Playing a key role in lessening vaccine inequity
Federally qualified health centers adapt to inoculate more people
As a home health care worker, Norwalk resident Amelia McClinton lived in fear of infecting her clients with COVID-19. She was looking for vaccination appointments online when her local community health center called her about a day-long clinic meant just for patients like her.
“I wanted to get vaccinated, so I would have kept looking, but this was so easy and convenient,” said McClinton, who is Black. “It takes a big burden off my mind.”
The Norwalk Community Health Center — where McClinton got her shot in March — is located in one of the state’s 50 priority ZIP codes, which have consistently lagged behind in vaccinations since January.
As the coronavirus pandemic grew and vaccines became available, federally qualified health centers like the Norwalk Community Health Center were in a critical position, particularly because their patients live in the same neighborhoods and priority ZIP codes that the state is trying to target. For decades, FQHCs have been providing primary care to underserved areas, with federal funds to support their efforts. Strategically located in areas that were slow to embrace the vaccine, FQHCs have emerged as a linchpin of the Biden-Harris administration’s efforts to boost vaccine equity and help racial minorities.
A lot rides on the shoulders of the FQHCs. But are they reaching their communities effectively?
It’s hard to measure. But some that were unsatisfied with their performance changed their approaches, and they say it made a difference.
The numbers
Federal data from mid-March, when individuals 55 and older were eligible to be vaccinated, show that 8% of the vaccines administered by the state’s FQHCs had gone into the arms of Black residents in the state. Twelve percent of vaccinations went to Hispanic residents. Those numbers were more similar to the state’s eligible population at the time than they were to the demographics of the ZIP codes served or the patient populations of Connecticut FQHCs — though those patient populations skew younger, making comparisons difficult. More recent data show potential improvement among Latino patients, though changes in how the data are reported make it difficult to compare March and April.
A study by the Kaiser Family Foundation found that nationally, FQHC data showed a similar trend, where vaccine recipients resembled the demographics of populations statewide. “They seem to be doing a better job of vaccinating people of color relative to the national vaccination rates of people of color, and pretty consistent with their share of the population,” said Jennifer Tolbert, a researcher at KFF. But they could do more to reach patients of color, the study concluded.
Connecticut’s FQHCs have consistently lagged behind the national average in the percentage of vaccines administered to minority FQHC patient populations, though it is unclear how much that is a product of the state’s largely agebased rollout policy as opposed to challenges reaching eligible populations. Connecticut continues to lag in the most recent data from early April, just before the state expanded eligibility to adults 16 to 44.
Interpreting statewide data to examine the vaccination efforts of individual health centers is an endeavor littered with caveats — but some FQHCs have evaluated their own numbers and taken matters into their own hands. Unsatisfied with their initial progress, two Connecticut FQHCs — Norwalk and Fair Haven Community Health Care — have switched up their approaches to booking appointments to reach priority ZIP codes over the course of the past few months, efforts that they say have been paying dividends
Correcting course
The U.S. Health Resources and Services Administration does not release vaccination rates by race or patient population percentages by federally qualified health center, but Fair Haven and Norwalk shared some of the data that they report to the HRSA with The Connecticut Mirror. First Choice, Charter Oak and Community Health Center declined to do so; CHC did not keep a copy of its responses from early March, a spokesperson said.
The CDC’s Vaccine Administration Management System “really was problematic in accessing many of the people we serve, in that you had to be computer literate, you had to have access to computers, you had to speak English, you had to have an email,” said Suzanne Lagarde, chief executive officer at Fair Haven. But leaving the VAMS platform alone wasn’t a solution; it presented its own challenges. “Now you had the challenge of, ‘How do you fill those spots now with the people whom you serve?'”
One of the key changes that Fair Haven has since implemented was to allow community partners — Apostle Immigrant Services, Unidad Latina en Accion, Junta for Progressive Action and New Haven Legal Aid, among others — to directly schedule appointments in their system without needing to go through Fair Haven staff. The team at Fair Haven then manually enters a client’s information into their preferred electronic medical record system, which is known as EPIC; community organizations do not have access to EPIC directly.
“The concept is, clients are going to trusted agencies in the community, and those agencies have the ability to give them the appointment in that moment,” Lagarde said.
Fair Haven moved off VAMS in early February, and their numbers show the difference, said Abigail Paine, vice president of quality — though the improvement in the numbers is also a result of expanded eligibility criteria. Over 65% of vaccines administered in January were to white patients; that number rose to over 70% in February and dropped to 40% in March. “We’re doing about 400 vaccines a day — but we’re trying very hard to be particular in who we target,” Lagarde said.
Prior to the one-day, patientonly clinic that Norwalk held on a Saturday, the center had managed to vaccinate only 13% of its 55+ patient population, according to numbers from Debbie Bailey, quality and performance improvement officer. Eligibility had just been expanded to people 45 and over at the time of the clinic, which was the center’s first attempt to vaccinate patients at this scale. The daylong vax-a-thon was the product of days of planning, during which the clinic manually called all eligible patients in its database to schedule appointments.
Norwalk Chief Medical Director Marcelyn Malloy said the FQHCs feel an obligation to reach their patients knowing that they already have built up some trust with them.
“It’s easier when someone calls you and says ‘Hi, we have an appointment for you.’ And you know what time, and that we’ll take care of everything for you, including your second dose — and if you have any questions, you know where to reach us,” she said.
Since early March, some state FQHCs have been ordering doses directly through the federal government to improve vaccine equity, amounting to over 300,000 doses. Four FQHCs were initially invited to participate in the program, and the invitation was subsequently extended to 13 more.
In addition, FQHCs and other providers operating in vulnerable ZIP codes have been allocated as much vaccine as they ask for to serve those communities, said Josh Geballe, the state’s chief operating officer. Connecticut has not publicly released vaccine allocation numbers by provider, though some other states do.
