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Special COVID-19 Webinar Recording: Ready, Set, Go ...
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Good afternoon, and welcome to this special edition of HCC Intelligence of the HCC Intelligence webinar. Today's webinar is entitled Ready, Set, Go! Planning Ahead to Administer the COVID-19 Vaccine to HBPC Patients. My name is Melissa Singleton. I'm Chief Learning Officer for the Home Centered Care Institute, and I will be your host for this event. Before we begin, I'd like to cover a few housekeeping items with you. All participants are muted, but please use the chat or question boxes located on your screen to submit comments and questions. Questions that are submitted will be answered during the Q&A session in the last 15 minutes of the webinar. And the recording of the webinar and slide presentation and our supplemental handouts will be made available on the HCC Intelligence webpage very soon after the webinar, certainly by early next week. At this time, I'd like to introduce to you our moderators, Dr. Paul Chang, who is Senior Medical and Practice Advisor for the Home Centered Care Institute, and also Medical Director of Northwestern Medicine Home Care Physicians, and also Brianna Plintzner, who is Manager, Practice Development at HCCI. Dr. Chang? Melissa, thank you so much for that. So, the objectives today, next slide, please, is to, yeah, is to describe some of the lessons learned from the household programs that have started to give the COVID-19 vaccine to patients and household caregivers in the home setting, and to discuss some of the logistics involved and advanced planning steps that are necessary aimed at enhancing the vaccine administration, efficiency, and efficacy for homebound patients. And lastly, to apply creative partnering solutions to ensure homebound patients receive the COVID-19 vaccine. Next slide, please. Before I introduce the speakers, you know, I'm really excited for this webinar, because we know at HCCI, home-based practice comes in many different flavors, and that one style is not going to fit, necessarily fit your program exactly. My program is different from Dr. Davis's program, even though we're similar in terms of being academic, part of an academic institution. And your program may look very different from the presenters, but what I'm hoping to do is that the presenters here can share some of the learnings that they have gained through this experience, and that we can all take away something today that will apply to your program in terms of getting a vaccination done efficiently, effectively for your group of patients at home. So, the presenter, just go back one slide, please. Let me just introduce first, we'll hear from Dr. Davis. Dr. Davis is the medical director for Rush at Home at Rush University Medical Center here in Chicago, Illinois. Next, we're going to hear from Dr. Lewis and Dr. Ranola. They are part of the VA home-based primary care program out of Madison, Wisconsin, where Dr. Lewis is the medical director, and Dr. Ranola is the home-based primary care clinical pharmacist, who can really help us navigate some of the logistics and the handling and the processing of vaccines. So, I'm really looking forward to hearing from her as well. And finally, we'll hear from Mr. Phillips, who is the chief executive officer for geriatric specialty care of Nevada. And his program is very, very interesting, very unique. So, I'm looking forward to hearing from Mr. Phillips as well, in terms of how his program came to be. All right. And now, I will turn this over to Dr. Davis. Hi. Thank you so much for having me here today. I'm excited to talk with everyone and also to learn from the other presenters. If you could go to the next slide, please. So, Rush at Home is our program of home-based primary care at Rush University Medical Center. And so, I'm going to be presenting our approach to this, which, you know, is very much reflects that we are part of an academic medical center. But what I'm hoping is that everyone can take something away from it, because really, it's about kind of harnessing the resources that we have. And hopefully, it'll give you some ideas for harnessing resources where you are as well. So, at our medical center, we have had a vaccine clinic open since December, initially focused on healthcare workers and now 1A and 1B. And so, as soon as 1B started to approach, I started reaching out to our leadership of our medical center and specifically of the vaccine clinic to see if we would be able to add our Rush at Home patients to our allocation. Our allocation comes from and is controlled by the Chicago Department of Public Health. So, the first response was, well, we need to check with the Department of Public Health. And as you can imagine, the Chicago Department of Health has a lot of things going on. So, it took, you know, maybe a week or so. Brianna suggested I share how much I advocated. So, I sent some emails over the course of this week to advocate to my own leadership, who is working closely with the senior leadership of Chicago Department of Public Health. And ultimately, I don't think it was a hard sell. I think everyone also just was juggling a lot of priorities. And they approved us vaccinating in the home. And the really cool thing is the leadership from the Chicago Department of Public Health let us know that there was actually a subset of 1B that we were unaware of that was caregivers of people who would otherwise be in a nursing facility or rehab facilities with people receiving that level of care at home. Their caregivers, 18 and up, were also in the 1B category, which we hadn't realized. And that had the extra benefit of we were able to share that across our institution. So, for example, pediatrics was able to get some vaccine for parents of children in that category. So, once we were able to identify that we would be able to get this allocation of vaccine, we had to order. And so, we had to order our vaccine 1.5 weeks in advance. And overall, we wanted to get this done. Our approach was to vaccinate all of our patients who wanted to be vaccinated as quickly as possible. And I think, you know, I'm concerned about the variants. I'm just in general concerned about our patients. And one of the things that I let our leadership know as we were advocating for this was that our program is relatively small. We only, you know, on a given day, our active panel is probably somewhere between 110 and 120. But with that active panel, we've already had two people die of COVID, you know. And that's not of people who had COVID. That's of our entire panel. So, our mortality rate from COVID is very high. And so, I think that made us feel the importance and the urgency of this and also helped us communicate the urgency to our leadership. And then one note I'll say here, you know, if you're not in an academic medical center, I think there are some