key: cord-0067621-rqroa9fx authors: Beste, Lauren A.; Chen, Anders; Geyer, John; Wilson, Maureen; Schuttner, Linnaea; Wheat, Chelle; Rojas, Jorge; Nelson, Karin; Reddy, Ashok title: Best Practices for an Equitable Covid-19 Vaccination Program date: 2021-09-15 journal: NEJM Catal Innov Care Deliv DOI: 10.1056/cat.21.0238 sha: 749845725848d0606bd84b77bbaf53137d65dbb1 doc_id: 67621 cord_uid: rqroa9fx Leaders at the VA Puget Sound Health Care System vaccinated Black, Hispanic, and multiracial patients at rates exceeding population averages through outreach efforts that are accessible to other health care organizations. The VHA is an integrated health care organization with 171 medical centers, 1,112 outpatient clinics, and more than 9 million enrolled veterans. 11 The VHA was allocated its own vaccine supply from the U.S. government, which was then distributed across VHA geographic regions and specific facilities. As a group, VHA patients are at risk of poor outcomes related to Covid-19 because of older age, a high burden of medical comorbidities, and disproportionate rates of social vulnerability. In December 2020, the VHA network rolled out a centralized vaccine prioritization schema developed in conjunction with the National Center for Ethics in Health Care. 12 Vaccination age strata diverged slightly from those of the Centers for Disease Control and Prevention (CDC), given the older population of the VHA compared with the United States overall (the median age of VHA enrollees is 65 years [interquartile range 50-73 years]). 13 The VHA also differed by recommending priority vaccination for specific groups at risk of severe Covid-19 disease or of viral exposure because of frequent contact with health care (e.g., hemodialysis, spinal cord injury, hospital-based chemotherapy, and solid-organ transplant) or communal dwelling status (e.g., nursing home resident or persons experiencing homelessness). " Approximately 1 month in advance of our facility's first administered Covid-19 vaccination in December 2020, we assembled a team to develop a facility-level framework for an equitable vaccine delivery strategy. Our plan included four main domains: allocation, outreach, delivery, and monitoring. Individual VHA facilities were given independent responsibility for developing their own outreach strategies and vaccine scheduling processes in conjunction with central VHA guidance. In instances in which the number of veterans within a priority group exceeded the local supply of vaccine, facilities were granted the authority to further substratify vaccination priority groupings. 14 The VA Puget Sound Health Care System is a 291-bed academically affiliated tertiary care hospital with two main divisions (Seattle and Tacoma, WA) and seven outlying community clinics. Approximately 1 month in advance of our facility's first administered Covid-19 vaccination in December 2020, we assembled a team to develop a facility-level framework for equitable vaccine delivery. Our strategy included four main domains: allocation, outreach, delivery, and monitoring (Table 1) . Core team members came from several disciplines, including primary care, ethics, diversity/equity/inclusion, rehabilitation medicine, nursing, physical therapy, informatics, and health services research. Our team designed a vaccination allocation and priority strategy that identified individuals for early targeted outreach to forestall systematic inequities in receipt of vaccination. We assigned equal Learning Health System approach using real-time data to guide operations (e.g., low vaccination rates in certain counties/ ZIP Codes leading to mobile vaccination clinic in that area; low vaccination rates in Native American veterans leading to discussion with VHA tribal representatives) *Note: Informed by the Equity Matrix in Ismail SJ, Tunis MC, Zhao L, Quach C. Navigating inequities: a roadmap out of the pandemic. BMJ Glob Health 2021;6:e004087. https://gh.bmj.com/content/6/1/e004087. Source: The authors. weight to CDC-defined high-risk comorbidities and high-risk racial or ethnic groups and created a simple score consisting of the sum of risk factors. CDC-defined high-risk comorbidities used in our risk score included cancer, chronic kidney disease, chronic obstructive pulmonary disease, heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies), weakened immune system (e.g., from solid-organ transplant), obesity (body mass index of 30 kg/m 2 or higher), sickle cell disease, smoking, and type 2 diabetes mellitus. 15 We summed up to five comorbidities in addition to high-risk race or ethnicity for a total risk score range of 0-6 for each patient. " We summed up to five comorbidities in addition to high-risk race or ethnicity for a total risk score range of 0-6 for each patient. Given that age is the dominant risk factor for Covid-19 mortality, with other characteristics conferring additional risk with unknown relative impact, we contacted veterans for scheduling, by age group, in order of highest to lowest risk score. Given that age is the dominant risk factor for Covid-19 mortality, with other characteristics conferring additional risk with unknown relative impact, we contacted veterans for scheduling, by age group, in order of highest to lowest risk score. If patients tied by risk scores, they were contacted in order of oldest to youngest. To minimize travel burdens and to preserve patientcenteredness, once veterans became eligible on the basis of age group, no veterans were turned away if they requested vaccination or if they had another appointment that would bring them to the hospital, regardless of their risk score within their age group. We conducted a systematic, multimodal outreach program for 100% of our veteran catchment population within 100 days to invite each patient for vaccine scheduling. We intentionally avoided relying on Web-based self-scheduling platforms as the primary conduit to vaccination appointments. Although it is more labor intensive than self-scheduling, we felt that initial personal outreach using individual telephone calls or emails