Sherry Perry has seen all the horrors of the pandemic. As a certified nursing assistant at a long-term care facility in Lebanon, Tenn., she has held a phone up to a window so a daughter could say goodbye to her dying father. She has watched residents die alone, not understanding why their families didn’t visit them in their final days. Earlier this month, she herself got Covid, suffering fever and chills, and passing out as she struggled to breathe.
As the Covid-19 vaccine arrives in long-term care facilities this month, however, Perry, who is also a board member of the National Association of Health Care Assistants (NAHCA), says she and many of her co-workers are concerned about side effects and distrustful of the government. With a maximum of six paid sick days a year, she fears having to take unpaid time off. Her facility hasn’t told staff anything about the vaccine’s arrival, she says, and “that throws people into panic mode,” because they fear they’ll be pushed into taking a brand-new vaccine that they don’t fully understand.
While the vaccine’s arrival is being heralded as the beginning of the end of long-term care facilities’ hard-fought war against Covid, not all workers and residents will be rolling up their sleeves for a shot. Widespread vaccine skepticism among direct-care workers and residents, and limited initial doses of the vaccine threaten to delay or even derail vaccination of swaths of the long-term care population.
Failing to vaccinate a sizable fraction of long-term care residents and workers could result in many additional lives lost and unnecessarily extend the isolation of residents in locked-down facilities. More than 110,000 long-term care residents and staff members have died of Covid-19, according to the Covid Tracking Project, accounting for about 40% of all U.S. deaths from the virus. The virus is claiming about 5,000 lives a week in long-term care facilities, according to the industry group American Health Care Association/National Center for Assisted Living. “If we botch the rollout of the vaccine in long-term care, we’re missing an opportunity to save tens of thousands of lives,” says Dr. Michael Wasserman, a geriatrician and former president of the California Association of Long Term Care Medicine.
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The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices recommended early this month that health-care workers and long-term care residents be placed at the front of the line for initial vaccine doses. States have leeway to prioritize different groups, but many are following the Committee’s recommendation. In some states, long-term care residents and workers can get the vaccine this week, although some workers will have to visit a local hospital to do so. A larger-scale vaccine rollout at long-term care facilities starts later this month, when pharmacies hold their first on-site vaccination clinics for both residents and staff.
In some states, it’s already clear that initial vaccine shipments won’t be enough. California, for example, is giving priority to health-care workers at risk of direct exposure to Covid and long-term care residents, and initially expected to receive 327,000 doses—but it has close to 1.6 million workers with direct patient contact, according to the Kaiser Family Foundation. The state should receive an additional 393,000 doses of the
vaccine next week, Gov. Gavin Newsom said Monday. Deborah Pacyna, spokeswoman for the California Association of Health Facilities, which represents skilled nursing facilities in the state, says, “We’ve been pressing for the state to prioritize us,” but hospitals are generally getting the first doses, and counties can also set their own priorities.
In other states, long-term care residents aren’t in the top-priority tier. In Utah, initial vaccine doses are going to major hospitals that care for the highest number of Covid patients.
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Many nursing-home workers, however, won’t be clamoring for a vaccine. Nearly three out of four certified nursing assistants (CNAs) surveyed by the NAHCA in early December said they wouldn’t take the vaccine, citing skepticism over the rapidity of its launch and lack of information on potential risks. Lori Porter, the association’s CEO, says she and her team have been fielding 3 a.m. phone calls from night-shift CNAs who have concerns about the vaccine. “They have no faith, no trust, because they’ve been dumped on so much,” she says.
That is a blow to residents. Penny Shaw, 77, a Braintree, Mass., nursing-home resident who served on a nationwide independent commission to assess the Covid response in nursing homes, says she probably can’t take the vaccine herself because she has an autoimmune disorder. When she started talking to staff members in her facility last week about the vaccine, she was shocked at their response. “They don’t want to take it,” she says. “Everyone is furious and angry,” and fears being pushed into vaccination.
