The current weekly data provided by the Centers for Medicare & Medicaid Services (CMS) shows that 1,136 nursing homes have met the provider-set national goal of getting 75 percent of staff fully vaccinated with a COVID-19 vaccine by June 30, up from 723 the previous reporting week. While that’s a significant improvement, it’s still less than 10 percent of the 13,000 to 15,000 nursing homes in the United States. In addition, “current data shows that, at nursing homes that have reported, approximately 75 percent of residents and 50 percent of staff in nursing homes have received a COVID-19 vaccine,” according to a June 17 CMS e-mail to the Post-Acute Care (PAC) QRP listserv.
On a state-by-state basis, only two states (Hawaii at 79.93 percent and Vermont at 77.51 percent) and Puerto Rico (96.30 percent) have achieved an average percentage of current staff with completed COVID-19 vaccinations at reporting facilities that meets the 75 percent goal. Three states have hit the low 70s, but the majority of states and territories are in the 60 percent range (15), the 50 percent range (15), or the 40 percent range (16).
The healthcare-focused Emergency Temporary Standard for Occupational Exposure to COVID-19 Interim Final Rule, which went into effect upon its June 21 publication date, from the Occupational Safety and Health Administration (OSHA) stresses “the grave danger from exposure to SARS-CoV-2 in healthcare workplaces where less than 100 percent of the workforce is fully vaccinated.” Note: Read a key excerpt on the importance of staff vaccinations that uses examples from both a skilled nursing facility (SNF) and a nursing facility (NF) in the chart at the end of this article.
The spread of SARS-CoV-2 variants gives a greater urgency to the race to vaccinate. The Centers for Disease Control and Prevention (CDC) now uses a three-level alarm system to classify variants:
- Variant of interest. As of June 14, the CDC classifies seven variants as lower-level variants of interest.
- Variant of concern. Six variants (B.1.1.7 (Alpha), B.1.351 (Beta), P.1 (Gamma), B.1.427 (Epsilon), B.1.429 (Epsilon), and B.1.617.2 (Delta)) are worrisome enough to be classified as variants of concern due to “evidence of an increase in transmissibility, more severe disease (e.g., increased hospitalizations or deaths), significant reduction in neutralization by antibodies generated during previous infection or vaccination, reduced effectiveness of treatments or vaccines, or diagnostic detection failures,” says the CDC. The Delta variant currently is the biggest threat in the United States, according to CDC officials at a June 22 White House briefing, but the Gamma variant is causing an increasing number of COVID-19 cases as well.
- Variant of high consequence. No variants currently are variants of high consequence, which would mean that there is “clear evidence that prevention measures or medical countermeasures (MCMs) have significantly reduced effectiveness relative to previously circulating variants,” says the CDC.
To provide nursing homes with insights on how to increase staff vaccination levels, AAPACN interviewed leaders at three facilities that have achieved a staff vaccination rate of 90 percent or higher:
- Hanceville Nursing & Rehab Center in Hanceville, AL. As of June 6, this facility reported that 96.81 percent of current healthcare personnel (243 staff members) eligible to work in the facility for at least one day this week had received a completed vaccination at any time.
- Inspire Rehabilitation and Health Center in Washington, DC. As of June 6, this facility reported that 92.89 percent of current healthcare personnel (222 staff members) eligible to work in the facility for at least one day this week had received a completed vaccination at any time.
- Northside Gwinnett Extended Care Center in Lawrenceville, GA. As of June 6, this facility reported that 100.00 percent of current healthcare personnel (131 staff members) eligible to work in the facility for at least one day this week had received a completed vaccination at any time.
Insights gleaned from those conversations include the following potential steps:
Consider either a hard mandate or a soft mandate
Hanceville Nursing & Rehab Center now requires that staff receive a complete COVID-19 vaccination as a condition of employment barring religious or medical exemptions, says Donna Guthrie, LNHA, the facility’s administrator. “We are an independent facility, so if we see the right path, we can just start heading down that path. I did have many conversations about the mandate with our attorney, but at the end of the day, it was always the right thing to do—to put our residents first. Ultimately, we lost six staff members when we made COVID-19 vaccination a requirement.”
While Hanceville was the only one of the three providers to do an official mandate, both of the other facilities employed a soft mandate to stop unvaccinated staff members from having direct contact with vulnerable nursing home residents. “From the start, my long-term goal was to make staff vaccinations mandatory,” says Bolaji Lakanse, BSN, MPH, LNHA, the administrator at Inspire Rehabilitation and Health Center.
