The Howard County Health Department (HCHD) serves a jurisdiction of approximately 250 square miles. Howard County is home to over 325,000 residents. Howard County’s overall population density is 1,144.9 people per square mile. Approximately one-third of the population is concentrated in 32 square miles that make up the county’s largest city, Columbia. Howard County is approximately 30 miles from both Washington DC and Baltimore, Maryland. Howard County is impacted by events and threats to those areas. Howard County is rich in language diversity with many foreign born immigrants choosing to settle here. In 2019, 21.1% of Howard County residents were born outside of the United States. 25.4% of all Howard County residents speak a language other than English at home. 

Early in 2021, HCHD identified that stationary mass vaccine clinic attendance was waning. Review of vaccine data showed that many of our most vulnerable populations had some of the lowest vaccination rates.  In an effort to meet the needs of these identified populations, HCHD began the Mobile Community Outreach Clinic (MCOC). These HCHD pop-up clinics were developed to respond to vaccine inequities.  HCHD looked to address barriers related to technology, language, transportation, disability/mobility, and employment status. HCHD's practice model allowed us to take the vaccine clinics into targeted locations such as businesses, homes, community centers, and worship centers. We targeted specific zip codes, communities, and ethnically rich areas that showed low vaccination rates and were underrepresented within the jurisdiction.

HCHD utilized staff and resources from HCHD standing clinics. HCHD's MCOC team used several vehicles from HCHD's motor pool. This included a small RV equipped with a refrigerator and a generator, a sprinter van, and a mini-van. The small RV became the main unit for the MCOCs but the other vehicles were utilized for clinics, also. HCHD took every opportunity to meet the communities in the communities. The goal of the MCOC was to breakdown any barrier to vaccine.

The objectives were to identify the steps to overcome vaccine barriers. For example, HCHD's first barrier was language. Early vaccine data showed HCHD was not reaching non- English speaking individuals. MCOC teams brought many devices to assist with interpretation. These were often difficult to work with in the field.  HCHD adapted and prepped for identified predominant languages before a clinic by including bilingual HCHD staff, and leveraging community groups/businesses to provide bilingual staff. This combination of  technology, HCHD staff, and community partners to address language barriers was highly successful.

The MCOCs is a constantly evolving practice. MCOCs use a multi-prong approach to reach individuals where they are to provide vaccine. Success of the MCOCs comes with the partnerships of communities/businesses. MCOCs were held at locations/hours that met the needs of those working/living in the jurisdiction. Most of the individuals served by MCOCs would not have been able to attend mass vaccination clinics. The public health impact of this practice has allowed HCHD to make strides in the ongoing effort to provide long term protection against COVID-19.,

HCHD’s use of MCOCs allowed HCHD to center the practice around meeting the needs of identified vulnerable populations within the jurisdiction. HCHD’s new practice model for MCOC will continue to shape and improve not only vaccination clinics but HCHD’s outreach programs in the future. HCHD met the community where they were. MCOCs addressed the barriers that specific populations had with technology, language, transportation, access, and mobility/disability.

The MCOCs went into areas of the jurisdiction based on data from county and state health equity partners. HCHD was able to strategically target areas that showed lower rates of vaccination and gaps in service.  Local businesses and community programs within identified through zip code mapping. These businesses and community centers were leveraged to become HCHD’s partners. These partnerships allowed MCOCs to be held at locations such as: apartment complexes, food banks, homeless shelters, libraries, private residences, group homes, treatment facilities, detention centers, manufacturing plants, soccer fields, YMCA, flea market, farmer’s market, etc.

Language barrier is one of the biggest health inequities addressed. HCHD identified several steps needed to overcome this barrier. First, MCOC needed to host clinics for non-English speaking individuals at locations that afforded the individual increased comfort levels. Clinic locations were chosen by those within the community that identified sites where individuals might gather – such as places of worship, community centers, or basketball courts/soccer fields. Second, lack of ability to read and write English caused a barrier in using the public vaccine registration portal. The registration portal offered limited translation services leaving many non-English speaking individuals unable to know when clinics were occurring or make appointments. MCOCs provided paper fliers in identified languages for community distribution. Community partners posted clinic information on their websites and fliers in their locations promoting the clinics. MCOCs promoted and provided walk-up registration. HCHD brought on  language line services with a live operator on screen or on the phone to quickly answer questions related to vaccine and help the non-English speaking population in the community get registered, vaccinated, and address concerns related to the COVID-19 vaccines available. MCOCs also found that some individuals not only had little to no English proficiency, but many of them were illiterate in their native languages. MCOC staff shifted to translation to live interpreters and manually registered those individuals.   

As MCOCs worked to address language barriers, more barriers were identified, and processes were developed to overcome. Many individuals had limited transportation options and worked long hours at multiple jobs. These factors added significant barriers to accessing care and constitute root cause health inequities. MCOCs were adapted to all hours of the day to meet these needs. Clinics were held at all hours of operations at local food distribution plants to meet the needs of families who could not take off of work to get vaccinated. MCOCs were held in the parking lots of locations at 5am. HCHD and the employer encouraged workers to bring their families members to get vaccinated, too. MCOCs always had onsite registration with translation services to allow for a technological barrier, such as no internet access. Transportation barriers were coordinated with the businesses, who used buses to transport their employees to the clinic between shifts at work. Ride sharing companies were enlisted to provide pickup and return individuals if needed.

