As Vaccine Clinics Wrap Up and Doors Open, Nursing Homes Must Start Planning for Waves of Future Shots

When emergency use authorizations (EUA) were granted to two COVID-19 vaccines in December 2020, health care workers and residents in long-term care facilities were granted first priority for the shots — and a federal partnership to vaccinate nursing homes kicked into gear.

By January 25, most nursing homes participating in the Pharmacy Partnership for Long-Term Care Program with CVS Health (NYSE: CVS) and Walgreens Boots Alliance (Nasdaq: WBA) had had their first clinic. And from the last week of December, when the first clinics in the partnership began, and the first week of February, weekly deaths in nursing homes fell 66%.

The pharmacy partnership involved three clinic dates at long-term care facilities, to allow for distribution of the full two doses of each vaccine. Facilities themselves were mostly positive about the experience; one operator, the Florida-based Consulate Healthcare, had rave reviews for its pharmacy partner in the setup, while most operators responding to a January Skilled Nursing News poll were mostly positive about the process.


However, it was not perfect, and even with the clinics mostly completed, there are still gaps in the process. Some staff, for instance, might decide to be immunized after some months of seeing colleagues work after the shots. And as SNFs open again to admissions, there’s a possibility of patients coming in who haven’t received COVID-19 shots of their own.

For the newest episode of Rethink, SNN sat down with Angela Perry, administrator at Vernon Manor Health Care Center in Vernon, Conn., to talk about her facility’s experience of the vaccination process, and how it’s thinking about the future of new admissions and — eventually — visitation.

Excerpts from the conversation, recorded on February 5, are below, edited for length and clarity. And if you like what you hear, be sure to subscribe on iTunes or SoundCloud.


What has been Vernon Manor’s experience with the vaccine process, even before the first clinic?

We really started focusing our efforts — I want to say back in September, we were preparing for our point prevalence survey for our influenza vaccination, and really wanted to have a robust compliance rate with that among residents and staff. And we did exceptionally well; we had a 99% conversion rate for our flu vaccine clinic.

So right after that, we really started digging deep into our COVID vaccination efforts. We realized there was going to be a lot of hesitance, obviously; it’s a newer vaccine. There were a lot of concerns among staff regarding the time that it had taken to create the vaccine. There’s a lot of religious and other personal issues that we really had to work with through with the staff, in conjunction with our medical providers and learning more research, factual research that was being put out via the CDC [Centers for Disease Control and Prevention], our local state departments, and so forth.

We had to have regular meetings on how we were going to execute our plan towards the end of September, after our influenza clinics. Some of our efforts included daily staff huddles. We maintained our staff and family town hall meetings; we’re actually on week 48 of our town hall meetings going back to March 11, 2020. They’ve been very informative and collaborative amongst staff and family.

In addition, of course, one-to-one education and getting a little more personal with staff who may not want to be as vocal during staff huddles. We customized a facility vaccination pamphlet, which we distributed during our weekly point prevalence surveys for our COVID testing; all of our staff have to be tested on a weekly basis. So that was just a great opportunity to be able to engage with all staff on a consistent basis, and that’s ongoing.

We provided personal letters on behalf of the managing partner/owner and myself, the administrator, to families and staff via email or snail mail, just providing updates as we were leading up to the distribution to get staff and families excited about the vaccine process, and just looking at dispelling some of the misperceptions that have been put out there. We provided fact sheets and initiated a video campaign. We provided vaccination education stations strategically throughout the facility.

One in particular is at our main lobby, so as soon as staff come in for their daily surveillance prior to starting to their workday, there’s a TV screen where we are able to loop vaccine messages, one from the commissioner’s office from the Department of Public Health. They initiated a campaign where they went to another facility in Connecticut, and staff there would talk initially about their hesitancy but also about the reasons why they ended up taking the vaccine, so that was very informative. And it allowed that peer-to-peer understanding of why the vaccine was important, just building that sense of confidence.

In addition to the vaccination station, we have pictures of staff during our first clinic, and one of the staff persons in particular had a history of underlying medical conditions, and it’s common knowledge throughout the facility; she’s very open with sharing her experiences. So for her to be the first staff person vaccinated, it really opened some eyes, to: Hey, this person can do it, let me consider it.

