Vaccination Campaign at Nursing Homes Faces Obstacles and Confusion

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By Rebecca Robbins and Jessica Silver-Greenberg, NY Times, Dec. 16, 2020

Walgreens and CVS staff will soon begin vaccinations at tens of thousands of long-term care facilities. Some staff and residents are wary, and there are thorny issues of consent.

CVS staff will soon begin vaccinations at thousands of long-term care facilities.Credit…Jeenah Moon for The New York Times

In coming days, squads of CVS and Walgreens employees, clad in protective gear and carrying small coolers, will begin to arrive at tens of thousands of nursing homes and assisted-living facilities to vaccinate staff and residents against the coronavirus.

It promises to be a crucial milestone in America’s battle against a pandemic that has inflicted especially severe carnage on nursing homes. At least 106,000 residents and staff of long-term care facilities have died from the virus, accounting for 38 percent of the country’s Covid-related fatalities.

But even before it begins, the mass-vaccination campaign is facing serious obstacles that are worrying nursing home executives, industry watchdogs, elder-care lawyers and medical experts. They expect nursing homes to be the most challenging front in the mission to vaccinate Americans.

Some residents and staff are balking at taking the vaccine. Short-staffed facilities are concerned about workers calling in sick with side effects, straining resources just as some frail residents are likely to experience fever and fatigue from the shot. Most nursing home employees work in shifts; will it be possible to vaccinate everyone over the course of just a few visits from CVS and Walgreens?

With days to go before the vaccinations begin, there is also widespread confusion about how nursing homes will get consent to vaccinate residents who aren’t able to make their own medical decisions. A CVS executive said such residents’ legal representatives will be able to provide consent to nursing homes electronically or over the phone, but officials at multiple large nursing home chains said they weren’t aware of that.

If residents or their representatives haven’t given consent before CVS or Walgreens employees show up, it is not clear whether or when they will have another chance to be inoculated.

Given the pace of this rollout, I am very concerned that nursing facilities won’t have the time or capacity to really explain the vaccine to residents and their families,” said Nicole Howell, a state-funded ombudsman in California whose office works with 29,000 long-term care residents.

Stuart Almer, who runs a New York nursing home, said he has been unable to answer vaccine-related questions from residents and staff.Credit…Benjamin Norman for The New York Times

Pharmacists from Walgreens are scheduled to arrive next week at the 460-bed Gurwin Jewish Nursing & Rehabilitation Center in Commack, N.Y., to begin vaccinations. Employees, residents and their families have been peppering Stuart Almer, the home’s chief executive, with questions. Can residents and staff orally agree to receive the vaccine or will they have to sign something? What role, if any, will nursing home employees play in vaccinating residents?

Mr. Almer said he has spent hours on the phone with federal and state agencies but has few answers.

“We still don’t know very much,” he said.

Executives from CVS and Walgreens said in interviews that they have been planning the vaccination campaign for months and are confident it will work. “If there are concerns or challenges, we certainly are open to work with facilities to try to minimize any disruption that they may have,” said Rick Gates, a Walgreens executive leading the company’s planning.

Dr. David Gifford, chief medical officer for the American Health Care Association/National Center for Assisted Living, which represents nursing homes and similar facilities, said most long-term care providers seem to be getting the information they need about the vaccination effort.

Still, he said, “this is a rapidly changing situation, and constant, clear communication from everyone is critical to make sure this program runs smoothly.”

The federal government has agreements with CVS and Walgreens to send pharmacists and support staff to vaccinate residents and staff at thousands of long-term care facilities such as nursing homes and assisted-living communities.

More than 40,000 facilities have opted to work with CVS. Nearly 35,000 chose Walgreens. It is up to each state to pick whether to have the pharmacies use vaccines made by Pfizer or Moderna (whose vaccine the Food and Drug Administration plans to authorize on Friday) at all its long-term care facilities.

Some states are starting vaccinations in their nursing homes this week, but the campaign led by CVS and Walgreens won’t begin in earnest until Monday. In some states, it won’t begin until the end of the month or January.

Because of the large number of facilities they must visit, CVS and Walgreens only have the capacity to go to each location two or three times. The Pfizer and Moderna vaccines both require two doses, separated by a few weeks, which means that at most nursing homes, all staff and residents will have to receive their shots on the same days.

Chris Cox, the CVS executive in charge of planning the vaccine effort, said that if the company hears from nursing homes worried that three visits won’t be enough, it will deal with those concerns “on a case-by-case basis.”

Nursing homes are now diving into the mundane but crucial details about what will actually happen — and where — when the pharmacists show up with vaccines.

At Genesis, the largest nursing chain in the United States, teams from CVS will vaccinate workers in common areas, while residents will be vaccinated in their own rooms.

“We don’t like to bring residents together into large groups because that can worsen any potential outbreak,” said Dr. Richard Feifer, the chain’s chief medical officer.

