For more than a year, my colleagues and I have been publishing a monthly COVID-19 Nursing Home Dashboard tracking the impact of COVID-19 on nursing home residents and staff. That's 14 months assembling data on how many nursing homes are understaffed or don't have enough personal protective equipment (PPE), 14 months documenting the rates of COVID-19 infections among residents and staff. And worst of all, 14 months reporting on the catastrophic loss of life. We have now lost more than 150,000 of our most frail and vulnerable friends and family members to this virus in nursing homes.
This May, CMS began asking all nursing homes to report staff and resident vaccination rates in addition to data they had been reporting since last summer, including PPE, staffing levels, and new infections and deaths. Facilities now report their COVID-19 data to CMS at least weekly. For our dashboard, we download and analyze the data monthly in order to best capture trends over time in collaboration with the Scripps Gerontology Center at Miami University in Ohio.
The Data
Preparing the data for our October update -- released exactly one year after our first dashboard -- was sobering because, by some measures, it showed we were back where we were a year ago. For the second consecutive month, the percentage of nursing homes reporting a shortage of nurses or aides jumped during the 4 weeks ending September 19, reaching levels comparable to the peak of the pandemic last winter. New infections among nursing home residents were also up, about 50% higher than the previous 4 weeks. Cases among staff rose from 22,000 to more than 27,000, as many as were reported in our first dashboard a year ago. We also learned that the rate of resident deaths had nearly doubled over the previous month, and that more than 2,000 nursing home residents lost their lives to COVID-19 between August 23 and September 19. Our newest update, released November 10, was only modestly encouraging on these fronts; new infections have started to come down in most states, but staff shortages are the highest we have seen, and for the second consecutive month, more than 2,000 residents died from COVID-19.
Amid all the numbers, what is perhaps most exasperating was that -- even after significant improvement from the previous month -- vaccinations among nursing home workers continue to lag in most states, with only 74% of healthcare staff nationwide fully vaccinated as of mid-October. The nursing home data confirm that this virus targets the unvaccinated and that vaccination controls its spread, just as it does in the wider community. Seven states demonstrate what is possible with more than 90% of staff fully vaccinated, but more than twice as many states failed to reach even two-thirds. Our latest update shows there are still nearly half a million direct care staff in nursing homes who are not fully vaccinated. Meanwhile, the vaccination rate for residents has been steadily inching up since June when CMS began reporting it, and was at 86% by mid-October.
Workforce Issues
Staff vaccination rates remain unacceptable. After seeing a significant uptick in COVID-19 cases in July and August, AARP called for mandatory nursing home staff vaccinations. Shortly thereafter, the Biden administration announced it was developing an emergency regulation requiring staff be vaccinated in the more than 15,000 Medicare and Medicaid-participating nursing homes nationwide. Now in effect, it requires that eligible staff be fully vaccinated by January 4 and, as has been the case since July, staff must be given paid time off to receive their vaccine.
There are people who worry this mandate might lead to staffing shortages, but I take a different view. The fact is, nursing homes have been short staffed for years, due, frankly, to terrible labor practices -- low wages, no benefits, unsustainable workloads. Mandates may contribute to shortages, but these other issues are surely coming to a head after 20 unrelenting months of crisis level working conditions. In fact, I am hearing anecdotally from some facilities where vaccines are required that staff are largely grateful for the protection. Significantly, vaccinated workers also take fewer sick days, which is a positive for staffing levels.
What Now?
While reporting on this pandemic in real time, my colleagues and I have begun considering what the last 20 months can teach us about how to better respond to the next public health crisis that threatens vulnerable, older adults. Job number one will be improving infection control more generally. For more than a decade, nursing homes have been falling short on their influenza and pneumococcal immunization programs, vaccinating well under the CDC's recommended 90% of residents against these two common infections. The temporary federal Pharmacy Partnership for Long-Term Care Program proved highly successful in getting nursing home residents (if not staff) vaccinated against COVID-19 between December 2020 and April 2021. How it succeeded should be studied and integrated into routine practice.
First, Do No Harm
There is no question that every nurse, every aide, every kitchen, clerical, and custodial worker in a nursing home should be vaccinated against COVID-19. Full stop. So should every resident and visitor. It is worth considering just how often potential new carriers are walking through the doors of any given nursing home. Take staff, for example. One recent study put nursing home staff turnover rates at over 100% annually. In terms of residents, there are about 2.5 million new nursing home admissions a year. Since many are returning from a hospital stay, or are newly arriving for rehabilitation following hospitalization, one action item could be assigning hospitals the responsibility to vaccinate older patients before they discharge them, particularly those going to congregate settings. And now, with new guidance from CMS relaxing pandemic restrictions on nursing home visitation, the potential for COVID-19 spread is even greater.
COVID-19 is here to stay, in one form or another, as are flu and pneumonia. In the COVID-19 vaccine, we have a public health miracle, but its efficacy depends on getting it into people's arms. With better planning, better data, and better accountability, we can beat back COVID-19 and create systems that better protect older Americans. They depend not only on healthcare providers but on industry leaders, policy experts and government personnel -- all of us -- to get this right.
Susan C. Reinhard, RN, PhD, is senior vice president and director of the AARP Public Policy Institute and chief strategist of family caregiving initiatives and the Center to Champion Nursing in America, an initiative of AARP Foundation, AARP, and the Robert Wood Johnson Foundation. She leads the LTSS Choices Initiative, promoting the transformation of long-term care in the U.S.