Building Equitable Vaccine Capacity

During the pandemic the adage of ‘many hands make light work’ rang true. Through successful community partnerships and strategic investments, the Healthcare Initiative Foundation (HIF) and *partners were able to break down barriers to access and build the necessary capacity to administer nearly 13,000 vaccines through #70 vaccine clinics in just (3) three months, fully vaccinate 6,500 Montgomery County residents. Most of the vaccines were administered in communities highly impacted by COVID-19 in collaboration with trusted community partners and leaders who were able to effectively engage our Black and Brown residents and residents who speak English as second language.

The County in March 2021 was seeing disproportionate COVID-19 vaccine pre-registration. An eligible tier at the time for pre-registration was 75 and older. The pre-registration rates for White residents 75 and older was at 73%, while the COVID prevalence was at 25%. Conversely, in the over 75 Hispanic population the COVID prevalence was 40% and yet only 6% of those 75 and older were pre-registered for a vaccine. Similarly, in the Black and African American population 75 years and older, there was a COVID prevalence rate of 19% with only 6% pre-registered. The disproportionate access among race was evident and it was not surprising knowing the connection between race and place that the pre-registration data also showed that the County residents gaining access to the vaccine were not from the most highly impacted communities.

Seeing this disparity, HIF proactively in early March requested proposals from our safety-net health providers and the HIF Board created a Vaccine Fund to respond to these proposals. The Foundation fully understood the complexity of the vaccine supply and the tiered eligibility. We also knew from past implementation roll outs with the Health Exchange, COVID-19 testing, etc. that it takes time to build capacity and we wanted our trusted nonprofit safety-net partners to be at the planning table and primed for scalable implementation so infection rates could be stalemated, and lives could be saved in the communities hardest hit by the pandemic.

Utilizing the proposals, the HIF team built an implementation plan that allowed for contiguous input from the nonprofit partners that identified the safety-net vaccine administrator, vaccine supplier source (e.g., County, Federally Qualified Health Centers, State of Maryland’s Equity Taskforce, Holy Cross Health System, Safeway Pharmacy, etc.), location of the vaccine clinic, date of occurrence, and available community food or outreach partner as appropriate. HIF then proposed the plan to the Montgomery County Department of Health and Human Services (DHHS) that was approved for execution.

In late March, HIF awarded $369,000 to MobileMed, Chinese Culture and Community Service Center (CCACC), Vietnamese American Services (VAS), Korean Community Services Center (KCSC), and Care 4 Your Health (C4YH) to develop and provide community-based vaccine clinics in COVID-19 highly impacted areas of the County to improve vaccine access and address the disparate outcomes for our Black and Brown residents. 

At the time of the HIF grants awards, public dollars were anticipated to be forthcoming. As a funder we had the ability to respond nimbly and quickly to save lives making funding available expeditiously to trusted community partners. We also knew that this frontend capacity building investment was essential to onboarding and training staff, site development, process management, establishing quality and safety measures, and identifying multiple access points for vaccine suppliers, so that when funds became available there was the capacity to scale up efforts.  

Through the planning and implementation phases, HIF facilitated weekly convening meetings where partners provided updates, shared new barriers and successes, and became each other’s champions. As the pilot progressed, the collaborations grew stronger with additional safety- net providers like Casa Ruben, Global Sustainable Partnerships (GSP), and ANGARAI CARES CBO joining the collaborative effort along with health systems and insurance carriers.

The partners have continued to meet weekly even after the conclusion of the HIF grants with the goal of reaching all residents that have not yet received the vaccine. HIF is proud of what these community leaders and partners have accomplished over the (3) three months and the efforts that they are continuing to lead with public investment.

As we reflect upon this work, HIF and the vaccine partners identified (7) seven pillars of success which can help lay the foundation for future community centered approaches for equitable access to care.