options of working with vaccine clinics, whether they're in federally qualified health centers or working with other hospitals or institutions that are receiving vaccines. So, I think this model of kind of partnering with an existing vaccine clinic can work well. You can go to the next slide. So, the next, I would say, strategy that we did was we used a lot of volunteers. So, our program is relatively small and we're all pretty busy already. And we didn't want to slow down our regular visits in order to do this. So, we did this in addition to our regular visits using a lot of volunteers. And our institution throughout COVID has actually had a lot of volunteerism and a lot of involvement from learners like residents and students. So, this was a model that we had used before. So, as we were, at the same time as we were working with our leadership to try to get approved to do this, we knew that we wouldn't have very much time once approved to order the vaccine. And we also knew that we didn't have time to have big discussions with all of our patients because we had talked with some of our patients about whether they wanted the vaccine or not, but not all of them. And so, we identified a group of three internal medicine residents who were actually global health residents who were supposed to be on a trip to Haiti, but they couldn't go to Haiti because of the pandemic and also political unrest. And so, they needed something to do for a week. And so, we turned it into a rotation about where they learned about vaccine hesitancy. We gave them some literature to read about that and about things like motivational interviewing and how to talk to patients and about the history of, for example, structural racism in science and in vaccines and how that, you know, relates to people's hesitancy now. So, you know, tried to make this a learning thing and then had them call all of our 1B patients and ask them if they wanted the vaccine and hopefully have like a informed, interesting discussion with our patients. So, they called everyone. So, we had a yes, no, maybe on all of our patients. We also asked them to identify if the patients had caregivers who fit into a 1B category who would also want to be vaccinated because another principle was we wanted to vaccinate as many people in the household as possible when we visited, not just the patient. So then, we had that. As soon as we got that go-ahead that we could go forward, we actually, I think that was on a Thursday or Friday, we had to have a full schedule done by Monday night. So then, our own team went through that list and actually confirmed and created the actual schedule. We decided to vaccinate everyone, all of our 1B patients and family members who wanted to be vaccinated over three days. We created that schedule and turned it in. And then, after that, we needed to do reminder calls. So, there was another student who had expressed interest in volunteering. So, we trained him how to do reminder calls and he called all of the patients to make sure they knew that we were coming. And that script involved all the usual things that I think reminder calls include, like, we are coming to you, don't come to rush, you know, and giving a window of time, a way to contact us, kind of the usual things that we would have in a reminder call. So, nothing too special there. And then, I should say, because we had all these volunteers helping us, we used Microsoft Teams so that we could have shared, which is something we have at Russian, that where we could have shared documents where we could keep track of, you know, who had called what patient and things like that. Go to the next slide. In terms of operational issues, again, our priority was to vaccinate people as quickly as possible. Our EMR team was in the middle of doing a lot of much larger builds for vaccination. So, we decided to use the existing EMR build. We knew this had the implication that we would not be able to build for vaccine administration because of the way it was built, but just decided that that was okay because we didn't want to wait to be able to do a new build. In terms of papers, there's a lot of documentation. We brought paper consents along with the same documentation that we used in our vaccine clinic we also used at home. So, our amazing pharmacy colleagues had put together packets for us with the consent, NFAQ, the v-safe document from the CDC, vaccine information, and then the little vaccine card with a sticker on it. We used our usual supply, our usual provider bags, although we had to create two extra ones because we had four teams going out to vaccinate. So, really, the key items there were EpiPens, vitals equipment, sanding wipes, hand sanitizer, gloves, band-aids, gauze. It was actually not that many items that needed to be in there. Chucks, I think that was it. And then, in terms of vaccine storage, I love this picture of the cooler. I'm not sure if you can see the sticker on there, but it says, keep calm and trust your pharmacy team. And I feel like that's the main take-home message of our effort. This would not have worked had we not had a lot of leadership and partnership from the pharmacists running our vaccine clinic. So, they put together these coolers for us. The funny thing is we're using the Pfizer vaccine, so it actually has to be at room temperature. So, the function of the cooler was actually to keep them from getting too cold because we were doing this in Chicago in winter, and I think it was 9 degrees or something the whole time. And we used pre-filled syringes, which had a six-hour window. So, another little tip there was we made sure to, well, the second and third days, we made sure to get pre-filled syringes that had just been filled. So, we had the full six hours. The first day, we didn't do that and realized we only had five hours, which was fine, but six hours is a little nicer. And then, I should mention the coolers also had, we had continuous temperature thermometers on there that had a display that you could see all the time. So, the probe was in the cooler display. It was outside the cooler so that we could make sure we could keep it in range because as we were driving around, we had to make sure the heat in the car was at a certain level such that that cooler remained at room temperature the entire time. Go to the next slide. So, in terms of our team, so as I mentioned, we were going with the full volunteer approach. This picture at the bottom here is actually not our volunteer team for this day, but a volunteer team for a different day when we were doing a COVID testing event, which in just going back to what I was saying earlier of this model of just, you know, volunteerism and people at our institution wanting to help out has really served a lot of really neat projects over the last year. So, we recruited folks at Rush who wanted to volunteer. Dr. Reckman and I were the leads. We did a Zoom training for everybody a