Best Practices for Ongoing COVID-19 Vaccinations in Nursing Facilities

Vaccines are saving the lives of nursing facility residents and staff. The Centers for Disease Control and Prevention’s (CDC) Nursing Home Dashboard showed that the widespread administration of COVID-19 vaccines among nursing facility residents and staff has resulted in a reduction in cases of infection and death among residents. From mid-December through the end of March, when the Federal Pharmacy Partnership for Long-Term Care was administering vaccinations, the rate of confirmed COVID-19 cases among nursing facility residents plummeted, from 30.92 to 0.86 per 1,000 residents.  And during the same period, the number of deaths among nursing facility residents dropped in a similar fashion, from 25.65 to 0.42 per 1,000 residents.

Yet, unfortunately, the impact of COVID-19 on nursing facilities has not ended with rates plateauing since the end of the Partnership program. From the end of March through May 9, 2021, the rate of cases hovered around 1 per 1,000 residents and deaths around 0.4 per 1,000 residents. This leveling off may indicate that many facilities are facing challenges in what the CDC is calling the maintenance phase of vaccination. Yet it seems that some facilities are beginning to innovate and put in place best practices to drive down the number of cases among residents and staff even further.

Tackling Vaccination Challenges with On-the-Ground Solutions

This past March, the CDC announced that to help enable nursing facilities to continue administering vaccines, facilities could partner with long-term care pharmacies that had enrolled as a vaccination provider with the state or in the Federal Retail Pharmacy Program. While many facilities already have relationships with such pharmacies, some have found it challenging to find and establish partnerships. Moreover, even facilities with long-standing pharmacy relationships are working out kinks. For example, certain facilities have reported that their long-term care pharmacy is waiting to deliver vaccines until the facility has a certain number of people ready to vaccinate.

Attempting to do avoid such snags, some states have tried to limit the number of vaccinations needed for newly admitted residents. Both New York and Maine, recognizing that many new nursing facility residents come directly from hospitals, issued guidance that required local hospitals to assess a person's vaccination status and, as appropriate, administer a vaccine prior to discharge and transfer to a nursing facility.

According to Kathy Bay, a nurse educator at the Washington State Department of Health, facilities in her state have met the challenge and put in place administrative best practices, including:

• dedicating certain on-site clinical staff to vaccinate both residents and staff;
• providing regular training to designated clinical staff to ensure efficacy and safety during vaccine administration;
• identifying a well-respected site champion, who can serve as an advocate for vaccinations and educate on the positive impact of vaccines; and
• when a facility is large enough, becoming official vaccine providers to gain direct access to vaccines.

Boosting Vaccination Rates among Staff

High rates of vaccination among not only residents, but staff, is critical to infection control. While national data are not yet available on the number of vaccines administered to each group, a CDC study in February showed the vaccination rates among these groups have not progressed at the same pace. Among facilities that held at least one vaccination clinic in the first month of the federal partnership, a median of 78 percent of residents received at least one dose, compared to only 38 percent of staff members.

The American Health Care Association and LeadingAge have embarked on a campaign to boost the staff vaccination rate to at least 75 percent in every facility by June 30. Facilities have responded to that call to action in very different ways. Some are offering incentives such as time off for vaccination, gift cards, or extra vacation days. One Florida facility offered staff a $1,000 bonus, $100 for proof of vaccination, and another $900 when the facility’s staff vaccination rate exceeded 75 percent; the rate reached 92 percent. Other facilities are requiring vaccination as a condition of employment. In Ohio, a provider with multiple facilities across the state and a low rate of staff vaccination announced that all staff, with exceptions for those who refuse on medical or religious grounds, must receive a first dose of the COVID-19 vaccine by June 1.

Still, others are using persuasion and education. In Washington DC, Forest Hills administrators directly addressed issues of vaccine reluctance among staff. Over the course of three months, staff developed specific appeals to meet the concerns of each individual – a resource-intensive, but a personal approach that helped the facility achieve a 79 percent vaccination rate.

Continuing to Strive for Change

Striving for no cases of COVID-19 infection or death among nursing home residents is a difficult, but important goal, and one that requires action at all levels. A recent Centers for Medicare & Medicaid Services' (CMS) interim rule takes a step toward that goal. In it, the agency proposes that all nursing facilities participating in Medicare or Medicaid offer staff and residents the opportunity to receive a vaccination and report data on all vaccinations to the CDC.

Furthermore, the best practices of facilities show that the goal is possible. As more facilities adopt these practices and implement policies to assess, anticipate, and meet vaccination needs among both residents and staff, we will see more lives saved and potentially the number of cases of infection and deaths reach and remain at zero.