Here’s Why Nursing Homes Continue to Have COVID-19 Outbreaks. Can the Trend Be Halted?

July 2021

In mid-December 2020, the Centers for Disease Control and Prevention (CDC) launched the Pharmacy Partnership for Long-Term Care (LTC) Program. By providing on-site COVID-19 vaccination services to over 63,000 assisted living facilities and nursing homes across the U.S., the CDC hoped to curb the spread of the coronavirus to the nation’s most vulnerable populations.

By the program’s conclusion on April 23, 2021, partner pharmacies had administered over 7.8 million vaccine doses to residents and staff of long-term care facilities (LTCF) nationwide. With more than 2.9 million fully vaccinated people in LTCFs, the .

So, why are nursing homes still experiencing outbreaks?

COVID-19 Cases at Long-Term Care Facilities

At the beginning of the pandemic, nursing homes and other LTCFs were some of the hardest hit with COVID-19 infections. In fact, by mid-2020, nursing home residents accounted for 42% of COVID-19 deaths in the U.S, with 11.5 weekly cases per 1,000 residents (10.9 for staff) in June and July. By December 2020, cases had increased to 30.5 per 1,000 (26 for staff).

Thankfully, the nationwide vaccine rollout led to drastically reduced rates of COVID-19 infections in LTCFs—up to 80% in some instances. According to the CDC, by the week ending June 6, 2021, cases in nursing home residents were down to 0.38 per 1,000 in the U.S. and 0.65 per 1,000 among staff members.

While these numbers are encouraging compared to the much higher rates at the end of 2020, some concerning trends persist.

Florida COVID-19 Case Rates Are Nearly Double

Despite increasing vaccination availability nationwide, some states such as Florida continue to experience higher-than-average rates of COVID-19 cases in LTCFs.

In Florida, nursing home resident COVID-19 cases for the first week in June came in at 0.69 per 1,000, close to double the national average. Staff cases followed a similar trend, with a rate of 1.12 per 1,000.

AARP also found higher rates in Florida nursing homes in mid-May 2021, with 0.63 cases per 100 residents and 1.23 per 100 for staff—compared to 0.4 and 0.8, respectively, in the U.S.

The Centers for Medicare & Medicaid Services (CMS), which collects self-reported data directly from nursing homes, reported 0.85 weekly confirmed COVID-19 cases per 1,000 nursing home residents in Florida.

Overall, during April and May, over 14% of nursing homes in Florida reported new COVID-19 cases in residents, and 50% reported new cases in staff. Experts believe the lower vaccination rates at LTCFs in the Sunshine State could be to blame, especially the relatively low rates of staff vaccinations.

Vaccination Rates Lag in Florida Nursing Homes

By the end of May, Florida nursing homes had the third-lowest vaccination rates in the country—with just 69.75% of residents fully vaccinated.

Nursing homes in Florida have a similarly low rate of vaccinated staff in comparison to the rest of the U.S., with just 42.21% fully vaccinated. However, when taking into account all long-term care workers, the number plummets to 38%. In comparison, Vermont, the state with the highest nursing home vaccination rates, reports 96.91% of residents and 78.33% of staff as fully vaccinated.

As social distancing and masking regulations relax all over the country and new residents move into LTCFs, unvaccinated staff members may unknowingly bring COVID-19 into work, putting everyone at risk.

Reasons for Vaccine Hesitancy and Low Vaccination Rates

Staff vaccination rates at nursing homes in Florida lag behind overall adult vaccination rates in the state (51.9%) and in the entire U.S. (54.4%). However, healthcare workers have had access to vaccinations longer than the general population, which means the numbers are likely more reflective of vaccine hesitancy than access issues.

While the reasons behind uncertainty with the vaccine are likely varied and numerous, some general themes are emerging that could explain why more than half of nursing home staff workers remain unvaccinated.

Reason #1: Previous COVID-19 Infection

According to CMS, more than 583,000 nursing home staff members became infected with COVID-19 during the pandemic. Experts still aren’t sure how long this natural immunity lasts, but previously infected staff may feel protected from getting or transmitting the virus a second time.

Reason #2: Staff Turnover

Among healthcare professions, turnover rates for employees working in nursing homes and other senior care environments are exceptionally high, with a median rate of 94%. With so many employees rotating through facilities, it’s logistically difficult for LTCFs to stay on top of staff vaccinations.

Reason #3: Shortage of Workers

Astronomic turnover rates lead to a continuous shortage of CNAs and other nursing staff in LTCFs. According to AARP, 21.2% of nursing homes in Florida are experiencing a shortage of workers who provide direct care. Nursing shortages mean that staff members are often spread thin, working at several nursing home locations, and perhaps not prioritizing vaccinations—and the time needed to take off work and recover if they experience side effects.

Reason #4: Misplaced Messaging

While the CDC and nursing home trade associations continue to research the reasons behind vaccine hesitancy in long-term care workers, experts suggest that correcting the messaging is crucial to bringing up vaccination rates.

As is, educational materials about the vaccine may not be geared enough toward immigrants and people of color, a large subsection of long-term care staff. Translating messaging into other languages and addressing concerns particular to this group, many of whom may have experienced bias and racism in healthcare, could make a big difference in dispelling myths.

What Are Authorities Doing to Improve Vaccination Rates?

Fortunately, trade associations and the federal government are taking significant steps to curb vaccine hesitancy and improve vaccination rates among LTCF staff.

American Health Care Association and LeadingAge: Education Campaigns

In February, the American Health Care Association (AHCA), which represents for-profit nursing homes and LTCFs, and LeadingAge, representing non-profit senior housing and care providers, announced a goal of vaccinating 75% of nursing home workers by June 30.

The trade groups aim to provide education initiatives and campaigns (such as ACHA’s #GetVaccinated campaign) to reach their goal.

Centers for Medicare and Medicaid Services: Data Reporting

On May 11, the Centers for Medicare and Medicaid Services (CMS) announced an interim final rule requiring all LTCFs to report weekly COVID-19 vaccination rates of residents and staff. Facilities report numbers to the CDC’s National Healthcare Safety Network (NHSN), and then CMS will post the data on their public Nursing Home Data website.

CMS also requires that all LTCF staff receive education on the benefits and risks of the COVID-19 vaccine and that skilled nursing facilities have a vaccination program in place that meets the needs of both staff and residents.

While LTCFs are already required to provide NHSN with data on COVID-19 testing, case, and mortality rates in their facilities, this is the first time they have to report vaccination status. Enforcement, and potential penalties for not reporting, began on June 14.

Authorities hope the initiatives and mandate will increase education and transparency and help them identify facilities that need more support. However, experts emphasize the importance of not judging or blaming LTCFs that have low vaccination rates. Understanding how to encourage staff to get the vaccine and providing additional resources is the key to reaching vaccination goals.