To Fight Nursing Home Vaccine Hesitancy, Operators Must Tackle Individual Concerns Head-On

For one skilled nursing operator, its ethos of maintaining a strong local footprint has paid off unexpectedly in the form of facilitating COVID-19 vaccination among its frontline staff.

But that facilitation wouldn’t have been possible without a focus on documenting the concerns of its workers and taking the steps to address them individually.

Carespring Health Care Management, which is based in Loveland, Ohio, operates 13 SNFs: eight in the Cincinnati-Dayton area in Ohio and five in Kentucky.


Of those buildings, 11 have had their first vaccine clinic as of January 15; Carespring has partnered with CVS Health (NYSE: CVS) as part of the Pharmacy Partnership for Long-Term Care Program to provide COVID-19 vaccinations to long-term care facilities.

The state of Ohio was one of several in the news in the early weeks of January for slow vaccine uptake among nursing home workers. To address this, Carespring focused on documenting their concerns and finding personalized ways to address them — and has seen its staff rates tick upward as a result.

And because of the company’s focus on maintaining a close network of facilities, getting staff to a vaccine clinic is much easier than it would be otherwise.


Chris Chirumbolo, the CEO of Carespring, spoke to Skilled Nursing News on January 15 — while he was on the way to one of the operator’s vaccine clinics — to talk about how Carespring has been navigating the vaccination rollout, and some of the ways it’s handled education for staff on the fence about getting the shot.

Going back to when the vaccines first received their emergency use authorizations (EUAs) from the Food and Drug Administration (FDA), what were the first steps Carespring took to start the education and logistics of vaccinating people?

When the Pfizer [COVID-19 vaccine’s] EUA came out around the second week of December, we took the fact sheet that came out, and before that came out, we had created a vaccination link on our website that was providing education to families on what the process generally would look like. We knew there were going to be three clinics — we’re with CVS for all of them, so we had posted some of the CVS information. We’ve posted the general process of: We’re going to have to get consent for them [the residents].

Every week, our nursing facilities used a messaging system where we told families and staff that what is going to happen is that there is going to be a consent process, educating them that: This is what we know about the vaccine. We’re only providing facts from the CDC and from various trusted sources on what it meant to get vaccinated — what we do know, but also what we don’t know as it relates to visitation, as it relates to other flexibilities that will come in the future.

We tried to provide what we knew exactly at that point. So when the EUA came out, we gave more facts — like what specific ingredients, because there’s a lot of people fearful of allergies. What’s in it, from a standpoint of: Were people theoretically worried about specific ingredients? We just posted it on our website and we educated the families and our staff.

From there, we started talking to all of our residents’ families and the residents, but then also our staff, and made a roster of all the staff and all the residents. Who’s a definite yes? Who’s a maybe? And then who’s a no?

With the “maybes” and the “nos,” we then documented what their concerns were. Then we try to find the trusted sources to talk those people — if it was a doctor, if it was a peer, if it was a nurse — to try to educate them on their concerns.

The biggest concerns for staff were this misinformation, which has been going on for a while now: Is it going to cause fertility issues? I’ve already had COVID, why should I still need to be vaccinated? [The latter’s] probably the number-one.

At Carespring we’re at about 50% and it’s going up; probably 60% of our staff are taking it. When you look at that number, some of the people that aren’t getting are people that have already had COVID. When we talk about protection, we still are advocating — as public health has — that those people need to get vaccinated. But then there’s some people within that group: “Let me just wait and see,” mixed in with legitimate things. Some people, it’s religious things.

But the main one is definitely: “I’ve had COVID before.” The second one is probably: “I’m worried about potential fertility issues.” We’ve tried to get some fertility docs to provide some feedback on that for those team members just as a global thing, and the state of Ohio and Kentucky have given video resources and different Q&As.

I think the key is you’ve got to sit down with each person, staff or resident, who’s concerned and try to get them to understand and not forcing people — just getting them to understand a little bit more about what’s going on.

But also at Carespring, our buildings are 90 miles distant between the furthest of each other, so we do have flexibility in the sense that we have some people going from one building to another. If they can’t make it on this day, they get a clinic date on another day.

