In early August, after months of deliberation, Christian Living Communities announced it was requiring all workers at its six long-term care communities in Colorado to be fully vaccinated against COVID-19. If employees didn’t get the shots — or a valid religious or medical exemption — by Oct. 1, they’d no longer have a job.
At most of the facilities, the mandate had the intended effect: vaccinations ticked up. But at one facility in rural Colorado, many workers wouldn’t budge. So the nonprofit chain pushed the deadline out to the end of October.
“We can’t have no team members,” said Jill Vitale-Aussem, president and chief executive officer of Christian Living Communities, who worried that many workers at the facilities would walk. “Yes, we have a risk with them being unvaccinated, but we also have a huge risk if we don’t have them to care for the residents.”
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“It’s hard,” she said. “There are risks both ways.”
As they did at Christian Living Communities facilities, vaccine mandates at nursing homes around the country appear to be pushing vaccinations up. The national vaccination rate for nursing home staff jumped from 67 to 74 percent between mid-September and mid-October, according to an AARP analysis of government data, as a wave of nursing home chains, individual facilities and states activated the requirements for workers. That’s the largest monthly increase since AARP began tracking COVID-19 vaccination data in June.
A federal mandate for most staff in health care facilities that receive Medicare or Medicaid dollars, which includes nursing homes, will also take effect in early January.
But even as the mandates appear to be working, many long-term care operators say they are intensifying staffing shortages. That’s especially true in pockets of the country where vaccine hesitancy is high. While shortages and high turnover have long plagued the long-term care workforce, the pandemic has exacerbated them, raising more concerns about inadequate care for residents. The pandemic has killed more than 186,000 residents and staff of long-term care facilities, including nursing homes, assisted living facilities and other settings, representing more than a quarter of all U.S. coronavirus deaths.
Almost a third of the nation’s 15,000-plus nursing homes recently reported a shortage of nurses or aides, according to AARP’s analysis, representing the worst monthly shortfall since the government began collecting COVID-19 data from nursing homes in May 2020. In Maine, Washington and Minnesota, more than 60 percent of facilities reported shortages. In Alaska, 81 percent did.
A recent survey of 1,200 senior care providers by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), which lobbies on behalf of more than 14,000 nursing homes and long-term care facilities nationwide, paints an even bleaker picture: 99 percent of nursing homes and 96 percent of assisted living facilities said they didn’t have enough workers. And more than a third of nursing homes said they were very concerned that the issue might force them to close.
“While we support the overall intent of this [federal] policy, we are concerned that the execution will exacerbate an already dire workforce crisis in long-term care,” Mark Parkinson, president and chief executive officer of AHCA/NCAL, said of the federal mandate.
A building wave of vaccine mandates
Requirements that long-term care staffers get inoculated have been scattered. A few private companies acted early, handing them down to employees as soon as residents and staff were prioritized for COVID-19 vaccines at the end of last year. When vaccine availability increased and more data emerged on the safety and efficacy of shots, more companies followed suit.
After California introduced the first statewide vaccine mandate for health care workers, including those in nursing homes, in early August, more states jumped on board. Now around half of all states have active mandates of some kind, though many offer regular testing and masking as an alternative to full vaccination.
President Biden announced in mid-August that all U.S. nursing homes that receive federal Medicare and Medicaid funding — the vast majority of facilities — must require their workers to be fully vaccinated against COVID-19. The move followed AARP calls for requiring nursing home staff and residents to be vaccinated. More recently, the Biden administration announced a Jan. 4 deadline for worker compliance, with no option to test out. Assisted living, memory care and other long-term care facilities are regulated by the states and are not subject to the federal mandate.
The mandates have clearly prompted more vaccinations. As of mid-October, staff vaccination rates exceeded 90 percent in Connecticut, Washington, D.C., Massachusetts, Maine and Rhode Island, where vaccinate-or-terminate policies have been adopted. Rates also exceeded 90 percent in California and Hawaii, which have a regular test-out alternatives to full vaccination.
Still, more than a quarter of nursing home workers nationwide were not vaccinated as of mid-October, according to AARP’s analysis. And recently, even as many mandates took effect, COVID-19 cases and deaths in nursing homes rose to their highest levels nationally since last winter’s peaks. While the death rate was only around one-tenth of what it was last winter, the 2,000 COVID-19 deaths that occurred between mid-September and mid-October represent a sixfold increase since early summer.
