The Los Angeles County Department of Public Health (LAC DPH), Health Facilities Inspection Division (HFID) contractually fulfills a portion of the California Department of Public Health's licensing and certification obligations and is responsible for ensuring that over 340 Skilled Nursing Facilities (SNF), who provide services to the most vulnerable population, within LAC meet the federal government's conditions for participation in Medicare and Medicaid. HFID meets this obligation by conducting recertification surveys and complaint investigations. These licensed facilities must continually meet conditions required by both State and federal law, including the federal Social Security Act and the California Health and Safety Code.
In December 2020, the LAC DPH fostered an important collaboration by innovatively rolling out the first series of vaccinations to residents of LAC's SNFs. The Federal Retail Pharmacy Partnership (FRPP) for Long-Term Care offered a logistically efficient approach to distributing vaccines to SNFs but limited the available opportunities for staff and residents to get vaccinated. Therefore, LAC DPH decided to develop a parallel local distribution system that built long-term capacity within each SNF for storing, handling, and administering COVID-19 vaccines. LAC was only one of 2 public health jurisdictions (West Virginia was the other) to directly distribute these vaccines to SNFs in this manner. By empowering the SNFs to tailor their own vaccination program, they were able to overcome the anticipated logistics of the FRPP vaccine administration program. A similar effort was utilized in the rollout of COVID-19 booster doses in the middle to late 2021, also resulting in a higher vaccine uptake rate in SNF residents as compared to national rates. As of September 1, 2021 (First season post-rollout), the vaccination rate was 87% and 88%, respectively, resulting in an approximate 80% drop in the SNF resident death rate between the 2020-2021 winter surges.
By early December 2020, SNF residents, representing 0.4% of the population of LAC and accounted for almost 40% of COVID-19 deaths within the County. Rapid vaccine administration to this vulnerable population was critical, given that another devastating COVID-19 surge had begun just before the vaccine was approved. The FRPP offered 3 visits to each SNF over a 3-month period to administer vaccine to SNF residents and staff who were interested and available at the time of the visit. While this program promised to lessen the administrative burden for SNFs and local health departments, the lack of flexibility was potentially detrimental in a number of ways:
· SNFs would be unable to stagger vaccine doses to protect against staff absenteeism due to frequent post vaccination side effects
· SNFs would not have vaccine doses on hand between visits to provide vaccines for absent and new staff and residents; the FRPP could not easily offer the vaccine to those who may be hesitant and initially refused the vaccine but might accept later after peer-to-peer education
· FRPP required a signature on a paper consent form, which meant that residents without local family could be denied vaccine.
The LAC DPH website is located at http://ph.lacounty.gov
The Model Practice initiated by LAC was in response to the limited availability for staff and residents of local SNF to get vaccinated through the Federal Retail Pharmacy Partnership. The FRPP offered 3 visits to each SNF over a 3-month period to administer vaccine to SNF residents and staff who were interested and available at the time of the visit, although the lack of flexibility was potentially detrimental in a number of ways:
· SNFs would be unable to stagger vaccine doses to protect against staff absenteeism due to frequent post vaccination side effects.
· SNFs would not have vaccine doses on hand between visits to provide vaccines for absent and new staff and residents; the FRPP could not easily offer the vaccine to those who may be hesitant and initially refused the vaccine but might accept later after peer-to-peer education.
· FRPP required a signature on a paper consent form, which meant that residents without local family could be denied vaccine.
By empowering the SNFs to tailor their own vaccination program, they were able to overcome the anticipated logistics of the FRPP vaccine administration program.
The goal of the Model Practice was to develop a local distribution system that would build long-term capacity within each SNF for storing, handling, and administering COVID-19 vaccines which would provide for an efficient timeline for the vaccination of the SNF residents and staff.
The novel vaccination distribution program used in LAC ensured that all residents and staff of County SNFs had access to lifesaving COVID-19 vaccines, regardless of any notable inequities, such as a facility's financial and staff resources. The program allowed facilities affiliated with large companies with greater levels of resources to distribute vaccine more efficiently, while allowing the LAC DPH to concentrate their vaccine strike team assistance on resource-challenged facilities that were unable to provide the vaccines efficiently to their staff and residents. This strategy ultimately led to more rapid roll-out to all facilities, regardless of their financial resources.
Additionally, because the local strategy allowed for more flexibility in the administration of the vaccines, there was more time for facilities to develop site-specific peer education and communication within their own community that ultimately led to higher rates of vaccination among otherwise vaccine-hesitant individuals.
The program used existing COVID-19 contract staff and permanent staff to onboard new SNFs onto the electronic program. Mobile testing teams were also repurposed into vaccine strike teams to provide vaccines to SNFs. There were no additional capital costs associated with rolling out the program, and all staff was redirected temporarily from other responsibilities to manage the program.
The objective was to develop a local distribution system that would build long-term capacity within each SNF for storing, handling, and administering COVID-19 vaccines which would provide for an efficient timeline for the vaccination of the SNF residents and staff. This objective was accomplished, LAC was able to assist SNFs with timely vaccinations that resulted in an increase in the vaccination rate for LAC and nationally, as indicated by the Center for Disease Control (CDC) publications.
According to a CDC publication (primary data source), by January 17, 2021, the median national first vaccination rate for SNF residents and staff was 77% and 37%1 respectively.
The SNF average vaccination rate in LAC on January 17, 2021 was 71% and 74%, respectively for residents and staff.
As of September 1, 2021, the vaccination rate was 87% and 88%, respectively, for residents and staff compared to 83% and 62% nationally2. No modifications were made as the results yielded positive results.
1 https://www.cdc.gov/mmwr/volumes/70/wr/mm7005e2.htm
2 https://www.cdc.gov/nhsn/covid19/ltc-vaccination-dashboard.html#anchor_1594393306
3 https://www.cdc.gov/nhsn/covid19/ltc-vaccination-dashboard.html
LAC DPH experienced very positive results collaborating with the local SNFs who were in need of the COVID-19 vaccine during the end of 2020. LAC DPH was able to once again able to utilize the practice for the rollout of the COVID-19 booster doses in the middle to late 2021.
As of February 23, 2022, the vaccine booster rate for LAC was at 87% of residents eligible for the dose versus 70% nationally3. These results demonstrate that LAC DPH in partnership with local SNFs were able to vaccinate residents, and especially staff, more completely and more rapidly than the FRPP, potentially saving lives. Additionally, the importance of booster doses to prevent hospitalizations and deaths became evident as the Omicron variant began causing record numbers of cases across the world.
Though the logistical challenge to set-up a program to service 340 SNFs in LAC in the middle of a COVID-19 surge required extensive short-term resources, other counties with fewer SNFs could work to develop similar capacity over time. This capacity ultimately saves lives and future resources within SNFs and local health departments by minimizing COVID-19 outbreaks, cases and deaths. A similar system in other counties could allow SNFs to provide COVID-19 boosters and annual Influenza vaccines instead of relying on less customizable options.
The post-vaccine 2021 winter surge SNF mortality rate plummeted to 20 residents per 100k, while the prior year's surge numbers was sadly, 105 residents per 100K - an approximate 80% decrease in deaths. LAC DPH attributes this significant decrease in mortality to the effective and novel vaccine administration.