Nursing home safety during COVID: Cases and Vaccines

Since last May, nursing homes have been expected every week to report to the Center for Medicare and Medicaid Services (CMS) nearly 100 pieces of data related to COVID-19, including diagnosed cases, deaths, tests, personal protective equipment (PPE) shortages and shortages of nurses, aides and clinical staff, which includes doctors.

At any point in time, there are about 1.3 million people with short-term rehabilitation needs or long-term illnesses who reside in the nation’s 15,000 nursing homes. During the period we examined, from May 31, 2020, through Feb. 7, 2021, we found that:

In the last week of May 2020, 466 nursing homes nationwide reported their very first cases. That number spiked to 500 on July 19.

With visitation to nursing homes largely shut off last spring, the virus was most likely being transmitted from newly admitted residents or from staff, some of whom worked at more than one facility or were contracting COVID in their own homes or the community.

The number of nursing homes reporting initial cases declined throughout the rest of July and August but started climbing again in September.

By Nov. 15, it was edging toward a new high, with 445 nursing homes reporting their first cases of COVID after escaping them all year to that point. That represented three percent of nursing homes.

While the trend started moving downward again, transmission of the virus was still a problem, with nearly 1,000 of the nation’s 15,000 nursing homes reporting their very first cases during the month of December. This phenomenon has declined tremendously, but still, during the first six weeks of 2021, 437 nursing homes that had beat back COVID during all of last year suddenly were dealing with their first cases.

“We can’t say for certain why that is happening. We know that COVID cases in nursing homes are primarily caused by high prevalence in their surrounding communities,” said Dr. David Gifford, chief medical officer at American Health Care Association and National Center for Assisted Living (AHCA/NCAL).

“It’s all the more reason to remind everyone, including members of the public, that even though the vaccines are here, we are not out of the woods yet, and we must remain vigilant — wearing masks, social distancing — until we defeat the virus.”

The new variant strains could have played a role in these cases, said Dr. Michael Barnett, assistant professor at the Harvard T.H. Chan School of Public Health, who has studied COVID in nursing homes extensively. In addition, “the surge from November to January was enormous and I’m not surprised there is a tail end of nursing homes getting their first cases very late,” he said.

When the coronavirus arrived in the United States in early 2020, nursing homes residents and workers were among the hardest hit populations. By late May and early June, when CMS started collecting data from nursing homes, some states were reporting hundreds of new cases among residents every week, while states including Hawaii, Montana, Vermont and West Virginia were reporting no new cases or fewer than a half-dozen for weeks.

All states were eventually affected, though the worst came at different times: For Massachusetts and Maine, the worst weeks of the entire pandemic for new cases hit just two months ago in January. Many states, such as California and Texas, saw spikes in July and August, then declines, then skyrocketing numbers of cases and deaths in late November and into December. Some states, such as Colorado and Wisconsin, didn’t see summer increases, but new cases surged in November and December.

Then, it was as if the COVID spigot magically shut off.

The Centers for Disease Control and Prevention (CDC) in November launched a public-private partnership to administer on-site vaccinations of residents and workers in nursing homes and other long-term care facilities nationwide. Called the Pharmacy Partnership for Long Term Care Program, the partnership involves CVS Pharmacy, Walgreens and Managed Health Care Associates, Inc.

The first vaccines were given in nursing homes across the country on Dec. 18. Even if you didn’t know that, you could figure it out pretty easily just by looking at a graphic such as this one because of how dramatically cases dropped almost immediately.

By mid-November, new cases exceeded 23,000 for one week. A month later, new cases exceeded 33,000 for one week. Then, boom — cases dropped by several thousand in one week. Within a month, cases were nearly cut in half from 33,212 for the week ending Dec. 20 to 17,269 for the week ending Jan. 24. Two weeks later, new cases plunged to 5,573 for the week — a decline of 83 percent in seven weeks.

The declines were similarly impressive for new cases among staff. The peak was the week ending Dec. 13, with 28,457 new cases among nursing home workers nationwide. That number dropped to 19,065 a month later and then dropped to 5,308 three weeks after that — a decrease of 81 percent in seven weeks.

A study released last month by the Center for Health Policy Evaluation in Long-Term Care showed COVID-19 cases dropped more quickly among residents as well as nursing home workers in homes that had done their first round of vaccinations compared with nursing homes that had not provided any vaccines yet. The study looked at 797 nursing homes that issued vaccines from Dec. 18 to Dec. 27 and compared them to 1,709 nursing homes in the same county that hadn’t yet administered any vaccines.

The vaccinated nursing homes saw a larger decline in new resident and staff cases of COVID-19 three weeks after the vaccine clinics were held. Vaccinated nursing homes saw a 48 percent drop in new resident cases three weeks after the first clinic, compared with a 21 percent decline in unvaccinated nursing homes in the same county.

Meanwhile, new cases among staff dropped by 33 percent in vaccinated nursing homes, compared with an 18 percent decline in non-vaccinated facilities.

