Dr. Leora Horwitz treats fewer and fewer covid patients at NYU Langone Medical Center in New York City. Still, she thinks there are too many.
And they almost all have something in common.
鈥淚鈥檝e only had one patient who was vaccinated, and he was being treated for cancer with chemotherapy,鈥 she said, on the vaccines鈥 limited effectiveness for cancer patients. 鈥淓veryone else hasn鈥檛 been vaccinated.鈥
While taking care of those seriously ill with covid, she asks patients, with sympathy and respect: Why not get vaccinated? A few of them told the internist and hospital researcher that they鈥檙e concerned about vaccine safety. But mainly, she said, the responses break down into two groups: One comprises people who have been planning to get vaccinated but didn鈥檛 get around to it yet. The second highlights a disturbing deficiency in the pandemic response: those eager to get vaccinated but unable to do so because they are homebound.
鈥淔or many of the older people, the people with chronic diseases, it鈥檚 been very difficult for them to get out and get the vaccine,鈥 she said. And, since many such patients receive home visits from health care providers, she wonders why the vaccine wasn鈥檛 brought to them.
鈥淭hey鈥檙e already connected to a health care organization that’s coming to their home on a regular basis. It seems like that should be a strategy we should be using,鈥 said Horwitz.
Doctors in , and have noted the same trend: The covid wards are filled with unvaccinated people. the Centers for Disease Control and Prevention, 76% of Americans ages 65 and older have been fully vaccinated, and about 87% have had at least one dose. Cities and states have slowly been rolling out programs to reach some of Americans, but the programs tend to have modest goals and target only a fraction of the people who likely need outreach.
To boost the financial incentives for vaccinating people in their homes, Medicare it will be reimbursing shots delivered this way at $75 per shot instead of $40 per shot.
New York City in March for reaching the homebound by working with housing agencies, private health care providers, the city鈥檚 Department for the Aging and teams of nurses from the Fire Department. By the second week in June, the program had reached 11,000 people, according to a City Hall spokesperson.
Horwitz and others say the city鈥檚 program for reaching these people appears to be working, but not as quickly and efficiently as possible.
For instance, the Visiting Nurse Service of New York, one of the area鈥檚 largest home care providers, has a contract with the city to vaccinate people in Queens. Anyone homebound in Queens is eligible, whether they鈥檙e a VNS client or not. But if you鈥檙e in Brooklyn, Manhattan, Staten Island or the Bronx and get home care from VNS, it won鈥檛 help you get vaccinated. You then must go through the central bureaucracy and get assigned to one of the other providers contracted to work in your area.
鈥淭he city and the providers we use are the primary entity for homebound vaccinations in the city,鈥 said Avery Cohen, a spokesperson for the administration of Mayor Bill de Blasio. 鈥淭his is a time-consuming and intricate operation, and we’re doing our best to reach as many people as quickly as we can.鈥
A spokesperson for the Visiting Nurse Service said that over the past 10 weeks its teams of nurses had administered 2,600 doses and vaccinated 1,700 Queens residents. The contract runs through the beginning of July.
About 75% of city residents 65 and up are partially or fully vaccinated, according to the about 10 points lower than the national average. It鈥檚 difficult to say how many of the remaining 25% are homebound, but advocates say it鈥檚 surely many times larger than the 23,000 people the city is targeting in its homebound vaccination effort.
Defining and counting the 鈥渉omebound鈥 is problematic. Laird Gallagher, from the Center for an Urban Future, said there are 141,000 people 60 and older who live alone and report ambulatory difficulty in New York City. Susan Dooha, with the Center for Independence of the Disabled, using a broader standard for disability, estimates there are 422,000 city residents age 65 and up who are either fully homebound or significantly impaired, including 262,000 who are at least 75.
She said the city should cast a broader net in defining the homebound and then create a network of public and private care providers to meet the vaccination needs of this population. Some who remain unvaccinated despite a desire to get a shot may tend to some needs on their own. But they may be cognitively impaired and lack the organizational wherewithal to find a shot, Horwitz said.
After raising the issue for much of the past six months, Dooha was glad the mayor announced a program but was immediately dismayed by its boundaries. 鈥淚 kept asking, What are the criteria?鈥欌 she recalled. 鈥淯nder the [Americans with Disabilities Act], if you need a home visit 鈥 you don’t have to be absolutely homebound by a disability 鈥 you deserve an accommodation.鈥
Manhattan Borough President Gale Brewer, who sits on a panel overseeing the vaccine rollout in Manhattan, said she has not been able to get a straight answer from the city about how it defines 鈥渉omebound鈥 and then decides who gets targeted for home visits for vaccines.
鈥淭here鈥檚 been a lot of back-and-forth and confusion,鈥 Brewer said. 鈥淚t鈥檚 like, 鈥楢m I homebound if I go downstairs to get my mail, but don鈥檛 go out?鈥 The real issue is transparency, and we don鈥檛 know what the rules are, and we don鈥檛 have any data.鈥
Dr. Zenobia Brown, a physician and executive with Northwell Health, the state鈥檚 largest hospital network, anticipates a difficult slog getting the remaining New Yorkers vaccinated.
鈥淲hat we find is that there’s not a single barrier, or even a simple set of barriers,鈥 Brown said. 鈥淲e’re to the point where this is hand-to-hand combat, to understand what the individual barriers are and then create solutions for them.鈥
For instance, the parents of a 22-year-old man with autism wanted to get their son vaccinated, but due to very fixed routines could make him available only at limited times. Another patient, in his 90s, didn鈥檛 want to trouble anyone to come to his sixth-floor walk-up apartment.
Robert Janz, 88, and his wife, Jennifer Kotter, 68, weren鈥檛 shy about seeking help. As soon as city plans were announced to serve the homebound, Kotter tried to get an appointment for her husband, an who鈥檚 bedridden due to what she describes as a 鈥渟eries of small medical failures,鈥 including back injuries from falling.
It took months before she could book her husband鈥檚 vaccination 鈥 even though caregivers already come frequently to their fourth-floor walk-up apartment in Manhattan. One of them gave Kotter a phone number to call, which led to another phone number and then another, until she finally succeeded. On June 1, a nurse and an EMT arrived together and gave Janz the Johnson & Johnson single-injection vaccine.
Kotter has come to expect such delays as a caregiver. 鈥淲hen you鈥檙e caring for a patient, you have to be patient,鈥 she said.
