This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

There are many barriers to making COVID-19 vaccines available to all Michiganders, but among the most difficult to reach are Michigan's estimated 110,000 homebound residents. However, a recent Michigan Department of Health and Human Services (MDHHS) initiative has helped county agencies begin making vaccine house calls. By partnering with Area Agencies on Aging (AAAs), Meals on Wheels programs, Medicaid, and local health departments, MDHHS has identified unvaccinated homebound residents. By early April, more than 21,000 of them had received their shots.

On April 20, MDHHS invited Michigan's AAAs, health departments, health care providers, and community organizations to request funding for vaccination programs. The goal is to provide mobile COVID-19 testing and vaccination services to the homebound and other high-risk Michiganders, such as seasonal agricultural workers and those living in shelters and transient housing.

Dr. Alexis Travis."Due to underlying chronic health conditions, the homebound are often at greater risk for serious illness when exposed to COVID-19. The homebound are not able to get out and access services and are often overlooked," says Dr. Alexis Travis, senior deputy director of MDHHS' Aging and Adult Services Agency. "We are urging the local health departments and systems to ensure equity in their approach to vaccination in serving this population, to identify who they are, and make sure that they have access to this service."

10-county agency got a head start last fall

Region VII Area Agency on Aging serves more than 10,000 residents aged 60 and above in 10 counties in central Michigan and the Thumb. Many of those residents live with multiple chronic medical conditions and are homebound as a result. They are at high risk for serious complications and death if they contract COVID-19.

"Any illness can send them to the hospital or lead to their unfortunate demise," says Nathaniel Bergman, pharmacist in charge of Region VII's homebound vaccination program.

In anticipation of a COVID vaccine being available in 2021, Region VII launched its influenza vaccination program for homebound people last fall.

Nathaniel Bergman administers a COVID-19 vaccine to a homebound resident in her home."Everything we did for that program prepared us for the COVID vaccination. It set us up very nicely," Bergman says. "Among the Area Agencies on Aging, being able to directly provide both influenza and COVID-19 vaccinations, we were the first in the state to take that upon ourselves. Our nurses were giving the shots. Our agencies were scheduling the shots. We're the direct provider."

In March, Region VII was able to fully vaccinate 300 individuals, 120 in their homes and 180 at clinics in communities without easy access to vaccination sites. MDHHS provided Moderna vaccines to the agency. Bergman hopes that MDHHS will be able to provide more doses so he and his colleagues can reach even more people throughout the region.

"Homebound people are calling our office asking for vaccines. We have their names on a waiting list," Bergman says. "Unfortunately, we have to tell them, 'We do not have any. If we can get a supply, we'll be out there to give you your vaccine.'"

Bergman believes that because Region VII already had an established relationship with most of the people who were vaccinated, they were less likely to feel hesitant about the vaccine.  

"Being able to have somebody talk with them about the vaccine, express their concerns, and have them validated allowed them to feel more comfortable to get the vaccine," Bergman says. "When somebody says to one of our nurses, 'I don't think it's a good idea,' that nurse would ask them, 'Would you like to speak with our pharmacy medical director?' We fully respected their decision. But if we can provide a trusted medical professional for them to talk to, that can increase their willingness."

As an agency, Region VII has shared its successful vaccine strategies with AAAs in Michigan and across the nation.  

"We encourage them to contact us, to reach out. We want to share. Nothing is proprietary," Bergman says. "If we can launch another organization and have the opportunity to impact more people aged 60 and older, we are here to help them. More power to them."

Calhoun County calls the shots

In Calhoun County, CareWell Services Southwest, Area Agency on Aging 3B, is in the midst of implementing its own vaccination program for homebound residents.

"For the homebound folks, getting a vaccine is a layer of protection. If their family members and caregivers are vaccinated, that's one more layer of protection. Their risk of death [from COVID-19] is so much higher. Their grandkids could be asymptomatic but they could get it very seriously," says Karla Fales, CareWell CEO. "By getting the vaccine, they can have greater confidence in letting family and caregivers come into their homes and provide that needed care."

Karla Fales.CareWell is working from lists of 2,100 names, phone numbers, and addresses provided by the MDHHS, as well as contact information for the approximately 1,200 people the agency serves. An initial test run vaccinated 20 homebound individuals.

"The homebound most definitely are one of our highest-risk populations for COVID complications or death. This is why we did a lot of things during the pandemic to keep them safe, like grocery delivery and [personal protective equipment] delivery," Fales says. "God bless the state for gathering the names."

CareWell is in the process of verifying addresses, creating routes, and scheduling eight hours of daily appointments for nurses recruited from the agency, local hospitals, and nearby federally qualified health centers. Like Region VII, CareWell is seeking to pair homebound patients with providers they already know to reduce vaccine hesitancy.

"The hesitancy is about fear of reaction to the vaccine. Many already have health concerns. They want to really know that it's safe, that they are not going to get sicker," Fales says. "One of the folks that participated commented that … he was glad to have it be [a nurse] he knew. For our homebound folks, it's definitely a big deal to have somebody they know and trust."

According to Fales, vaccine hesitancy is a huge issue for Calhoun County, where vaccine clinics are not filling all available appointments. However, she sees less reluctance among the county's older adults.

"We have seniors who say, 'Give me my shot! I led the way for polio vaccinations and I'm leading the way now,'" Fales says. "They want to see those grandbabies, go back to the senior center, and not feel afraid to go into the grocery store."

A recent surge of new COVID-19 cases in Michigan has begun to subside, but the state is certainly not out of the woods yet. As of early May Michigan still had the nation's highest case rate per 100,000 residents and it ranked 27th among the states for vaccination rate. Those leading vaccination programs for homebound residents hope to continue playing a part in turning those numbers around.

"This is a marathon, not a sprint," Fales says. "We have to keep looking at vaccination like that. Every time we have a challenge, we have to overcome it and move on — and take our time to do it right and as effectively and efficiently as we can."
 
A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Vaccination photos and Alexis Travis photo courtesy of MDHHS. Karla Fales photo courtesy of Karla Fales.