Using the MCOCs, we were able to focus on the community members that had social disparities due to lack of knowledge of resources in their area. During the clinics, MCOC staff provided information for other programs within HCHD to the community. Information was printed in multiple languages. Information shared included:  hours of operation, programs/services within HCHD.

This practice is better than what was previously done because it allowed for more opportunities to access vaccine. HCHD held 4-6 flu clinics a year in the past. These would be held at large facilities to allow for maximum attendance, some were drive through. However, the intimidating long lines, lack of translation services, lack of transportation, limited mobility services, and anxiety around COVID-19 vaccine, would not work with previous model. MCOCs allowed for smaller groups to be vaccinated, have their questions answered, increase comfort levels within a  community, and personable service..

This practice can be considered an innovative use of HCHD’s vaccination clinics because we were able to take the resources available from health department to the community. Bringing services to those individuals who could not physically go to the health department. HCHD  was able to leverage many new partners in the community to deliver these services. These partnerships allowed community members to create new processes to achieve the goal of getting individuals vaccinated. For example, a business utilizing buses to bring employees and their families to the MCOC site, the translation services that they provided that community members did not have access to for vaccine purposes, and finally updating our current Point of Distribution (POD) contracts to include more distribution facilities that had access to larger buildings, and reached a greater amount of community members in less time. These clinics were a way to build trust and begin conversations with these partners about becoming closed PODs for future public health emergencies that require dispensation of medical countermeasures.

Utilizing current local health department employees for COVID-19 operations allowed us to quickly allocate staff for the MCOC, as well as our Medical Reserve Corps (MRC). We reached out to staff and MRC who were bilingual to help with language services, and utilized them for faster translation of our signs, pamphlets, flyers etc.

HCHD had a recreational vehicle (RV) for  outreach programs, previously used for cancer screenings, smoking cessation, and peer to peer counselling for behavioral health. The COVID-19 operations team used this vehicle at all of our Mobile Community Outreach Clinics, since it had visible signage for the health department, and we used social media to promote the RV and where it would be so that community members knew where to go for all of our clinics. The RV became the vaccine site landmark for community residents.

On December 29, 2020, Howard County Health Department (HCHD) began COVID-19 vaccine clinics three to five days per week on its premises. In January, operations expanded to a second location at Howard Community College three to four days per week. As vaccine efforts continued , HCHD  COVID-19 Operations began to look at data showing that HCHD was not focused enough on eliminating barriers to vaccination equity for residents of Howard County. Using data provided by the Maryland Department of Health and Howard County Government, HCHD was able to pinpoint zip codes within the county that made up areas of low vaccination rates or ethnically disproportionate vaccinations. HCHD began a tactical outreach campaign, contacting community partners in those areas who could prove effective in aiding the efforts to reach those unvaccinated. HCHD decided to eliminate one of the greatest barriers to vaccination, lack of transportation. HCHD would bring the clinics to the unvaccinated. Using a small fleet of RVs and commercial vans, HCHD began mobilizing all the necessary materiel and manpower needed to establish a “pop-up” clinic at almost any given location in the county. After successful early mobile outreach clinics with higher immigrant employed businesses, we expanded to methadone clinics and the detention center.   Many community partners began expressing interest as word spread of HCHD’s vaccination mission. By early May of 2021, HCHD was operating mobile clinics five to six days per week, with as many as three separate mobile clinics per day. By August, HCHD had set up clinics at food processing plants, restaurants, swimming pools, schools, apartment complexes, breweries, cleaning companies, sports facilities, and more.

Community partners were essential to planning mobile outreach clinics because they provided insight into the demographics of their employees and patrons. HCHD liaised closely with each point of contact to determine which days, dates, and times would allow the most people to get vaccinated at that location. For some companies, that meant scheduling clinics that overlapped shift changes, whereas businesses like breweries attracted more customers during the evenings and closer to weekends. HCHD also always made sure to ask if the community partner engaged with populations with little or no English proficiency. Fliers were always distributed to community partners to advertise the upcoming clinics in English, and they were translated as needed to ensure community members from different language populations could also stay informed. Planning for language needs ahead of time also allowed HCHD to provide printed materials and translators for a given language at those clinics.

Community partners were consistently welcoming, and in addition to providing space and sometimes materiel for MCOC’s operations, they often played a critical role in encouraging their employees or patrons to get vaccinated on the day of the clinic. Many employers granted staff time off to receive a shot, and had vaccinated employees persuade unvaccinated staff to get their shots. When HCHD exhausted translation staff, partners were able to recruit their own staff to assist with language needs. Some business owners ran promotions or discounts on their products for customers who got vaccinated at their pop-ups, and others went out of their way to advertise the clinics to surrounding establishments.