“It may seem low compared to the course of the pandemic” says AARP’s Ari Houser, a senior methods adviser and coauthor of AARP’s analysis, “but more than 2,000 [residents] dying from COVID in just one month is not a small number.”
Losing staff, but no regrets
Many nursing homes that adopted COVID-19 vaccine requirements are now reaping the rewards. They’ve lost workers, but their operators have no regrets.
The Jewish Home Family, a nonprofit long-term care provider with two campuses in New Jersey, is celebrating having more than 99 percent of its workforce fully vaccinated after mandating shots in summer. More than 99 percent of residents are also fully vaccinated. Since the July deadline, there have been no COVID-19 infections among residents and just one breakthrough case among workers.
Infection control protocols, such as social distancing and masking, are still in place, but “life looks pretty normal around here,” says Carol Silver Elliott, the Jewish Home Family’s president and chief executive officer. Visitation, communal dining and a full calendar of activities, entertainment and exercise have all returned. “I’m even teaching them yoga twice a month,” she says. “We’re doing it all.”
While the company lost five of its 530 employees due to the requirement, “it’s a small price to pay for a real sense of safety,” says Silver Elliott. “We prayed for a vaccine for months and months and months. So to not [mandate] would be criminal — it’s putting people’s lives at risk, and we exist to care for vulnerable elderly. We exist to protect them.”
Other long-term care providers that instituted vaccination mandates early on have also lost staff. Atria Senior Living, a chain operating more than 400 long-term care communities across the U.S. and Canada, and Juniper Communities, which operates about 20 facilities across four states, lost roughly 5 and 2 percent of their workforces, respectfully, according to media outlet McKnight’s Senior Living.
But Silverado, a memory care provider operating around 20 facilities across six states, lost no staff and instead attracted new applicants. And Aegis Living, a long-term care provider operating more than 40 assisted living, memory care and respite care communities in Washington, California and Nevada, is marketing its high staff vaccination rate to recruit new staff and residents. “Where are you going to go where you’re going to see higher than 98 percent of people vaccinated?” says Dwayne J. Clark, founder and chief executive officer. “This feels like one of the safest places on the planet.”
But that comes after Clark let go of almost 100 staffers who failed to meet the company’s July vaccination deadline. “That was painful. … We couldn’t afford to lose 97 people,” he says, noting that some positions were empty even before the vaccination requirement kicked in. “I would say we’re now down seven or eight staff in every building.”
Aegis is reluctantly enlisting temporary workers from staffing agencies, who are often more expensive and provide lower-quality care because they aren’t as familiar with a facility’s procedures and residents. Nearly 70 percent of nursing homes and 40 percent of assisted living facilities are doing the same, according to AHCA/NCAL’s survey.
But Clark doesn’t regret requiring the shots. “Our cases have plummeted,” he says. “We have some breakthrough cases, but no one is in the hospital, no one is seriously ill, compared to dozens before,” he says. “It’s a game changer.”
Edgewater West Des Moines, a long-term care community in Iowa, waited until 90 percent of its workforce was inoculated before introducing a requirement in August that gave workers until November to get fully vaccinated. Doing so gave leadership two months to “move six or seven people over that finish line,” says executive director Glen Lewis, describing vaccine-hesitant workers. In the end — after lots of one-on-one vaccine education, a rewards raffle and round-the-clock access to the shots — Edgewater lost no workers; all were compliant by November.
Lewis and other long-term care operators say that the recent flurry of federal, state and industry mandates that cover all health care workers, not just long-term care workers, have helped. They’ve “really leveled the playing field,” says Vitale-Aussem of Christian Living Communities in Colorado, where the state required all employees in licensed health care settings to be vaccinated by Oct. 31.
“When it’s just certain organizations requiring it, people leave and go to a place where they don’t,” she says. With widespread mandates, unvaccinated health care workers are “starting to see that their employment options are going to be limited.”
Some operators, like Aegis, are even starting to circle back to employees they let go to see if they’ve reconsidered. “I don’t think it’s a big number,” says Clark, “but some have come back.”
