because we have been mass vaccinating individuals across populations and trying to think a bit more about access and about deliberation that patients [00:09:00] might have around vaccination, but this is a longstanding challenge that we've experienced. I think we think a lot about the common vaccines, pneumonia, flu, COVID, but even the Shingrix vaccine. Another vaccine that we deliver to many of our older adults, or tried to, there's significant disparities that exist across both non-Hispanic, black and also Hispanic patients on large scale studies around vaccination rates.

And, and this is true across education and income levels. So even when we control for those variables, we find that there's significant disparities in acquiring these vaccines in in older adults over age 60. So, These disparities are not just in COVID, although we are seeing them magnified in that space. But there are you know, this is true across many, many different vaccines we've, we've attempted to deliver in the past. And what we know is that going to people where they are makes a huge difference in that deliberation and meeting them where they are also in their deliberation [00:10:00] and their hesitance is important.

Timothy Farrell, MD, AGSF: And thank you Dr. Roberson. I think that theme of meeting patients where they are and their specific needs is, is coming back to the forefront. 

So Dr. Roberson, you've spoken about advocacy efforts to bring vaccines to patients rather than expecting to come to us and several ways to collaborate with community partners and different assets and resources to reach older adults across various settings of care.

I'd like to go to a third key point, which would be innovations. I'm hoping you can share with our audience some special considerations when planning for vaccination of older adults and tracking across various vaccination sites.

Mariah Robertson, MD, MPH: Absolutely. We experienced, again, I think in COVID, a mass need to vaccinate individuals across settings of care. And that raised some concerns where we weren't able to access all people at risk. And you know, when we think as geriatricians, our [00:11:00] patients were at the highest risk and were the highest need for getting vaccination, particularly those living in long-term care settings where we were seeing the highest rates of of death- mortality as well as spread of COVID in the early days in particular. As a result of that, and particularly in the long-term care settings, we've developed massive large scale efforts to help vaccinate older adults that were living in long-term care. The government created a federal retail pharmacy program that worked with local pharmacies to actually provide vaccination on site within long-term care. And we saw lots of state and local health departments expanding their immunization programs to really try to increase reach vaccination for older adults. 

The hard part about that is that there still exists disparities in the long-term care setting, even within this expansion, particularly because this did not cover beyond nursing home level care and skilled nursing facilities. So we did still see significant disparities in access, in behavioral health settings [00:12:00] and in some congregate community based settings like assisted living facilities and group homes and adult day centers. Which ties back to some of what we were already talking about around collaboration and advocacy and how we really needed to be precise and use precision approaches with some of these community groups because they weren't included in these larger scale efforts.

It continues to be a concern and an important piece though that we, we think about how we leverage what we've learned in the COVID pandemic about things like the Federal Retail Pharmacy Program to potentially continue providing access to vaccines on site for other vaccinations important for older adults.

I wanna consider another population near and dear to my heart are home bound and home limited older adults. A lot of education has already been given to home care groups and home health providers around how to provide vaccines, but it's essential to delivery of vaccination to home bound and home limited individuals that you train all medical care, work workforce [00:13:00] within the home about vaccine handling, management and administration.

There is a lot of teaching in this space, particularly along within the American Academy of Home Care Medicine, where they talk a lot about how we, the nitty gritty of, of training your home-based medical care workforce in this space. It's especially important though that we recognize that even when we bring the vaccine to people, we need to be conscious of some of the accessibility issues that still exist for these individuals.

That means having paperwork available that's accessible for individuals who are unable to see or have limited vision. That is in large fonts, that's in braille. Having amplification devices available for our older adults who are harder of hearing, and this is true for any setting, but especially when we're coming to them in the home and we need to bring things with us and plan around that.

Thinking about non-English speaking patients and how we wanna make sure information's available to them in their native language. And those who have lower literacy, making sure there's visual cues and information so that when we're [00:14:00] bringing this to them, we're making sure they understand what we're, what we're doing and and helping build trust in that way.

And I think we often forget that there are individuals who are older adults that we aren't caring for in our traditional healthcare system, either in the house or home, in long-term care or in hospital settings. And that includes our older adults who are experiencing houselessness or homelessness and those who are currently or formally incarcerated.

