Operationalizing Equity in COVID-19 Vaccine Distribution MARCH 2021

Informing Policy. Advancing . Contents

3 Framework Summary 3 Principles for Equitable Vaccine Distribution 4 Partnering with Community 5 Transparency 5 Ensuring Vaccine Distribution Methods Meet the Needs of Priority Populations 6 Using Data to Make Decisions 7 Roles and Responsibilities Summary 7 Funding and Resources 8 Additional Needs for Priority Populations 9 Resources 9 References

About MDPH The Metro Denver Partnership for Health (MDPH) is a partnership of key stakeholders committed to improving health in metro Denver through regional collaboration and action. MDPH is led by the six local agencies (LPHAs) serving the seven-county Denver metro area, including Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, and Jefferson counties. MDPH is a partnership between public health, health systems, Regional Accountable Entities (RAEs), , and regional health alliances. MDPH works alongside regional leaders in behavioral health, environment, philanthropy, local government, education, and other areas to achieve its goals of promoting health and well-being across the region. MDPH’s work impacts nearly 3 million Coloradans — 60% of the state’s population — who live in this region.

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Framework Summary MDPH’s public health and partners have committed to proactive planning for equity The following plan is the Metro Denver in vaccine distribution policies and plans. This Partnership for Health (MDPH)’s proposal for commitment includes the following principles: operationalizing equity in its regional COVID-19 vaccine distribution collaboration efforts. There • Partnering with community as shared are many strategies that health care partners, decision-makers to improve trust, address local public health agencies (LPHAs), and disproportionate COVID-19 impacts, prevent future health disparities, and lay the foundation community-based organizations (CBOs) can 1 integrate into vaccine distribution efforts to for future partnerships. This includes tailoring promote equity. The suggested roles for health communications to reach historically care and health systems — including Federally underserved populations with updated, Qualified Health Centers (FQHCs) and Regional accurate information that is delivered by trusted Accountable Entities (RAEs) — LPHAs, and CBOs leadership and voices within these communities. capitalize on each partner’s respective strengths. • Being transparent with the public about The plan also considers partners’ differing historic and existing inequities, activities capacities, and vaccine supply and allocation underway to address them, and progress made plans. MDPH’s framework outlines suggestions on efforts. for centering equity within a spectrum of approaches to vaccine distribution. • Ensuring vaccination sites meet the diverse needs of multiple populations and collaborating Principles for Equitable with local providers and community leaders to ensure processes at these sites are culturally Vaccine Distribution appropriate and are responsive to community needs and preferences. Across the Denver metro area, the state, and the nation, segments of the population have • Using data to make decisions: COVID-19 case, been disproportionately impacted by COVID-19 hospitalization, and mortality data combined and the economic impacts of the pandemic with community data including age, race/ response. Coloradans who are Black, Indigenous, ethnicity, , and health Latinx, and other communities of color, those status at the census tract level will help identify with lower incomes, and individuals who lack priority communities for proactive vaccination documentation are at higher risk of severe illness outreach efforts. Current vaccination data from COVID-19. The circumstances of their lives — can identify needed changes in strategy to fill crowded housing, work environment, underlying gaps. It is important to expand vaccination sites health conditions, and limited access to care — and vaccine availability in under-vaccinated put them at higher risk of severe illness. Historic, neighborhoods and populations, working systemic racism and have also in collaboration with local providers and generated mistrust in the medical system and community leaders. vaccines, and traditional vaccine distribution methods may limit accessibility. As a result, • Prioritizing funding to support vaccine equity, thousands of the region’s most underserved including support for community partners and residents may be going without the vaccine. leaders.

Operationalizing Equity in COVID-19 Vaccine Distribution 3 Partnering with Community Community Partnerships At its core, this work must include robust and MDPH has started a community ambassador authentic community involvement. In order to program to promote the importance of promote trust, community members should be flu and COVID-19 vaccination with priority included as equal partners in vaccine planning populations. LPHAs are partnering with up and distribution efforts. Collaborating using to 24 CBOs who are trusted leaders and shared leadership models with ambassadors and who understand the issues facing their cultural brokers (see below) is one strategy. These communities (see Resources on Page 9 professionals help bridge public health and the section for additional information). In addition community by informing interventions; connecting to promotion and communication, these groups, neighborhoods, or organizations who partners may host and help recruit and can help fill in gaps; and helping immunization schedule community members for vaccination. planners understand historic barriers and Affiliating with a CBO for establishing vaccine challenges to vaccination. sites can help with hesitancy and improve vaccine trust with various communities. Shared Leadership Models Members of MDPH’s Health Equity Workgroup Shared leadership comes out of the environmental are also available to identify the partners and justice movement and is a framework for having locations to implement this work. partners—including­ community members— share responsibility for change. The community We recommend using MDPH’s Guidelines should be involved in every level of the vaccine for Expanding Immunization Delivery dissemination process, including in identifying During COVID-19 for information on partnerships, problem solving, decision making, leveraging partnerships and developing representativeness, and collaboration. See Figure 1 and strengthening relationships with these for an overview of community engagement tactics. community partners.