couple days before our vaccination days. We also did huddles at the beginning of each day to go over everything. And then we made sure we had basically text communication the day of, which was important for a number of reasons, but including that for we did have some instances where people, there were last minute cancellations and we had to very quickly find a new person to be vaccinated in order not to waste a vaccine. Go to the next slide. So, over those three days, we vaccinated 71 Rush at Home patients and caregivers. Again, our program is relatively small. So, this was actually all the 1B patients and then affiliated caregivers. Sorry, I should say 1B patients that wanted to be vaccinated. Not everyone wanted to be vaccinated. We could do one household about every 40 minutes. This includes the observation time post-vaccination and includes the documentation we document in EPIC. And although it's fairly streamlined, if it was a household of five people, that documentation did end up taking up most of the observation time. So, this model ends up being not that efficient, but sort of efficient if it's a household of five people and not that efficient if it's a household of one person. We had some last minute cancellations. We had some week of cancellations, which we were able to deal with before we even went out, but then we also had last minute cancellations while we were already out in the field. These were things like hospitalizations or caregivers not being there. And so, we had a backup list and this ended up being really important so that we didn't waste vaccine because we were not allowed to bring the vaccine back to Rush, so we had to use everything in the field. And so, the main backup people ended up being caregivers like households who had other 1B people who decided last minute that they want to be vaccinated or caregivers of Russian home patients who are 1C where the patient's 1C, but because they're receiving rehab level care, their caregiver is 1B. We had a funny learning. It was sort of funny to us because we actually were in such a sprint to do that schedule and get it turned in that we didn't fully geographic schedule. We did it by, and there were also a lot of households, so we did it by zip code. Turned out, no surprise to anyone on this call, since this is like the first lesson of base primary care, you got to geographically schedule. So, after that first morning when we were zigzagging all around, we actually had to redo the whole schedule and actually geographic schedule everyone. I just think it was sort of funny we didn't do that in the first place since we know so well how important that was. And then, the feedback that we've gotten is that patients and families have really loved it. And we have a cool video, but before I jump to that, two more quick things, which are that we did for second doses, we ended up doing them in batch later, so we didn't schedule them at the time of the appointment. We did it sort of all together later. And then, we did also have one of those patients who couldn't be vaccinated because he was hospitalized. We were able to, it was hospitalized at our own hospital, and we worked with leadership to be able to just vaccinate him in the hospital, which our hospital was wanting to do anyway, so we ended up doing the first inpatient vaccination out of necessity. But without further ado, here's our video. This is like a blessing to have somebody come to the house, especially when you have a Latina, 92-year-old, beautiful mother that has dementia and cannot do hardly nothing for herself. And to have somebody come here, the service is really good, and it's really saddened me because I do a lot of community work, and not a lot of seniors have this kind of service. I mean, this is why we do this, right? For folks like your mom who cannot get out of the house without moving mountains. We're going to do this vaccine in your left arm. Just talk her through it, tell her she's going to feel a little. Not a lot of seniors have this kind of service, so that's the only thing that bothers me. So I just, I'm very blessed to have you guys here, and you know, you guys take good care of my mother. Dr. Davis, thank you so much for that fantastic presentation of your program. I know I got lots of questions already, but we're going to save that towards the end. Next, we're going to hear from Dr. Lewis and Dr. Ranola about their program at the VA up in Madison, Wisconsin. So take it away, folks. Well, everyone, Dr. Ranola and I are very happy for this opportunity to come speak today. We'll be talking to you all about our experience in rolling out the COVID-19 vaccinations in our home-based primary care program at our William S. Middleton VA today. Next slide. Just kind of getting started, I know that when the VA came out with their priorities for vaccination amongst their veterans, home-based primary care was actually listed as one of their top priorities. But it did take a little bit of push from us in terms of just reminding people that when they're thinking about vaccination and setting up the vaccination clinic, that vaccinating kind of in the home would be a little different, and that we'd have to kind of plan for those things. I will say, in our instance, we started vaccinating in the hospital, at least, at this VA in December, late December. And by the time they got to the 1B kind of category for us, they had already, our vaccine team at the facility had already been focusing on how they were going to set up kind of remote vaccine clinics that were not at our main facility. And we kind of kept touching base with the vaccine team here and just saying, like, when can we kind of be part of this kind of rollout? And to their credit, I think they were very busy trying to, one, just get all the employees vaccinated and then move on to how we set up an outpatient clinic. And then how do we set it up with these remote primary care clinics? And so it just took a little bit of gentle kind of nudging. But as with everything, it did kind of feel like a hurry up and wait. You know, we had reached out to other home-based primary care programs in the VA because there were other programs who, their facilities were already in the process of setting up to vaccinate their HBTC patients. And so, you know, when we were nudging leadership, we would say, you know, we have example kind of standardized operating procedures. We could be ready to go. We just kind of needed to coordinate everything with our vaccine team. And I think once we basically, when we finally got the green light, it was one of those, okay, now we're ready to kind of get this started. See if you can get this all, all the details worked out within a week. So it definitely was a hurry up and wait and a little bit of a scramble. So I hope today the things that we go over here and share from our experience can kind of help maybe ease that scramble feel that we kind of felt