Abstract:
The COVID-19 pandemic has had a significant impact on the state of Mississippi. As multiple waves continue to challenge public health resources, widespread racial, ethnic, and age-related disparities have highlighted new challenges and opportunities for a coordinated state response. During the initial waves, midlife and older adults were disproportionately affected and a multiorganizational approach was implemented to combat poverty and associated barriers like resource availability, fears, social isolation, vaccine access, and vaccine hesitancy. Lessons learned will inform best practices as the state continues to navigate the pandemic and move forward.
Key Words:
Mississippi, Mississippi State Department of Health, disparities, state response, resources, social isolation, vaccine access, hesitancy
The COVID-19 pandemic has had a significant impact on the state of Mississippi, one that was felt across the spectrum, most notably on public health resources. Although the pandemic’s impact has been significant, there was strong strategic response between multiple state agencies. Mississippi has seen widespread racial, ethnic, and age-related disparities in the initial impact, which continue as the fourth wave highlights new challenges and opportunities for the state. Both negative and positive impacts have reshaped response efforts in the state.
The Governor’s State of Emergency declaration lifted restrictions on personnel that allowed the Mississippi State Department of Health (MSDH) to deploy more than 800 public health employees to work the state’s COVID-19 response. This has been a serious issue to date for Mississippi, and the agency has responded in kind. All state agencies were activated and willingly partnered to offer services that included: SNAP relief benefits, housing, transportation, traffic control, emergency provider licensing for staffing facilities, healthcare coordination, and more than 1,700 Mississippi National Guard members to assist with response efforts. Mississippi has worked to use every resource it has to address this issue.
The Mississippi Department of Health and Service Division of Aging and Adult Services (DAAS) also played a significant role in response efforts for midlife and older persons in Mississippi. DAAS uses a multiorganizational approach to combat issues of poverty and associated barriers to providing needed services and support like resource availability, older adult fears, social isolation, vaccine access, and vaccine hesitancy. Many of older adults and people with disabilities that DAAS serves are dependent upon the programs and services provided to maintain their day-to-day health and well-being. At the start of the COVID-19 pandemic, with the increased risk the virus posed to older Mississippians, those of us at DAAS knew we had to take immediate action to ensure these vital services continued.
DAAS collaborated with the Administration for Community Living (ACL) to develop a plan to continue providing services to older adults with an increased emphasis on safety. These discussions stressed the need to properly use personal protective equipment (PPE) and implement guidance provided by the Centers for Disease Control and Prevention (CDC) and the MSDH. The Mississippi Emergency Management Agency was instrumental in procuring and disseminating PPE to facilities across the state.
The Department of Public Safety also served in a support role for maintaining order, testing/vaccination throughput, and lending forensic support across the state during the pandemic. ACL created a COVID-19 Response Page, which was updated weekly with frequently asked questions posed by State Units on Aging like DAAS. This web page provides real-time information and guidance that assists DAAS leadership in disseminating information from the federal level to local Area Agencies on Aging (AAA).
DAAS provides a variety of key statewide initiatives including Home- and Community-Based Services (HCBS), Adult Protective Services (APS), State Long-term Care Ombudsman (SLTCO), and discretionary programs such as the State Health Insurance Assistance Program (SHIP) and Mississippi Access to Care (MAC) Centers.
‘Mississippi has worked to use every resource it has to address this issue.’
HCBS assists older eligible homebound adults and adults with disabilities by providing home-delivered meals. Meals are also provided at congregate meal sites for those who qualify and can access the sites. Homemaker Services help older adults remain in their homes by performing housekeeping tasks such as cooking, cleaning, mending, grocery shopping, laundry, consumer education, safety education, bathing, dressing, and oral hygiene help.
Respite care provides temporary relief time for the regular or primary caregiver (spouse, child, relative) of a functionally impaired older adult or person living with dementia that requires constant in-home care. APS investigates reports of alleged abuse, neglect, and exploitation of vulnerable persons, older adults, and adults with disabilities, living in the private home setting.
