Vaccinating Los Angeles County’s Hardest-to-Reach Against Covid-19

When staff members at Los Angeles Christian Health Centers vaccinate a patient, they ask an unusual series of questions:

Where do you hang out? Where do you sleep at night? What color is your tent? Do you have an advocate or navigator? Can we take a photo of you?

Shannon Fernando, chief innovation officer at Los Angeles Christian Health Centers (LACHC), explained that roughly 40% of the health center’s patients are experiencing homelessness. Many don’t have cell phones, which makes it harder to track them down.

In the race to vaccinate as many people as possible against Covid-19, they’re the likeliest to be left out.

As Los Angeles County’s mass-vaccination sites open, then close, then open again, several of the county’s health centers are focusing their energies on vaccinating the people for whom traveling to a vaccination site is hardest. They include not just people experiencing homelessness, but seniors, non-English speakers, and anyone who’s not comfortable with technology or navigating a complex online sign-up process.

“You can’t really marry volume and value very cleanly,” explained Louise McCarthy, the president and CEO of the Community Clinic Association of Los Angeles County, or CCALAC. Seek to vaccinate large numbers of people, and the people who need additional outreach or assistance are likely to fall through the cracks.

Many of the county’s safety net providers may deal with comparatively small numbers of doses – Fernando said her health center receives about 100 doses per week. “They’re not big but they’re very important,” said McCarthy of the organizations that are taking a more targeted approach to vaccination. They’re going “where no one else is willing to go.”

Since the pandemic began, Direct Relief has provided more than $15 million in assistance to health centers and clinics in Los Angeles County ($8.9 million in medicine and medical supplies and $6.2 million in cash grants). That includes a $500,000 grant to CCALAC, and $50,000 grants to two of the health centers interviewed for this story, LACHC and Kheir Center.

“A Relationship and a Rapport”

To reach its homeless population, LACHC has reached as many patients as possible via phone to invite them to come in for a vaccine. They’ve partnered with three local shelters. And they’ve packed up their gear and gone out to their patients, “doing the vaccines in the street,” Fernando explained.

Fernando explained that, for many of LACHC’s patients, mainstream vaccination sites aren’t “amenable or safe or familiar.” For people without a car, many aren’t accessible at all. And for patients who may feel wary about the vaccine in particular or the medical system in general, more interaction may be needed.

“One thing that’s been really important about our model is it’s contextualized within the trust and relationships and rapport we’ve already built,” Fernando said. Some of LACHC’s patients “might not get the vaccine at all if it’s not in the context of a relationship and a rapport” that already exists.

For a transient population, getting a second dose adds a layer of complexity, which explains the long list of questions – and the photograph, which can help LACHC’s staff members locate and identify a patient.

“It’s one of the reasons we can’t do hundreds every day, because of the amount of information that we need to gather,” Fernando said.

And every interaction with a patient is an opportunity to address other health concerns. “Now that you’re here, let’s talk about blood pressure; let’s talk about sugar,” said Fernando. “We’ve built some sort of bridge now.”

“Small Communities”

When Erin Pak, CEO of Kheir Center, picked up the phone, she was a little nervous.

She explained that the community health center was planning a special event to vaccinate Black patients later in the week. Everything was scheduled and ready to go. But whether the vaccines would arrive on time was another matter.

Kheir Center, a community health center with locations in Los Angeles and Orange Counties, serves an incredibly diverse population. Pak explained that patients speak between 23 and 25 languages in any given year, and the health center is equipped to provide care in English, Spanish, Korean, Bengali, and Thai.

“We have to address the very specific needs of small communities that are very overlooked,” she said. And when it came to vaccinations, “we were concerned about our seniors, as well as those who are not computer literate or do not have a smartphone or Internet access.”

To ensure they understood the difficulties of registering for a vaccine, Kheir’s staff members underwent the process themselves. They advised patients to carry a printout of all of the necessary information so that they could fill out a registration form at a moment’s notice. And they set up specified office hours – although Pak said many people received help from family and neighbors.

Pak also wanted to make sure that Kheir was reaching patients who weren’t native English speakers or who might be harder to contact – and reached out to them with targeted approaches.

For example, to engage Thai patients, Kheir invited senior monks at local Thai temples to come and be vaccinated and documented the process so that the monks could share with their communities. They asked the Bangladeshi Consul General to come in for a vaccine and spread the word on social media.

And for some seniors, they simply visited their homes. “They were very excited about seeing us,” Pak said.

Asked about the significant amount of outreach that had gone into Kheir’s vaccination efforts, Pak said, “It’s our obligation. If we don’t address the needs of these specific vulnerable communities, they would just fall through the cracks.”

“Ear to the ground”

At a recent clinic, a woman came up to the staff at Behavioral Health Services, a Southern California community health center. She asked if she could bring her senior parents for a vaccine. The parents, it transpired, didn’t speak English and didn’t have a cell phone or access to the Internet. And they’d already lost four children to Covid-19.

“It was very rewarding to be able to offer that to people who otherwise would not have had any access to a vaccine,” said Bruce Kinley, director of quality management at Behavioral Health Services.

Behavioral Health Services is focused on vaccinating its population of seniors. To do that, they’ve partnered with a local food bank, churches, and a senior wellness center to make vaccination appointments.

“It was kind of having your ear to the ground, and listening to the frustration and the experiences we were hearing” from senior patients,” Kinley explained. “We would hear stories from our clinics about people spending hours and hours
and being confused on [registration] websites.”

Kinley, a health worker, found the process of getting vaccinated “overwhelming, intimidating, confusing. It sent me to the wrong address. I had to walk three blocks,” all things that concerned him when it came to the health center’s patients.

Although staff members will vaccinate people in their cars if they prefer, Kinley said that, for many older adults, being able to walk right down the street is part of the draw.

“We’re located in areas that tend to be low-income, more communities of color…we’re positioned well to serve that community,” he explained. When they arrive, team members take the time to sit with patients and talk to them about their lives.

Kinley said the approach has been successful with senior patients.

“I feel like it’s given us a little bit of hope in a very negative pandemic,” he said. “I feel as health center workers we needed that.”