The development of safe, effective, lifesaving vaccines is complex scientific work. But the job does not end there. As we’ve seen with COVID-19—and now with monkeypox, polio, measles and other serious public health issues—there is also a science to the process of connecting with the community and getting the vaccines actually administered.
Aggregating health data from disparate sources (regional and state registries, health plan member data and EHR clinical data) is essential in helping public health agencies identify and reach specific high-risk or vulnerable populations. Having person-level data on race, ethnicity, ZIP code, preferred language, disability status and gender identity, combined with vaccine records and other health data, moves us one step closer to improving health equity and better health outcomes for everyone.
One health plan in California was able to increase COVID-19 vaccination rates by 40%, showing us that the right health data can be a powerful ally in population health, providing granular insights to identify and build trust with individuals and communities that in turn help increase vaccination among those most vulnerable as quickly as possible.
Outlining the path to success
Health Plan of San Joaquin (HPSJ) is a leading Medi-Cal managed care provider in California’s Central Valley region. A nonprofit public health plan, HPSJ serves 400,000 members who are mostly working families and children, as well as seniors and disabled residents, in a region home to America’s most diverse city. The health plan’s network includes more than 300 primary care providers, 16 local hospitals, five federally qualified health centers and eight rural health centers. For over 20 years, HPSJ has worked with partners, including community-based organizations, network providers and local stakeholders, to get more healthcare resources into the hands of those most in need in the community.
From the start of COVID-19, HPSJ recognized that individuals with low incomes, older adults, people of color and those with complex medical, behavioral health and social needs would likely be disproportionately impacted by the pandemic. This area of California was also particularly hard-hit by the 2020 California wildfires and ensuing smoke pollution, putting additional strain on their healthcare system.
As the COVID-19 vaccination rollout began in California in the spring of 2021, HPSJ explained, “It is time for our community to rally around the hardest-to-reach, most hesitant members and help them understand the risks of not getting vaccinated, as well as the benefits to themselves, their families, and our community as a whole. Our role is to support our members through the decision-making process and to make sure the resources are available for members when they are ready to get vaccinated.”
Using data to prioritize the most vulnerable populations
HPSJ turned to its statewide health data network Manifest MedEx (MX), a California nonprofit, and its local affiliate, San Joaquin Community Health Information Exchange, for the data it would need to support its vaccination efforts and target its most high-risk and underserved members.
To have the biggest impact, HPSJ needed to know which members of its community were at the highest risk for COVID-19 and should be prioritized. The plan wanted to know the status of who was and wasn’t already vaccinated and the patient’s latest contact information as well as insights about what language(s) were spoken in the household and what challenges might prevent them from traveling to a vaccination site or doctor’s office. And, in order to team up with patients’ trusted clinicians to better coordinate care, HPSJ needed to know who they usually saw as their primary care physician.
Race and ethnicity data were also important to capture. Black communities, people of color and low-income families were hit especially hard by COVID-19. Data showed Black and Latinx Americans were twice as likely to contract and die from COVID-19 as their white neighbors. Without very specific clinical, claims and social determinants of health data, it would have been very difficult for HPSJ teams to quickly target and support the populations who needed help the most. The data also helped HPSJ identify who was at the highest risk of having a serious complication from COVID-19 based on existing conditions, enabling them to prioritize those community members.
On a weekly basis, MX coordinated and aggregated valuable HPSJ claims data, vaccination data from the California Department of Public Health and the regional vaccination registry and clinical data from participating providers to produce a sortable report including these often impossible-to-find details HPSJ needed to reach out. These reports allowed HPSJ and its partner, SameSky Health, a cultural experience company, to target vaccination outreach to the highest-risk members and address both concerns and barriers to COVID-19 vaccination in a more personalized and ultimately more effective way.
Since March 2021, these reports helped HPSJ’s vaccination rate increase from 5% to 47% for patients five years and older—and to 54% for patients 12 years and older as of July 2022. Diving deeper into the data looking at race and ethnicity, in March 2021, only 3.05% of HPSJ’s members who identified as Black and only 3.51% of Hispanic members were vaccinated. By July 2022, the number of vaccinated had increased to 36.49% and to 44.84%, respectively, thanks to outreach efforts. HPSJ’s program also vastly increased vaccination for those with chronic conditions from only 5.86% to a whopping 70.3% in July 2022. We know the rates of hospitalization and death are substantially higher for those unvaccinated against COVID-19. The increased rate of vaccination that HPSJ was able to achieve, especially among so many high-risk individuals, likely greatly reduced hospitalizations and the number of cases with serious complications in their community.
The story of HPSJ’s vaccine rollout program is one of success—facilitated by reliable data that were able to be quickly accessed and acted on. Vaccines during a pandemic like COVID-19 are most useful when deployed quickly to the people most vulnerable. Having the data to know who is really at the highest risk in your population is powerful. Having actionable details on their contact information means you can reach out with confidence. Having the foresight to build in elements of trust using sensitivity to language, social determinants and the collaboration of a patient’s regular primary care clinician makes the work of HPSJ truly innovative.
Erica Galvez is CEO of Manifest MedEx, California’s leading nonprofit health data network. Prior to joining MX, she led the HIE work for Aledade and also led the Office of the National Coordinator for Health IT’s Interoperability Portfolio.
Lakshmi Dhanvanthari is chief medical officer at Health Plan of San Joaquin.