Mersey Care Roving Vaccination Team – case study

Liverpool had the 38th lowest COVID vaccine uptake rates out of 314 local authorities, with the lowest rates reported across the Liverpool City Region.

Uptake in first doses for people aged 25 and over was 84.4% in the least deprived communities but only marginally above 30% in one of the most deprived communities.

There were concerns too about the numbers of care home residents and staff who had not had two doses, with 62,000 people in total across the city region who had taken up the first dose but not the second.

Through a request for mutual aid support, Mersey Care NHS Foundation Trust collaborated with system partners to develop the roving model operating across the City of Liverpool, working in conjunction with the ten primary care networks and with support from specialist teams and services from February to June 2021.

It has delivered a person-centred approach offering vaccinations to prioritise extremely clinically vulnerable groups in their own homes or other appropriate settings, such as a day centre, community centre, place of faith or their residential.

It was then commissioned in July 2021 by Liverpool CCG, initially until December 2021 then to the end of March 2022.

The need:

The impact of the pandemic was being disproportionately felt by communities who already experience longstanding inequalities in Liverpool, which was contributing to significant variations in vaccine uptake:

• Liverpool had the 38th lowest COVID vaccine uptake rates out of 314 local authorities in England, with the lowest levels reported across the Liverpool City region.
• 50% of Liverpool patients aged 25+ had taken up the 2nd dose, which is the 48th lowest rate in England. 73% of Liverpool patients who have had the first dose have also had the 2nd dose – compared to the England average of 74%
• Uptake of first doses among the over-25s was 84.4% in one of the least deprived communities but just 30.1% in one of the most deprived communities
• Liverpool had the 2nd lowest uptake of the core cities for care home residents (89%) and uptake for care home staff (73.7%) for both dosages.

System partners wanted to maximise delivery, narrow these gaps and prioritise people who were most vulnerable to severe disease and from underserved communities and cohorts.

Their response also needed to minimise risk of adverse experiences to ensure people would be happy to receive follow up vaccinations and other appropriate care, such as annual health checks.

Visiting people at home or other non-clinical settings where people were most comfortable, would ensure the offer was both convenient and supported a person-centred approach to making reasonable adjustments for people with complex needs. 

The solution:

System partners agreed the priority groups that would be supported via a roving team, as follows: 

• People aged 50+ who have not yet received a first dose, and those eligible for a second dose.  From September this also included third, booster and fourth doses.
• People identified as Clinically Extremely Vulnerable.
• People with learning disability or communication difficulties.
• People experiencing severe and enduring mental illness.
• People living in care homes and care homes or supported living staff.
• People who use drugs and have multiple co-morbidities.
• Homeless people and rough sleepers.
• People who are housebound or severely visually impaired.
• Gypsy and traveller groups.
• People seeking asylum and living in shared accommodation.
• People with a long-term health condition.

The team accepts email referrals from the PCN, local authority, community mental health, learning disability teams and drug addiction treatment services. A template referral form which is based on a complexity scoring formula helps to identify individuals’ needs and the reasonable adjustments necessary, so that appropriate venues are agreed with staff from other teams and services who have the right skills to support.

Vaccine and consumables are provided through the PCN’s, and the Roving Team liaises with the PCN’s to manage referrals.

They will contact patients or key workers and carers in advance, to confirm a visit is still necessary, and to agree appropriate timings and arrangements.

Flu jabs are also given to those who need them, but if other health needs are identified, the Roving Team will signpost or refer to the appropriate service.

Data is reported through Pinnacle, with the trust and CCG feeding back monthly activity reports into the Liverpool vaccination programme cell. The PCN’s also receive exception reports on any patients who were referred but did not receive a vaccination. Mersey Care NHS has a dedicated database for the Roving Team so that the audit trail is detailed with accurate activity and operational efficiency.

Costs:         

The was team commissioned from the 1 July until 31 March 2022.

Challenges:

• Number and availability of staff, who have other roles, limits the numbers of possible visits
• Short term funding limits ability to bring in more staff
• Competing with other services for vaccinators
• Data quality – referrals details have sometimes been incorrect. Staff need to check vaccination status on Pinnacle
• Timing of information sharing – information may be received late by which time people are vaccinated or not available/ no longer willing
• Family attitudes – an individual may agree to be vaccinated but other household members refuse access
• Gaining access to people in gated accommodation and keysafe numbers

Impact:

The team will work collaboratively with Local Authority Leads, Clinical Commissioning Groups and Primary Care Networks (PCN’s) to ensure maximisation and deployment of capacity, skills and expertise to protect the greatest number of at-risk people in our local communities

The Roving Vaccination Team supported access to vaccination sessions, provided clinical leadership and support and help to staff the Vaccine Bus and Pop Up Clinics, particularly those sessions aimed at increase uptake in our most vulnerable communities e.g. Homeless, Asylum Seekers, Afghan Refugees and Carers 

Between July 2021 and January 2022 the roving team saw 1838 people and vaccinated 1347 people.

