Meet Them Where They Are

BY FARIN JACOBSEN

Finding a COVID vaccination clinic and registering for an appointment can be confusing even for a well-equipped, tech-savvy individual. But for some people — namely agricultural workers, the elderly, and individuals experiencing homelessness — accessing and navigating government websites to find a vaccine clinic can be impossible without help. With such populations, local officials say, the best solution is to bring the vaccine directly to the patients. “Public Health is keeping those hard-to-reach populations top-of-mind,” said Madera County Public Health Director Sara Bosse. “That’s a really important role of the Department of Public Health is always to figure out how to equitably make vaccinations available. But how you do that depends on what resources are available and what partners you have.”

Collaboration is a mark of a crisis, with multiple agencies working together for the greater good. Madera County’s Department of Public Health has contracted with community-based organizations and collaborated with the Madera County Farm Bureau and Ag Commissioner as well as other agencies that work closely with the agriculture community to get farmworkers vaccinated. The Madera County Office of Emergency Services was also a huge part of the health department’s response to the pandemic from the beginning, Bosse said.

“I think that [the collaboration] has been extremely helpful given the high demand on Public

Dr. Oscar Sablan and Dr. Marcia Sablan have partnered with AMORE to deliver vaccines to ag workers in rural Fresno County. Over 1000 have been vaccinated at clinics at Pappas Family Farms, Holland Nut Company, Bar 20 Dairy and the Firebaugh Community Center.

Health to be able to take on things that we weren’t funded to do up to this scale,” she said.

Fresno and Madera County public health departments, along with several partner agencies and employers, have come up with dedicated and creative solutions to serve their ag workers, seniors, and unhoused populations.

VACCINES REACH AG WORKERS THROUGH THEIR EMPLOYERS

The Wonderful Company, which produces and packages POM Wonderful juice, Wonderful Pistachios,

and Halos oranges among other products, has vaccinated employees onsite through standing clinics and mobile clinics, said Dr. Raymond Tsai, the company’s executive medical officer.

“As an ag company, there is a lot of interest to be sure that our workers are vaccinated, both because it is good for business, frankly, to be sure that our workers are protected, but two, it’s just the right thing to do,” he said.

While vaccines are traditionally distributed by hospitals and clinics because of their existing infrastructure and staff, focusing on non-traditional ways to vaccinate atrisk groups is increasingly important, Dr. Tsai said.

“Thinking about how to get vaccines to people where they are, instead of getting people to vaccines, I think is something that we need to do more of,” he said.

The Wonderful Company offers COVID vaccines to employees at its two Wonderful Wellness Centers in Lost Hills and Delano in Kern County. But because produce for The Wonderful Company is grown throughout Central California, Tsai has headed pop-up mobile clinics to be sure that all employees have easy access to the COVID vaccine.

“As we know, throughout the pandemic agricultural workers, essential workers, and particularly Latinx communities have been disproportionately affected

by COVID-19,” Dr. Tsai said. “These are populations that don’t get the privilege of being able to self isolate, meanwhile are also taking on the burden of ensuring the supply chain of food. I think there is also an almost society debt to these populations that have put themselves at the frontline and literally risked their lives during this pandemic.”

Pop-up clinics have vaccinated employees at the POM facility in Del Rey in Fresno County as well as citrus farms in Visalia in Tulare County, and a pistachios and almonds facility in Madera County, Dr. Tsai said.

The Wonderful Company partnered with Del Rey

Packing Co., another ag company, to vaccinate their employees. First doses were given on February 10 and 11, and second doses were administered March 11, bringing the total to 605 people vaccinated.

“We’ve been using our mobile clinic to go out to those areas, and then doing one-day, large events to vaccinate our employees, but we always ask for extra vaccine because then we have the opportunity of advertising to surrounding ag employers to see if there’s interest in vaccination amongst their employees,” Dr. Tsai explained.

Another pop-up clinic held March 16 vaccinated more than 100 ag workers in the rural, westernmost part of Madera County.

Ease of access location-wise isn’t the only benefit of these employer-sponsored mobile clinics, Tsai said.

Leveraging pre-existing relationships with employers has been a working strategy for vaccinating ag workers because there is a level of trust and open lines of communication between the employers and employees.

“If this is company-sponsored, they don’t have to worry about losing time from work or that they’re going to get in trouble for not being at work,” Dr. Tsai said.

Fresno County Public Health Director Joe Prado said location is key, but there is another barrier to vaccinating food and ag industry workers: trust in the vaccine. In working to vaccinate people in those industries, the Fresno County Public Health Department found free education was key to getting closer to 80 to 90 percent of people accepting the vaccine.