Some facilities plan to mandate vaccination for workers. “We are going to make [vaccination] a condition of employment,” with limited exemptions for workers with medical or other issues, says Lynne Katzmann, CEO of Juniper Communities, which operates 22 long-term care facilities in Pennsylvania, New Jersey and Colorado. That idea doesn’t go over well with workers like Perry. If her own employer required the vaccine, she says, she’d consider leaving her job, even though she has worked in the same facility for 25 years. “There are so many other places, such as home health, I could work,” she says. If facilities mandate the vaccine, “they’re going to lose a lot of staff.”
So far, there has been little communication on the vaccine rollout plan aimed directly at nursing home staff, long-term care experts say. “There has been no targeted education campaign for nursing home staff,” says Dr. Kathleen Unroe, associate professor at Indiana University School of Medicine and a nursing-home physician. In a November survey of Indiana nursing home staff, Unroe found that only 45% were willing to take the vaccine as soon as it became available. Both staff and residents, she says, fear they’ve been designated “guinea pigs.”
In the days leading up to the vaccine’s rollout, confusion over vaccine-consent requirements sent the already overwhelmed long-term care industry scrambling. Pharmacy chain CVS, which has joined with the CDC to offer Covid vaccination at more than 40,000 long-term care facilities nationwide, said it would mail facilities paper consent forms—in triplicate—and asked that they be completed before the vaccination clinics, which will start as early as Dec. 21.
another pharmacy giant participating in the federal partnership program, also said it would collect consent forms from facilities on the day of vaccine administration. Getting those forms completed on time—and collecting signatures from the authorized representatives of residents who don’t have capacity to make their own health-care decisions—would pose some major logistical challenges, industry groups said.
In recent days, however, some of the requirements shifted. After discussions with the industry about the paperwork burden and the impact it might have on vaccination rates, the major pharmacies dropped the signed-consent requirement, according to industry group AHCA/NCAL, and will now accept documented verbal or email consent as well as electronic signatures. CVS started telling facilities about the additional options on Monday, says spokesman Michael DeAngelis. When facilities collect verbal consent, they still have to complete and sign the consent form, he says. Walgreens consent forms incorporate industry input and are provided to facilities “days in advance of any clinics conducted on-site,” a company spokeswoman said.
Other challenges remain, including vaccinating workers who aren’t regular full-time employees at facilities. Some long-term care providers say they’ll include staffing-agency workers, hospice workers and others who may only occasionally visit their buildings in their head counts for vaccine distribution, but such workers may not always be prioritized. Paul Ruderman, CEO of staffing agency All American Healthcare Services, says he has spoken to dozens of long-term care clients about vaccine distribution, and “they are going to prioritize their residents and their full-time nursing personnel.” Agency workers may need to visit a local hospital to get their shots, he says.
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Residents and workers who miss out on their initial vaccination opportunities may have to find another way to get their shots or wait months for another chance. Generally, the pharmacies are scheduling up to three vaccination clinics at each facility, and for those who don’t get their two vaccine doses within that schedule, “the next steps to the process haven’t been laid out,” says Peter Van Runkle, executive director of the Ohio Health Care Association.
Given the compressed schedule, strong vaccine uptake among nursing-home staff could present its own challenges for facilities. There is not much flexibility to stagger the vaccination of staff and residents, as many facilities would prefer. Many nursing homes are already short-staffed, and vaccinating all workers on the same day “could be a recipe for disaster,” Van Runkle says, because many may call in sick due to vaccine side effects. Only about two-thirds of nursing homes reported no staffing shortages as of late November, according to data from the Centers for Medicare and Medicaid Services.
For Genesis HealthCare, one of the largest nursing home operators, “it’s a concern,” says Dr. Richard Feifer, the company’s chief medical officer. Genesis is looking at shifting staff between facilities and pulling in agency workers, he says. “We can’t afford to be short-staffed when our residents need care the most.” But some facilities are struggling to get agency staff, given the stiff competition for front-line workers. “The bodies are just not there,” Pacyna says.
The burden of managing the vaccination process and dealing with the side effects comes on top of other Covid-related requirements, such as mandatory twice-weekly testing in some facilities, and the additional resident care accompanying the surge in cases. For direct-care workers, it all adds up to extreme uncertainty. Given the tight vaccination schedule, “the whole building’s going to be sick,” says Sheena Bumpas, a CNA in Duncan, Okla., and NAHCA board member. “This is just the unknown, and it’s scary.”
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