“While we wait until we get approval from our corporate office, we are finding ways to highly encourage staff without making it mandatory,” he explains. “As we got closer to our goal of 90 percent staff vaccinations, we exerted increasing levels of pressure, eventually including changing staff assignments for any unvaccinated employees who interact with residents at all.”
Northside Gwinnett Extended Care Center took a similar approach, says Tamey Stith, LNHA, the facility’s administrator. “We set a target date to complete all staff vaccinations. Everyone kept their jobs, but we ended up having to reassign six staff members elsewhere in our health system rather than have them continue to work in our nursing home with our vulnerable residents.”
Look for leadership commitment
Getting over 90 percent of staff vaccinated takes a collective effort, says Lakanse. “One of the first steps we took was to meet with our entire leadership team. We have a daily morning meeting with the management team, and I dedicated about 30 minutes each morning to educate and appeal to them about the importance of getting vaccinated. Once every department head got vaccinated, I was able to put the onus on them, saying, ‘It is your department. You need to figure out how to reach your staff on a personal level because you know your employees better than I do.’ My job was to follow up with staff who did not agree to be vaccinated.”
Leadership needs to demonstrate that they believe in science, agrees Margaret Apara, DNP, APRN, NP-C, director of nursing services at Northside Gwinnett. “That helps staff have confidence in your leadership and get on the same page more easily.”
Set weekly goals
Getting a high number of staff vaccinated without making it a condition of employment requires an aggressive approach, says Lakanse. “It is about carrots and sticks—and having innovations every week. As we got close to the goal of having 90 percent of staff vaccinated, we had weekly conversations with the department leaders: How many got vaccinated this week? What strategies will we use next week? What will we do differently?”
Provide multiple rounds of education via multiple routes
Misinformation is rampant among people who have chosen not to be vaccinated in the United States, including resistant nursing home staff, notes Guthrie. “Many staff members, particularly those in dietary and environmental services, don’t watch the news. Instead, they may pick up social media every once in a while, and they often believe some of the off-the-wall information that they see. You hear a lot of comments like ‘The vaccine will make me sterile,’ ‘It has dead babies in it,’ and ‘It’s microchipped.’”
The only way to combat that high level of misinformation is to “educate, educate, educate,” says Guthrie. “You have to get staff to trust you and to trust the science before you make COVID-19 vaccination a work requirement. We made available six to seven hours of in-service training about the vaccines. For example, one of our top attending physicians came in to do a presentation and talk with staff. In addition, our medical director and other facility leaders, including myself, had one-on-one conversations with staff who still had concerns after those group trainings.”
Multiple educational opportunities are critical, agrees Apara. “There is a lot of misinformation out there, so it’s crucial to educate staff on the safety of the vaccines and the protection they offer. We had four town hall meetings where we provided information about the research and studies, and staff could ask questions.” These town halls included sessions led by the facility’s medical director, the facility’s health system vice president, and the director of infection prevention at Northside Hospital’s Lawrenceville campus, adds Stith.
In addition, Northside Gwinnett gave staff opportunities to ask questions and talk about their feelings and concerns during daily huddles, points out Apara. “We tried to address their fears in different environments so they could be comfortable talking to us.”
Be transparent about side effects
Potential side effects were a significant concern for many staff members, says Stith. “The majority of people have minor side effects, such as sore arms and headaches. Staff gained confidence seeing peers get the vaccine and have mostly minimal problems.”
Offer to schedule vaccination appointments for staff
“Initially, we offered staff the Moderna vaccine at multiple vaccination clinics in the facility through the Walgreens and CVS government contracts,” says Lakanse. “In addition, we partnered with our pharmacy provider to bring in the Janssen (Johnson & Johnson) vaccine for anyone who wanted it. We also collaborated with other local long-term care facilities that opened their doors for our staff to get vaccinated. Over the course of four months from January to April, we had 17 vaccination clinics made available to employees.”
Once the first phase of the Pharmacy Partnership for Long-term Care Program ended, Inspire turned to making staff vaccination appointments off-site through the CVS online portal, says Lakanse. “We have designated staff, including the human resources (HR) staff person, the HR assistant, the staffing coordinator, and transportation coordinators, who reach out to employees who have not been vaccinated to ask if they would like help setting up a clinic appointment. The employee data needed to make the appointment, such as their age and where they live, is available in our staff management software, so these in-house schedulers only have to ask staff, ‘What day would you like to go, and what type of vaccine would you like?’ Once the appointment is scheduled, a confirmation e-mail is sent directly to the employee.”