during that one week. And just, I think as a theme that you'll hear throughout the entire day, our standardized operating procedure, which is the first thing we had to develop to even get this off the ground, was heavily kind of work closely with pharmacy. We basically took our, the pharmacy kind of standardized operating procedure for these outpatient rural clinics, and then kind of adapted it to work for home-based primary care. And just for everyone's knowledge, our VA got a secure to supply of the Moderna vaccine. Next slide. All right. So in terms of priority outreach, we follow CDC guidelines and as well as the VA guidelines for priority. By the time we were able to get our vaccinations up and running, we had already, the RVA facility had already started vaccinating people 70 and above. We had first started with 80 and then 75. And by the time we got everything up and running, they were already down to 70 and above. And so our home-based primary care team, it was just our team. We didn't have any additional volunteer group on outreach over two days to our entire panel to just try to gauge interest. Also, while we were trying to gauge interest in setting all the details up for working out all the logistics we had per our facility, we did actually request to see if any of our patients could make it into the main facility to get vaccinated. And so if they could, we would help arrange with travel and transport. And I would say, once we gauged the interest and we got the green light to go ahead and we knew we'd have vaccine, we went through and started scheduling appointments. And in terms of our appointment scheduling, we kept it to where we would schedule just on a couple of days a week. And we would have to schedule our appointments within the six-hour window that we'd have to get where the vaccine wouldn't be able to be used after that six-hour window. Mostly because for our kind of workflow, if we had unused vaccine, if we were able to go all the way out to a veteran's home, and for whatever reason, we could not give that vaccine on that day, the goal was for us to get back to the main facility VA within that six hours, so they could go ahead and use that vaccine for probably someone who was inpatient. Next slide. I would say, one of the main components was getting our team trained for being vaccinators and transporting the vaccine. Fortunately for us, the VA had already established a web-based kind of Moderna and Pfizer vaccine because some of the other VAs had Pfizer, but there is a web-based kind of vaccination training module that everyone was required to do. And then here at our facility, we actually had our vaccine team requested that our team members go and actually shadow in the outpatient vaccine clinic before they actually went out into any homes. And I think one of the big key learning pieces from our experience was, once we had our standardized operating procedure, and once we got the green light and we had people trained, we actually then kind of got down to the nitty-gritty of, how are we going to implement this? How are we going to make sure that we standardize each of our visits? And so we actually, the documents that you see bolded there, we actually developed kind of our own specific documentation. I think the one, so that we made sure that we were documenting and encountering the vaccinations and the medical record system consistently. And I think the second piece of the standardized COVID-19 vaccination clinical workflow sheet was one of the most important job aids that we created so that anyone going out would have kind of a step-by-step of how they'd have to go and get the vaccine from pharmacy, what they would have to do during the visit, what they had to do after the visit. So it's literally a step-by-step checklist. And I believe those documents were shared with you all in the Zoom webinar. And of course, we also gave them the Moderna fact sheet, as well as just kind of a VA-specific side effects and adverse reporting fact sheet as well. Next slide. All right. I am actually going to turn it over to Dr. Rignola to help kind of finish out our next few slides, because they're very pharmacy kind of specific, and I think she would do an excellent job taking over at this point. Thank you very much. So as Dr. Lewis mentioned, we worked very closely with our pharmacy department, and our pharmacy department is really the one who, of course, was securing all the allocation of the Moderna vaccine for our hospital system. So they requested that we really give them an estimate of the number of vaccines that we would need two weeks in advance, so that when a new shipment came in, they'd be able to allocate enough for our HBPC veterans, and then be able to allocate the rest over to the vaccine clinic. That said, once we had kind of the estimated number of vaccines that we needed, our pharmacy department also asked that we contacted them 24 hours in advance to let them know how many doses we would be using that next day. As the vaccinator on the team, myself, the two nurses, and the nurse practitioner, we would be charged to do that individually. So our appointments we made with our individual patients, and we would contact pharmacy to let them know about what time we'd be coming to pick up the vaccine, so that they could draw it up at the point of contact. And as was mentioned in the previous talk by Dr. Davis and by Dr. Lewis, the vaccine is good for six hours, both the Moderna and the Pfizer's, they're both good for six hours once it's drawn up. Our home-based primary care team has a very rural population, and so we really wanted to be able to extend that six-hour window as much as possible, so that we could be able to get the vaccine back to the VA, if necessary, for them to be able to use in the hospital, like Dr. Lewis said. So once we had that email out to the pharmacy department, we would go to the pharmacy window the next day, 24 hours later, and in our kits that we would pick up, we would have the vaccine doses themselves. The pharmacy also provided us with the CDC vaccination cards that we would write down the information, like lot number and so forth. It's those cards that you're seeing on social media everywhere that people are showing up with, but it's kind of the proof of that you've gotten the vaccine. They'd also give us the tracker sheet that we as vaccinators would go through with the patient, and it just goes through all the information, making sure that they're eligible to get the vaccine. It also tracks on there what time we gave the vaccine, what arm we gave it in, etc. Those sheets, those tracking sheets, need to be returned by the end of the day back to pharmacy, and pharmacy then compares the sheets that they've gotten back from our entire hospital system with the number of doses that have been dispensed to make sure that they've all been used, and if not, they have to figure out where those discrepancies