Clackamas County is located within the Willamette Valley and is the third-largest county in the state of Oregon covering 1,883 square miles. The county is densely urban and very rural. The county has a population size of over 400,000 people. 82,400 residents (19.35%) are of the age 65 or above, less than 1% of the Clackamas County population is registered for developmental disability services that is about 3,910 individuals.

The immediate need was for COVID-19 vaccines to reach homebound individuals because they are historically one of the sickest and most vulnerable populations. Homebound individuals include any persons with mobility issues, physical or intellectual disabilities. There was no system in place for this vulnerable population to get any vaccine assistance unless they left their home which was a large barrier.   

The goal of this project is to create an equitable and trauma-informed system for Clackamas County homebound residents to get their vaccines.  The objective of the program is to vaccinate people with intellectual/developmental disabilities (I/DD). 

There are many aspects to this project. The first step is identifying who needs assistance. Each partnered agency provided a large list of individuals to contact and inform of the opportunity. The next step is to call these people and provide them with home vaccination options. If they determined that the vaccine was right for them, an appointment would be scheduled. At the start of the program when vaccines were in short supply and eligibility was limited there was a screening process to ensure they met requirements and to collect all necessary information. The nurses would then drive to the patient's home and complete more screening documentation. After administering the vaccine, the paperwork would be entered into an online system and the patient information would be saved and tracked if another vaccine needed to be administered. This program can visit one person at a time all the way to largely congregate-care facilities with 100 people.    

The current outcome of this project shows that over 1,400 individuals have been vaccinated and approximately another 200 people were vaccinated within congregate-care facility settings. Most of these individuals have received their full COVID-19 vaccinations including boosters. Some have also received their flu vaccine and one person has received their Tdap vaccination. This project and system were created to be flexible in which flu multiple vaccines can be administered.   

This team kept health inequities at the forefront when developing this project. The process of getting an in-home vaccine does not require much work from the patients. It is simply a phone call and answering some questions. The rest of the process is mostly completed by Clackamas County staff. 

This project's focus is to prevent disease by administering vaccines.  The mass vaccination sites were not accessible to homebound individuals. This project brings the vaccine to them. This project provides an opportunity for individuals to prevent disease by getting vaccinated and impacting the health of the population.

The target population affected by this problem are individuals who are home-bound. This could include people with intellectual/developmental disabilities and people who are immunocompromised. In Clackamas County, the most accurate population size would be the 1% of individuals registered for developmental disability services, which would be about 3,910 individuals. This does not include everyone within the target population. Another group could include the different care facilities within the county. Some care facilities are not large enough to have the capabilities of vaccinating their residents. Their residents are required to set that up themselves with their primary care provider. Some of these residents are not capable of keeping track or knowing what vaccines are recommended. Even if the facility directors wanted to get their residents vaccinated the process is costly and difficult for the directors and the residents. 

The root cause of this problem is the inability to reach this population and fill a gap in the rollout of vaccinations across Oregon. This target population has extreme difficulty leaving their home due to their disability. Even if someone could leave their house, if they are immunocompromised, it is more dangerous for them to leave their home and get a vaccine than it is to stay home and not be vaccinated. Unfortunately, there are limited resources for home vaccination. People were forced to choose between risking leaving their homes for a vaccine or not getting vaccinated. 

The current practice is better than what was implemented before. There was nothing implemented before this program. This gives people within the I/DD community the choice of where to get their vaccine.   

Our team created a new program for local public health. The creation of this project came about to address a need that was highlighted with COVID-19. This was always an issue and an underserved population, but this new program created a way to get the vaccines they needed to the population. 

We had an obligation, as the local public health authority, to get this life-saving service to the community as quickly as possible during this deadly time. In the beginning, there was no coordination between state and local agencies to vaccinate homebound residents. The county was sent an Excel list of residents and was thrust into the intake, management, and delivery of thousands of vaccines. Additional staff was immediately required to accomplish goals and traditional workflows were not meeting those goals, staffing needs, and resulting in the residents being underserved in a time-sensitive scenario. Cross department collaboration, leveraging additional resources, developing new workflows, and conversion of data into a geographic information system improved efficiencies and overall effectiveness of the program and initiative.   