Then, the day before the appointment, Inspire’s staffing coordinator follows up, says Lakanse. “They keep it simple and say, ‘Don’t forget that you are set up to go to CVS at this particular address tomorrow to get your vaccine.’ Sometimes, people will just decide not to go. We receive an addendum e-mail from CVS that lets us know whether they went, and if they skipped the appointment, our schedulers call them again. Consistent follow-up is critical.”
Make sure staff can access more than one vaccine
Providing staff with vaccine options is important, says Guthrie. “For example, if a staff member is convinced that one particular vaccine is microchipped or will make them sterile, they may still be willing to get vaccinated using another vaccine that they haven’t gotten bad information on.”
At Northside Gwinnett, some staff members had significant concerns about the Pfizer-BioNTech vaccine, adds Stith. “We didn’t argue or push a vaccine they didn’t want. Instead, we made arrangements for them to receive the Moderna vaccine.”
Use communication tools creatively
Inspire’s staff management software allows leadership to send out targeted communications to staff members who haven’t been vaccinated, points out Lakanse. “For example, if we know of an open vaccination shift, we can send out an e-mail blast to those employees and ask, ‘Who wants this appointment?’ We also use the communication tools in the software to ‘advertise’ the vaccines to those staff members who have concerns. For example, we sent out the link to the documentary, COVID-19 Vaccine And The Black Community: A Tyler Perry Special.”
Cushion the ‘blow’
To address financial barriers to vaccination and promote more equitable vaccine distribution, effective June 21 providers are required to “support COVID-19 vaccination for each employee through reasonable time off and paid leave (e.g., paid sick leave, administrative leave, etc.) for the full vaccination series (i.e., each required dose) and any side effects experienced following vaccination” under OSHA’s Emergency Temporary Standard for Occupational Exposure to COVID-19 Interim Final Rule. Note: For leave provided from April 1, 2021 – Sept. 30, 2021, employers with fewer than 500 employees that don’t have sufficient available paid leave for staff can recover the costs for that paid time off via tax credits under the American Rescue Plan.
“It’s critical that staff feel supported throughout the vaccination process,” says Lakanse. In addition to paying staff for an average of three hours of work time when they get vaccinated on their off shift and allowing staff to use their sick hours for vaccine side effects long before the OSHA rule went into effect, Inspire implemented two key steps to ensure that staff knew that leadership was on their side:
- No sick leave impact on bonus payments. “Due to the COVID-19 pandemic, we usually offer a biweekly bonus of about $250 as an incentive to not call out. That money is significant for low-income staff such as nurse aides,” says Lakanse. “We allow staff to access their sick leave without repercussions for the first 48 hours after they receive the vaccine if they experience side effects. As part of that no-repercussions policy, they still receive their bonus if they call out due to vaccine side effects. We don’t penalize them for that.”
- Free transportation to and from the appointment. “If staff don’t have their own transportation or even if they just don’t want to drive and look for parking, we offer transportation to them free of charge,” says Lakanse. “When an appointment is scheduled, our transportation office calls the employee to offer to set up a ride to the clinic using our company Uber account. Then, when the appointment is finished, they can call the transportation office, and we will set up their ride back home.”
Slowly, consistently ramp up the communication
“As an administrator, I have never made a personal request of staff. However, when we got closer to 90 percent, I personally called every employee who did not get vaccinated despite the assistance and encouragement that we offered,” says Lakanse. “I called when they were off shift, and I told them that I understood their fears, but I also let them know how important vaccination is and appealed to them to get vaccinated. If I couldn’t reach them, I had our staffing office take them off the schedule until they returned my call.”
That personal call worked with many of the vaccine hold-outs, notes Lakanse. “However, some staff told me they would think about it, but still chose not to take it. The next step for those employees was to send them a certified letter, signed by me, telling them that they needed to get vaccinated within the next two weeks or provide a letter from their clergyman or doctor explaining why they shouldn’t get vaccinated. For direct-care staff who remained unvaccinated at that point, we made the decision, in consultation with our legal team, to remove them from all direct-care responsibilities to protect the residents and meet the needs of the facility.”