are. Additionally, we would pick up our anaphylaxis kit that contained epipens and oral diphenhydramine or Benadryl. As vaccinators in the home, we decided as a team that we probably would not be using the oral Benadryl, the diphenhydramine, that is included in the Moderna's recommendations on how to treat any sort of adverse reaction or anaphylaxis, but when you're in the home and you don't have that extra support by clinic backup, you know, everything else that you can find in a hospital setting, we really didn't want to risk it because you just don't know how quickly an adverse reaction like that would go forward, so we really would probably just use the epipen if we needed something. Additionally, if we found out before we went out on a visit that one of our patients had to cancel, let's say they got sick or were inpatient, we needed to notify the pharmacy as soon as we knew that so that that dose could be allocated back to the vaccine clinic or used inpatient. Next slide, please. As far as the administration logistics, as Dr. Lewis mentioned, all of us on the team that were giving vaccines were all trained in a standardized way. We took the online training modules and we also followed in clinic. When we were shadowing in clinic, that was really more for us to see how the documentation was done because it was a very specific way that we had to do it for first vaccine versus second. Luckily, it was all that documentation is all standardized, so it's very easy just to click through it, but that was part of the training we got while we were in the clinic itself. It was also really nice to hear the nurses because you got to hear a variety of first dose versus second dose and what they were saying, the differences between those two encounters as far as what to tell the patient. We also were requested by pharmacy to pick a couple of days that we would be administering these vaccines, so our team administers vaccines on Wednesday and Thursday. They did this so that they could have someone allocated to us and available to us when we showed up at the pharmacy window. Again, that was because we had decided that everyone would be getting vaccines that were drawn up at the point of contact so that we would have very long window, that six-hour window. Once we're out in the home, we all stayed in the home for at least 15 minutes if they've had no prior reaction or 30 minutes if they've had any sort of adverse anaphylaxis reaction in the past. During that time, we would schedule the second dose with the veteran as well and, of course, go through all the side effects and so forth. At the end of the day, if there was any unused vaccine, again, remember some of our patients are pretty rural, we would try to get back as quickly as we could so that those vaccines could still be used within that six-hour window. Those are the administration logistics that we were really working with. As far as documentation and reporting, we have a very standardized process for that as well. As Dr. Lewis mentioned, our clinic flow sheet outlines all of that for us very nicely. Our reporting system really is standardized within our electronic medical system. It's very easy, as I mentioned, just to click a few of those radio buttons, document what the dose, if it was the first dose or second dose, and what lot number expiration date. Our standardized templates also include in there all the patient education that we did in the home as well. It's very minimal workload to actually document this within our CPRS or our electronic medical record. We would also have to report at the end of our day when we came back, we'd have to report to our chief of home-based primary care how many doses we gave, if it was the first or second dose, if there were any adverse reactions, or any wasted doses. We actually did have one wasted dose so far, and that happened when we were putting a vaccine into the insulated bag that we carry that has the thermometer on to make sure it's kept at room temperature. When the nurse put it into that little bag, ours are pretty small. They're not big coolers like I saw Dr. Davis had, so the plunger actually got pushed a little bit and some of the vaccine came out. We did have a wasted vaccine that way. That's something to keep in mind when you're having your storage containers. Then internally, we also have some documentation that we're doing. Again, as Dr. Lewis mentioned, we kept track of interest in the vaccine, who was interested in getting the COVID vaccine. We also asked during that call if they had already received the vaccine from some other healthcare facility, or for example, a lot of our people in our assistant livings had already gotten the vaccine and were going on to their second dose by the time we were able to bring this out. Those veterans were able to get it through different pharmacies that were bringing it into our assistant livings already. That was really neat to hear that they had already gotten the vaccine and that we didn't need to bring it out to them. We're also keeping track of the administered doses. If someone had come in originally for their first shot of the vaccine, we were able then to, during this call, be able to offer them their second dose in the home to save them that trip from coming in. They're in home base for a reason and it does get very difficult for some of our patients to come into our facility. Our final lessons learned, I think really we were very lucky that we have a vast network of other home-based primary care teams within the VA system itself. As Dr. Lewis mentioned, a lot of our partner facilities had already been giving the vaccine prior to us. We were able to use some other SOPs along with what we were doing in the outpatient setting at our VA, kind of combine them together and get a policy and SOP together fairly quickly. I think also really important is that clinic workflow, that checklist that Dr. Lewis mentioned, and I think it's being provided to all the participants. That's really a great time saver for all of us who are actually going out and giving the vaccine because it outlines exactly what to do, starting from email pharmacy 24 hours in advance, when you're coming, how many doses you need. Then it goes on to list when you're at the pharmacy, this is exactly what you'll be getting. Make sure you have these things in your kit that you're picking up. When you're out at the home, this is what you need to do. When you come back, you need to email how many doses you've used. You need to use this template to track. I'd like to mention too, our template that we're using to track our vaccine doses, that's what also reports the doses to the CDC. It's all connected together and makes for a very cohesive workflow. Then finally, just coordinating with the pharmacy was essential. The pharmacy is really the one who knows how many vaccines they're getting in, what the allocation is for certain age groups, and what's really