“As we continue to penetrate these vulnerable communities and populations, you’ll see an increased uptake with proper education and letting people make that decision of whether or not they want to be vaccinated,” Prado said.

PACE PROVIDES A SENIOR-SPECIFIC VACCINE CLINIC

In the early days of COVID vaccination drive-thru clinics, seniors 65 years or older were eligible to receive their vaccine according to state guidelines — but had to wait in their cars in line for hours.

“Nobody wants to do that, especially someone that is more frail, has more comorbidities, or is more sick than your average 65-year-old,” said Nicole Butler, center director for Sequoia PACE (a Program of All-inclusive Care for the Elderly).

WelbeHealth’s Sequoia PACE center at 1649 Van Ness in downtown Fresno was one of the first five COVID vaccination sites in Fresno County and began doling out vaccines in early January, Butler said.

To make things easier on the senior population, WelbeHealth made appointments available by phone instead of using online registration and caters specifically

to the 55 and older crowd.

Finding out where to get vaccinated and registering online for a vaccine is a common issue for seniors, Butler said.

“The [vaccine clinic] list is housed on the Fresno County website, which is not an easy website to maneuver,” Butler explained. “It’s go onto the county website, download 50 locations that are providing vaccination, and then start calling at the top of them.”

For those who don’t have the list or don’t have someone to help them schedule an appointment, this task can be daunting, time-consuming, and frustrating, Butler said.

“We tried to make our vaccination clinic a little bit easier, so we’ve only been vaccinating the senior population,” she said.

Sequoia PACE can vaccinate 120 seniors per clinic day; the clinic is held every Thursday.

Appointments are scheduled every 15 minutes and seniors are asked to come at their designated time, waiting in their car if they arrive early. Seniors can park right in front of the building, come inside to get their vaccine, wait 15 minutes in an observation area for any adverse side effects, and then go home, Butler said.

“We don’t want people lined up around the side of the building. We want it to be very calm and an easy experience for them — better than going to the doctor’s office,” she said. “It’s been really nice to do it in a setting that’s not as fast-paced as some of the other vaccination sites because this is not a fast population. I mean, they’re coming in with walkers and canes and wheelchairs and so it really allows for them to take their time.”

Sequoia PACE has reached out to local senior living facilities and provided transportation for their residents from those facilities to the vaccination clinic. Now they’re reaching out to see if the independent living facilities would

want staff to come to them to vaccinate seniors, but PACE is finding that most of the elderly living in those facilities who wanted the vaccine have already gotten it, Butler said.

SINGLE-DOSE SHOTS SEEM BEST FOR UNHOUSED POPULATIONS

People experiencing homelessness have a higher risk of mortality from COVID-19, according to the California Department of Public Health, and thus became eligible for the COVID vaccine on March 11. However, the Madera County Department of Public Health was a step ahead.

The department had already worked with the Madera Rescue Mission, which provides shelter to men, women, and children experiencing homelessness, to deliver vaccinations on February 10 and March 10 due to two COVID-19 outbreaks at the mission, said Bosse.

“Our health officer prioritized that group due to that vulnerability, and so we moved forward with people who are actually living at Madera Rescue Mission,” she said.

The health department administered 30 Moderna vaccines and 7 Janssen vaccines to people staying at the mission. The Janssen COVID-19 vaccine manufactured by Johnson & Johnson is administered as a single dose.

“We got feedback that the single-dose vaccine is ideal for the population, certainly because scheduling followup appointments is really a challenge for a lot of reasons,” Bosse said.

At this point, county health departments are taking whichever vaccines they are allotted and vaccinating as many people as possible, as quickly as possible, officials say.

“We’re looking forward to an increase in single dose vaccines and I think that’s really the ideal vaccine,” Bosse said. “It’s also easier to handle so that we can actually go out to encampments and … be able to set up a clinic that’s walking distance from locations where we commonly find our unhoused populations. That’s the plan in Madera County.”

Part of Madera County’s strategy is to engage with the unhoused population through a chronic disease staff member who is well-known and trusted in the unhoused community. The individual has worked with the county’s unhoused population for years with regards to testing and treatment of sexually transmitted diseases, Bosse said.

That staff member will be key in helping those unhoused individuals feel comfortable and — with the help of multilingual staff members and community-based organizations that speak indigenous languages — get their questions answered about the COVID vaccine, Bosse said.