For example, Inspire had some unvaccinated nurse aides working evening and night shifts, points out Lakanse. “We would say, ‘You’re not losing your job, but we are taking you off your shift because we can’t have staff who haven’t been vaccinated providing care to residents. You need to be here from 8 a.m. to 4:30 p.m. on the day shift to do clerical or administrative work in the business office (e.g., answering phones or filing).’ Two staff members resigned, but several said, ‘I can’t have my assignment changed. I will get vaccinated.’”
That prohibition against unvaccinated employees interacting with residents extends to the business office, adds Lakanse. “One unvaccinated employee in our business office does banking with the residents as part of their job, which they are no longer allowed to do. Therefore, their vaccinated manager has to do the resident banking. My hope is that the manager will influence that staff member to get vaccinated.”
Don’t expect medical exceptions to be significant
At Inspire, several staff members claimed they had medical reasons for not getting the COVID-19 vaccination, says Lakanse. “However, when I sent out the certified letter giving them two weeks to provide me with a letter from their clergy or their doctor, I never got a single letter from any physician indicating a medical reason. We had a staff member who was post-chemotherapy, and I planned to give her the exemption if I got that letter. However, she came to us and said, ‘My doctor says I do need to get the vaccine because I am more at risk.’”
Have a process for getting new staff vaccinated
To meet the goal of 100 percent staff vaccinations, Northside Gwinnett also helped staff schedule vaccination appointments—and is continuing that process for all new employees, says Stith. “When new unvaccinated staff come in, we get information in their hands about the importance of vaccinations, and we provide avenues for them to get vaccinated.”
OSHA COVID-19 Standard Highlights ‘Grave Danger’ of Less Than 100 Percent Staff Vaccinations
|The evidence shows that the advent of vaccines does not eliminate the grave danger from exposure to SARS-CoV-2 in healthcare workplaces where less than 100 percent of the workforce is fully vaccinated. Unvaccinated workers can transmit the virus to each other and can become infected as a result of exposure to persons with COVID-19 who enter the healthcare facility. An outbreak of COVID-19 due to an unvaccinated, symptomatic HCP [healthcare personnel] was recently reported in a skilled nursing facility in which 90.4 percent of residents had been vaccinated (Cavanaugh, April 30, 2021). The outbreak, due to the R.1 variant, caused attack rates that were three to four times higher in unvaccinated residents and HCPs as among those who were vaccinated. Additionally, unvaccinated persons were significantly more likely to experience symptoms or require hospitalization. Therefore, unvaccinated employees at these workplaces remain at grave danger of infection, along with the serious health consequences of COVID-19. … |
Although the risk appears to be lower, breakthrough infections of vaccinated individuals do occur, but the potential for secondary transmission remains not fully substantiated. For instance, a small yet significant portion of the population does not respond well to vaccinations (Agha et al., April 7, 2021; Boyarsky et al., May 5, 2021; Deepak et al., April 9, 2021; ACI, April 28, 2021) and may be as vulnerable as unvaccinated individuals. These individuals could potentially transmit the SARS-CoV-2 infection to unvaccinated employees. In a California study, seven out of 4,167 fully vaccinated health care workers experienced breakthrough infections (Keehner et al., May 6, 2021). A similar study from the Mayo Clinic, included 44,011 fully vaccinated individuals with 30 breakthrough infections being recorded (Swift et al., April 26, 2021). Of those breakthrough cases, 73 percent were symptomatic. Secondary transmission was not evaluated in the study. A nursing facility in Chicago found 22 possible breakthrough cases of SARS-CoV-2 infection among fully vaccinated staff and residents (Teran et al., April 30, 2021). Of those cases, 36 percent were symptomatic. However, no secondary transmission was observed in the facility. The lack of secondary transmission was likely due to the facility’s implementation of non-pharmaceutical interventions and high vaccination rates. The authors concluded that to ensure outbreaks do not occur from breakthrough infections in workplaces with vaccinated and unvaccinated workers that the facilities need to maintain high vaccine coverage and non-pharmaceutical interventions. While these breakthrough events appear to be uncommon, it is important to remember how quickly a few cases can result in an outbreak in unvaccinated populations.
Editor’s note: On May 27, the Mississippi Department of Health reported 12 fully vaccinated residents at two nursing homes who had breakthrough infections from the South African origin B.1.351 (Beta) variant strain. The state epidemiologist noted the importance of staff vaccinations.
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