SLTCO serves as an advocate supporting residents’ highest possible quality of life and care. The SLTCO also is responsible for investigating and resolving concerns and complaints of residents in long-term care facilities.
SHIP provides free, in-depth, unbiased, one-on-one health insurance counseling and assistance to Medicare beneficiaries, their families, and caregivers.
MAC Centers are the statewide No Wrong Door system that provide a central source of reliable, objective, and unbiased information about a broad range of programs and services.
Challenges and Barriers to Service Provision for Older Adults During the Pandemic
A few service areas were dramatically impacted by the COVID-19 pandemic, including food insecurity, access to healthcare, housing, access to social services, harm reduction programs, and transportation. One of the most troubling was the increase in reports of abuse, neglect, and exploitation handled by APS, which doubled in 2020. APS received 4,749 reports in 2020, which is an increase of nearly 50% from 2019 reports. APS workers followed CDC recommendations when going out on investigations and visiting alleged victims in-person. The APS call center added COVID-19 questions as a part of the intake process to help keep alleged victims and APS workers safe. The limited availability of PPE posed a challenge to the requirement for APS workers to respond to reported allegations with face-to-face contact within 48 hours. APS responded to this challenge by conducting initial interviews via virtual platforms when possible. With added safety measures in place, APS workers continued to respond to reports of abuse, neglect, and exploitation. These measures were effective in preventing APS staff and the people they encountered from contracting COVID-19.
There were multiple challenges in long-term care facilities, with misinformation being the most significant. Conflicting information from the National Institute of Health, CDC, and the Centers for Medicare & Medicaid Services resulted in many nursing facility administrators limiting access to staff only and not permitting local STLCOs to enter. Adequate food, medication compliance, and clean rooms were a concern, along with social isolation as reports of outbreaks and staff shortages emerged. Family members were denied access to their loved ones and were not provided information on their care status. In consultation with the Mississippi Attorney General’s Office, DAAS’ STLCO sent letters to nursing facilities informing them the emergency orders did not suspend the federal mandate to allow SLTCOs access for advocacy and protective services for individuals in the facilities.
To limit the residents’ risk of exposure, most services were rendered through telephonic/virtual contact when possible. The MAC Centers played an instrumental role in assisting STLCOs by providing Chromebooks to nursing facilities, which allowed video call contact with residents. Other innovations needed were strengthening PPE dissemination, conducting group testing at LTCs, and conducting infection control surveys. Infection control surveys helped to identify the process being implemented at long-term care (LTC) facilities and make recommendations for improvement.
Early tragedies were seen in LTC facilities. Controlling outbreaks and death rates were major issues in the early part of the pandemic. “There was an eerie feeling walking the halls of a LTC when going to vaccinate. Sixty percent of the residents had passed during the pandemic by the time we went back to vaccinate,” said the COVID-19 Mississippi deputy incident commander.
We also had logistical issues early on in dealing with homebound citizens. Home health agencies were stalled due to the pandemic, shelter-in-place orders, and infection risk, which contributed to difficulties vaccinating the homebound. The state worked to develop mechanisms for delivering PPE, prevention education, best practices, and prioritizing this group for vaccinations. The state worked closely with LTC facilities to coordinate treatment and protection. The key best practice is to have a plan ready to address homebound elders due to their high risk.
MAC Centers also helped address social isolation by partnering with local facilities to provide transitional care for older adults seeking to be discharged from nursing facilities. Transition services provided homemaker services to low-income older adults who otherwise would not be able to move into the community. South Delta Area Agency on Aging began holding events in February 2021 that helped combat social isolation. Older adults participated in Moving for Better Balance activities, which helped participants feel strong, steady, and safe living in their homes. This activity provides an opportunity to address safety and social isolation.
‘Sixty percent of the residents had passed during the pandemic by the time we went back to vaccinate.’
