Pa. nursing homes are playing catch-up on vaccinations and boosters

Retired first-grade teacher Sheryl Kalick has beaten the odds — twice. She’s “75-and-a-half.” She lives in a Philadelphia nursing home. She’s unvaccinated.

And she’s just recovered from her second bout of COVID-19.

Nursing homes have seen a disproportionate number of deaths from the very beginning of the pandemic, due to both the vulnerability of the people they serve and the high risk that comes from living in close quarters.

“If they ever get around to opening the dining room again, it’s not going to be the same,” Kalick said, “because so many of our friends are gone.”

Vaccinating staff has been a key component of efforts across the country to protect nursing home residents. In Pennsylvania, about 20% of staff still haven’t been fully vaccinated, according to state estimates. Of all staff who are eligible for boosters statewide, 60% haven’t received one.

The Biden administration got a Supreme Court go-ahead this month to implement a federal vaccine mandate for Medicaid- and Medicare-funded facilities that requires staff to show evidence of full vaccination.

That federal mandate could have a sizable impact in Pennsylvania, which did not implement a mandate but instead set a voluntary goal of fully vaccinating four out of five nursing home staffers. Almost half of the nursing homes in the state have failed to meet that target.

Advocates for nursing home staff vaccine mandates say they're effective at increasing inoculations and protecting residents. But industry representatives call mandates unnecessary and warn they can exacerbate existing staffing shortages, compromising patient care.

Kalick doesn’t know how she got COVID-19 a second time during the current omicron surge, but she worries about continuing to be exposed. She isn’t vaccinated because of past allergic reactions, but she asks nursing home employees she interacts with whether they are. Her regular caregivers say yes. Temporary workers there on a daily basis sometimes say no.

“It's very important,” she said. “My health depends on it. My life depends on it.”

Vaccine mandates increase nursing home staff vaccination rates

More than 100,000 healthcare employees work in Pennsylvania nursing homes, according to the state Department of Health estimates. About 80% of those workers are fully vaccinated — currently defined as two mRNA doses or one shot of the Johnson & Johnson vaccine. And about 41,000 staffers have been fully vaccinated but are not boosted, despite being eligible. That would mean half of the workers are not at peak immune protection — not vaccinated, or not boosted despite being eligible.

By contrast, almost 80% of residents are at peak protection against the virus, according to an Inquirer analysis of state data. (Estimating the total number of residents in nursing homes is difficult, as facilities often host short-term residents who cycle in and out of the system.)

Industry representatives say existing vaccine uptake is evidence that mandates are unnecessary. Zach Shamberg, president of the Pennsylvania Health Care Association, noted that at the average Pennsylvania facility, 80% of staff and 90% of residents are fully vaccinated: “Those are two really strong numbers.”

But averages only tell part of the story.

About 56% of Pennsylvania’s 700 or so nursing homes have met the state’s 80% staff vaccination goal so far, up from just 12.5% when the goal was first announced. Some nursing homes are part of national chains that implemented their own mandates.

“Facilities can do more, and I think the [state] Department of Health can do more,” said Karen Buck, director of the Philadelphia-based SeniorLAW Center. A “mandate is called for.”

Mandates have proven effective at increasing vaccination rates.

An Inquirer analysis found 89% of Philadelphia nursing homes have met the state’s goal after the city implemented a healthcare worker mandate in the fall. And states that required vaccination now generally see higher vaccination rates across their nursing homes. Mandates have had the most dramatic impact on increasing vaccination rates in nursing homes that previously trailed the pack.

The range in a state’s staff vaccination rates depends partly on how strictly mandates are enforced, said Arthur Caplan, a bioethics professor at New York University’s medical school.

Some states allowed for religious exemptions, while after a legal battle, New York did not, for example. In New Jersey, healthcare workers were allowed to take COVID tests regularly instead of getting vaccinated until earlier this month.

Nursing homes warn vaccine mandates can exacerbate staff shortages

Critics note there are two ways mandates can increase vaccination rates — either people get vaccinated, or they leave their workplaces entirely.

Philadelphia’s vaccine mandate for healthcare workers, announced in August, resulted in an average of seven fewer staff at each nursing home, according to a city survey conducted in October. About 2% to 4% of the 9,000 healthcare workers in Philadelphia nursing homes left or were in danger of leaving as the mandate was implemented, city data show, and 30% of staff were vaccinated between August and October.

Even a small percentage loss in an already-stretched workforce exacerbates ongoing staffing shortages, Shamberg said, compromising the quality of care that patients receive.

Nationwide, the American Health Care Association estimates that more than 220,000 nursing home employees left work between March 2020 and October 2021, a 14% decrease in the overall size of the workforce.

The Centers for Medicare and Medicaid Services tracks and publishes data on whether facilities are experiencing staffing shortages, but it doesn’t track how acute those shortages are. Earlier this month, more than one in four nursing homes in Pennsylvania that submitted reports indicated they were experiencing staff shortages.

PHCA, the industry group, supports staff vaccination, but not a statewide mandate. It has instead advocated for vaccination policies to be left to individual facilities.

“Some of our providers who did it did it with great success with losing very, very few workers,” Shamberg said. “But we also had providers who did it who did see their workers leave and go to a competitor down the street that wasn't mandating the vaccine.”

The upcoming federal reimbursement rule could make it harder for workers to jump to another nursing home to avoid vaccination, though facilities may still have broad leeway in the granting of religious and medical exemptions.

And in the long term, vaccine mandates can help keep the workforce stable, Caplan said, by reducing the likelihood that outbreaks will force staff to miss work.

Biden’s federal vaccine mandate is coming

The upcoming federal mandate ties Medicaid and Medicare funding to staff vaccination. More than 60% of Pennsylvania nursing home residents are reliant on Medicaid for funding and 8% depend on Medicare, a Kaiser Health analysis found. Losing that money could be “disastrous,” Shamberg said.

The first deadline for compliance with the federal mandate is for staff to have received their first dose by Thursday. The deadline for full vaccination is Feb. 28.

Pennsylvania nursing homes will likely see an increase in both vaccinations and staff departures in the next few weeks. The mandate underscores the need for the government to plan for further staff shortages, Shamberg said.

“We sounded an alarm on the issue in September,” he wrote. “We asked Pennsylvania leaders for a plan to address the care capacity crisis.”

The next vaccine mandate question: boosters

Kalick’s nursing home is still in the throes of an outbreak. “I hope I don’t get infected again,” she said.

The facility is in a “semi-lockdown,” meaning Kalick gets to leave her room sometimes to walk in adjoining hallways. It’s unclear when the facility will reopen for visitors so she can see family and friends again.

That kind of isolation “can really destroy the lives of older people,” said Buck, the head of SeniorLAW Center. She called for Pennsylvania to go beyond vaccination and implement a booster mandate: “I want people to be thinking about it as another crisis prevention tool.”

At least six states, including New Jersey, New York, Massachusetts, and Connecticut, have already begun requiring booster shots for nursing home staff this month, pointing to evidence that immunity wanes after six months. Omicron in particular has been able to infect people who are fully vaccinated but not boosted.

Philadelphia has no immediate plans to mandate boosters, said James Garrow, a spokesperson for the city’s health department. “It’s only been a few months since healthcare workers were required to be fully vaccinated in Philadelphia,” he said, “so many healthcare workers are not yet eligible to receive a booster dose.”

But Pennsylvania’s booster numbers already show that the majority of eligible nursing home staffers haven’t been boosted. And as time elapses, more healthcare workers will become eligible.