COVID-19 vaccination in nursing homes is a tale of bumpy logistics, fear and uncertainty about the future

Jan. 10—Joshua Uy, a Penn Medicine geriatrician, could have gotten a COVID-19 shot a week ago through his hospital. But Uy, who is also medical director of Renaissance Healthcare and Rehabilitation Center, decided to wait until Tuesday when vaccinators are coming to the West Philadelphia nursing home.

He wants to send a message to his wary staff that the shot is safe.

Federal authorities made nursing homes a top priority for vaccines because they have been hot spots for deadly infections. After two vaccines were approved last month, officials have focused on logistics, like shipping and deep-freezing.

After 12 years at Renaissance, Uy foresaw an emotional problem.

"I knew that the real issue ultimately is going to be vaccine hesitancy," he said. He thinks evidence for the vaccines is "really good," but he reads medical journals regularly and personally knows doctors involved with vaccine decisions and research. His workers, he said, "are processing it in a really different way."

So far, only about half the staff has signed up to get a first shot Tuesday. A worker who lost a son to COVID-19 early in the pandemic has insisted on being first. Uy and the director of nursing will follow.

Renaissance's experiences illustrate some of the early bumps in the rollout. Its workers are getting access to the vaccine a month later than hospital employees, who also got top priority, and many aren't sure they want it.

Being among the first offered the vaccine was meant as recognition that some groups have taken greater risks to protect the rest of us, and some have paid a higher price. But vaccination experts have long worried that many Americans, particularly those in some racial minorities, might balk at taking a vaccine developed in record time during a period of deep political polarization. At the same time, funding has been tight for education efforts, and even for vaccine distribution.

This all leaves nursing home leaders with no simple answer to everyone's question: When can life for staff, residents, and family return to normal? Facilities have clamped down on visitation to keep the virus out, but that has meant months of damaging isolation for fragile residents. Now they await government guidance on when they can relax rules, which will depend on how many people choose vaccination, how well the vaccines work, and how quickly cases in the community fall.

In the short term, Uy said, "nothing changes."

On the positive side, he and other nursing home officials said the vast majority of residents want the shots.

In most states, including New Jersey and Pennsylvania, vaccines are being distributed to nursing homes and assisted-living facilities through a federal program that partners with CVS and Walgreens. The federal government allots doses to states, which then decide how many go to long-term care facilities. The doses are shipped directly to the retailers' storage hubs.

Several long-term care leaders in Pennsylvania and New Jersey said distribution so far has been frustratingly slow and uneven. Hospitals began vaccinating their workers two weeks before the first shots arrived in some area nursing homes on Dec. 28.

"The overarching theme that we're hearing from providers on the front line is that this is taking much longer than expected," said Zach Shamberg, president and CEO of the Pennsylvania Health Care Association, which represents long-term care facilities. Shamberg said some nursing homes have not been scheduled for first visits until February or later.

Shamberg questioned why nursing homes aren't getting a bigger share of the vaccine pie. They got 39,000 of Pennsylvania's 166,725 doses in the week of Jan. 3, he said. Pennsylvania has reported that 127 nursing facilities had vaccination clinics the week of Dec. 28 and that 222 were scheduled for clinics the week of Jan. 4. Shamberg said the state has about 700 nursing homes and 1,200 personal care homes with 240,000 residents and staff.

CVS and Walgreens declined to say how many doses of vaccine they have received or given. A CVS spokesperson said his company's efforts are going "as planned." Data are not yet available on state websites.

Lynne Katzmann, founder and CEO of Juniper Communities, was initially told to expect vaccinations to start on Dec. 21. Instead the first was on the 29th — in Colorado. Juniper's first clinic in Pennsylvania was scheduled for Saturday in State College. New Jersey shots are to start on Monday. Katzmann pronounced the pace "disconcerting, frankly."

Stuart Shapiro, interim CEO of the Health Care Association of New Jersey, said CVS and Walgreens got off to a slow start, but the "process has picked up speed."

Richard Feifer, executive vice president and chief medical officer of Kennett Square-based Genesis HealthCare, the nation's largest nursing home group, said last week that 45% of Genesis centers have had first clinics and he expects that almost all will have been offered first doses by mid-January.

The rollout, he said, is "extraordinarily complicated. This is the biggest public health undertaking that we've every experienced or contemplated in our lifetimes." Given all that, he said, it's "going remarkably well."

The American Health Care Association agrees with Uy that vaccine hesitancy is the problem to watch.

