Dr. Leora Horwitz treats fewer and fewer Covid patients at NYU Langone Medical Center in New York City. Still, she thinks there are too many.
And they almost all have something in common.
“I only had one patient who was vaccinated and he was treated with chemotherapy for cancer,” she said, reflecting recent research into the vaccines’ limited effectiveness in cancer patients. “All others are not vaccinated.”
While caring for the seriously ill, she asks patients with sympathy and respect: Why not vaccinate? Some of them told the internist and hospital researcher that they are concerned about vaccine safety. But mostly, she said, the answers split into two groups: One is people who have planned to have a vaccination but haven’t gotten around to it yet. The second highlights a worrying flaw in the response to the pandemic: those who want to get vaccinated but are unable to because they are home chained.
“For a lot of the elderly, the people with chronic diseases, it was very difficult to get the vaccine,” she said. And since many of these patients receive home visits from health care providers, she wonders why the vaccine hasn’t been brought to them.
“You are already connected to a health organization that comes to your home on a regular basis. It seems that this should be a strategy that we should use, ”said Horwitz.
Doctors in Denver, Cleveland, and other cities have noticed the same trend: Covid wards are filled with unvaccinated people. According to the Centers for Disease Control and Prevention, 76% of Americans aged 65 and over have been fully vaccinated and approximately 87% have received at least one dose. Cities and states have been slowly rolling out programs to reach some of the estimated 4 million Americans in the country who are at home, but the programs tend to have modest goals and target only a fraction of the people who are likely to need to be contacted.
To increase the financial incentive to vaccinate people in their homes, Medicare announced Wednesday that vaccinations delivered this way will be reimbursed at $ 75 per shot instead of $ 40 per shot.
New York City launched a program in March to reach out to the homebound by working with housing agencies, private health care providers, the city’s aging department, and fire department nursing teams. According to a spokesman for the town hall, the program had reached 11,000 people in the second week of June.
Horwitz and others say the city’s program for reaching these people seems to be working, but not as quickly and efficiently as possible.
For example, New York’s Visiting Nurse Service, one of the largest home care providers in the area, has a contract with the city to vaccinate people in Queens. Anyone home in Queens is eligible, whether or not they are a VNS client. But if you’re in Brooklyn, Manhattan, Staten Island, or the Bronx and you get home care from VNS, that won’t help you with vaccination. You then have to go through the central bureaucracy and get assigned to one of the other contract providers in your area.
“The city and the providers we use are the primary sources of home vaccination in the city,” said Avery Cohen, a spokesman for Mayor Bill de Blasio’s administration. “This is a time-consuming and complicated process and we are doing our best to reach as many people as possible.”
A spokesman for the Visiting Nurse Service said his nursing teams had administered 2,600 doses and vaccinated 1,700 Queens residents in the past 10 weeks. The contract runs until the beginning of July.
Approximately 75% of city residents aged 65 and over are partially or fully vaccinated, according to the city’s vaccine dashboard. That is about 10 points less than the national average. It’s hard to say how much of the remaining 25% is home-based, but proponents say it is certainly many times larger than the 23,000 people the city is targeting in its home vaccination campaigns.
Defining and counting the “homebound” is problematic. Laird Gallagher of the Center for an Urban Future said there are 141,000 people over 60 in New York City who live alone and report walking difficulties. Susan Dooha of the Center for Independence of the Disabled estimates that there are 422,000 city dwellers aged 65 and over who are either fully home-shackled or severely impaired, including 262,000 who are at least 75 years old.
She said the city should cast a broader web on defining homeboundness and then create a network of public and private providers to meet the vaccination needs of that population. Some who remain unvaccinated despite wanting to be vaccinated may be prone to some needs themselves. But they can be cognitively impaired and they lack the organizational means to find a chance, Horwitz said.
Having raised the issue for much of the past six months, Dooha was glad the mayor announced a program but was instantly dismayed by its limitations. “I kept asking: what are the criteria?” She recalls. “Under the [Americans with Disabilities Act]if you need a home visit – you don’t have to be handicapped – you deserve a place to stay. “
Manhattan Borough President Gale Brewer, who sits on a panel that oversees the introduction of vaccines in Manhattan, said she had not received a direct response from the city on how it defines “home-bound,” and then decides who will do house calls targeted for vaccines.
“There’s been a lot of back and forth and confusion,” Brewer said. “It’s like, ‘Am I tied home if I go down to get my mail but don’t go out?’ The real problem is transparency and we don’t know the rules and we don’t have any data. “
Dr. Zenobia Brown, a doctor and senior executive at Northwell Health, the state’s largest network of hospitals, anticipates a difficult task getting the remaining New Yorkers vaccinated.
“We find that there isn’t a single barrier or even a simple set of barriers,” Brown said. “We have reached a point where it comes to hand-to-hand combat in order to understand the individual barriers and then develop solutions for them.”
For example, the parents of a 22-year-old man with autism wanted their son to be vaccinated, but were only able to provide him for limited times due to very strict routines. Another patient, in his mid-90s, did not want to bother anyone entering his walk-in apartment on the sixth floor.
Robert Janz, 88, and his wife Jennifer Kotter, 68, are not afraid to seek help. As soon as the city’s plans to serve the homebound became known, Kotter tried to get an appointment for her husband, an artist and poet, who is bedridden due to a “series of minor medical failures”, including back injuries from falls.
It was months before she was able to book her husband’s vaccination – even though nurses already frequently come to her fourth floor apartment in Manhattan. One of them gave Kotter a phone number to call, which led to another phone number, and then another until she finally succeeded. On June 1, a nurse and paramedic got together and administered the Johnson & Johnson single injection vaccine to Janz.
As a caregiver, Kotter has to expect such delays. “When caring for a patient, you have to be patient,” she said.
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