3. Impact of COVID-19

The emergence of COVID-19 had a significant impact on the program. We had to alter our delivery model many times in response to the changing COVID conditions. Set out below is a summary of the impact of COVID on the program and the way it was delivered.

3.1 TIPS CLASSIC

After a successful pre-launch awareness and marketing campaign and detailed consultation with resident groups, we launched the TIPs program in September of 2019. The program was extremely popular with residents, and we quickly achieved the target of 200 enrollees which had been set for the entire 2-year program. The telehealth screenings were supported and enhanced by multiple health-related social programs which gathered residents for activities such as eyesight and hearing screenings, chronic disease management classes, walking clubs, Zumba classes and more.

The classic TIPs model was based on a congregate setting program. In-person sessions were held twice-weekly on site, in the Grace West Senior Community Room and in the Community Center that serves the Townhomes.

The COVID-19 pandemic altered the project in some fundamental ways. Our model was predicated upon a congregate setting with vitals screenings and wrap around social services being delivered to groups of residents. Many of the participants in the program are both elderly and/or suffer from multiple chronic conditions and therefore fall into the highest risk categories for COVID-19. We took the difficult decision to suspend what we now call the “TIPs Classic” program on March 11, 2020.

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3.2 TIPS IN TOUCH

Within 2 weeks of the suspension of the program, we had implemented a “TIPs in Touch” telephone screening service, whereby our Telehealth Technician Assistants (TTAs) used enrollee lists to call all participants in the program. They asked standard behavioral health status questions that were in use as part of the telehealth screenings pre-COVID to check on residents’ general health and to enable us to continue to collect consistent data.

The system used responses to these questions to trigger health alerts, which were followed up by the remote nurse. Additionally, the social services wrap around programming shifted away from group programming and took the form of telephone wellness checks and ensuring consistent delivery of essential food and medical supplies to residents.

3.3 TIPS CLASSIC OUTDOORS

During a late summer window of opportunity when COVID cases in the region were dipping and the weather was agreeable, we launched a COVID-compliant TIPs Classic Outdoors service, in addition to the TIPs in Touch telephone wellness checks.

Through a carefully scheduled appointment system and strict COVID protocols, we were able to resume inperson vital signs readings in an outdoor setting, which minimized COVID transmission risks. These ended in October 2020 when a second wave of COVID infections began to materialize across the country.

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3.4 TIPS AT HOME

Even during the TIPs Outdoors period, we were planning for a return to lockdown conditions, when we would not be able to hold in person sessions. With the agreement of Fannie Mae, we diverted funds within the contract towards the purchase of in-home vital signs monitoring equipment to enable residents to continue to manage their health from home. We knew this was important to residents, not just to collect vital readings but also to help counteract the social isolation and boredom that lockdowns brought with them.

By mid-November 2020, we had begun a phased rollout of in-home monitoring devices to a total of 60 enrollees. Residents were then able to collect their own vital readings as frequently as they wanted to and reported them to the TTAs during their weekly TIPs in Touch calls.

3.5 RETURN TO TIPS OUTDOORS AND TIPS CLASSIC

In April 2021, with lower COVID transmission rates and a return to warmer weather, we restarted the TIPs Outdoors program, offering face-to-face screenings for the first time since the Fall. In-person wrap around services have also begun to take place. As restrictions around the country relax, and vaccination rates increase, we plan to move back to our TIPs Classic model and recommence screenings and group wrap around services, making use of the community facilities at Grace West.

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3.6 GENERAL IMPACT OF COVID-19

The COVID pandemic has underscored the overwhelming pattern of inequality and racial health disparities that exist in our country. It has called attention to the long-standing inequalities that pervade the health care system and society at large. We see these gaps as having potentially widened during COVID, making this program even more vital for residents.

With the easing of COVID restrictions, we will be reviving resident focus groups to learn more about the impact of the pandemic. We intend to re-engage with residents in the co-production of the remainder of the program. Their leadership and their role as ambassadors are an important ingredient for the success of the program.

COVID has also significantly affected our ability to collect consistent data from the program and has affected the economic analysis that evaluates the impact of TIPS on health outcomes and usage.

3.7 COVID-19 VACCINE CLINICS AND ANALYSIS

Although the spread of COVID and the ensuing lockdowns led to a halt in the delivery of services, it also created a new opportunity to explore how our program may have influenced vaccine take-up. The race to vaccinate against SAR-Cov-2 is essential for halting the spread of COVID-19.

Jonathan Rose Companies successfully applied to be part of the CDC’s Pharmacy Partnership Program which delivered vaccines initially to elderly and vulnerable sections of the population, at a time when vaccines were very scarce. RSCs at Grace West worked in partnership with Walgreens to provide on-site COVID-19 vaccine clinics in January and February 2021. 175 Grace West residents were vaccinated as part of this program.

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Despite the availability now of multiple, effective vaccines, hesitancy is a major hurdle for reaching socially desirable levels of immunity. The hesitancy is particularly notable for African Americans, who not only suffer disproportionately from COVID but also indicate a lower willingness to obtain a vaccine. Lack of trust, stemming from centuries of historical maltreatment, is a major reason for this.

Access to “trusted messengers” who deliver clear, transparent messages regarding vaccine safety, effectiveness and availability may help increase take-up for this group. Other studies have suggested that religious leaders and other community leaders can serve as trusted messengers for increasing vaccine take-up. We believe that the frequent interactions with residents suggest that the involvement in TIPs, especially with the presence of an RSC, may serve as another venue for creating a trusted messenger.

To assess this, we proceeded in two steps. First, we compared the mean vaccination rate of TIPs participants to non-TIPs participants at Grace West. Three COVID-19 Vaccination Clinics were held at the senior tower at GW in January and February 2021 as part of the CDC’s Pharmacy Partnership Program. The vaccine rate for TIPs participants at GW was 68%, compared to 30% for non-TIPs participants. When we later surveyed 31 TIPs participants about vaccination beliefs, 52% indicated that participation was helpful in that decision.

Second, to explore whether these results may hold more generally, we explored whether the presence of an RSC relates to vaccine take-up rates. We gathered data on vaccine rates, presence of an RSC, and demographic characteristics of the residents from 47 properties managed by JRCo (including GW), all of which ran three COVID-19 vaccine clinics through the CDC’s Pharmacy Partnership Program as well. We performed a multivariate linear regression of vaccine rates on an indicator for RSC presence, adjusting for demographics, with results shown in Appendix Exhibit 1.

Summary statistics indicate that approximately 51% of the 10,219 residents across all properties had been vaccinated. 51% of the properties had an RSC present. The regression analysis indicates the presence of an RSC was associated with a 6.5 percentage points increase in vaccine rates. We found higher vaccine rates for older populations (41.6 percentage point increase), consistent with vaccine rollout policy, and lower vaccine rates for African Americans (10.7 percentage point decrease).

We recognize important limitations in this analysis. As an observational analysis, confounding is a possibility. Participation in TIPs is voluntary, opening the possibility of selection bias whereby factors correlated with TIPs participation may explain the difference in take-up. Similarly, despite the inclusion of several control variables, properties with an RSC may differ along other, unobserved dimensions that explain the higher vaccine take-up rate.

Nonetheless, given the timeliness of the issue and the need to act on limited knowledge, our study suggests that connections formed through place of residence may aid in creating trusted messengers who encourage vaccine take-up, further supporting the notion that trusted messengers is one strategy for increasing vaccine uptake to improve public health and the fight against COVID.

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