Pillars to Addressing Equitable Vaccine Access

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1. Lead with Trusted Community Partners and Leaders – It is critical to partner with community organizations that residents trust at the onset of planning if you want to transform the systemic barriers to access to care. Community organizations are led by leaders trusted by and often from the community with strong reputations of offering services with integrity. For addressing vaccine access, this necessitated HIF to invest on the frontend partner planning and coordination efforts so that the deployed strategies centered community voice and patient needs and were designed with community. This advanced planning enabled the healthcare safety-net providers to collaborate with the faith community, food distribution sites, grocery stores, businesses, neighborhoods, other nonprofits, and with community organizers to bring the vaccine clinics where residents were already engaged. It also required funding trusted community ambassadors and case managers with the cultural understanding and linguistic capacity to assist with navigation, address concerns, help with the registration process, and connect with health providers for medical advice. Through the HIF grant to CCAC, VAS and KCSC were provided subgrants to provide culturally and linguistically centered patient navigation services for the CCAC ‘s vaccine clinics. In addition, HIF outside of the Vaccine fund granted GSP and Identity, Inc. funding to support culturally and linguistically centered community outreach efforts around vaccine education and vaccine access.
2. Integrate Service Delivery – Many of the safety-net partners shifted their models from having residents come to them in the more traditional clinic model to going to where residents were accessing services such as food distribution locations, health fairs, grocery stores, businesses, community events, faith services, etc. Further, as opportunities presented, additional services were integrated into the clinic outreach days such as vision exam for children, health screening, other immunizations, etc. This advanced collaboration and resource sharing amongst nonprofits made multiple services more readily available to the community. Moving a clinic model to community takes multiple site visits and advance planning particularly as you concentrate on the safety planning and the flow of operations. Through effective collaboration and planning, ANGARAI CARES CBO, American Diversity Group (ADG), KloudData, and DHHS partnered to successfully launch a community service organization in the Plum Orchard area of Silver Spring to provide critical services out of a single center in English, Spanish, Amharic, French, and Mandarin-Chinese. These services include food distribution; free COVID testing; COVID vaccination; and chronic disease management clinics.
3. Convene Collaborative Strategic Planning and Build Partnerships – Philanthropy serves a vital role as neutral convener bringing partners together to assist with the planning and service integration. We know that successful collaboration takes time and support is needed beyond grant dollars for planning, information sharing, and implementation. For these projects, HIF designed the initial implementation plan integrating the proposals from the (3) three safety-net clinic partners to create a comprehensive plan for addressing the inequitable access to vaccines. The implementation plan was approved by DHHS and subsequently updated weekly enabling the foundation and partners to coordinate and ensure that these resources were being deployed strategically to highly impacted communities. HIF also hosted weekly partner-led provider meetings to allow a safe space for learning, collaboration, continuously planning, and support. The vaccine partner group has affectionately named itself, ‘Rebels with a Cause,” leaders working towards systems transformation. Through this collaboration, they celebrate each other’s successes and bolster one another during hardships.  One of the partners, GSP, was working for several months to expand their integrated diabetes and vaccine education community outreach program into Montgomery County to serve Black and Brown residents. The partners rallied around GSP, offering encouragement along the journey, and celebrated with GSP when they reached the pivotal milestone of their getting their request for a bus approved.  
4. Strengthen the Healthcare Workforce – Training our future healthcare workforce on community centered approaches built around cultural and linguistic needs is paramount.  At the onset of the vaccine partnership, HIF engaged with Montgomery College and The Universities at Shady Grove to connect nursing students with the community-based vaccine clinics. This collaboration not only increased the capacity of the safety-net partners to offer efficient and effective clinics, but also allowed valuable training opportunities for nursing students on community-based responses, safety protocols, pop-up clinic operation, and quality patient engagement. Many nursing students were unable to work directly with patients for over year because of the pandemic missing vital experiential learnings and these clinics helped many students regain their purpose and passion for nursing and passed along crucial skills. One example of this is MobileMed, utilizing Montgomery College nursing students to help staff up their vaccine clinic at the Lakeforest Equity Center (LEC). The pre-registration was done the day before the clinic by the LEC team during their food drive-up event by trusted community organizers. The day of the clinic, Nourish Now offered additional food resources for participating residents.  Each of the partners utilized their strengths to offer training to future healthcare workers and provide comprehensive and integrated services for vaccines and food distribution that were culturally centered at a trusted provider location where residents were already accessing services.  