We created a facility-specific herd immunity proxy spreadsheet, and that’s been pretty cool to track on a weekly basis, what our actual facility herd immunity threshold or benchmark is. Of course, it’s going to change on an ongoing basis as we have new admissions coming in. We may have residents who transition whether back to the hospital or another route. And we know in health care, unfortunately — we hate that there’s turnover, but there’s likelihood of turnover. So the new staff who may have come and left, we’ll be able to track that as well.

In addition, in November 2020, Vernon Manor had our first COVID outbreak, and it was a pretty significant outbreak. A total of 55 residents were affected and 34 staff were affected. So according to the CDC guidelines and also the state of Connecticut’s Department of Public Health, we do not retest those individuals for a period of 90 days. It is assumed throughout that period that they may have antibodies, so we included those individuals in our herd immunity proxy as well.

So just to summarize, included in the proxy are residents and staff who were COVID-positive, with the assumption of having antibodies, and staff and residents who were vaccinated, and then any turnover that may happen on a week-to-week basis. We started out with a 54% herd immunity proxy on January 4, and as of last week Monday, our current herd immunity proxy is 74%. Staff not vaccinated and presumed to have antibodies were 25, patients were zero [in that category] at that point.

Vaccinated due to personal choice and/or never having COVID-19: There were 75 residents at that point, and 23 staff.

Not vaccinated due to having COVID current: There were zero residents at that time, four staff.

Not vaccinated due to personal choice: There were three [residents] at that time, and 32 staff.

So with the 32, that definitely was an opportunity to meet with those individuals, whether in a small huddle or a one-to-one to learn more of the reasons why they were not vaccinated. Largely again, some religious, some based on historical reasons — African-Americans or people of color shared their reasons. But also we have a lot of young women who have plans of getting pregnant, and not really having a lot of information of the effects on fertility. How that relates to the vaccine has been probably the biggest topic of conversation.

We always encourage the staff to communicate with their primary providers in the community, but there are others in the child-bearing age who want to have more children, so we encouraged staff to talk to each other and learn why those decisions were made or not made.

That concern has come up consistently across the country. Were you expecting it?

Actually, no. I’m still in child-bearing age — I do not have any children personally, but that wasn’t the first thought that came to mind. I never had a doubt in my mind that I did not want to be vaccinated. The vaccines were being distributed right after our first outbreak at the facility, and I saw the impact.

We did lose nine of our residents, but in speaking at different forums, I’ve been told that we were very fortunate that we did not have more loss of life, compared to others in the state and nationally — especially if they were impacted earlier on in the pandemic, when there wasn’t a lot of information about how the virus spread, testing wasn’t necessarily as available as it was toward the summer, cohorting practices, and so on.

Of course no one wants to have an outbreak in their facility, but we definitely were prepared, and the team did a phenomenal job with the care they provided to the residents. We actually kept all of our residents in-house, we didn’t transfer to a designated COVID facility or a facility with a COVID unit.

We treated in place, largely because our outbreak began on our memory care unit. We consulted immediately with the Department of Public Health, and we went over the layout of the facility via the blueprints, and just knowing the dynamics of the population who just needed constant redirection with keeping their masks on and social distancing — the thought was at that point, there were only five residents who were COVID-detected, but we knew that the spread was going to affect the entire unit, and it did. So the decision was to treat those residents in place.

They were all placed on full transmission-based precautions, and they weren’t moved. We ended up having two COVID-dedicated units, one in the memory care unit and one on a unit directly above, but we were able to minimize the spread elsewhere in the facility.

There’s still a good handful of staff who are not vaccinated; our 90 days are approaching next week where — I believe — 24 staff will be at the end of the 90-day time period and they are presumed to no longer have antibodies. That is all the more reason why they should consider vaccination. Many of those nurses and CNAs, they work on our new admission cohort. The new admissions, they are not being vaccinated in the hospital setting. So the point of exposure here in the facility could put the staff at risk, where the spread can happen amongst each other, to other residents.

Granted, they are wearing full PPE [personal protective equipment], but there’s still that potential risk. We’re really talking a lot about those particular scenarios, and at the end of the day, we go home. We don’t want to expose any of our loved ones in the community either. So that’s where a lot of our focus is.