Complicating the task, some nursing-home employees are reluctant to get inoculated, even though Pfizer and Moderna’s vaccines have been found safe and effective during trials involving tens of thousands of people.

A nurse in Connecticut administers the Pfizer-BioNTech vaccine.Credit…Joseph Prezioso/Agence France-Presse — Getty Images

“I don’t want to be a guinea pig,” said Sheena Bumpas, a certified nursing assistant at a home in Duncan, Okla.

She is far from alone. When the National Association of Health Care Assistants, an advocacy group for caregivers, recently surveyed certified nursing assistants who work in long-term care facilities, nearly 72 percent of respondents said they do not want to receive the vaccine.

Lori Porter, the group’s co-founder and chief executive, said employees are also worried about what happens if they experience side effects — some participants in clinical trials experienced mild to moderate side effects — that force them to stay home. Ms. Porter said many nursing assistants had to use sick days to quarantine earlier in the pandemic and now have little or no paid sick leave left for 2020.

Nursing home chains like Genesis have started campaigns to inform workers, residents and family members about the importance and safety of getting vaccinated.

“Written letters, emails, PowerPoint presentations, videoconferencing sessions, live face-to-face dialogue, small group, large group broadcasts — we’re doing it all,” Dr. Feifer said.

But the more employees who get the vaccine, the more who are likely to experience side effects — and that could cause more problems.

“If even as little as 10 percent of your staff calls off the next day — while at the same time all of the residents are irritated, upset and having adverse effects — you’ve created a perfect storm,” said Chad Worz, chief executive of the American Society of Consultant Pharmacists, which represents pharmacies that serve long-term care providers.

A box of the Pfizer vaccine arrived this week at a military base south of Seattle.Credit…Ted S. Warren/Associated Press

Among the biggest remaining challenges, however, is getting the informed consent of residents taking the vaccine.

There is no federal requirement for people to give consent before getting vaccinated, but it is standard practice and is often needed for billing purposes. States have different requirements about how medical consent can be given and what information needs to be provided to the person who is consenting. The Centers for Disease Control and Prevention’s guidance is that residents or their representatives should receive a fact sheet about the coronavirus vaccine and then consent to receiving it.

The task of getting consent is not always straightforward at nursing homes. Many residents, like those with dementia, aren’t capable of giving it on their own. Instead, nursing homes need to get the permission of their family members or other legal representatives.

CVS and Walgreens have created paper and digital consent forms that nursing homes can use. Consent must be given in advance; the pharmacies need to know how many doses of the vaccine, which must be kept very cold, to bring with them.

There’s significant confusion among nursing homes about getting consent, especially when it involves representatives who aren’t physically at the nursing home and can’t come because of concerns about spreading the virus. Will an email suffice? What about consent over the phone? Or will consent forms have to be signed, either in hard copy or electronically?

Mr. Cox, the CVS executive, said the company this week has provided nursing homes with additional guidance on how to get consent. He said he expects most facilities to simply have an employee get consent over the phone from a resident’s medical proxy and then enter it in the person’s medical record. A nursing home employee can then sign the consent form on the resident’s behalf, he said.

Even getting over-the-phone or electronic consent in a matter of days could prove time-consuming.

Employees at SavaSeniorCare, one of the country’s largest nursing-home chains, don’t think they can start getting consent from residents and staff until they get the forms from CVS. As of Monday, they hadn’t received them, said Annaliese Impink, a SavaSeniorCare executive who is coordinating the vaccine rollout. (T.J. Crawford, a CVS spokesman, said the last batches of paperwork should arrive at nursing homes by Wednesday.)

In the meantime, Ms. Impink said, nursing home staff have been calling family members of residents who can’t make their own consent decisions to confirm contact information to quickly get in touch for approval of the vaccination.

Cissy Sanders, whose 71-year-old mother has a neurodegenerative disease and lives in a nursing home in Austin, said she has felt pressure to make a quick decision about vaccinating her mother.

The administrator of her mother’s nursing home sent her an email on Monday, she said, informing her that the vaccine process was moving swiftly and doses were likely to run out.

“I am not in any way an anti-vaxxer,” she said, “but an email like that is designed to hurry me up, and I want the time to get all the information I can.” Ms. Sanders said she is worried about how the vaccine might affect her mother. (The F.D.A. has said that the only adults who should not get Pfizer’s vaccine are those with histories of severe allergic reactions to ingredients in the vaccine.)

Officials at some facilities said they are optimistic about most of their residents agreeing to be vaccinated. Sunrise Senior Living, which operates 275 senior living communities in the United States, last week surveyed its residents and their family members about their willingness to get a Covid-19 vaccine. About 80 percent of respondents said they are definitely willing.

At Genesis, which has been building its own electronic system for getting consent from residents’ medical proxies, executives are cautiously hopeful about the start of vaccinations.

“It will be challenging; it will be complicated; it may get messy at times. But we’ve got to start quickly and lead the way,” Dr. Feifer said. “We’re going first. That’s a privilege and a responsibility to make sure we get this right.”