To encourage vaccination, Juniper made getting a shot a "condition of employment." Gracedale Nursing Home in Nazareth offered a $750 bonus to employees who got vaccinated. Uy said Renaissance's owner has offered employees who get the shots a comp day. He hopes there will be some sort of reward for everybody if some not-yet-determined percentage of the staff gets vaccinated, a form of recognition that immunization is a community effort. These steps all come in addition to extensive education efforts.

Other companies hope that education, openness to questions, and a festive atmosphere during vaccine clinics will counter hesitancy.

"We believe that the protection the vaccine offers should be incentive enough for staff to receive it and thereby protect themselves, their coworkers, and the residents they serve," said Dan Davis, chief operating officers of Presbyterian Senior Living, a Dillsburg, Pa., company that operates retirement communities in Pennsylvania, Maryland, Ohio, and Delaware.

At Gracedale, Jennifer Stewart-King heard rumblings that staff members were afraid of the new vaccines because they were created so quickly. Even though the clinical trials were as large as usual for vaccines, workers feared being guinea pigs. She suggested the $750 bonus to Northampton County Executive Lamont McClure Jr., who thinks vaccines will "save lives and livelihoods."

Gracedale, which has 529 residents and about 665 employees, is the state's largest nursing home under one roof. Seventy-six of its residents died of COVID-19.

A CVS vaccination team has gone to the nursing home twice, on Dec. 29 and Jan. 3, a Sunday. Just 188 staff members — 28% — and 145 residents have been vaccinated. A "large majority" of residents want the shot when it is available for them, Stewart-King said.

The amount of employee uptake "makes me despondent," McClure said. "After what we watched in the last year, all the death and dying, it's crushing to me that we didn't get greater participation."

Stewart-King, who got her first shot at the nursing home, hopes the numbers will improve after two more scheduled clinics. The first CVS visit was a surprise. She had told the staff to expect it in January, but got a text on Dec. 28 saying the vaccination team was coming the next day. Plus, staffing is low on Sundays. And CVS worked from 11 to 5, not convenient hours for the night shift. She thinks workers will be more open to the vaccines now that colleagues have led the way.

Katzmann expected that most of her staff and residents would want the vaccine, but Juniper's corporate team decided to mandate vaccination for staff, a step many companies are loath to take.

"My belief is that you want to do this for the common good, and that's our culture," she said. "Most people at this point are really excited about the opportunity to have some certainty in their lives again, to just feel safe."

So far, one Colorado employee, who had previously resisted wearing a mask at work, quit because of the vaccine rule. Everyone else at the recent clinic there got the shot. All but three residents were vaccinated. "People were elated," Katzmann said.

Companies like Genesis and Sunrise Senior Living are offering solely education, not carrots or sticks. Sunrise has been holding frequent meetings to address staff concerns. More than 90% of its residents have said they want to be vaccinated. The company wouldn't release numbers about staff. Sue Coppola, chief clinical officer, said Sunrise has hosted frequent town halls to discuss vaccine worries with staff and has made vaccine clinics fun with balloons, nonalcoholic Jell-O shots, Life Savers candies, and bull's-eye stickers.

Feifer said staff vaccination rates at first clinics have varied greatly at Genesis facilities, with some above 75%, many at 50% to 75%, and some lower.

Susan Wehry, a geriatric psychiatrist and Sunrise adviser, said some reticence is normal. "Not everybody is an early adopter," she said. "There are people who wouldn't do the first of anything."

Offering money to take the vaccine, she said, could backfire. "If this is so safe," people might ask, "why do you have to pay me to take it?"

She thinks it will be more effective for people to witness coworkers getting the shot. "Getting a vaccination needs to become the cultural norm in long-term care settings," she said.

Assuming large numbers of residents and staff eventually are vaccinated, shouldn't that mean family members — especially those who have also been vaccinated — can hope for visits soon?

Nursing home leaders wish it were that easy. While the vaccines were tested in older people, they were not tested in nursing home residents. Vaccines might not be as effective in this group and it's not yet known whether people who have been vaccinated can still spread the virus. Feifer pointed out that nursing homes get new staff and residents all the time, yet the federal program has no provision for vaccinating new people.

"There is no plan for that, and there needs to be one," he said.

The biggest issue, officials said, is that long-term care is heavily regulated. Nursing home leaders take their cues from health departments, the U.S. Centers for Disease Control and Prevention, and the Centers for Medicare and Medicaid Services (CMS). These agencies have not factored vaccination rates into their guidance on socialization and infection control.

In the meantime, nursing homes plan to keep testing for coronavirus, wearing masks, enforcing social distancing, and following the current rules on visits.

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