Interim Guidance for Health Departments: COVID-19 Vaccination Implementation for People Experiencing Homelessness

Interim Guidance for Health Departments: COVID-19 Vaccination Implementation for People Experiencing Homelessness

Vaccination for people experiencing homelessness is important. Homeless services are often provided in congregate settings, which could facilitate the spread of infection, including infection caused by the virus that causes COVID-19. Because many people who are homeless are older adults or have underlying medical conditions, they may also be at increased risk for severe illness. The Advisory Committee on Immunization Practices (ACIP) recommends that, when supplies of COVID-19 vaccine are limited, vaccination should be offered in a phased approach. Public health professionals at state and local health departments are working on how to distribute COVID-19 vaccines in a fair, ethical, and transparent way for different groups, including people experiencing homelessness. Because of the increased risk described above, some states have prioritized people experiencing homelessness and homeless service staff in earlier vaccination phases.

When implementing the vaccination phases, it is important to consider that people experiencing homelessness might have low levels of trust in the medical system and often have difficulty accessing vaccinations through traditional healthcare delivery methods, such as clinics or health departments. Lessons learned from hepatitis A outbreaks show us that offering vaccination in homeless service sites and places where people experiencing homelessness visit, as well as using mobile units, are important strategies. This webpage outlines implementation strategies to improve delivery of COVID-19 vaccination services to people experiencing homelessness. Please review Vaccination Implementation Strategies to Consider for Populations Recommended to Receive Initial Doses of COVID-19 Vaccine for general considerations for vaccination implementation.

Reinforce partnerships

  • Improve COVID-19 vaccine access, acceptance, and delivery by strengthening partnerships across health departments, health care for the homeless clinicsexternal icon, and homeless service providers. These entities and others, such as street outreach teams, generally know how to reach people experiencing homelessness and have trusted relationships with the population. Homeless service providers include Continuum of Care agenciesexternal icon —the local planning bodies responsible for coordinating the full range of homelessness services in a geographic area.
  • Leverage partnerships that were developed in conducting community-based COVID-19 testing events to establish vaccine distribution pathways.
  • Reference previous vaccination plans for reaching people experiencing homelessness. For example, jurisdictions that responded to hepatitis A outbreaks might have hepatitis A vaccination plans that they can adapt to reach people experiencing homelessness.

Estimate the population size

  • Use the Department of Housing and Urban Development’s most recent point-in-time countexternal icon to estimate the number of people experiencing homelessness by state or region and help inform vaccine distribution planning, or contact your local Continuum of Care agencyexternal icon for the most recent estimates.
  • Map the distribution of the population or the facilities or locations that are accessed by people experiencing homelessness.

Identify when vaccine roll out will take place

  • Review state and local vaccination plans to identify when homeless service staff and people experiencing homelessness are prioritized for COVID-19 vaccination. Some states have included people experiencing homelessness in Phase 1.
  • Consider approaches to the timing of vaccinating homeless service staff and clients. Approaches might include the following:
    • Vaccinating homeless service clients at the same time as staff because they have a shared increased risk for becoming infected with the virus that causes COVID-19.
    • Staggering homeless service staff who receive vaccination, so that not all staff are vaccinated on the same day. This approach might help minimize potential staff shortages resulting from vaccine side effects. At this time, we do not know how common these symptoms will be among staff but do not expect that all staff who experience symptoms following vaccination will need to miss work. Considerations for staggering COVID-19 vaccination for homeless service staff might be similar to some of those for healthcare personnel in long-term care facilities.

Review prioritization and sub-prioritization

  • Work with case managers, healthcare agencies, and community organizations to identify people experiencing homelessness who might be eligible for vaccination in earlier phases due to belonging to another group prioritized by state or local vaccination plans (e.g., due to age, employment, or underlying medical conditions).
  • Consider sub-prioritization by housing status if there is limited vaccine supply. Not all jurisdictions will need to sub-prioritize; however, some health departments might sub-prioritize homeless shelters with increased risk of transmission, such as those with increased crowding, shared rooms, or higher turnover.

Identify who will administer COVID-19 vaccines

  • Plan which entities (e.g., health department, health care for the homeless clinic, retail pharmacy, or other health care entity) will be responsible for ordering, storing, distributing, administering, and documenting data pertaining to vaccines.
  • Identify vaccination providers and staff who are known and trusted by historically marginalized communities to help build vaccination confidence among racial and ethnic minorities and lesbian, gay, bisexual, and transgender people experiencing homelessness.
  • Identify strategies for surge staffing for vaccination events. When available, Medical Reserve Corps or volunteer associations for nurses, pharmacists, and emergency medical technicians can provide additional staffing capacity. Students in pharmacy, nursing, social work, and medical programs can serve as additional volunteers if available.
  • Ensure all vaccine program providers have completed all vaccination provider agreements and requirements.
  • Register with Health Resources and Services Administration’s COVID-19 Uninsured Programexternal icon if seeking reimbursement for vaccinating uninsured people experiencing homelessness.

