PHILADELPHIA— Nationwide, the rollout for the COVID-19 vaccine has been inequitable, with white individuals being vaccinated at higher rates compared to Black individuals. In Philadelphia, only 21 percent of the vaccine had gone to Black residents by March 2021, even though this group makes up 42 percent of the city’s population. As such, leaders from Penn Medicine, Mercy Catholic Medical Center, and the community partnered on designing and running a series of community-based clinics that vaccinated almost 3,000 people, 85 percent of whom were Black. A retrospective of their efforts on the three initial clinics was published today in NEJM Catalyst.
“Addressing the vast disparity in both COVID outcomes and vaccine distribution is a critical priority both locally and nationally,” said the paper’s lead author, Kathleen Lee, MD, director of Clinical Implementation in the Penn Medicine Center for Health Care Innovation and an assistant professor of Emergency Medicine. “We wanted to share our insights in the hope that this will both bring further attention to the issue and help inform the efforts of others.”
The process described in the paper was designed to intentionally center equity and address the structural barriers – such as clinic location, web-based sign-ups that require a computer and stable internet connections, and the time to navigate complicated forms – that have prevented Black and other underrepresented minority communities from being vaccinated at equitable rates.
Ultimately, the paper emphasizes that any community clinic must be highly tied to the unique needs of a community, and both informed and designed with the input of its key leaders. This includes an emphasis on building trust and utilizing existing neighborhood-level networks.
While the paper describes the efforts in detail, Lee, senior author Eugenia South, MD, an assistant professor of Emergency Medicine, and other members of the team describe some of the main takeaways for cities, health systems, non-profits, and others looking to equitably distribute the Covid-19 vaccine:
- Leadership Buy-in a Must
“The success of this equity effort was only possible because it was prioritized, led, and resourced from the top,” Lee explained.
In Penn Medicine’s case, the community vaccine clinics utilized partnerships with local faith communities. Having the health system’s senior leadership – which included this paper’s co-authors P.J. Brennan, MD, the chief medical officer, and Phil Okala, the chief operating officer, of the University of Pennsylvania Health System – directly involved in discussions with faith leaders from the start facilitated the baseline trust that was crucial in establishing successful clinics.
“The reality is that the relationship between health care systems across the country and the Black neighborhoods where many are located, has been complicated,” South said. “As healthcare institutions, if we want to actually achieve health equity, we must acknowledge past and present harms while simultaneously doing the work to move forward. Part of that work is centering community voices at our decision-making tables, and relationships between healthcare leaders and community leaders are at the core of that.”
On top of smoothing some trust issues with health systems – and the COVID-19 vaccines themselves – leadership interest is vital for the pure fact that any undertaking of this scale requires widespread institutional support for infrastructure, as there are many moving pieces that touch different areas across a health system. This includes technical areas like setting up a registration system, to the logistics of moving vaccine safely, and the staff to administer the vaccines.
- Locate Rotating Clinics in the Heart of Black Neighborhoods
Often, vaccine clinics around the country have been located in what are viewed as centralized locations, but they are actually not easily reached by underserved populations. Some require a car to reach or, if they are reachable by public transportation, it’s not easily done and could require multiple transfers.
“It’s important to remember that if you’re trying to convince someone to do something, especially if they’re skeptical, you need to make it as easy as possible to complete,” said South. “Locating these clinics in Black neighborhoods, where COVID has hit the hardest, is a simple way to do that. If a person can walk to the site or only has to travel a handful of blocks versus taking a train and a bus, you’re much more likely to reach them.”
Not only does ease of access play a role here, but the location also signals a commitment to meet people where they are, where they feel most comfortable.
- Embrace the Low/No-Tech Approach
“Developing a low-tech/no-tech sign-up and engagement process is crucial to fostering ‘techquity’ – technological equity – and bridging the digital divide to ensure all eligible patients have access to the vaccines,” said co-author Lauren Hahn, an innovation manager at the Center for Digital Health. “We co-designed our platform with the community, for the community.”
Early input from community members clued the team into the need for something beyond the online sign-ups that dominate most vaccine clinics. Many of the patients they hoped to reach – who were older, per guidelines at the time – didn’t have the internet savvy to easily navigate such methods for registration. And that was if they had reliable internet at all.
Avoiding methods of outreach that required high levels of technology and know-how also allowed for people to help family members or friends who qualified to get signed up as well. These “super-referrers” were particularly valuable as they became unofficial extensions of the effort.
So, a Penn Medicine team developed two methods to reach out to potential patients to make sign-ups easier for them: one where text messages with sign-ups were automatically sent out, and another phone-based system run by a dedicated team.
- Adapt Clinics to be Scalable in Any Space
The clinics held by Penn Medicine, Mercy Catholic Medical Center, and their community partners were held in three different spaces: a church, a school, and a community center. Each space was unique, but each worked well enough to vaccinate hundreds of people.
“The importance highlighted in this operation is that it demonstrates a new model of care,” said Nida Al-Ramahi, another co-author and an administrative fellow at Penn Medicine. “It shows that we are nimble enough to be successful outside the traditional brick-and-mortar standard of practice, creating the ‘hospital in the neighborhood.’ It is the start to how we can operationalize addressing social determinants of health.”
Importantly, creating such a flexible design also allows for the experience of vaccination itself to be much smoother for people. That includes something as simple as making every effort to reduce the potential for waiting in lines, such as creating check-in lanes within the sites’ entrances organized by alphabet. Another practical method to reduce the likelihood of a line was equipping everyone administering vaccines with a paddle reading “READY” when they could take a new patient.
“This was less about making people wait a minimum amount of time than giving people an unparalleled experience,” Lee said. “It’s important for people to feel good about the experience because it not only validates them, but it increases the likelihood that others who hear about how the experience went will become interested themselves.”
This effort was driven by a multidisciplinary team with representation from senior health system leadership, Public Safety, Physical Plant and Supply Chain, Information Services, Environmental Services, Community Engagement, communications, clinical experts, and the Penn Medicine Center for Health Care Innovation.