Also, there’s been a lot of restrictions that other facilities have been a little more liberal with. For example, we have not allowed any delivery or takeout food for the facility since the beginning of the pandemic. Granted, speaking with the infection control team, the potential exposure droplets on food being delivered are very minimal. But we just haven’t bent that policy yet. We were thinking potentially if we were able to achieve a greater vaccination count, we might scale back on that restriction.

I think that would definitely be an incentive for staff, though of course not 100% — you still have your personal beliefs, and we don’t want to be too forceful. Everybody has the right to make their own decision with this, especially since it’s not mandatory. But we do want to get back to a sense of normalcy and that’s one foot in the right direction.

Did it surprise you, the degree of hesitancy that there was when it became obvious the vaccines were coming?

I did feel the compliance would have been higher than what it is. However, there were staff who wanted to see other staff take the second shot, because there was discussion that the effects from the booster shots were more significant than the first. And I do have to say, for several of us — including myself — the booster shot did provide some effects. But they were short-lived, 12 hours or 24 hours and then back to normal.

We do have several staff members who will be participating in that third clinic on February 15. My understanding as of yesterday, per the infection control nurse, is that CVS will provide us with a fourth clinic if we have at least 25 new individuals agreeable to be vaccinated. That’s another opportunity where we’re trying to encourage staff, again with the incentive that we may be able to liberalize some of our practices.

We’ve been doing trivia over the overhead system, and we still have a hotline for staff to call in, and they can engage specifically with our infection control nurse and our staff development coordinator to ask more of those intimate questions that they may not want to share in a larger group. We’ve had huddles with our medical director, question-and-answer huddles, and those are ongoing. The medical directors here have a really close relationship with the staff; they are here all the time. So hearing from them, I think, has really given some confidence to the staff; I’m expecting the third clinic to have more staff participation.

That one-on-one focus and the question of who is sharing information — that’s something I’ve heard a lot of, the need to find out who is a leader among the staff and has a voice that staff will listen to.

Absolutely. As the administrator, I can speak to the staff all day, but they still hold you in a different light versus their peers. Having someone that they can have different types of conversations with, I think is valuable.

Another opportunity we’ve had is: We were able to register the facility through the VAMS program, the Vaccination Administration Management System program. I knew nothing about it prior to December 23. The facility has a really close relationship with our local municipality, in particular the lieutenant at the police department has been very supportive and resourceful for the facility. He just inquired with me one day about our first clinic, and I told him: It’s scheduled for January 25. That was the initial date that we were given, although our clinic was January 4, but we did not know that at that time.

He suggested getting the facility registered through the VAMS program. We had to do our homework and learn what it was about, and contact the Department of Public Health to see if facilities could even participate, because we were only aware of the pharmacy partnership through CVS. So myself and several other staff, we were able to be vaccinated through that program.

You cannot be vaccinated through the VAMS program at the facility; you have to register, create your own personal link and then be vaccinated at a local health clinic of your choosing, based on the particular mileage that is convenient for you. So the local hospital, we just went there on whatever date that was available, and we were able to be vaccinated ahead of our first clinic. That was very valuable, and we still offer that; it’s a never-ending program.

What was the process like in terms of engaging residents and families on the vaccine?

The reachout and engagement for the families was very easy. We maintain our weekly town hall calls with the families, and they were asking us way back in September: When can we find the consent forms?

Obviously we didn’t have them available until the end of December. But the compliance on that end was phenomenal. There were only three residents who were not vaccinated at our first clinic; the families were all for it, especially coming off the heels of our outbreak. That was even more so a factor for families, and the residents themselves who are self-responsible and able to make those decisions, there was no hesitancy at large.

The dilemma is for our new residents coming in from the hospital, what the plan is going to be moving forward. We don’t have the vaccines readily available through our own pharmacy to provide the shots. At this point, I know the state of Connecticut hasn’t identified any plans yet, but we’ve been thinking about that. As new admissions come in, the herd immunity proxy is going to be reduced, so how do we keep our new admissions safe from exposure? That’s definitely a challenge and an opportunity as a state that we have to figure out together.