Figure 1: Community Engagement Continuum Increasing Level of Community Involvement, Impact, Trust, and Communication Flow

Outreach Consult Involve Collaborate Shared Leadership • Some community • More community • Better community • Community involvement. involvement. involvement. involvement. • Strong bi- • Communications • Communication • Communication • Communication directional flow is bi- relationship. flows from one flows to the flows both ways, directional. to the other, to community and participatory form • Final decision • Forms partnership inform. then back, answer of communication. making is at seeking. with community • Provides • Involves more on each aspect community level. community with • Gets information participation with of project from • Entities have information. or feedback from community on development to formed strong the community. issues. solution. • Entities coexist. partnership • Entities share • Entities cooperate • Entitles form structures. • Outcomes: bi-directional information. with each other. • Outcomes: Broader Optimally, communication establishes • Outcomes: • Outcomes: Visibility channels. health outcomes communication Develops of partnership affecting broader • Outcomes: community. Strong channels for connections. established Partnership outreach. with increased bi-directional trust building, trust built. cooperation. building.

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Tailoring Communications Ensuring Vaccine Distribution Effective communication with community Methods Meet the Needs of members is crucial and a major facilitator of Priority Populations successful distribution of the COVID-19 vaccine. When partnering with cultural brokers and Equity strategies should be routinely integrated community ambassadors to target priority into health care partners’ efforts to vaccinate their populations, MDPH’s Guidelines for Expanding patients in ambulatory settings as well as LPHA Immunization Delivery During COVID-19 includes vaccine clinics. There are also multiple opportunities key communication strategies that can help to operationalize equity principles into large-scale address barriers such as vaccine hesitancy. vaccination events that aim to immunize many of our Additional recommendations include: community members at once. • Working with cultural brokers who understand In-House Vaccine Clinics the nuances of various communities to ensure • Establish additional criteria (beyond state culturally appropriate messages are being requirements) for selecting patients from a waiting utilized and how messaging can be tailored. list such as ZIP code of residence (prioritizing • Soliciting community member/CBO feedback communities with high COVID-19 morbidity on what should be addressed or included in and mortality), place of residence (such as a any communications plans and materials multigenerational household), mobility limitations, before publicizing. and/or occupation. These criteria can also be used to identify patients who do not yet meet the state • Engaging targeted media outlets that have requirements so they can be ready and registered connections to the audience, including when vaccine is available for their onsite clinics. neighborhood newspapers, social media LPHAs can assist with identifying criteria. platforms, and audio and video news outlets. • Ensure the sign-up and registration process is user- Transparency friendly. Use care coordinators and navigators, or contract with CBOs, to help support patients with MDPH endorses being transparent with the this registration process, especially for those who public about historic and existing inequities, may not have access to the internet or who could activities underway to address them, and use additional computer support. progress made on vaccination efforts throughout the entire vaccination dissemination • Consider how to assess progress and how to define process.2 This may include efforts such as: success upfront. Then monitor who gains access to the vaccine by reviewing vaccination data post- • Data display and public-facing dashboards to assess reach and impact. Evaluate whether (and using these to make decisions- see equity goals were reached, and if not, how to “Using Data to Make Decisions” section). change the approach. • Public updates hosted on accessible and Large-Scale Events diverse platforms. These suggestions may be most beneficial in the • Publication of vaccine dissemination plans short-term during times of vaccine scarcity or when and decision-making processes that includes partners receive extra allocations of doses and would how priority in line was determined and who like to disseminate them quickly. The strategies listed constitutes a specific occupation. in this section can also be integrated into outreach clinic interventions listed below. • Updates on vaccine allocation from the Colorado Department of Public Health and • Ensure sites are accessible, including for individuals Environment to various health care partners, with limited mobility and those relying on public neighborhood sites and priority populations. transportation.