feasible for them to be able to draw up the vaccine when we come. I think working very closely with your pharmacy department is a really critical piece. Having them part of planning that SOP or your policies is a really good idea. Any other thoughts, Dr. Lewis? No. I would just say that I think one of the big things other than coordinating with pharmacy was just taking what your facility and other programs have already done and just build off of that. We would not have been able to get this off the ground within a week if we didn't utilize other resources and what had already been done and just adapt it to our needs. Nothing else to add. Thank you so much for that presentation. As Dr. Ranola mentioned, for the learners who are either live with us or viewing the webinar later, they were gracious enough to share with us their standardized COVID-19 vaccination clinical flow. I really encourage you all to look through this. I've had a chance to review earlier this afternoon. It is such a time saver. It literally spells out what you need to do and what to do at the visit and so on and so forth. Obviously, documentation might be different for you depending on which EMR you're using, but you get the idea of what should be documented and what kind of language should be included. Thank you so much. Please look through this wonderful resource as well. Finally, we're going to hear from Mr. Jeremy Phillips, who is in charge of the geriatric specialty care of Nevada. His program is very different. I really am interested in terms of how he is partnering with community agencies to get his patients vaccinated. Mr. Phillips, take it away, please. Thank you very much, Dr. Chang. Thank you, HCCI. Everything you do is absolutely amazing. Thanks for the opportunity and the other presenters. They definitely went into the weeds of how to actually run a program. As Dr. Chang said, we have a totally different approach to it. A little bit about GSC. In 1993, we were founded in northern Nevada. We started with a clinic doing hospital-based and then skilled nursing. In 2001, we started doing our home-based primary care and left the hospital. Then in 2004, we discharged about 5,000 active seniors back to the community and went just focusing on home-based primary care. Then in 2020, with COVID and quite a few primary carers in northern Nevada shutting down their practices, we thought it'd be a smart idea to open practice back up. It's working now. People are coming in, but that one's limping along a little bit. COVID-19 and the impact in northern Nevada. We are the largest home-based primary care practice in northern Nevada. We have about 1,500 active members. We go all the way from Carson City, Gardnerville, through Reno Sparks, out to Elko. It covers about 350 miles in northern Nevada. One of the ALFs that we have, about 85% of the members was the first in northern Nevada to really get hit hard by COVID-19. GSC was asked to step in by the county and state and local health systems to help facilitate the members and stop the transfer because when it first hit, everyone just wanted to send them to the hospitals. We helped the facility set up rooms for the memory care units to help those members. That is what facilitated GSC being able to do the home-based primary care vaccinations, was that relationship. Then in June 2020, we started partnering with the local health plan to actually shorten the length of stay in the hospitals and have them discharge home versus skilled nursing with a wraparound transitional care home-based primary care program, as well as to intervene pre-admission. Then lastly, skilled and assisted living in northern Nevada, they were the first to receive it. 100% of our patients who want the vaccine have received it. They are continuing to administer in our assisted living facilities. They're on a schedule where they do it once a month now for new admits into assisted living. Then they did the standard drive-through, 80 plus, 75, 70. Reno is currently on a 65 plus time frame and within the next week, they're going to lower it to 65 and below. Then that leads to why we're all here, which is the home-based primary care and what GSC has done to help our population there. Three times a week, the EMS and Washoe County Health District go and vaccinate members in the community. It's Tuesday, Wednesday, Thursday. They have two cars running right now, so they can do up to 24 a day, those three days. We also work with our home health agencies and fire departments, so it's kind of a bootstrap effort, if you will. GSC was the first practice that they came to because they knew we were already doing home-based primary care to provide them with a list so they could get these vaccines out to the folks who need them the most. We provided those lists about four weeks ago. Now we're down to 24 a day. When they first started that first week, they wanted to hit it hard and they had four cars, Monday through Friday, go out to really vaccinate everyone that needed it for GSC. This week, this Friday, we'll have 250 of our home-based patients will be receiving their second dose, and we're up to 250 as well that have just received their dose one. I think our lessons learned, you don't have to build it, and especially GSC. We're a home-based practice that doesn't do a lot of interventions, so we don't do many vaccines. We've always partnered with outside agencies and pharmacies and even phlebotomist groups, so it was kind of a natural fit for us. Now what we're doing is we're helping the health plans in northern Nevada identify other members that would benefit from this service as well as their home health agencies. That's all I got. Thank you so much. Thanks to all of the presenters and now we're going to transition into some Q&A time. I'm looking at the first question here, and the question is, if the MD gives a shot and spends 15 minutes in the home, can we build the code 99348? Brianna, you are the coding specialist with HCCI. Would you care to comment on that, please? Sure. Thank you, Paul. Hi, everyone. I'm Brianna Plunstner, the manager of practice development with HCCI. From a coding perspective, you do have the availability to bill an E&M visit, but not if you're only seeing the patient for COVID vaccine administration. If you were going to bill a 99348, which is the level two established home visit code, you would need to do a separate and distinct E&M service. There is a code for vaccine administration. It only pays about $16, and if you look in the chat, I shared a link to the January HCCI intelligence webinar where we did reference those resources on what those vaccine administration codes are. So, again, if you're only seeing the patient for vaccine administration, the only billing opportunity is the vaccine administration code. Otherwise, if you're seeing the patient and managing their chronic conditions or addressing an acute concern and something above and beyond, then