Couldn’t Have Happened at a Worse Time: Nursing Homes Struggle to Increase Booster Rates as Covid Surges

As nursing home operators find themselves in the middle of a tripledemic – with Covid-19 cases, respiratory syncytial virus (RSV) and the flu on the rise during winter months – concerted efforts to get staff and residents boosted against Covid have fallen by the wayside.

And nursing home operators dealing with staffing shortages and burnout, and rising costs related to inflation, say that they need more support to convince residents and staff to get the latest boosters.

“It couldn’t have happened at a worse time,” said J. Mark Traylor, president of Traylor-Porter Healthcare in Alabama. “Throw in the burnout, throw in the pay dynamics and everything else and this just puts skilled nursing in another challenge and we’ve got to figure out how to get out.”

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Nationally, only 22.2% of staff are up-to-date with their Covid vaccinations, meaning they have received their primary series and all additional booster shots for the virus, including the bivalent booster. Resident numbers are slightly higher at 48.5%, according to data published on the Centers for Medicare & Medicaid Services (CMS) website.

The agency on Thursday addressed low results in a stakeholder call, calling vaccination efforts a “No. 1 priority.” CMS officials said they plan on implementing programs to help providers get staff and residents up-to-date, while reminding operators of existing programs to administer single-dose Pfizer vials through pharmacy partners.

To understand why booster vaccinations floundered among residents and staff, those in the sector must think about the “extraordinary efforts” made in early 2021 to vaccinate nursing home residents against Covid, Ari Houser told Skilled Nursing News; Houser serves as senior methods advisor for the AARP Public Policy Institute.

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“That effort was quite successful … the highest vaccination rates that we’ve seen in nursing homes ever,” added Houser. “We didn’t get that kind of campaign for the first round of boosters. The take up on that, eventually, has been the same rate that we’ve seen for flu vaccination historically.”

Between 2006 and 2019, the average vaccination rate among residents for pneumococcal and flu vaccination was 74% and 75%, respectively, he said. Initial Covid vaccination rates were higher at 87%, and boosters not including the bivalent booster was 76% – right in that expected range.

“Despite how successful that was, there really hasn’t been a follow up quite like that. Since then we’ve kind of left it to nursing homes themselves, to try to get staff vaccinated,” said Tamara Konetzka, co-author of a study published in JAMA focused on staff and resident vaccinations in nursing homes.

Operators need guidance, support

Traylor said staff and resident expectations on the efficacy of the vaccines is something affecting booster uptake. Many were under the impression that they wouldn’t get Covid if they got the vaccine.

A re-education of sorts needs to happen, he said, with assistance and guidance from federal and state entities, to help staff and residents understand the vaccine helps with case severity instead of shielding people from getting it at all.

“You can’t recover from that one too easily,” added Traylor. “We’re telling them what we were told, and then we found out that that’s not the case. That put us in a bad position, I think, with some of our employees.”

Some residents have opted out of being boosted out of a lack of understanding around the vaccine and boosters, added Envision Healthcare Director of Clinical Services Kim Barnes. Envision is Cascadia Healthcare’s regional division for Boise and Southwest Idaho.

“Many also have the decision made not by themselves but instead by a legal guardian or power of attorney,” Barnes added in an email to Skilled Nursing News.

So far, the five Traylor-Porter facilities’ up-to-date statistics are all over the map – literally. Traylor said it’s been harder to convince staff and residents in his two rural facilities to get up-to-date, resulting in lower numbers.

Its Arbor Lake facility is reporting 0% of staff and residents are up-to-date. About 50% of residents and 4% of staff at Arbor Woods received the bivalent; 67.7% of residents and 22.8% of staff at Arbor Springs; 51.3% of residents and 4.9% of staff at Traylor in Roanoke, Al.; and 50% of residents and 33.9% of staff at its fifth facility in Hueytown, Al.

Traylor urges government officials and industry associations to help with vaccination efforts.

“I need guidance, whether it’s our industry, or the powers that be in Washington or whoever it is to help us to fight that argument,” added Traylor.

The argument coming from some residents, their families and staff, he said, is that vaccines don’t prevent the spread of Covid, don’t stop people from getting it completely, and they don’t want to be “jabbed with something brand new.”

It’s similar to what operators were hearing when trying to get numbers up for the initial round of vaccines.

Houser expects the lagging bivalent percentage to tick up, but perhaps not to the 75% range. It all depends on whether state and federal entities replicate that initial push for vaccines that occurred in early 2021.

“I don’t see it going higher than 70% to 75% without extraordinary effort,” he said.

Long-term policies and campaigns

Konetzka doubled down on Houser’s thoughts on campaign efforts – study findings suggest longer-term policy options must be drafted to increase booster uptake.

CMS’ staff vaccination mandate that was first announced in summer 2021, which applies to all health care workers who work for providers that receive Medicare or Medicaid funding, has not been revised to include booster shots.

Vaccine requirements went through several rounds of litigation as a slew of state attorneys general challenged the mandate, before SCOTUS upheld the vaccine mandate the following year.

“It would be really naive to think that we’ve accomplished what we needed to accomplish with the initial mandate – these things change,” said Konetska. “Many of us have said all along that even if we hadn’t had these new variants, it wasn’t like you have one vaccine clinic, or two for the two doses, and then you’re done. There’s turnover of residents, there’s turnover of staff; this has to be an ongoing effort.”