The health department served arguably the most vulnerable population of Clackamas County, which may have not received their vaccinations. This program saved potentially hundreds of lives just by serving this population. This community of people is very difficult to identify and assist. This program made it possible for the county to serve this community and made it into an enjoyable and rewarding process. This program assisted in reaching countywide numbers for reopening businesses and schools. Much of which was achieved through developing creative solutions that enhanced current planning and objectives. It also set the foundation for similar initiatives for the near future. 

Using the evidence-based guidelines presented from the Community Guide we were able to determine this practice is evidence-based. The Community Preventive Service Task Force “recommends using a combination of community-based interventions to increase the vaccination rates within a target population”. An intervention mentioned is enhancing access to vaccine services. By taking the vaccine to people in their homes increases access.   

The first step in implementing the program is identifying who needs assistance. To find this information, the team needed support from other agencies and Partnered with the Oregon Health Authority (OHA), Clackamas County Developmental Disabilities Services, and Maternal Child Health home visiting services. Each agency provided a large list of individuals to contact and inform of the new project. The next step is to call these people and provide them with home vaccination options. If they determined that the vaccine was right for them, an appointment would be scheduled. At the start of the program when vaccines were in short supply and eligibility was limited there was a screening process to ensure they met requirements and to collect all necessary information. The nurses would then drive to the patient's home and complete more screening documentation. After administering the vaccine, the paperwork would be entered into an electronic system and the patient information would be saved and tracked if another vaccine needed to be administered. This program can visit one person at a time all the way to largely congregate-care facilities with 100 people. 

The planning and implementation process of this project had help from different partners. Many key factors led to the success of this project, one includes the collaboration of different departments such as Social Services and Aging and People with Disabilities. Without collaboration, there would be fewer individuals who could have been offered this service. The flexibility and hard work of all staff members of this project were critical. This team had to be able to switch gears quickly and efficiently. Without everyone having the same determination to reach this population it would have taken much longer. The technology collaboration of this project was also critical in this project. This allowed the nurses to have their schedules mapped out for them at the beginning of the day. This allowed the scheduler to schedule more people and in an effective route. Without the ideas and collaborative efforts from our partners 

The cross-departmental collaboration resulted in streamlined workflows that assisted in the smooth and dignified delivery and administration of over 1,400 in-home vaccinations in a shorter time than anticipated. Exceeding timelines assisted in Clackamas County meeting countywide goals, from other vaccination initiatives, earned the recognition from Governor Kate Brown as exceptional work that pushed numbers of vaccinated residents above reopening guidelines 

Modifications were made to staffing and technologies used, based on analyzations of the data. Additional nurses were hired when appointments outgrew the ability of nurses to conduct them. Additional administrative staff was hired once nurse routines were enhanced to serve more residents than in prior months. New technologies were embraced to streamline workflows and monitor needs.   

These improvements helped reduce inequitable health outcomes by creating a process with health inequities at the forefront in the first place. The team brings all necessary documents in multiple languages to the appointment and can assist in filling out the information. Many patients were illiterate or had some physical or intellectual disability that wouldn’t allow them to write. The nursing team has the capability of assisting these individuals on-site allowing them to not stress about the documents. Also, there isn’t a need for internet access to schedule an appointment. Individuals can call our scheduler and get their appointment situated over the phone. We also limit the verbal barriers; our scheduling and nurse staff speak Spanish and have access to tools to speak to people in other languages. 

We have already successfully mobilized COVID 19 vaccines and the flu vaccines. Currently, the Covid and flu vaccines are free, and in high demand. Making these the most desired vaccine currently. The goal is to make this program a permanent part of the Clackamas County Public Health Department. To do that we need a more comprehensive supply of different types of vaccines and more than one nurse with the capabilities of billing insurance agencies. This target population will still be homebound and disabled well after COVID is under control. With that knowledge, we hope to have the accessibility and capability of providing all vaccine needs to this community. 

The lessons that were learned have allowed this project to grow and adapt to the needs of this target population. Providing in-home vaccination services improves health equity.  This project has identified the larger need for services to this population. Another lesson learned is how to safely administer vaccines to this population with dignity in their homes.  

A critical lesson learned with this project is the need for collaboration. Without the added support of technology to be able to collect data, schedule, and keep track of people’s doses, the project would not have been time-effective. Without the collaboration efforts with other home visiting services and our county DD services, it would have been more difficult to identify the target population and their needs. The lesson learned is when developing a new project or idea, collaboration with other departments who have worked with the population will help.