Food insecurity increased for older adults and adults with disabilities during the pandemic. There were 97 congregate meal sites across the state prior to the pandemic that in 2019 served 425,182 meals. Congregate meal sites were forced to close due to emergency executive orders limiting social gatherings, which increased the need for home-delivered meals. This was a significant shift in resource allocation that was addressed by Trio Community Meals (Trio), the state vendor for home-delivered and congregate site meals. Trio accommodated the need by ensuring that all congregate meal sites were supplied with pre-plated meals that met dietary requirements. The number of home-delivered meals provided during the 2020 federal fiscal year increased by more than 1,000,000 meals from the previous year.
Homemaker and respite services continued to be a challenge during the pandemic. Many personal care professionals were afraid to go into older adults’ homes, and older adults were equally afraid of those individuals coming into their homes. Because of the workers’ commitment, 211,359 hours of homemaker services were provided, which was a decrease from the 240,529 hours of services provided in 2019. Although this does not represent a significant decrease in the total number of service hours, some individuals who needed services opted to suspend them until they felt comfortable allowing someone to come into their home. In 2020, 84,526 hours of respite care were provided to older adults and adults with disabilities. In 2019, 88,269 hours of respite care were provided.
Health Equity Initiatives Among Minority Populations and COVID-19 Vaccine Hesitancy
This is the first response for which Mississippi has created a Health Equity Unit, to zero in on equity in the state’s emergency response, and it is a critical best practice to continue. It is crucial when using this practice in response plans to have a dedicated unit for all emergency responses. The Health Equity unit coordinated work by developing the state’s Hispanic and Vietnamese Task forces. coordinated efforts for the Limited English Proficient–speaking communities across the state by providing health education and health promotion activities via culturally and linguistically appropriate channels. Town halls and educational materials were developed in Spanish and Vietnamese, and testing sites were conducted in immigrant communities. Mobile vaccination clinics were held in the community, and local community leaders were engaged to identify and remove barriers to access resources to help prevent spread, coordinate care for older adults, and build trust with the state.
Older Mississippians were second only to frontline medical workers in being eligible for vaccinations in Mississippi. DAAS, in partnership with MSDH Office of Preventive Health and Health Equity, collaborated to assist homebound older adults and people of color with access to vaccines and to combat vaccine hesitancy. The two agencies worked together to determine how many homebound older adults and adults with disabilities had not been vaccinated and were interested in receiving the vaccine at a trusted local location. The North Delta Area Agency on Aging (NDAAA), in Clarksdale, MS, was the pilot agency selected to provide inoculations for older adults who had no vaccine access. The participants were provided free transportation by NDAAA to and from the Aaron Henry Community Health Services Center. There were approximately 40 older adults and caregivers vaccinated during this event.
To combat social isolation, Three Rivers Planning and Development District’s MAC Center provided laptops to nursing facilities throughout their planning service areas to allow residents to see and speak to their loved ones. These areas included South Delta, Northeast, North Delta, North Central, and Three Rivers Area Agencies on Aging.
Central Mississippi Planning and Development District’s MAC Center partnered with Harmony House Calls and Medical Services, along with MSDH, to provide COVID-19 vaccinations for homebound people ages 60 and older and individuals with disabilities. They also partnered with Inspire Transport to provide transportation to COVID-19 vaccination appointments.
‘This is the first response for which Mississippi has created a Health Equity Unit, to zero in on equity in the state’s emergency response.’
We conducted a Mississippi Vaccine Confidence Survey to better inform the response effort with disseminating vaccines and addressing hesitancy issues. More than 11,000 responses from all 82 counties in the state flooded in. We learned that the key influencers with vaccine decision-making were recommendations from primary care providers, the CDC, State Health Officer, or a close relative. Of those who were hesitant, key concerns were vaccine safety, side effects, FDA approval, and effectiveness. This information was important for the state to use while developing communication and messaging to promote vaccine uptake.
Unique Lessons Learned During the COVID-19 Pandemic
Innovation was a valuable tool during the pandemic. One key lesson the state learned was to address and ensure information access to all adults. Improving the COVID-19 phone line user-friendliness by adding a line dedicated to older adults for testing and vaccination appointment access was one example of a lesson learned. It was critical to find ways to connect and offer timely information to citizens through different mediums. Especially with older adults, it was crucial to communicate via methods that were not solely reliant upon modern technology.
