By Christopher Rowland and Will Englund, The Washington Post, December 4 2020
The United States is about to embark on the mammoth challenge of giving vaccines to 3 million residents of nursing homes and assisted-living centers, which have struggled to protect elderly people in their charge, as well as caregivers, from coronavirus infections, resulting in more than 100,000 deaths.
But even as retail pharmacy giants CVS and Walgreens lay ambitious plans under a government agreement to deliver the first available doses to this most vulnerable population, health-care advocates are raising concerns about logistical and ethical challenges that could complicate the task.
Building on the experience they have delivering flu shots, the pharmacy chains are expected to administer the vaccines — which must be delivered in two doses a number of weeks apart — to 50,000 residential settings across the country.
The pharmacies said they are coordinating with individual states and nursing homes to decide where to go when the first batches of shots begin to arrive, later in December. The shots will be free for patients, paid for by the federal government. The drugstores and other providers that administer shots covered by Medicare or Medicaid will get a $45 fee for each two-shot regimen.
But the barriers to a successful vaccination campaign are formidable.
A federal advisory panel, the Advisory Committee on Immunization Practices, recommended nursing home residents and staff be included among the first groups of people to get the vaccine along with health-care workers because they account for a disproportionately high number of coronavirus deaths.
Millions of staff members also need to be vaccinated, many of them low-wage workers and members of minority communities that have a historic distrust of vaccines. Staff members are the most common source of infection brought from outside into nursing homes, according to multiple studies. Any effort that does not make them a priority is doomed to fail, officials say.
“The concept of vaccinating all the staff and residents in our facilities is monumental,” said Richard Feifer, executive vice president and chief medical officer of Genesis HealthCare, the largest nursing home chain in the country with 341 facilities in 24 states. The company has about 30,000 residents in its care and 45,000 employees.
Timing and volume of the vaccine that could be arriving at the doorstep of the nursing homes remains unclear. “That could begin in a matter of days to weeks,” Feifer said.
Families who have been physically cut off from residents — waving through windows and talking on cellphones — will need to be located and educated about the vaccines so they can decide whether to provide consent for relatives with dementia and other cognitive problems, said Mike Dark, staff attorney at California Advocates for Nursing Home Reform.
“The population inside a nursing home has been extraordinarily isolated for the past nine months,” he said. “It is unlikely they have seen a lot of the public information. Many nursing home residents don’t even know who their doctor is.”
Executives at CVS and Walgreens said in interviews that their biggest challenge remains uncertainties about the flow of vaccine supply. If the job goes smoothly, it could be complete by March.
Long-term care facilities were given a deadline to choose which pharmacy they wished to use to conduct on-site clinics. If they did not want to use CVS or Walgreens, they were free to choose another channel, but few have chosen that route. Walgreens said it was selected by about 20,000 of the facilities; CVS said it was chosen by about 30,000.
“For us the complication has really been about planning for a wide variety of different outcomes in terms of timing and product available,” said Chris Cox, senior vice president at CVS who is the company’s liaison to Operation Warp Speed. The goal is to get all the long-term care residents vaccinated within three months — a schedule that includes both the initial shot and the booster, Cox said. CVS said it also will be vaccinating staff members in nursing homes.
For the Pfizer vaccine, expected to be the first to gain emergency clearance from the Food and Drug Administration this month, CVS and Walgreens will be breaking into smaller batches shipments of vaccines packed in dry ice and bringing them to individual nursing homes for vaccination clinics. Then they have to return and do it again 21 days later, to provide the second booster shot. The Moderna vaccine will also require two shots, four weeks apart, and minus the dry-ice storage requirements.
“It’s just a lot of pieces that have to be put together for this to roll out smoothly,” said Tricia Neuman, a senior vice president at the nonprofit, nonpartisan Kaiser Family Foundation, which focuses on health care and has been tracking deaths among residents and workers in long-term care facilities. “There couldn’t be a higher-risk, priority population.”
A top official in the Trump administration’s lead effort on the distribution of vaccine, Army Gen. Gustave Perna, the co-leader of Operation Warp Speed, said at a news briefing Wednesday that plans were taking shape rapidly.
“I am incredibly confident that these private-public partnerships are ready to execute, based on governors’ priorities,” Perna said.
But some industry officials complain of confusion and a lack of coordination between the federal government — which paid manufacturers to develop vaccines and get them ready to distribute in record time — and state governments, which will dictate where doses go within their borders.