“We need supports to be able to educate and inform that group as well about the benefits of vaccination — and we’re ready to do that,” Bosse said. “The strategy is to go to them and provide [vaccines] in a location that’s really convenient.”

The health department hasn’t surveyed the unhoused population to see if the group is apprehensive about getting vaccinated, but Bosse said the vaccine seemed well received at the Madera Rescue Mission.

“People were really open to getting the vaccine,” she said. “But with any group, especially those who have challenges with accessing information that’s largely digital… we want to make sure that people are well informed and when they’re making a decision that they have all the information.”

Bosse looks forward to the day everyone is eligible for the COVID vaccine, as long as the doses are available and the infrastructure is in place to administer doses to anyone who wants to be vaccinated.

“I think the most important thing for people to know is that Departments of Public Health want to vaccinate people. We don’t want to prevent people from getting vaccinated,” she said. “So the eligibility process that we’re following is really because I don’t have enough vaccine for everyone. It would be, honestly, easier for us to just open enough to be able to vaccinate anybody.

“As soon as we have enough vaccine, we’ll get around to everyone.”

WELBEHEALTH IS A PHYSICIAN-LED, CALIFORNIA PACE OPERATOR WHOSE MISSION IS TO UNLOCK OUR MOST VULNERABLE AND FRAIL SENIORS' FULL POTENTIAL WITH EMPATHY AND LOVE

Its teams coordinate every aspect of their participant's care so they can live in their own homes and communities rather than a nursing home. This care coordination includes all necessary medical and dental care, therapies, long-term care and services, meals, socialization, transportation, day center services, and activities in a fully coordinated 24/7 program. WelbeHealth delivers these services through PACE (Program of AllInclusive Care for the Elderly), a Medicare and Medicaid program. PACE is a well-established financing and care delivery model for older adults age 55 and older who meet their state definition of needing nursing home care. The PACE model of care aims to keep frail elders as well as possible, manage any medical crises at home, and reduce admissions to both hospital and long-term service and support (LTSS) settings.

BETTER OUTCOMES WITH COST SAVINGS

Among the 138 PACE organizations operating in 30 states, ninety percent of participants are dually eligible for Medicare and Medicaid, 9 percent are eligible only for Medicaid, and less than 1 percent are eligible only for Medicare. The typical participant has 5.8 chronic medical conditions, including dementia, coronary artery disease, cerebrovascular disease, and diabetes. These people have a 24 percent lower hospitalization rate using PACE than dually eligible beneficiaries who receive Medicaid nursing home services. At the same time, states pay on average 13 percent less than the cost of caring for a comparable population through other Medicaid services, including nursing homes and home and community-based waiver programs. This model of care makes a significant positive impact on quality of life for medically frail seniors and is essential to communities at a time when more than 10,000 baby boomers turn 65 each day. PACE has demonstrated significant improvements in participants' quality of life, life expectancy, depression rates, and sense of health empowerment and engagement. It also serves as a helpful partner to families and caregivers. It generates significant taxpayer savings by improving participants' health and well-being.

For frail elders, whose needs span both medical care and LTSS, the impact of Covid-19 has been catastrophic. High morbidity and mortality rates among those infected have been widely reported, with the most severe impact occurring in the nursing home resident population. However, less than 7 percent of PACE enrollees have tested positive for Covid-19 and 1.66 percent have died of the virus. These rates are below other care models serving nursing homeeligible individuals, according to the National PACE Association.

A SHIFT TO TECH

At the onset of the pandemic, WelbeHealth rapidly shifted to a fully remote home-based care model. In a matter of days, its teams deployed senior-friendly technology allowing low-income patients to access integrated care teams from the safety of their own homes on a 24-hour a day basis. These internet-connected WelbeLink computer tablets not only kept participants better protected from COVID-19 by facilitating remote care, WelbeHealth teams also invented new programming to combat social isolation through group therapy. In late 2020 when vaccination disbursement began in California counties, WelbeHealth was among the nation's first PACE programs to begin rapid and safe vaccinations among its participants. Its teams vaccinated the majority of its elderly patients and team members by utilizing strong relationships with healthcare partners and county governments. It is also acting as a community vaccinator, successfully vaccinating thousands of Californians against Covid-19. Since 2019, WelbeHealth has maintained its standing as one of the fastest-growing PACE operators in the U.S., opening four California programs to serve greater Stockton and Modesto, the Pasadena-GlendaleBurbank region, the greater Long Beach area, and Fresno. It has plans for additional expansion in underserved communities.

For more information, visit https://welbehealth.com