In a separate report, the CDC said 12,702 skilled nursing facilities were enrolled in the vaccination partnership and that 90 percent of facilities, or 11,460, had at least one vaccination clinic during the first month. During those vaccination sessions, a median of 77.8 percent of residents and 37.5 percent of staff members received at least one vaccine shot. A total of 713,909 residents and 582,104 staff members received at least one shot.

The value of those first shots is clear, and the decline in cases after just the first shot isn’t surprising. While the Pfizer and Moderna vaccines require two shots weeks apart to hit the desired efficacy of 90-plus percent, both have demonstrated more than 50 percent effectiveness after just one shot in early studies.

Gifford of AHCA/NCAL said researchers believe, based on the study, that vaccines may not only be preventing severe illness, but may also reduce spread. He added that nursing homes, which right now have much higher vaccination rates than the general population, are seeing cases decline at a much faster rate than in the overall population. “With the dramatic decline, it is evident the vaccine is the reason for this tremendous progress,” he said.

In its own report, the AHCA/NCAL, which represents more than 14,000 nursing homes and long term care facilities nationwide, pointed to the days around Dec. 20 — when vaccinations started — as the time when things changed for the better.

Further, the AHCA/NCAL is encouraging more staff to get vaccinated, because nursing homes still face risks and the vaccines work, AHCA/NCAL President and CEO Mark Parkinson said in a statement.

“The rapid decline of nursing home cases is incredibly encouraging and a major morale boost for frontline caregivers who have been working tirelessly for a year to protect our residents,” Parkinson said. “We hope this will help persuade those staff members who preferred to wait and see how the vaccines went that they are safe and effective, and that by each of us doing our part, we can save lives.

“I’ve long said there is a light at the end of the tunnel, but we still have a long road ahead. The more of us that receive the vaccine, the quicker we can end the pandemic and be together again.”

The AHCA is working with the CDC on a #GetVaccinated campaign, financed in part by the CDC. Its website, getvaccinated.us, includes medical information from respected medical professionals and scientists and urges vaccinated staff to share their personal experiences on social media. Its goal is to get 75 percent of staff vaccinated by June 30.

“My guess is that most of the fall is because of aggressive vaccination campaigns prioritizing this population,” said Barnett of Harvard.

He added that there may have been other smaller contributing factors, including better control measures, improved PPE availability, improved testing capacity and herd immunity within individual nursing homes, given how widespread infections were.

The on-site Pharmacy Partnership for nursing homes provides for three vaccination clinics with roughly a month in between each of them. The vaccination program sounds great, until you realize there aren’t necessarily provisions to vaccinate new residents who were admitted after the second clinic and got only one shot — or after the last session and got no vaccination.

“This is absolutely on our radar,” said Jocelyn Bogdan, program and policy specialist at National Consumer Voice for Quality Long-Term Care of Washington, D.C., a consumer advocacy group. “We recently wrote to the CDC and CMS asking about this very concern — CMS said that they’d circle back with us.”

The way the procedures generally work, people aren’t necessarily required to be vaccinated before being admitted and coming into contact with other residents or staff who may not be fully vaccinated. Nursing homes generally test new residents for COVID and place them in a two-week quarantine regardless of the results, which ensures they don’t bring COVID into the home. But quarantining alone does nothing to prevent them from contracting it in the home once the quarantine is over if they’re not vaccinated, particularly since CMS relaxed visitation guidelines this month to allow unvaccinated residents to have visitors, who aren’t required to be tested or show documentation of vaccination.

Consumer Voice is worried about new residents who entered homes after the second or third vaccine clinic at that home who don’t receive both shots.

“For example, there are residents now being admitted to facilities who received their first dose at the third vaccine clinic and are being told that they are responsible for obtaining the second dose on their own,” Bogdan said.

“This leaves residents to schedule and find transport to an off-site visitation appointment which can be very difficult logistically. The burden will, in most cases, fall to residents’ family or loved ones, but fails to take into account residents who do not have support to help them obtain the vaccine. It’s even more complicated because in many areas, it may be difficult to obtain the vaccine within the required three to four weeks or even to receive the same vaccine.”

The nightmare doesn’t end there. You also have unvaccinated individuals who are entering nursing homes after the third vaccine clinic “and have no means of obtaining the vaccine in the facility,” she said.

“These gaps in vaccinations leave residents at risk of infection and harm,” Bogdan said.

And it can set in motion the risk of another outbreak in a nursing home.

Personal protective equipment has been a problem for nursing homes throughout the pandemic. They didn’t have ample supplies when the pandemic started, and the federal government didn’t provide access to any supplies it may have had in the Strategic National Stockpile.

By late August, 20 percent of nursing homes had a critical shortage of one or more types of PPE, such as masks, gowns or gloves. A critical shortage is defined as a less-than-one-week supply, which can quickly be reduced to zero supply if cases spike. Plus, homes have no guarantee when they’ll get their next shipment, so they often start rationing PPE when the supply drops to less than one week. Our analysis last fall found that 226,495 residents in 2,981 nursing homes nationwide were at risk because of the shortages.