“We just are really behind the eight ball as far as knowing what is going on,” said Peter Van Runkle, executive director of the Ohio Health Care Association, which represents nursing homes. “It seems like the story changes daily, and nobody has a complete handle on it, because it’s divided between state and federal government and neither side knows completely what the other side is doing.”
Ohio is among states that are planning to require nursing home and assisted-living staff members to travel to central locations to get vaccinated, instead of vaccinating them at the facilities where they work, Van Runkle said. Advocates and industry officials across the country are arguing that is a bad idea, and that staff in all states should be vaccinated at their facilities by the CVS and Walgreens teams when they conduct clinics for residents.
People who work in nursing homes often take public transportation to their jobs and work multiple jobs. Many do not have the means or the time to travel to central vaccination facilities, doctors and advocates said.
“The most dangerous job in the United States in the last nine months has been people working in nursing homes, and the people on the front lines of nursing homes are low-wage people of color,” said Mike Wasserman, a geriatrician who is past president of the California Association for Long Term Care Medicine. “If we want to protect the residents, the first thing we want to do is protect the staff.”
Genesis, the large nursing home chain, said it plans to ensure that staff can get vaccinated at the nursing homes to make it as convenient for employees as possible.
Genesis is not planning any vaccine requirements for staff, said Feifer, the chain’s chief medical officer, although he acknowledged vaccine hesitancy could be a challenge.
“Once you start creating mandates and requirements, in some ways that may be counterproductive to building trust,” he said, “and we really want to build trust.”
Then there is the track record of the industry itself. Infection control deficiencies were common before the pandemic and have been cited repeatedly by inspectors since. Chronic short staffing grew worse as employees quit, fell ill or died. Nursing homes encountered difficulties obtaining enough personal protective equipment for staffers and training them in their proper use. And they were slow to gear up for regular coronavirus testing — in part because tests were so hard to come by and because until August most states and the federal government did not require it on a regular basis. Now they must coordinate a new undertaking.
In past years, U.S. nursing homes have struggled to provide the flu vaccine to all residents. “Nursing homes don’t have a great track record in rolling out vaccinations,” said David Grabowski, a Harvard Medical School expert on the nursing home business.
In the 2018-2019 flu season, the last for which records are available, 73 percent of nursing home residents got a flu shot, according to figures from the Centers for Disease Control and Prevention. That varied from 49 percent in Nevada to 88 percent in South Dakota. Nationally, 78 percent of White nursing home residents were vaccinated and 69 percent of Black nursing home residents. Other ethnic groups fell between those numbers.
“It’s never realistic to get 100 percent,” Grabowski said, “but I’m hopeful that 73 percent will be the floor” for the coronavirus vaccine rate. The flu vaccination requires only one annual shot; the coronavirus vaccine will come in two doses, a couple of weeks apart, further complicating the procedure.
“I think unfortunately there are a lot of reasons to be concerned,” he said. “You need education and guidance around this. And most importantly you need the staff.”
Cristina Crawford, the public affairs manager for the American Health Care Association, the trade group representing for-profit nursing homes, said in an email that the coronavirus testing difficulties were “because of our public health system’s inability to offer clear recommendations on rapid, point-of-care antigen testing.”
She rejected the comparison to spotty delivery of the flu vaccine.
“This is not the flu,” she wrote. “Approximately 5 to 6 percent of long term care residents succumb to the seasonal flu; covid has taken the lives of more than 100,000 residents in all long term care settings, and has a 20 percent mortality rate among our population. ”
Employees, she said, are acutely aware of how much the vaccine offers a chance to return to normal.
She acknowledged that staff shortages have made the task more difficult. “Even before the pandemic, long term care struggled with staffing shortages, and that has only been exacerbated now with staff providing more one-on-one care to limit spread, as well as many staff members becoming ill or needing to quarantine.”
More than 1 in 5 nursing homes report staff shortages to the Centers for Medicare and Medicaid Services.
Grabowski said he also worries about residents refusing to get the shots out of fears for their safety. “This is an area where CMS has struggled,” he said, “just educating older adults about vaccination safety.”
But having national pharmacy chains manage the vaccinations could work more efficiently than the flu shot procedure, said Eric Carlson, a lawyer with Justice in Aging, a national organization that advocates for nursing home reform.
“They’ll handle the distribution, billing, documentation, all the rest,” he said. “There are some issues regarding consent and the ability to obtain consent. It can’t be imposed upon people. They need to choose it.”
Nonetheless, he is hopeful that when residents realize that taking the vaccine could allow them to see their families for the first time in nine months, they may be eager to do so.
“For all of us, this is much more important than the flu vaccine,” he said.