5. Accessible and Flexible Service Delivery Models– Flexible approaches are needed when countering access barriers to care. No one can do it all but making investments strategically that meet the continuum of care for the entire population is vital. Working with community partners, HIF invested in the multiple strategies for vaccine administration funding partners to offer vaccines in the home, in the community, at their clinics, and with partner organization to ensure the right delivery model was offered to meet the resident’s individual and household circumstances. C4YH patients are primarily Hispanic residents over 65 and many were homebound and did not have the capacity to go outside of their homes for the vaccine. The younger members of the community had severe transportation barriers making it difficult to community to get to the needed services.  Additionally, most of those that were employed could not leave their jobs to receive services.  Understanding these challenges, the C4YH leadership designed the safety workflow and protocols to offer vaccines in the home, in the community after-hours, and on the weekends. This innovative approach made access available more quickly to those that did not have access through the mainstream offerings.
6. Fund Diversified Partners – Investment in diverse and multiple partners to manage the vaccine education and vaccine process allowed for services to be delivered in culturally and linguistically respectful ways. HIF and the partners were cognizant that there were going to be unforeseen barriers that emerged during the implementation and there was a commitment to work through these together. CCAC partnered and gave subgrants to Vietnamese American Society (VAS) and Korean Community Services Center (KCSC) knowing that language and cultural norms may circumvent residents from coming to their clinic. Working with VAS and KCSC they were able to work through these intrinsic challenges and build bridges of trust and connect residents with vaccines.
7. Build the Capacity of the Healthcare Safety-Net – HIF intentionally funded healthcare nonprofit providers to build the capacity for the safety-net health clinics to both scale-up their services locally and engage more residents in long-term health services. By having a nonprofit medical provider in the community offering the vaccines, residents have become more aware that healthcare is available, and they learn how they can be connected to a medical provider and gain access to health coverage. An example of this is the efforts being led by Dr. Ligia Peralta, founder of Casa Ruben, who is a strong advocate and a pediatrician. Through her work, she is ensuring that children not only receive the COVID-19 vaccines, if eligible, but that children are also linked to care and up to date on all their immunizations which in many instances have lapsed due to the pandemic.  Working with a trusted a community provider is key, and the UpCounty Distribution Hub has collaborated with Dr. Peralta to join them as a part of their food distributions taking place in the community. These integrated clinic and food events further offer valuable opportunities to engage caregivers in discussions about health coverage and healthcare resources available for themselves and their children. Another partner, CCAC through their vaccine clinic engagements, was able to enroll #150 Montgomery County adult residents, that had no prior healthcare, into Montgomery Cares connecting them with health coverage and consistent medical care. We have always known the vital importance of connecting residents with consistent healthcare and now seeing the harmful impact of COVID-19 on individuals with pre-existing conditions the necessity of quality healthcare access for all is even more abundantly clear.

Thank you to all the collaborative partners that are our community heroes! The progress made in these initial months provided the seminal foundation for countering the disparate inequities in getting access to the vaccine.

Vaccine Partners

*MobileMed, Care 4 Your Health (C4YH), Chinese Culture and Community Service Center (CCACC), ANGARAI CARES CBO, Vietnamese American Services (VAS), Korean Community Services Center (KCSC), Identity, Inc., Montgomery County Department of Health and Human Services (DHHS), Holy Cross Health, Global Sustainable Partnerships (GSP), Nourish Now, American Diversity Group (ADG), Casa Ruben, Montgomery College, The Universities at Shady Grove (USG), Gaithersburg Cares Hub, LakeForest Equity Center (LEC), and UpCounty Consolidation Hub at BlackRock Center for the Arts