And this is an evolving virus, she said; the original vaccine doses are “no longer sufficient” to deal with the new variants.

Operators, as well as state and federal agencies, must generate the urgency and excitement again that was part of the initial round of vaccines, Konetzka said, as a first step toward higher booster numbers.

Step two – make it just as easy to administer booster shots to staff and residents as it was to bring the first series to facilities.

In terms of campaigns, there have been small, concerted efforts by nursing home operators themselves and states, but nothing on the scale of the federal partnership program to get residents vaccinated as the first round of shots became available.

National efforts to get clinics to the nursing homes, through CVS and Walgreens, set the bar high, she added.

“What we don’t see now is this huge organized effort to make it very easy for facilities to get all their residents up-to-date,” noted Konetska. “We just see nursing homes doing their own thing. Some of them are devoting more time and energy to try to get those vaccinations done, others are not for various reasons.”

The White House did release a Covid-19 Winter Preparedness Plan on Dec.15, including a range of initiatives and partnerships with aging services organizations like LeadingAge and the American Health Care Association/National Center for Assisted Living (AHCA/NCAL).

The associations in support of White House plans developed the All Hands on Deck campaign to increase bivalent booster uptake through weekly reporting of booster numbers among members, and continued advocacy and collaboration with the Department of Health and Human Services (HHS).

As of Dec. 18, LeadingAge reported 61.71% of its nursing home residents were up-to-date on boosters, much higher than the national average published by CMS. LeadingAge members week over week have seen a 7.01% increase compared to 3.75% for all nursing homes.

The association also launched a test kit portal with the Department of Housing and Development (HUD) and HHS, along with Vaccine Education and Access Programs through a partnership with the Centers for Disease Control & Prevention (CDC).

Traylor says it’s a compounding of problems during these winter months so far, with Covid and flu cases making the staffing crisis worse. Traylor-Porter staff have had to call in sick already this season.

“A lot of nursing homes, they’re still in crisis mode, their occupancy rates haven’t quite recovered,” added Konetska. “The idea of organizing a vaccine clinic and getting all their residents vaccinated may just not rise to the top of their priority list … it’s one of those things where I think public policy could play a role here.”

Traylor likened it to “coming up for air” after getting stuck underwater.

It’s really all about surviving until the virus reaches endemic state in the nursing home industry, Barnes added. The sector is slowly moving toward the ability to treat Covid cases in the same manner that facilities have historically treated the flu.

“We will see Covid ebb and flow throughout the year. Also like the flu, new strains of Covid will come and go and with those you may see surges of cases. With the different strains you will have different reactions, some may be more symptomatic than others,” said Barnes.

Currently, certain parts of the country are seeing an influx of cases while other areas seem to be in a lull, she said. Barnes expects this pattern to continue in the years ahead.

Too late for a campaign?

Before the holiday break, AARP sent a letter to CMS Administrator Chiquita Brooks-LaSure urging the agency to take additional steps to enforce vaccination requirements, increasing education and offer Covid-19 vaccine clinics.

The winter surge “indicates that more action is needed” to address Covid in nursing homes.

Confirmed Covid cases among residents jumped from 8,623 the week ending Oct. 2 to 20,148 the week of Dec. 11, according to data collected by the Centers for Disease Control and Prevention (CDC). Covid cases dropped somewhat to 16,633 for the week ending Jan. 1.

Traylor said he’s seeing an uptick in Covid and flu cases that coincide with CDC numbers, so much so that they’re back to using contingency staffing.

“The flu is the one that’s hurting us probably more than Covid right now,” added Traylor. While he could only speak to his buildings, Traylor said flu symptoms have been a lot worse than Covid symptoms.

Houser, Traylor and Konetzka agree it’s not necessarily a ‘Groundhog Day’ scenario in terms of Covid severity, since the surges were far more deadly in previous winters without any sort of vaccinations, but Houser does feel like he’s been sounding the alarm about booster rates since early fall – with little success.

“I certainly am having a Groundhog Day moment on that,” Houser said of trying to drum up action on boosters.

For Konetzka, the difference comes down to public policy approaches. It shouldn’t be unexpected, she said, that we are seeing a surge in cases at this time of year.

“Our research shows that we could be saving tens of thousands of lives just by bumping up staff vaccination by about 10%. I just don’t think that’s going to happen without a mandate,” said Konetzka.

Vaccination impact on other protocols

In terms of low booster rates impacting masking and visitation, it’s unclear if the industry will revert back to early pandemic protocols.

Houser sees masking in medical and long-term care settings as the new handwashing – in more than a few years, we’ll look back at 2020 and think of staff not wearing masks the same way as not washing their hands.

For Barnes, Covid protocols will likely continue to be situational. Cascadia monitors community prevalence rates of Covid through weekly CDC data before making decisions about masks, and what signage is needed for visitors on protocols to expect per building.

It’s not likely that visitation will revert back to 2020 restrictions, Houser said.

“I don’t think there’s an appetite for restricting visitation to any significant degree, like the first year of the pandemic, except in limited circumstances where there are active outbreaks that are not under control,” he said.

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