Operationalizing Equity in COVID-19 Vaccine Distribution 5 • Make culturally responsive resources accessible metro area. During this collaborative decision- onsite (can be identified in collaboration with making process of assessing gaps, partners LPHAs and CBOs if needed) and have staff should assess roles, who can take on what available to address participants’ concerns responsibility, and how to implement needed about the vaccine. strategies.

• Consider nontraditional hours. a. Maps and other data sources that outline areas of need, such as COVID-19 vaccination, MDPH also recommends an efficiency approach cases, and hospitalization rates, should be when conducting immunization sites. For example, used to help make these decisions. While vaccinate all eligible individuals when going into reviewing the data, consider both who is at hard-to-schedule locations or facilities serving high risk of exposure as well as who is in a high- hard-to-reach populations. This is especially risk population. Example data sources include: important in congregate settings including shelters, prisons, and jails. When mobile or i. Denver Public Health is tracking vaccination outreach teams are deployed for homeless rates by census tract. shelters populations for example, we recommend ii. Tri-County Health Department has outlined vaccinating the staff at the same time. This also important outcomes to consider. applies to homebound individuals and their caregivers. This efficiency approach ensures that iii. CHI’s Vaccine Distribution Equity Map can potential outbreaks among high-risk staff, unpaid/ serve as a useful tool to ensure the COVID-19 informal caregivers, and community members are vaccine is reaching populations who are at mitigated in a unified way. high risk of complications from COVID-19. Using Data to Make Decisions b. Partners should consider whether to engage with locations and organizations that In addition to in-house clinics and large-scale requested, but did not receive, a CDPHE events, small-scale approaches in specific equity vaccine allocation. These lists can be neighborhoods reaches the community where requested from CDPHE. they are at compared to mass vaccination sites that may draw in mostly high- and active c. RAEs also have information on higher-risk, healthcare-seeking populations. Supporting eligible patients enrolled in , as well and promoting these targeted, nontraditional as care navigation/coordination mechanisms strategies, rather than implementing only in place that can assist with outreach and/or traditional large-scale events, puts equity at the registration for vaccination. center of the work. d. Identify areas that lack pharmacies providing Community/Outreach Clinics vaccine. People in these neighborhoods may not have this relatively-available access point The following steps outline how to operationalize to the vaccine, and solving this problem is an vaccine equity strategies in community sites when important step in creating vaccine equity. enough vaccine is available or when partners receive equity allocation doses. Overall, MDPH e. In the short term when vaccine supply is low, partners suggest looking at equity-focused data this prioritization of “hotspots” for outreach weekly so that health care partners/LPHAs can clinics will occur at the regional level with collaborate to fill gaps and identify opportunities. MDPH partners. 1. Identify areas for COVID-19 vaccine clinics f. If possible, neighborhood clinics should be in under-vaccinated neighborhoods and long-term vaccination sites (rather than only populations. Health care/LPHA partners should one time “pop-ups”). Establishing fixed sites in prioritize and reassess vaccine sites weekly by key neighborhoods may be more effective for using burden as part of the prioritization community partners, as it increases certainty for selecting community vaccination sites in the about when and if a site is operating.

