The Centers for Disease Control and Prevention (CDC) has put residents and staff of nursing homes and assisted living facilities near the top of the list for receiving a covid-19 vaccine. That is the right call. But public health officials should not forget about the millions of frail older adults living at home who are at risk of dying from covid-19. And as it stands today, they may have to wait months for the vaccine.  That delay could result in many needless deaths.

Since residents and staff of long-term care facilities are at such high risk for contracting the disease and dying from it—they represent 40 percent of pandemic deaths in the US—they correctly are at the head of the line along with health care providers. Not only do long-term care residents have medical conditions that put them at high risk of severe illness or even death, they live in close quarters where it is easy to spread the virus.

But keep in mind that the vast majority of older adults with multiple chronic medical conditions, and even the vast majority of those with functional or cognitive impairments, live at home, and not in long-term care facilities. They, and their caregivers, need to be vaccinated as soon as possible.

CDC Guidelines

The CDC guidelines appear to place adults 65 and older and adults with high-risk medical conditions in the same bottom tier of its Phase 1 list. It is a curious choice since those with chronic conditions are far more likely to become very ill or die from COVID-19 than those who are 65+ and healthy. And most of those at-risk—by far– live at home.

Here is the (very rough) math: According to a landmark 2017 study by the Rand Corporation, about 80 percent of the nearly 53 million Americans over age 65 have two or more chronic conditions—roughly 40 million people. Some of the most common conditions, such as heart and lung disease and diabetes, are associated with high mortality in covid-19 patients, according to a new study in PLOS Medicine.

Roughly 13 million people are living with functional or cognitive impairments. And one new study shows that those who are very frail are far more likely to die of covid-19 than those who are not.

But only about 2 million live in nursing homes, assisted living, and other long-term care facilities (another 700,000 receive post-acute care in skilled nursing facilities). That’s only about 15 percent of those with functional and cognitive impairment, and less than 0.5 percent of those with multiple chronic conditions.

Vaccine challenges

Those frail older adults living at home who contract covid-19 may face similar risks of severe illness and death as those living in long-term care facilities. To be clear, those living at home are far less likely to contract the virus. But if they do, the consequences could be just as severe.

Vaccinating these seniors won’t be easy. It will be challenging enough to vaccinate residents and staffs of long-term care facilities. Vaccinating home-bound older adults one at a time will be even more difficult.

But it is not impossible. Health officials could start with those receiving Medicaid home and community-based services and those in managed care plans such as Medicare Advantage, Special Needs Plans, and Program of All-Inclusive Care for the Elderly (PACE) programs. Fee-for-service Medicare records could point them to others at highest risk. So could home care agencies.

Remember those at home

Home care workers and family caregivers also need to be high on the vaccine list. It appears that home care nurses, for example, will be given the same priority as other health care  providers.  But it is not clear when non-medical home care aides will get their shots. They should be high on the list, as should those living with frail relatives.

It likely will be summer before vaccines are widely available, so the states will have to ration. But as they do, they should remember the millions of people who are at high risk of severe illness or death from the virus, but who are living at home.