was less likely to lead to disparities. During our vaccine drive, which launched December 21, 2020, and concluded May 30, 2021, our facility redeployed approximately 25% of our scheduling staff from routine hospital duties to support mass vaccine outreach. Outreach began with up to three automated, outbound telephone calls with direct connection to a live scheduler if the recipient answered the phone. For nonrespondents to phone outreach, we sequentially proceeded with a no-reply email with instructions to call our vaccine scheduling hotline, a mailed letter with the same information, and, lastly, a selfscheduling option using SMS text messaging. To facilitate uptake among those suspected to be at risk of barriers to vaccination, our facility worked with trusted frontline personnel, community stakeholders, our Social Work service, and local nonprofit veteran advocacy groups. We specifically disseminated tailored outreach to homeless veterans and rural and minority veterans. During the initial period, interest in vaccines was strong and exceeded available doses. In more recent months, the outreach team has encountered vaccine hesitancy. Outreach workers By monitoring delivery at 10,000-vaccine intervals, the team was able to ensure equitable distribution by race and ethnicity. While uptake was greatest among white veterans at the first interval, over time, we saw increased vaccination rates among eligible Black, Asian, and multiple-race veterans. The period covered is from December 18, 2020, through July 28, 2021. Pac 5 Pacific. were provided a script for such instances, and they were instructed to refer patients to their primary care provider for specific questions on side effects or other medical concerns. We encountered a variety of barriers to equitable vaccine delivery, summarized using the validated Equity Matrix framework (Table 1) . 7 Approximately 70% of vaccinations were given at large mass vaccination sites based at our two medical center campuses. We also offered vaccinations at four community-based rural clinics on a rotating basis. We compiled ZIP Code data using the most recent home address to identify locations with high concentrations of unvaccinated veterans and deployed targeted mobile outreach to five carefully chosen rural popup clinic locations. Additional mobile vaccination offerings included offsite teams sent to individually vaccinate homebound veterans or groups of veterans living in homeless shelters. We identified veterans for individualized vaccination via referrals from our home-based primary care program and the program's waiting list, our homeless primary care program, our rehabilitation medicine service, and our mental health department. Vaccine equity was monitored at intervals of every 10,000 vaccinations by comparing the cumulative proportion vaccinated by race and ethnicity, sex, and rural status within each age cohort ( Figure 1 ). These data were discussed by the vaccine equity team and translated into proactive, tailored interventions consistent with Learning Health System principles and vaccine equity best practices (Table 1) . 16, 17 For example, the team quickly noticed that vaccinations in rural counties lagged rates in King County, where Seattle is located. In response, we reviewed vaccine coverage rates by ZIP Code to select destinations for pop-up clinics based out of our hospital's Mobile Medical Unit. We promoted vaccination among rural veterans by collaborating with nonprofit veterans service organizations located in rural areas. These organizations often also assisted us with logistics, such as clinic setup and veteran transportation to the vaccination clinics. The initial vaccine supply was erratic and required a flexible outreach strategy that could be rapidly adjusted depending on the quantity of available vaccine. Fluctuating vaccine dose allocation required methodical and repeated communication to patients and community partners to apprise them of the availability of doses and locations for vaccination offerings. This communication was accomplished through public town hall-style meetings, direct patient email outreach, a recorded vaccine information hotline, and regular social media updates. With a limited initial vaccine supply initially, our personnel faced challenges communicating the rationale for phased eligibility to veterans who flooded our telephone lines seeking vaccination. We delivered frequent internal communications to staff members so that they were able to provide accurate information to veterans. We created scripting for telephone staff on the basis of prior research suggesting that veterans prefer a sickest-first allocation strategy for limited health care resources. 18 An important hurdle was the large staffing resources needed to support personalized telephone outreach. This was made possible by repurposing staff whose typical duties were on hiatus because of the pandemic, as well as by authorization from hospital leadership to allow overtime. " Vaccine equity was monitored at intervals of every 10,000 vaccinations by comparing the cumulative proportion vaccinated by race and ethnicity, sex, and rural status within each age cohort. Limitations of our approach include lack of data on vaccination that occurred outside the VHA, because VHA and state immunization information systems are unable to exchange data in Washington state. Some patients received multiple outreach communications before they were vaccinated, but our study was not designed to assess the effectiveness of the individual methods or combinations thereof. Finally, it is unclear whether results from a veteran population can be generalized to the United States as a whole (particularly its younger and non-English-speaking populations), although we believe strongly that our efforts define best practices that would support equitable vaccine allocation in any setting. Replication of the VHA's strategies to support vaccine equity in other settings would depend partially on states' departments of public health working with payers and health systems to achieve the level of