The situation has improved significantly but shortages still existed as of Feb. 7.

One might wonder how there can still be critical shortages of supplies a year after everyone knew we were in a pandemic. It’s notable that nursing homes aren’t alone. For example, 10 percent of acute care hospitals had an urgent need for PPE over the winter, according to GetUsPPE, a nonprofit created by emergency room physicians a year ago that gets PPE via donations and manufacturers and delivers it at no charge to facilities in need. In addition, 15 percent of COVID testing centers and vaccination sites also were reporting urgent shortages.

Nursing homes and other health care facilities may finally get the help they need to get caught up on PPE with funds in the American Rescue Plan that was signed into law March 11. It provides $10 billion for using the Defense Production Act to produce and purchase PPE and other COVID-related supplies. This isn’t aimed just at nursing homes — but it should help.

The much-heralded $1.9 trillion American Rescue Plan that Congress approved this month will help nursing homes in a few ways, although it doesn’t go as far as some in the industry would have wanted.

Besides the $10 billion for PPE and other COVID supplies for health care facilities nationwide, the package includes:

• $250 million to pay for “strike teams” to go into skilled nursing facilities that have diagnosed or suspected COVID cases. Staff shortages have been another critical problem for nursing homes throughout the pandemic, with shortages increasing as 2020 went on and with 23 percent of homes in December dealing with shortages of nurses, aides or doctors severe enough that it affected patient care.
• The strike teams in the new bill will help with clinical care, infection control or staffing during the emergency period and for one year following. This should shore up but not eliminate short-term shortages. It won’t address long-term issues. Nursing homes overall had staffing shortages before the pandemic started and they will after it’s over.
• $7.5 billion for vaccines — planning, distributing, administering, tracking, etc. Again, this isn’t just for nursing homes but will help the cause, particularly as the industry tries to move the percentage of vaccinated staffers from 38 percent to its 75 percent goal in the next three months.

The rollout of vaccinations and the funds for extra personnel to help nursing homes are both huge in the efforts to wipe out COVID. But more is needed, and not just from the federal government:

Among the solutions that are still needed:

• States should designate pharmacies connected with nursing homes as priority vaccine providers and allocate vaccines to nursing homes to get all existing residents and workers fully vaccinated as quickly as possible.

• Nursing homes shouldn’t allow new residents to move in until they’re fully vaccinated, unless they’re coming from a hospital and there’s no other option. In these cases, and for cases where any unvaccinated person is already in a home, the resident should be quarantined until vaccinated and treated only by vaccinated staff. This policy would offer maximum protection to existing residents and staff.

• Hospitals should be directed to vaccinate patients with the one-shot Johnson & Johnson vaccine before they’re discharged to a nursing home. They shouldn’t discharge to a nursing home until then.

• People planning to enter any long-term care facility should be given priority access to vaccination.

• All nursing homes should be required to report vaccination rates of residents and staff publicly to CMS to hold the homes accountable to families and prospective residents.

• Federal and state governments should prioritize PPE to providers coping with severe shortages and make sure homes have the money to buy PPE, which remains priced higher than in the past. Government offices can also buy in bulk and sell directly to smaller facilities at affordable prices.

• Because experts believe staffing shortages have contributed to outbreaks, homes should be encouraged to allow select family caregivers to provide care for their loved ones, as they often did before the pandemic. This obviously would require safety precautions such as COVID screening/testing and PPE, consistent with CMS guidelines. Loved ones can help reduce the burden on aides and nurses for basic needs, such as refilling a water pitcher or helping someone to the restroom.

• CMS should revise its new guidelines issued March 10 that allow indoor visitation “at all times and for all residents, regardless of vaccination status of the resident or visitor.” There are a few situations when the CMS still recommends restrictions, such as if the resident actually has COVID or less than 70 percent of the home’s residents are fully vaccinated. The CMS says “visitation can be conducted through various means based on a facility’s’ structure and residents’ needs, including in resident rooms, visitation spaces, and outdoors.” It goes on to say: “While visitor testing and vaccination can help prevent the spread of COVID-19, visitors should not be required to be tested or vaccinated (or show proof of such) as a condition of visitation.”

  As with the states that are carelessly getting rid of mask mandates and allowing large gatherings, it seems nursing homes may act too hastily to ease restrictions and needlessly pose a risk to residents, especially those who haven’t had the opportunity to be fully vaccinated. While no one disputes the emotional trauma that many nursing home residents have dealt with while unable to see loved ones, it’s irresponsible to eliminate restrictions now when we may be only a few weeks away from a much safer environment in nursing homes.

How to find information (PPE shortages, staff shortages, outbreaks, etc.) about a specific nursing home.

How to look up all nursing homes in a particular city, zip code.