Additional Benefits

• Reduce the rate of COVID-19 transmission in and between care homes
• Support wider workforce resilience.

• Offering person centred vaccinations in least restrictive a manner as possible to people with learning disabilities.
• Visiting people at home will enabled the Roving Team to speak to people where they felt most comfortable and offered advice and onwards referral as required. For example, the Roving Team provided dietary and general self care advice, escalation to GP and 111 services and also signposted to specialist services where required, for example Respiratory and third sector services such as Citizens Advice
• Delivery of vaccinations to some of the most vulnerable people in Liverpool in a safe, supportive and least restrictive manner based on the needs of the individual.
• Integrated and multi professional mix of staff within the Roving Team with representation from all clinical divisions as well as GP support.
• Opportunities for discussion with partners, service users/patients and carers about wider factors which influence health in addition to vaccination such as LD Annual Health Checks.

Case study examples

Sam

Sam experiences health anxiety in addition to paranoid ideation and auditory hallucinations related to schizophrenia. His care co-ordinator explained the purpose of the visit, the Roving Team’s role and arranged a time for the visit to take place.

Mental health nurses from the community mental health team, who also work within the Roving Team, attended in support so that everyone there had a clear understanding of his needs, and could spend the time he needed discussing his concerns and answering questions in an appropriate way. It allowed for planning for further vaccinations which, when the time came, helped Sam to feel less anxious.

Joe

Joe has PTSD and agoraphobia in addition to other mental and physical health conditions which mean he is extremely clinically vulnerable.  Joe’s PTSD is related to his experience in the Hillsborough disaster.  Joe confided in his care co-ordinator that the invitation messages to book in at the vaccination site in the football stadium had made him anxious and led him to refuse the vaccination offer.  Joe’s care coordinator worked with the Roving Team to offer all three vaccinations in his home. 

Tina

Tina has severe learning disability and multiple health needs.  Like many people with learning disability, Tina is needle phobic.  The Roving Team, GP, learning disability team and phlebotomy staff worked together with Tina’s carers to support vaccination with care plans and bloods pathway in the least restrictive, least distressing way and in Tina’s own home. Following the first vaccine, the team debriefed on what worked best to support Tina in the least restrictive way and found that by the time the booster vaccine was administered Tina did not require additional medication to help her.

Carla

Carla lives in a specialist nursing home due to her mental health needs. She initially refused to be vaccinated when the home was visited by the GP but over time and with support and information from the care home staff, agreed to be vaccinated.

She went to the local vaccination centre but struggled with feelings of anxiety and fear and then left when she was told she would have a half an hour wait to be seen.

Through the care home check in the nurse (who is also part of the Roving Team) offered to make arrangements for a home visit, where she was supported by staff who know her and by the vaccinator who understood her needs. Carla has now received three vaccine doses, the latter two delivered by her GP at home.

Tim

Tim is a person who smokes heroin daily.  Tim has COPD and liver cirrhosis in addition to anxiety and depression.  Tim doesn’t attend his GP surgery and has difficulty reading so doesn’t tend to answer letters; he doesn’t have a telephone so hadn’t received his invite for vaccination.  Tim was able to get his vaccination through the 'We are With You' Drop-in Service where he sees his key worker and receives support, and was also able to get hand gel and masks, a foodbank voucher and advice around benefits.

Sarah

Sarah has anxieties. Sarah had twice attended a vaccination centre and then had walked away as she was worried of catching Covid but also the possibility off vaccine side effects.

The Roving vaccination team visited Sarah at home and gave her reassurance around the vaccine and as a result of this Sarah had her first Covid-19 vaccination at home. Sarah later contacted the team to say she had had no side effects at all, and could we visit her for her second vaccination. Sarah has now been able to book a holiday abroad with her family.

Lessons

Recommendations for other areas and development opportunities

• Vaccination status of people referred needs to be checked on pinnacle or other clinical system which links to NIMS
• Data quality and information sharing is key
• Collaborative working with specialist colleagues (Community LD and MH services) is essential and improves uptake
• Longer-term funding will ensure greater scope to recruit staff

Next Steps:

The system is considering options on whether the model is needed and can be commissioned into 2022/23.

Should that happen, they will consider whether the team can provide additional interventions, such as physical health checks, in conjunction with COVID-19 and flu vaccinations making every contact count.

NHSE Planning and Delivery Guidance recommends a Spring Booster at least six months after the last dose for 75’s and over, care home residents and the immunosuppressed.