you can certainly bill an E&M visit in addition to administration, but the documentation would need to prove that. And I will reshare the link in the chat. Kost, I apologize if it didn't show for you, and we'll also make sure that's included in the email if needed and follow up to this webinar. Thank you, Brianna. A question came to us earlier to HCCI, and this is a question for all panelists. One of the learners was concerned about vaccinating patients who are immunocompromised, either because of an illness or perhaps they're taking a medication that reduces their immune system. Dr. Ranola, do you have any words of wisdom for us in that aspect? Sure. That's a really great question, and it's actually come up several times on our team, and so we've dealt with this specifically with our patients. In general, overall, immunocompromised patients can still get the vaccine. If you are giving someone some sort of medication, let's say it's a new immunocompromising medication at the same time as the COVID vaccine, we usually generally say to space that out about two weeks just because if someone gets a new medication of any sort, you can always have a reaction to that. So we wouldn't want that to get confused with the vaccine itself. But yes, you can give immunocompromised patients the vaccine. Thank you very much. Panelists, do you mind sharing with us what's in your emergency kit? I heard Epi and Benadryl. Anything else that you recommend? I'm looking at a document, and I think we can link that in the webinar as well from the CDC regarding vaccinating homebound patients with COVID-19 vaccine, and they recommended three EpiPens, three doses of Epi. I just want to get the panelists' thoughts on what you carry in your emergency kit. Well, I think it speaks to how key pharmacists are that I think most of these questions are for Dr. Ranola, but I'll say we followed the advice of our pharmacist, which was to bring an EpiPen. We did not bring three, and each team had one, but we had four teams out at the same time in the same area of the city. So theoretically, the other teams could have brought their EpiPens back if needed. I think it is important to note that anaphylaxis is very rare, where I'll need to be prepared for it, but I think it's on the order of one in a million or something like that. But I'll defer to our pharmacist in the room. Sure. This is Tricia speaking again. So we are given two EpiPens by our pharmacy when we go out on the road, but our policy, if you look at our larger vaccine policy, not just specific to COVID, states that if we were to use one EpiPen, then our protocol is to call 911. So we wouldn't try to handle the situation on our own. We'd give the EpiPen, call 911 and wait, and then hand them off to emergency personnel. I think if you're trying to solve the issue with the three EpiPens on your own and then try to wait, I think it's better just to call 911. And I would agree with Dr. Davis that part of it is too, is that if you're giving a vaccine in a clinic situation where you have backup and so forth, the three EpiPens might be more doable because you have other people there that can come very quickly. But I think if you're out in the home, using one and calling 911 right away is probably best. And like Dr. Davis said, it's very, very, very rare that people are having severe reactions to this. Yeah, that's a great point. And that's our protocol as well, to call 911 and being in the city, they generally come right away. Thank you so much for that. I've heard a lot about drawing up, getting the vaccine into the syringe. On a technical aspect, who does the drawing up? Is it done at the pharmacy side or are the providers doing the drawing up from the vials, whether it's Moderna or the Pfizer, BioNTech? For us, the pharmacist did it in advance. So then we collected the pre-filled syringes directly from the pharmacist. And this is Tricia speaking again. And that's pretty common for most of the SOPs that we, that Dr. Lewis and I looked at. Pharmacies are typically the ones drawing up because they're also the ones who are responsible for keeping track of the overall supply, the supply chain and so forth. Pfizer's a little bit more persnickety with the vaccine as far as how it should be handled and kept before it's actually reconstituted. But once it's reconstituted, both Pfizer and Moderna are exactly the same. You can keep them in a syringe at room temperature for six hours. So that's something else to keep in mind. Got it. We're up here in cold Chicago and we've talked about, you know, keeping the vaccine at room temperature during transport. Jeremy, with you out in Nevada, we, you know, we think about cold here. But in Nevada, I'm thinking about heat and listeners who might be in, you know, Texas and Florida. Are you taking any special precautions when it comes to transport of the vaccine in more hotter climates? That is a fabulous question. And honestly, I have no idea. Okay. We're partnering with EMS and the health department. I assume that's what they will have to do is follow whatever the appropriate procedures are. And I don't know, Dr. Rinala may know that answer as well, because I assume that at some point, you know, Wisconsin will get warm. That's a great question. You know, we haven't really thought that one through yet. I do know that neither of the vaccines can be, once they're in the syringe, the question of using, putting them on ice packs. There's no, we don't have any data and it's not currently recommended to do that. It's room temperature, right? So I think we'll have to deal with that. I'm not really sure how to answer that one. If any other panelists have any ideas, be glad to hear about that. But right now there's no data on keeping them on ice packs and it's not recommended actually, because that would go over the room temperature excursion. So I guess insulated packs would be great if, in using thermometers that have temperature excursions associated with them, so they alert you if they go outside of the normal room temperature range is probably the best that we can probably do at this time. We have a comment here from one of the learners. The state of Tennessee health department absolutely possibly stated that I cannot pre-fill syringes and drive to homes and the only way I can get vaccine was to buy a power refrigerator that is compliant, oh that looks like it goes into a cigarette lighter into my car. It costs about $120 to buy. It looks like it might be a state-by-state kind of policy when it comes to what can be done with these vaccine pre-fill or not pre-filled. Dr. Rachman, are you still on the call with us? Yes, I'm here. Yeah, you were in the video, you know, with a family member. I'm curious, how did you spend the 15 minutes or the 30 minutes post-vaccination with a family member? Did you do a visit with them at that time or did you just talk with a patient and the family? So every time was a little bit