We’re offering it to everybody who’s available, but we’re also expanding out to the staff that we have to test, the vendors — like the pharmacy consultants, the imaging techs, the phlebotomists who come in that we have to test anyways. We’re offering it to some of those folks, because again, the more people we vaccinate who come into the nursing homes, along with our residents, the better protected we’ll be.

I’ve heard of a phenomenon with the clinics for staff in particular, where there’s slow uptake during the first clinic but an increase during the second one because workers have had time to process it and see how their coworkers are doing. Is that something you’ve noticed?

Yes. Our very first clinic was December 22, so the EUA had just come out the week before — and first clinic, here we go! At that first clinic, we had like 32% participation of staff. We had about 95% of our residents. I was shocked.

But we had our most recent first clinic just the other day at another building, and we were closer to 50%. So in that second clinic ,of that one that just happened again, we had about 20% additional staff who decided to do it, the first dose at the second clinic. So it does go up.

I think what we’re trying to do, and what we have to do as a country and a state and region, is we’re trying to push down on the fact that there’s now been millions of doses administered. You’re not the first one anymore. You know, people are saying: “Well, I don’t want to be the guinea pig.” You’re not.

That first building, I get there’s some concerns. But now here we are almost four weeks in. We’re telling the building that’s going to [receive vaccines] today that we’ve now had 2,000-plus people at our Carespring company who’ve received the first dose.

We’ve had some people with minor aches and pains, and we don’t shy away that you might have some aches, pains, soreness. Some people might have a fever, some people might have these mild symptoms, and we’ve educated them on that, that that’s normal. It’s an immune response. It doesn’t mean you have COVID. It doesn’t mean something’s wrong.

When you talked about the misinformation, did you have a specific strategy? The concerns around potential confusion and bad information came up very early in the vaccine process.

We got a tally of what people are hearing, and we went and got answers and put it on our website — frequently asked questions about the COVID vaccine with factual, objective answers to each one of those, that we posted as early as we could, as early as we knew it.

It also prepared our staff. We’re talking to those team members that these are the facts. It gave the staff in the buildings talking points about how to answer that question, or how to answer that objection or how to answer that concern.

I think what’s really being forgotten is that in the American public, people 65 and older, I imagine — as residents, 90% or more are receiving the vaccine — you’ve got a generation or a couple generations of people that have seen polio, who’ve seen really big things from their loved ones years ago, and they’re used to understanding what life is like when vaccines aren’t there.

Now, when you have people that are under 65 and who haven’t had maybe a direct correlation or direct experience with some loved one who’s had those types of experiences, I think that’s also a [reason] the American public and national government has to strategize about just this ongoing, massive education push to counteract all those misconceptions.

People just don’t understand the benefits of vaccines as much. They’re used to getting it when they’re a kid, and they’re not used to getting it besides the flu vaccine, in many circumstances, at any point in the rest of their lives. Just look at how the shingles vaccine came out. That type of push takes time. So I think that our goal has to be to get as many shots in arms now as everybody — that’s my personal goal.

The same point is: There can’t be a naive approach from all the other non-nursing home people in the world that “my people will just take it.” I would venture to think that the nursing home staff is a representation of the American public who are 18 to 65, and their willingness to take it.

So Kaiser [Family] Foundation says 71% of people will take it. Well, if you include the people that are above 65, yeah — that is correct. But when you look at just that cohort — and again, layer in the fact that unfortunately the trust around our country is probably a historic low right now. People just don’t trust things.

So independently, we’ve got to educate, [by] I think arming people with the facts but then sitting down with them one-on-one. It is extremely time-consuming, but it’s very much worth it. I think going forward, we’re going to find more nursing homes’ acceptance rates will continue to go up for future clinics, for future people, because they’re going to see more people in the community getting it. It will become the new norm.

And as you see more people get it without bad things happening to them, I’d imagine that helps considerably too.

No one who has been vaccinated, fully vaccinated in these circumstances from the clinics — they didn’t die. I think that every day, we become numb to the fact that 3,000 to 4,000 Americans are dying every day. And we worry about the one anaphylaxis reaction we hear at a clinic that happened somewhere else in the state, when we don’t react to the fact that we have 3,000 to 4,000 people dying of COVID every single day. I think we’ve become numb to it as an American public.