“More like 5 than 50 percent”
Hard numbers on the impact COVID-19 vaccine mandates have had on long-term care staffing shortages are limited. But Ashvin Gandhi, a health economist at the University of California Los Angeles, expects that the number of workers who resign over getting vaccinated is going to be lower than feared.
“The data we’re increasingly seeing in other industries, and that I suspect we will see in this industry, is that when push comes to shove, staff members would rather get vaccinated than pursue another job, especially another job in another industry,” he says.
Gandhi, who researches nursing homes, estimates that the number of staff who actually quit over getting vaccinated will generally be a fraction of what some fear: “The numbers I’m hearing look more like 5 than 50 percent.”
But for facilities in areas of the county where COVID-19 vaccine hesitancy is high, that percentage could be much greater. Maureen Cadwell, chief executive officer of Weston County Manor, a 58-bed nursing home in eastern Wyoming, worries that her facility will be one of them.
Neither her facility nor her state has a COVID-19 vaccine requirement for nursing home workers, and more than 40 percent of West County Manor’s staff was unvaccinated as of Oct. 31, according to government data. And almost 70 percent of residents in surrounding Weston County remain unvaccinated. So when the federal mandate for nursing homes was announced, “it was not received well,” says Cadwell. “There has been a lot of pushback. Those that do not want to get the vaccine do not want the government telling them what to do with their bodies.
If workers quit, she says, the facility may need to downsize the number of residents it admits. Almost 60 percent of nursing homes and 30 percent of assisted living facilities are already halting admissions, according to the ACHA/NCAL survey. Numerous studies have found that facilities with low staffing levels have lower-quality care and worse outcomes for residents — more falls, pressure ulcers, weight loss, dehydration, hospitalizations, COVID-19 spread and, ultimately, death.
But allowing unvaccinated staff to work won’t prevent staffing shortages, says Jonathan Blum, principal deputy administrator and chief operating officer administrator for the federal Centers for Medicare & Medicaid Services. “Where we have lower vaccination rates, we have more COVID cases that create staffing shortages,” he says. “And we know that in those states that do have vaccination mandates, they have higher vaccination rates and have fewer COVID cases that create temporary shutdowns.
“It’s really the virus, not the vaccination requirements, that cause shortages,” he says.
One of the deadliest jobs
Staff turnover in nursing homes was “alarmingly high” even before COVID-19 vaccine requirements, Gandhi notes. His research found that the average annual turnover was roughly 94 percent, so to maintain a staff of 100 employees over a year, a facility would have to hire 94 new ones.
That’s comparable to high-turnover industries like trucking and over-the-phone sales, which many attribute to a mix of deep-seated workforce issues in the long-term care industry, including poor compensation, working conditions and culture.
Most certified nursing assistants (CNAs), who make up the largest group of employees in long-term care facilities and provide more than 90 percent of the direct patient care, make less than $15 per hour. Many don’t qualify for paid sick leave or benefits. The vast majority are women, including many people of color and immigrants. Most have arduous shifts and work overtime due to chronic understaffing, performing such laborious tasks as lifting, bathing, dressing and feeding residents.
“These workers can get more money as a janitor or in all kinds of entry-level jobs,” says Charlene Harrington, a nursing home researcher at the University of California, San Francisco. “Why would they be a nursing assistant when the workload is heavy and hard?”
The pandemic has made conditions even worse for them. CNAs in nursing homes had one of the deadliest jobs of 2020 as they faced widespread COVID-19 outbreaks without adequate personal protective equipment and testing. Overtime demands increased as more than 670,000 nursing home staff were infected with the virus, rendering them unable to work while sick or quarantined. Many didn’t receive hazard or hero pay, and many who work at multiple facilities to make ends meet were villainized for unknowingly spreading COVID-19 to residents, even as other frontline health care workers were lauded for their COVID-19 work.
All of which means that COVID-19 vaccine mandates are “just one drop in the much, much larger bucket” of factors driving high staff turnover and shortages, says Gandhi. And if something has got to give in order to improve this caregiving crisis, he says, it shouldn’t be protective policies, like vaccine mandates, “that are crucial to the health and welfare of residents and staff.”
Emily Paulin is a contributing writer who covers nursing homes, health care, and federal and state policy. Her work has also appeared in Broadsheet, an Australian lifestyle publication.