Determine how and where vaccines will be delivered

  • Involve people experiencing homelessness and homeless service provider staff in the decision-making process for vaccination planning.
  • Ensure vaccines can be offered on a recurring basis; plan to offer repeat events in the same location to improve vaccine uptake among people experiencing homelessness. Work with homeless service providers to identify the most convenient days and times to reach the highest number of individuals.
  • Plan to use multiple, focused strategies to reach people experiencing homelessness directly:
    • Points of dispensing (POD) – Establish locations throughout the community to offer vaccination. Identify convenient locations that people experiencing homelessness can easily access.
    • On-site clinics – Set up temporary locations where homeless services are offered, such as meal service sites, homeless shelters, day centers, or public libraries.
    • Outreach teams or mobile vans – This can include a combination of staff from public health and community outreach organizations. Law enforcement officers with training as homeless outreach liaisons might also be helpful; however, consider that some people experiencing homelessness might have encountered trauma in prior interactions with law enforcement. This might be an option for reaching people living in unsheltered locations or who do not access other services.
  • Consider complementary strategies to reach people experiencing homelessness through other venues:
    • Health clinics – Communicate with clinics where people experiencing homelessness might be more likely to access services, such as Health Care for the Homeless, Federally Qualified Health Centers, and behavioral health clinics. Ensure that clinics are aware of when homeless service staff and people experiencing homelessness are prioritized for COVID-19 vaccination in state and local vaccination plans. Share vaccination provider requirements and enrollment procedures.
    • Pharmacies – Many pharmacies are already involved in providing vaccination to the public and can be accessible for people experiencing homelessness, especially in rural areas. Ensure that pharmacies are aware of when homeless service staff and people experiencing homelessness are prioritized for COVID-19 vaccination in state and local vaccination plans.
    • Emergency departments – Identify a vaccine “champion” who takes responsibility and initiative in emergency departments to encourage other healthcare providers to identify people experiencing homelessness or other priority populations proactively and offer vaccination. Utilize electronic alerts and standing orders to streamline workflows. See example standing orders for Pfizer pdf icon[186 KB, 3 pages] and Moderna pdf icon[177 KB, 3 pages]
    • Other social service organizations where a high proportion of clients might be experiencing homelessness, including harm reduction services or syringe services programs – Consider these as additional venues for on-site clinics. Collaborating with these partners can help to reinforce messages on the importance of vaccination and ensure follow-up of a second dose when needed.

Prepare logistics for vaccination events

  • Ensure that the vaccination provider can follow cold chain requirements for vaccine storage and use once thawed.
  • Confirm that vaccine distribution locations have staff with capacity to perform safe delivery of vaccination services, who can adhere to clinical considerations for vaccine administration, and who can provide clinical care for potential adverse events, such as anaphylaxis.
  • Review existing vaccination clinic planning checklists and ensure adequate supplies, including epinephrine.
  • Reinforce to staff and vaccination recipients the core COVID-19 prevention measures (masks, physical distancing, avoiding crowds, handwashing) and provide masks as needed during vaccination events and post-vaccination observation periods. Reinforce that these prevention measures must be sustained for the coming months, even after people receive COVID-19 vaccination.

Develop a communication strategy

  • Connect with trusted communicators, such as people with lived experience of homelessness, who can provide vaccination education and information to people experiencing homelessness. Engage these individuals in planning and implementation of vaccination events.
  • Advertise vaccination events for people experiencing homelessness in advance. Use multiple communication strategies such as flyers at encampments, in shelters, and on public transportation; announcements at healthcare and other service programs; or messages via email, text messaging, social media, television, and radio.

Anticipate and address vaccination questions

  • Provide opportunities for homeless service provider staff and clients to ask questions about the vaccines. Vaccinators can familiarize themselves with answers to common questions pdf icon[217 KB, 2 pages] to help address these concerns including learning vaccine facts and reading information for healthcare providers pdf icon[367 KB, 4 pages].
  • Partner with organizations that have established trusted relationships with people experiencing homelessness. Share COVID-19 vaccination communication toolkits for healthcare providers and community-based organizations to address vaccine hesitancy.
  • Know the elements of effective vaccination conversations: start from a place of empathy and understanding, give your strong recommendation, address misinformation by sharing key facts, and connect people with trusted healthcare providers to answer questions.

Provide post-vaccination observation and care

  • Ensure adequate space and staff for post-vaccination observation for potential adverse reactions.
  • Consider providing medical respite care and shelter options for people experiencing vaccine side effects.

Ensure appropriate documentation, second-dose follow-up, and reporting

  • Use multiple second-dose reminder methods simultaneously to improve completion of each vaccinee’s two-dose series. Examples include vaccine cards, text messaging, electronic health record alerts, and automated reminders or flags in Homeless Management Information Systemsexternal icon. Personal outreach through homelessness outreach teams can help to connect with individuals who might be lost to follow-up.
  • Record complete contact information at the time of vaccination to improve second-dose follow-up. Ask for back-up contact information or an alternate contact (with permission). Plan for who will be responsible for ensuring follow-up and what strategies they will use.
  • Consider innovative strategies for second-dose reminders such as providing prepaid phone cards, prepaid cell phones with programed reminders, or second-dose incentives.
  • Review general strategies for vaccine documentation and reporting, including training qualified vaccination providers on use of the jurisdiction’s immunization information system (IIS) or other system connected to the IIS if needed, enrolling vaccination providers in VaccineFinderexternal icon, and reporting adverse events.
  • Ensure that vaccination teams have sufficient vaccination record cards.