The early tragedy of the pandemic in terms of the number of deaths was focused on long-term care (LTC) facilities. Having an infection control plan and a training program was important, but outbreaks and high transmission rates required an elevated response. The MSDH placed infection control surveyors, equipped in PPE, to observe LTC facilities in real time and provided best practices for quality improvement. As a result of the pandemic, our MAC Centers now provide information for callers on available vaccine sites.
MAC Centers also collaborated with local community health organizations to provide vaccine access to homebound older adults, adults with disabilities, and their caregivers. Individuals can receive the vaccine at home, or transportation is provided to community health centers to get the vaccine. MAC Centers also developed television and radio advertisements aimed at reducing vaccine hesitancy. The advertisements provide reliable information about the effects and benefits of getting one of the COVID-19 vaccines.
MAC Centers have been essential in connecting older adults, adults with disabilities, and their caregivers with services and supports needed throughout the pandemic. MAC Center staff have conducted weekly follow-up calls with program participants to increase social engagement and connectedness. This program supports the goal of the ACL in efforts to decrease social isolation for older adults and adults with disabilities during the pandemic.
Southern Mississippi Planning and Development District’s MAC Center developed a program to support individuals seeking to transition from hospital-to-home and nursing facility-to-home by establishing an Emergency Transitions Support program to provide meals and homemaker services for older adults and adults with disabilities needing meals and homemaker services to transition safely during the pandemic.
The Ombudsman program and MAC Centers work in coordination with LTC facilities. The Ombudsman program provides interventions such as mediation for complaints from residents. Supports are provided through MAC Center for community transitions out of the LTC facilities, which include a host of community services and providers as needed by the older adult.
Call to Action
There were some areas in which the state needed improvement, including: figuring out how to better collect data and coordinate staffing needs; working with national or reginal associations to identify and share best practices; and the uncertainty regarding the length of a pandemic requires that states find ways to address pandemic fatigue; and lastly, finding ways to continue to motivate staff, and let them know there is light at the end of the tunnel even as the tunnel constantly lengthens.
It is key to communicate early and effectively about nonpharmaceutical interventions, along with risk factors to marginalized communities. These interventions included stressing the importance of wearing PPE, social distancing, and other effective measures. As the response continues, a repository of best practices for resource distribution, treatment, and vaccines is needed. Most importantly, the state must continue to develop appropriate communication channels for the various communities. Medical transport was one of the biggest gaps in the state response. It is imperative the state grows this plan to better coordinate access, which includes using ride-share options such as Uber and Lyft.
The COVID-19 pandemic was an unprecedented event in current history that has touched the world. Every day, many people, such as TRIO delivery drivers, MCBS homemakers, APS workers, and SLTCOs have worked tirelessly to ensure the safety and well-being of older adults and adults with disabilities, despite the challenges. Partnerships have been extremely important in response efforts. Organizations like DAAS have collaborated with other state agencies and AAAs to develop innovative ways to provide services while complying with ever-changing guidelines and restrictions. We have learned that we work better together to look out for the best interests of vulnerable adults in Mississippi. The lessons learned will inform best practices as we navigate the pandemic and move forward. We continue to aim to be a trusted resource in the community.
Chigozie Udemgba, DrPH, MSHP, CHES, is Office of Health Equity director in the Office of Preventive Health & Health Equity at the MSDH in Jackson. Kina L. White, DrPH, MHSA, FACHE, is the Office of Community Health Improvement director in the Office of Preventive Health & Health Equity at the MSDH. KenYada Blake-Washington, MEd, CIRS-A/D, is the Mississippi State Unit on Aging director in the Division of Aging and Adult Services at the Mississippi Department of Human Services (MDHS) in Jackson. Mary Shearrill, LSW, BSC/ASCP Certified, is director of Programs in the Division of Aging and Adult Services at the MDHS.