different. Again, I'm Sasha Rachman with Rush at Home with Dr. Davis. So yeah, the patient encounters, I did not do any other E&M. You know, I did not do any other full visitation. It was mainly just chatting. However, we took a bit of a different route with how we typically did it, did the vaccination, which is, you know, there's a lot of check-in process on the computer, a lot of documentation. Also, we did the first round and had to schedule the second dose. So actually, there's a lot to do, you know, when you're in the home to actually just document and get the next scheduled appointment. So really, it was just mainly documentation of the vaccine, even afterwards, and just chatting with the patients. And of course, came a couple clinical questions, but not necessarily a full visit. Thank you for that. And I have comments for both Dr. Davis and Dr. Lewis and Dr. Ranola. Dr. Davis, you mentioned vaccinating family members. I assume they are not part of regular HPPC patients that Rush is taking care of. Was that an issue with their PCP? Was there a liability issue if you went in vaccinating the patient and then also vaccinating the family member, which makes sense, obviously, but did that cause any disrupt? That's a great question. So we made, there were a few family members who were not already Rush patients. A lot of them actually were already in the Rush system. For those that weren't, we did have to sort of have them become a Rush patient. So they got an MRN, they had to sign a consent, things like that. So I guess that must be how we got through the liability stuff is they became a regular Rush patient. And then at that point, we're just providing the vaccination service to them. And then we, frankly, it didn't occur to us to talk to their PCPs about it. I think vaccines are so hard to come by right now that all the caregivers we vaccinated were just really grateful to have the opportunity because a lot of them had struggled to find a way to get vaccinated otherwise. Yeah, does that answer? Was that all of your questions or did I miss one? I'm not sure. No, I think you answered it. And Dr. Lewis, Dr. Ranola, at the VA, I assume you only administered the Moderna vaccine to the veterans and not to family members. Is that correct? Yes, that's correct. We only administered to the veterans. We weren't able to administer to any non-vet population. Was there any envy from the non-vet population that said, you know, gave you a hard time about it? Or did you use, no, you didn't waste any vaccine. I was thinking, well, if you had a vaccine that was about to be wasted, I assume you couldn't give it to the family members. You had to bring it back to the VA, correct? Yeah, we had to bring it back. And I guess Dr. Ranola could talk about if there was any kind of envy from family members in her visits. Outside of home-based primary care, I do a geriatric clinic. And I will say, you know, a lot of my vet patients could get their vaccine sooner than their spouses who were not veterans. But a lot of them just were happy that one of them was getting the vaccine. So I hadn't encountered that. But I'll leave it to Dr. Ranola to see if she had any examples of that. Yes, we actually did have several caregivers who were hopeful that we could also give them their vaccine when we arrived to give the veteran their vaccine. But unfortunately, like Dr. Lewis mentioned, we're not able to give anything, you know, give the vaccine to non-veterans. So there were quite a few people that were really disappointed that they couldn't get it at the same time. I can imagine. I just have one final question. I know we're up against time. Jeremy, logistically, how did you coordinate the list of your patient with the agency that you work with in terms of, you know, sharing lists, who to vaccinate, and so on? I know you may not have time to go into the details of it, but maybe just give us an idea for learners as they are thinking about partnering with others. Yeah, definitely. So internally, we use Microsoft 365 at GSC. And so we created an Excel spreadsheet that we shared internally to get the list of member names throughout all of our pods. And then we prioritize those, you know, mainly age and comorbidities internally and RAF scores. And then we just shared that list directly with the county and EMS. And then they are just managing that list now. And so we actually get to see real time the patients coming off and getting the vaccine. Well, thank you so much. It is now 5.01. Melissa, do you have any closing comments before we finish the webinar for today? And again, thank you to all the panelists. So rich, great information from all. So thank you very much. Yeah. Hi, thanks everybody for being part of this. I want to encourage you to continue the conversation on our HCCI LinkedIn group for COVID. The instructions are here. And you will also be able to get some information on our COVID information hub, which is located on our website. The HCC Intelligence Resource Center does include archives of all of our past webinars, including this one. Give us a few days. We'll get the recording up there along with all of the handouts from the VA program and copies of today's slides. I want to thank everybody so much for participating and have a good rest of your day.
Video Summary
This special edition of the HCC Intelligence webinar focused on planning ahead to administer the COVID-19 vaccine to home-based primary care (HBPC) patients. The presenters shared their experiences and lessons learned in vaccinating HBPC patients. Dr. Davis from Rush University Medical Center described their approach, which involved partnering with their existing vaccine clinic and using volunteers to call patients and schedule appointments. They vaccinated all 1B patients and family members who wanted the vaccine over three days. They also highlighted the importance of geographic scheduling and using volunteers to help with reminder calls. Dr. Lewis and Dr. Ranola from the VA home-based primary care program in Madison, Wisconsin discussed their collaboration with the pharmacy department and the use of standardized operating procedures. They talked about the priority outreach to their HBPC patients and the coordination with EMS and home health agencies to administer the vaccine. Mr. Phillips from Geriatric Specialty Care of Nevada shared how they partnered with community agencies to vaccinate their HBPC patients. They worked with EMS and the local health department to provide vaccinations to their members. Overall, the presenters emphasized the importance of collaboration, standardized processes, and utilizing available resources to successfully administer the COVID-19 vaccine to HBPC patients.
Keywords
COVID-19 vaccine
home-based primary care
HBPC patients
vaccination
geographic scheduling
reminder calls
EMS
home health agencies
collaboration
standardized processes
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