data resources available within the VHA. Nevertheless, vaccine equity is achievable with relatively simple interventions, regular monitoring of vaccine administration rates, and collaboration with community stakeholders. Our results demonstrate that vaccine equity is feasible and within reach. The team included three primary care-based general internists who served as the medical directors of the Covid-19 vaccine program. Representatives from other disciplines included an ethicist; geriatrician; physiatrist; diversity, equity, and inclusion expert; vaccine operations specialist; informaticist; health services researcher; and health psychologist. We reported up to the facility Emergency Operations Command, who reported up to the facility executive leadership. After conducting vaccine outreach, we identified all unique patients who received at least one dose of Covid-19 vaccine at VA Puget Sound ( Figure 2 ) using data from the VHA Corporate Data Warehouse, a comprehensive repository of information from VHA electronic health records. 19 Because data were obtained and analyzed as part of an operational quality improvement project, this project did not require Institutional Review Board review or exemption. Drafting and submission of this manuscript complied with applicable VHA policies. Our facility achieved equitable rates of vaccination using a targeted, multimodal, risk-based outreach strategy that included age, race and ethnicity, and rural status. Several factors contributed to our success. First, the VHA rolled out a clear, national vaccine prioritization plan that underpinned local facility efforts but also provided flexibility to tailor outreach within age cohorts. Second, the VHA is an established Learning Health System with access to real-time data resources, including clinical and demographic information for our catchment population. 16 This allowed us to identify veterans at greatest clinical risk and to reach out systematically to them, including those from racial or ethnic groups at risk of vaccine disparities. Third, we worked closely with trusted community-based stakeholders, nonprofit veteran advocacy groups, and other local experts to help us promote vaccination offerings to rural areas and minority groups. For example, when conducting mobile outreach to rural areas, we worked closely with local Veterans Service Organizations to help announce vaccine offerings, provide space, and recruit volunteers on the day of the vaccine clinic. Our interventions are consistent with peerreviewed best practices for navigating vaccine inequities. The roots of disparities in vaccination rates are complex and require thoughtful, multimodal solutions. Health care systems would benefit from strategically designing their vaccine operations in ways that reduce sources of inequities within their unique target populations, especially by making scheduling accessible and using personalized outreach. We also relied extensively on trusted messengersespecially veterans service organizationsto help engage rural and underserved veterans. The use of multiple outreach strategies was critical, as was the use of scheduling personnel repurposed from other hospital operations during the Covid-19 pandemic. We thank the hundreds of staff and volunteers across VA Puget Sound Health Care System for their tireless work to support veteran vaccination. Note: The denominators within each cell show the number of eligible patients. Rurality is based on definitions by the Office of Rural Health of the U.S. Department of Veterans Affairs The Advisory Committee on Immunization Practices' updated interim recommendation for allocation of COVID-19 vaccine -United States Counties with high COVID-19 incidence and relatively large racial and ethnic minority populations -United States Trends in racial and ethnic disparities in COVID-19 hospitalizations, by region -United States Race, ethnicity, and age trends in persons who died from COVID-19 -United States Health Disparities: Provisional Death Counts for Coronavirus Disease 2019 (COVID-19) Demographic Trends of People Receiving COVID-19 Vaccinations in the United States No populations left behind: vaccine hesitancy and equitable diffusion of effective COVID-19 vaccines Blue Star Families. Pulse Check. Military Families' Perceptions of the COVID-19 Vaccine Military Families' Perceptions of the COVID-19 Vaccine (Part II) Department of Veterans Affairs. Veterans Health Administration. About VHA The Veterans Health Administration approach to COVID-19 vaccine allocation-balancing utility and equity Primary care spending in the Veterans Health Administration in COVID-19 Vaccination Plan for the Veterans Health Administration. Version 2.0 Underlying Medical Conditions Associated with High Risk for Severe COVID-19: Information for Healthcare Providers Moving from discovery to system-wide change: the role of research in a learning health care system: experience from three decades of health systems research in the Veterans Health Administration Navigating inequities: a roadmap out of the pandemic Eliciting patient views on the allocation of limited healthcare resources: a deliberation on hepatitis C treatment in the Veterans Health Administration Insights from advanced analytics at the Veterans Health Administration COVID-19 Vaccinations in the United States, COVID Data Tracker We aimed to achieve an equitable, coordinated, and data-driven Covid-19 vaccination drive with respect to race, ethnicity, age, and geographic distance in a veteran population. This work was funded by the Primary Care Analytics team through the Veterans Health Administration Office of Primary Care. We gratefully thank Drs. Tiffanie Fennell, Bessie Young, Elizabeth Vig, Christopher Vanderwarker, and David Glickman for their contributions to this work, as well as the thousands of staff and volunteers at VA Puget Sound who made the vaccination drive possible.Disclosures: Lauren A. Beste, Anders Chen, John Geyer, Maureen Wilson, Linnaea Schuttner, Chelle Wheat, Jorge Rojas, Karin Nelson, and Ashok Reddy have nothing to disclose.