You’ve talked about the education initiatives and the work on that front. Some places have also done incentives such as financial bonuses or raffles and such. Is that something you’re doing, and what was the reasoning behind the decision?

We did offer incentives. We gave a “resident thank you” bonus for each team member who is vaccinated. So it’s a thank-you note from a resident, they receive a small bonus, and then we’re to also going to be entering buildings into a raffle for team members who’ve received it for a higher amount as a second layer of thank-you, to try to work on increasing the acceptance.

And we did that because I know at the end of the day, it’s not been the major swayer of people doing it, but I think it is important just to individually recognize them and thank them for what they did — and not shame the people that didn’t, because we’re not shaming them. We’re recognizing the people that did it.

Lastly, what are some things you’ve learned along the way that you’d want other people, particularly operators, to know about the vaccination process?

I would just reinforce keeping track of who your “yeses” are, because you move on from those folks. But between the first and second clinic, make sure all those people come back to the second clinic, just like outpatient appointments: “Here’s your appointment. Make sure you come back this day.”

Putting up posters throughout your building, letting people know. Also reinforce in your second clinic: As of today, it’s your last chance to get your first dose. You can’t say, “Well, I’m going to wait for another one.” If you’re 30 years old, you might not get a chance for three or four months.

But then hitting on the people that are the “maybes” or the “nos,” talking with them again or having a different trusted resource talking to them, a doctor or someone else. Not to put pressure on them, just to understand them. But also it might be that if I’m a nurse aide and you’re a nurse aide and you see that I got it and I’m the same age group, same demographic, having someone like that maybe talk to that other person, because that might resonate with them more.

It’s time-consuming. It’s time-consuming to prepare. But just keep everything written down. I’m a big proponent of keeping a log of: Who’s got it? Who needs to come back to the second clinic? And making sure you document why your “maybes” and “nos” after your first clinic are that way, so when members with them at the second clinic, they have a head start. It makes the second conversation more personal because you already know their objection or concern.

It’s also not talking about the negatives of vaccination; it’s talking about the benefits. We put posters up all throughout our building because of course, it’s about the residents — that’s most important.

But also we put posters up: Help put your kids back in school; get vaccinated. Help so you can go back to concerts, go back to sporting events, help [so you can] go back to being with your families, helping all those outside things that are impacting everyone.

I think deep down, it’s sitting down with each person and asking: “What’s your pain point from this pandemic? This pandemic has not been great for a majority of the population; everyone is unhappy in their own way. This is how we’re going to get there, and vaccination is a big part of it.”

In some cases, it’s getting rid of PPE [personal protective equipment] eventually; it’s letting people visit more, not having to worry about doing all these things that we have to do today, like testing. Those things will come when we get enough people vaccinated.

I wish we knew more about the vaccine, because some staff members ask, “If I get vaccinated, do I have to keep getting tested?” That’s probably one of the things too that people ask: If I’m fully vaccinated, why do I have to keep getting tested two times a week? Because we’re in a red county, so they get tested twice a week.

And I’m like: As of right now, it probably will change, it definitely will change as cases go down. But we don’t know when it will change. We also don’t know if someone’s been vaccinated, could they still technically have a small dose of it in their system that could affect another person? We just don’t know yet. And I know that is frustrating for people.

The main point of vaccination is protecting you, then we’ll protect others. You’ve got to find that connection point, so I tell people: Don’t give up. Don’t assume that you’re just going to get 50% to 60%. There’s a Dayton provider, in Ohio, she’s the owner of the nursing home, and she had 100% staff participation.

Her main point was: She first made sure her department heads were bought in; she sat down with each one, they all had to be bought in. Then she went down each one, and they actually posted up in the facility, who’s signed up to get it? And by seeing other people, by seeing: Oh, well I see Sally’s getting it, then I’ll get it.

Because people didn’t always talk about it, that was her way of publicly putting it up so people would see who was getting it, and not who is not. But that helped, she felt, a lot, in swaying people, seeing who else was getting it.

But I think there’s a ways to go, and I think your reporting the best practices is a good thing. There is no silver bullet; there is no one-shot, this is how you do it. It’s individual for each person. And the American public needs to recognize that, because this is a microcosm of what’s going to happen across the country, when enough vaccine becomes available for the entire general population. You’ve got to start doing it now.

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