Vaccine supply was not an issue at Norwalk Community Health Center, but staffing and costs are, Malloy said. The one-day clinic cost the center about $10,000, including security. Fair Haven is also administering shots at capacity.
HRSA data also show that FQHCs list staffing and reimbursement as their main challenges in vaccine administration.
“It takes a village to run a vaccine clinic,” said Everett Lamm, vice president of Clinical Affairs at Fair Haven. Staff need to manage vaccine supply, checking in clients, translation, vaccine administration, social distancing compliance and post-vaccine observation. “It — really early on — depleted us. We’ve been reliant on, at first, the Connecticut Army National Guard, and lucky most recently to have a seven-member team from the Connecticut Air National Guard. We have volunteers with us on a regular basis at Wilbur Cross from the medical reserve corps. We have students from Wilbur Cross High School who are dedicating and donating their time.”
What is a reasonable expectation of Connecticut FQHCs?
FQHCs are an important part of addressing vaccine equity — but “focusing on health centers alone won’t fully address the issue,” Tolbert said. The number of vaccines allocated and distributed by FQHCs is dwarfed by the vaccines administered by all partners every day.
The state aims to distribute vaccines proportionally to the number of residents that live in vulnerable ZIP codes, so its target has varied over time as eligibility has broadened. The state wants all provider types to send at least the “target” percentage — currently 31% — of vaccines to priority ZIP codes because they all have a presence in communities that rank high on the “socially vulnerable index” — a measure of communities that are most likely to need assistance in a public health emergency, Geballe said.
FQHCs have met the state’s target at times — though they fell short at 30%, as of the most recent data from April 12-17. But the state as whole has not achieved its goal yet, hitting 26% in the most recent data available.
The statewide data on progress towards equity targets could paint a misleading picture of the efforts of individual FQHCs, which might be far exceeding their percentage goal. Some — such as Community Health Center — have run mass vaccination clinics, which cater to the entire state, and therefore cannot be expected to reflect anything but the demographics of the state. Given the sheer volume of doses administered via that site, their efforts could be driving the overall FQHC statistic.
“We’re doing thousands of doses a week at the mass vaccination sites, but then you know we’re a health center, and we know full well that not everyone who is within the universe of our patient population can get to these places. We know that the majority of people who are out there at the mass vaccination sites are not CHC patients,” said spokeswoman Leslie Gianelli. “We’re trying to bring the vaccine to the communities of color really almost concurrent with opening the mass vaccination sites.”
HRSA percentage figures from early March did not include those mass vaccination efforts, Gianelli said, complicating the data. Later reports include the mass vaccination statistics CHC has since started to report to HRSA. As of data this past week, 7% of shots statewide have gone to Black patients and 20% to Hispanic ones.
At Fair Haven, defining their goals and progress has been as much a qualitative enterprise as a quantitative one. The center isn’t just trying to reach patients — but to reach residents that are not already in its orbit.
“I was less worried about our patients, because we had care coordinators calling patients oneby-one, addressing any concerns they might have,” Lagarde, Fair Haven’s CEO, said. “I was more concerned about people who live within blocks from us in Fair Haven and don’t seek care from us and don’t seek care from anyone because many of them are undocumented.”
Those people may not even show up in Census estimates, as they are historically undercounted. In as much as data can illuminate, bad data can obscure. The center relies instead on feedback from community partners to gauge how well they’re reaching those populations, Paine said. Canvassers are also going door-to-door to sign up people for appointments then and there and offer them rides if they need them.
The center has set itself a different sort of numerical target: “The goal is to knock on all 5,642 doors in Fair Haven,” Lagarde said.
Making the case to get a vaccine
Back in March, Norwalk hoped to get Johnson & Johnson vaccines for their ease of administration. Much has been made of the Johnson & Johnson vaccine’s potential to reach under-served communities in the wake of its sudden suspension earlier this week as federal regulators investigate rare blood clots potentially linked to the shot. At a press conference earlier last week, Geballe said that the state was not analyzing how many J&J doses went to high-SVI communities in particular.
Only 9% of doses orderer by federally qualified health centers in Connecticut have been Johnson & Johnson vaccines, which amounts to 34,800 doses, wrote HRSA spokesperson Scott Kodish last week.
Past polling suggests that the Johnson & Johnson “one and done” vaccine was the most appealing option for those who were on the fence about getting vaccinated, prior to the pause; however, side effects were the most commonly cited fear for those people, so it is unclear if that will remain true.
J&J-related worries could compound existing problems.
“We know that there’s some — and I don’t love the term — vaccine hesitancy among people of color, so it’s not as simple as saying, ‘Hey, you’re eligible.'” Tolbert said.
National polling has shown that hesitancy among people of color has been dropping.
Getting people vaccinated is urgent, Lamm said. The pandemic continues to disproportionately impact his patient community, and towns with higher vaccination rates tend to see lower case rates.
Norwalk’s patient population was devastated by the pandemic.
“At the beginning of the pandemic, we had almost a 60% positive rate among our patients,” Malloy said. “But you have to remember [that] a lot of our patients, multiple generations of the same family live all together, sharing a bathroom. You cannot quarantine. Essentially if one person gets COVID, everyone gets COVID, and that’s why we had such a high positivity rate.”
Malloy sells people on the vaccines on the promise of restoring a modicum of normalcy.
“We need to get people vaccinated. This is not just about getting sick,” Malloy said. “For some people, and most people actually, it’s about getting back to a lifestyle where our kids are educated, or people are able to work and their kids aren’t at home remote-learning, paying additional costs for babysitters. This is about getting back to being a human being, which is why we’ve decided that it is really part of our mission is to vaccinate our patients and the community.”