And yet, these are populations that have had some of the greatest disparities in access to preventive care. So when we think about, for example, our older adults experiencing houselessness, we really need to think about mobile vaccination coming to them to increase vaccination rates, partnering with community health workers who are trained and who understand well that community and are able to provide consistent messaging.

Thinking about how we're transparent in providing data around the vaccine effectiveness, symptoms and safety, because credibility in this [00:15:00] population is super important. Making sure they understand that we're there to help and not harm. And in the criminal justice system, we know that similar to long-term care facilities, prisons, and jails, were spaces where where COVID went rampant early on in particular was spread as we were learning more about how it was spread. And these populations were at ex extreme risk for spread of COVID and should be high priority for vaccination and also have a lot of lack of trust because of some challenges that exist with the current prison healthcare system.

And so I just wanna highlight those populations because I think we often don't, as geriatricians think of this immediately as populations that we should be recognizing and trying to reach. But they are absolutely patients that we need to be thinking of and advocacy we need to be putting forth a systems leaders as we think about how we get vaccines to these populations.

Timothy Farrell, MD, AGSF: Thank you, Dr. Robertson. I think as I'm, I'm listening, I'm, I'm hearing some themes [00:16:00] coming back up. Even as we're talking about innovations and these special considerations for various populations, advocacy sort of keeps coming up, and I think geriatricians are really well positioned to be advocates because we understand those various settings of care.

I'm thinking about some of the trainees that I work with and educational needs in terms of understanding these various settings. If you don't know the various settings, it's gonna be hard to advocate and to understand that, you know, folks in, in these various locations across settings really need to have innovative strategies tailored to them.

So I feel like this last discussion really brought together the three major themes: advocacy, collaboration, innovation. So Dr. Robertson just wanted to thank you for joining us. Did you have any additional comments or, or observations before we conclude? 

Mariah Robertson, MD, MPH: Thank you so much. I, I'm so glad to have gotten to be here.

I, I wanna make one, one final sort of keeping one final statement and then, and then share just [00:17:00] one more thing about tracking access and vaccinating when and where you can. We as geriatricians, I think, recognize as part of who we care for, but often get forgotten in the healthcare system are our caregivers as well. And so I just wanna encourage that as you're building a vaccine access program or initiative in your own work, thinking about how you also ensure caregivers are vaccinated in these efforts. They are critical to the health of our older adult patients. They're critical to keeping them safe and at home, or existing wherever they want to be and where they want to age in place.

And so, so when we roll out initiatives to increase access, particularly as I think about our home bound older adults, we really should also be thinking about including caregivers in those vaccine efforts. 

And then the last thing I just wanna say is that I really think that, that like a big sort of take home message is that we really should be vaccinating when and where we can our older adults across the healthcare system and in the community settings.

And that means even in short-term stays in skilled [00:18:00] nursing or in other respite care spaces, that we should really take our chance to give a vaccine where we can with ample information and building trust in those ways. We have systems to track vaccination across settings, but they really are lacking. 

And I guess just to bring it home one more time to the advocacy piece. There is a, a system built called the Immunization Information System, which is available in every state and should be tracking in some way vaccines across settings. However, every state's leadership, their governor and their leadership makes decisions about how much funding goes to these Immunization Information Systems.

So some states have more robust systems than others, and I think as, as geriatricians who take care of patients across so many settings, it's important that we understand what our immunization information systems look like for our states, and that where we can, we advocate for those to be made more robust so that we're able to really track when we do vaccinate people wherever they are in the healthcare system.[00:19:00] 

I think that's all I, I had to say at the end there, but I, I'm really grateful for the opportunity to speak with you today, Dr. Farrell. 

Timothy Farrell, MD, AGSF: Well, thank you, Dr. Robertson. And that's, that's such an important point on the, IIS, Immunization Information Systems to, to conclude with. I can say I, I'm not sure I really was fully aware of, of that infrastructure, if you will that supports tracking vaccinations.

You can imagine how, how difficult it can be to track vaccinations across various sites. But nonetheless, there's a great opportunity. I think the geriatricians can lead to improve how we capture that information and to be familiar with IIS so, so thank you for pointing that out in the context of this discussion of settings of care.

And I'm grateful Dr. Robertson, for your participation. This concludes our session on Vaccine Access Across Settings of Care for the AGS Older Adult Vaccine Initiative. Thank you so much for listening and take care. 

Mariah Robertson, MD, MPH: Thank you.