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2. LPHA, representing the jurisdiction of the Roles and Responsibilities vaccine site, will connect with CBOs to assess interest and capacity to support scheduling, Summary outreach, recruitment, and wrap-around MDPH proposes the following roles and services to be offered at the vaccine site. Initial responsibilities for outreach clinics based on community engagement will be through partners’ strengths and assets. Some partners existing MDPH community ambassadors and may fill multiple roles. For example, FQHCs are also other historical connections. well-positioned to play an outreach and trust- a. Being flexible about roles of CBOs in this building role (FQHC’s understand the community’s decision-making process is important. needs, have existing strategies in place for working Community partners should be equal with priority populations, and are in already in key partners throughout planning and underserved locations across the Denver-metro execution. area) and LPHAs can provide logistical support. An additional key partner, COVID Check Colorado 3. Health care partners, including pharmacies, may be able to support all efforts listed below. can provide support through mobile or outreach clinic logistics. Primary Roles: • Health care partners: Logistics (vaccine supply, a. Ensure that health care partners are chosen staffing, personal protective equipment, and based on community data and consider the disposal). following questions: • LPHAs: Building trust, scheduling events, i. Do they have a safe/appropriate space to liaising, convening/coordination, training, and hold the clinic? supporting communications. ii. Are there equity/access concerns • Community partners/CBOs: Trust, outreach, (geographic, transportation, occupation, scheduling support, registration, navigation, etc.)? and communications. iii. Do they have enough supply available and • RAEs: Outreach, scheduling, and navigation staff needed to manage the clinic, as to from care coordinators. not exceed clinic capacity? Locus of control: iv. Is the location sustainable (can it be used • Regional/MDPH level: Review of maps/data, for multiple clinics at different times)? decisions on where to distribute vaccine, and suggestions for advocacy/policy/distribution b. Monitor who gains access to the vaccine changes. by prioritizing outreach and scheduling through CBOs and LPHAs, rather than open • Local level: Hosting and running clinics. scheduling. This may mean supporting CBOs by providing them both staffing and other Funding and Resources financial support. In order to operationalize equity, partners should c. Make sure to reserve vaccine slots for think about funding and resources in new and community partners who serve as innovative ways. ambassadors or recruiters for the vaccine site/clinic. • Community members: The COVID-19 vaccine is available to all residents, regardless of 4. MDPH will review vaccination data post-clinic documentation status or insurance coverage. to assess reach and impact. There is an opportunity to engage individuals who may be disconnected from ongoing care by leveraging resources so vaccination sites can offer wrap-around services (SNAP enrollment, access to care navigators).

Operationalizing Equity in COVID-19 Vaccine Distribution 7 • Community-based organizations: Support CBOs to host and schedule clinics and to sign up patients by providing them with both staffing and financial support. This may include grassroots approaches (e.g. door- to-door canvassing), and support for hiring navigators. • Providers: • Engage safety-net clinics in this work and ensure their costs are covered. Resources need to be adequate to support this critical infrastructure for underserved and under- resourced communities. • Develop budgets that include fixed and variable costs. Review budgets and Registration and Scheduling determine the percentage dedicated to priority populations. It is important to consider the spectrum of times during which to engage with the community. • Reallocate doses to FQHCs and LPHAs who This includes ensuring that the registration and can help engage with the community. scheduling process is accessible and inclusive for all community members. This includes ensuring • Engage human services in these efforts and that the registration and scheduling process partner to identify key populations. is accessible and inclusive for all community • Public Health: Use federal dollars to invest in members, including not requiring identification these areas. Public health agencies may be and also considering processes for documenting able to host outreach sites as well, which will name/ markers. These considerations are also require staffing and stock resources. especially important for the LGBTQ+ and New American communities. • Additional resources needed include funding for communication efforts, including Administration assistance with transportation needs and Mobility and accessibility concerns are especially frequent rapid assessment of community important for older populations, those with various attitudes, concerns, and evolving strategies medical conditions, and persons with . among community leaders. Consider innovative strategies for administrating shots from their car or by going to homebound Additional Needs for individuals and ensure patients are not standing Priority Populations and waiting in long lines in the heat or cold. In addition to the framework outlined here, As new dosage requirements for the COVID-19 specific populations have unique barriers and vaccine become available (e.g. Johnson & Johnson concerns about vaccination. Acknowledging the vaccine), also consider what populations may differences in various communities can ensure benefit from a one-dose versus two-dose shot. that interventions address priority populations’ Populations that are more transient or difficult needs. This document will be updated as to follow-up with may benefit from getting the additional barriers, needs, and strategies are vaccine that does not require a follow-up visit for identified. the booster.

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Resources References MDPH recommends the following reports for 1, 2 Schoch-Spana, M., Brunson, E., additional guidance on operationalizing equity. Hosangadi, D., Long, R., Ravi, S., Taylor, M., Trotochaud, M., & Veenema, T. G. on • Equity in Vaccination: A Plan to Work with behalf of the Working Group on Equity Communities of Color Toward COVID-19 Recovery in COVID-19 Vaccination. (2021). Equity and Beyond, including the included “Action in Vaccination: A Plan to Work with Checklist for Ensuring Equity In and Through Communities of Color Toward COVID-19 COVID-19 Vaccination” by the Working Group on Recovery and Beyond. Baltimore, MD: Equity in COVID-19 Vaccination. Johns Hopkins Center for Health Security. • Supporting an Equitable Distribution of COVID-19 Vaccines: Key Themes, Strategies, and Challenges Across State and Territorial COVID-19 Vaccination Plans by the National Governors Association, Duke-Margolis Center for , and COVID Collaborative. For more information on MDPH’s community ambassador program, please see here.

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