HCHD realized there was a population of individual that were unable to leave their home due a physical or mental issue. HCHD partnered with the local fire and rescue department. Fire and rescue were able to provide the individual vaccination at home. This service was opened to an individual attesting to need. All community and county partners and healthcare providers were encouraged to reach out to HCHD to provide information on individuals needing home vaccination. Information was collated on shared spreadsheets. A live answer phone line allowed the general public to provide information on family and friends that needed in home vaccination. Family members as far away as California called in to ask for a loved one to get vaccinated. This service has increased trust with fire and rescue among the community. Fire and rescue has also been able to identify individuals that may need to be contacted by HCHD for services.

HCHD’s Local Healthcare Improvement Coalition (LHIC) has provided grants to several community partners to assist with vaccination and testing efforts throughout Howard County. However, perhaps the most important way that HCHD has fostered relationships with community partners during the COVID pandemic has been through the mobile outreach clinics. The clinics helped build trust with community members who had limited interactions with the health department before. This trust was evident in the way that word spread between the partners themselves about their support for HCHD’s vaccination campaign—HCHD became inundated with so many requests for mobile clinics that health department administrators no longer had to initiate contact, and some mobile clinics had to be turned over to the Fire and Rescue staff and their Mobile team.

HCHD took advantage of the newfound trust with these community partners to engage them in conversations about becoming formal Closed POD partners. In medical emergencies that require dispensation of medical countermeasures, closed PODs share the operational burden of that distribution by serving as a location where employees of that establishment can pick up their medical countermeasures. This eases the strain on resources of HCHD in emergency situations.

After vaccines became readily available to HCHD, the largest barriers to vaccination for those who live and work in Howard County were lack of access to transportation to vaccine clinics, and limited English proficiency. HCHD’s mobile outreach clinics eliminated both of those barriers by providing vaccines in the workplace for thousands of employees, and by utilizing the Language Line, CyraCom language services, and live translation staff members to ensure that no community member missed their vaccine because of communication barriers.

HCHD implemented our COVID-19 vaccination program on December 29, 2020 and we quickly realized there would be significant challenges with the web-based registration system that we were required to use.  The system was not user friendly and was only available in English, immediately excluding individuals who did not read English.  For individuals who were able to access the system and secure transportation to one of our large vaccination clinics, we provided access to interpretation via Language Line and the Cyracom system which provides video interpretation services.  In addition, individuals who called our phone bank were able to have an operator make appointments for them if they were unable to access the internet. 

When vaccine became more available, a review of the vaccination data and trends quickly identified underserved zip codes.  In an effort to reach these individuals, HCHD developed an outreach strategy to bring vaccine to the public through the implementation of MCOCs.

As we established vaccination clinics, in the identified priority areas, we encouraged individuals to register in advance, but always advertised that walk-up appointments were available.  Initially we underestimated, the number of individuals who needed walk up appointments straining the limited resources dedicated to these clinics.  As part of our improvement process, we specifically recruited and hired bilingual staff and expanded the use of Language Line and Cyracom devices.  In addition, we worked with employers who were able to provide translation assistance to ensure access for all employees. We also held clinics at non-traditional hours to provide access to individuals working morning and evening shifts, arriving onsite by 5:30am or as late as 7pm and staffing weekend clinics.

The Health Department implemented a grant program for community organizations, pharmacies, or health care groups that specifically worked with non-English speaking patients to assist in providing broader access to COVID-19 vaccines. These partnerships allowed us to have multiple mobile clinics in a day that were within walking distance or had easy public transportation access to where people live or work.

Walk up appointments, improving translation services, bilingual staff and community partnerships reduced barriers to vaccination thereby improving health outcomes.  These improvements directly addressed inequitable access by allowing the resident to feel that they could speak and communicate effectively if they had concerns related to COVID-19 vaccine, and aided residents who could not read or write in the language they spoke. 

Reallocation of health department resources has been required since the beginning of the pandemic response. The HCHD RV that was used for the mobile clinic program was primarily used by the HCHD Behavioral Health Program prior to the pandemic.  As the mobile clinic program continued to show success, this key resource was reallocated full time to the vaccination effort. In addition, all HCHD staff was required to work a minimum of one day per week (20% time)  in a COVID-19 vaccination clinic while managing their regular responsibilities. Lastly, prior to the pandemic the emergency preparedness program was not an independent bureau, however effective July 1, 2021, HCHD elevated emergency preparedness by creating the Bureau of Preparedness and Response.  This newly formed Bureau is not only charged with updating all documents and plans related to emergency preparedness but is responsible for all COVID-19 operations including testing, vaccination, contact tracing, outbreak investigations and staffing a phone line that operates daily to specifically answer constituent questions and concerns about COVID-19.  

Throughout the pandemic, HCHD learned lessons and implemented various process improvements to ensure access to COVID-19 vaccination plans.  These processes have also improved other services provided by the health department.  For example, HCHD was able to expand our community flu clinics by using the enhance interpretation services obtained over the past year and partnering with organizations who we built relationships with during our COVID-19 vaccination response.  These improvements have allowed us to meet residents and community members in spaces that are most comfortable to them thereby building trust, improving health and reducing disparities.