Florida nursing homes have low staff vaccination rates. Resident cases and deaths are rising.

Michelle Pasko visits her elderly parents and disabled brother almost every day at the Miami nursing home and independent living center where her family has lived since 2019.

Pasko and her parents and brother are vaccinated against COVID-19, but they typically gather outdoors on the campus of Miami Jewish Health and they keep a healthy distance because “I always, in the back of my mind, knew the elderly were much more susceptible.

“I did not think the vaccine was the end-all to perfect health and everything is going to be OK,” Pasko said.

Still, Pasko expected that the nurses and aides and other nursing home workers who care for her 86-year-old mother, Joan Magliolo, would be vaccinated.

When she discovered in early August that the private-duty nurse who spends 12 hours a day with Magliolo was not vaccinated, Pasko said she grew alarmed. (Pasko’s father lives in the independent living part of the complex.)

“I thought that everybody at this point would have chosen to have the vaccine, or actually in the nursing home, I thought it was mandated that they needed to be vaccinated,” Pasko said.

At about the same time, Pasko said she learned from Miami Jewish Health administrators that due to the resurgent pandemic and the predominance of the more contagious delta variant of the virus that causes COVID-19, visitations with nursing home residents would once again be restricted until the facility had no new cases for at least 14 days.

“I immediately called the nursing home and said, ‘You’re doing another lockdown supposedly, but how is that even helping if the people who are coming in to take care of my mom and other residents are not vaccinated’,” Pasko said she told the facility’s administrators.

That’s when Pasko said she learned that Miami Jewish Health, which operates one of the state’s largest nursing homes with 438 beds at 5200 NE Second Ave., is one of the few long-term care facilities in Florida to mandate that all employees be vaccinated against COVID-19.

Jeffrey Freimark, chief executive of Miami Jewish Health, said it was not an easy decision to adopt a vaccine mandate. Nursing homes have struggled with staffing shortages since before the pandemic, he said, and no one wants to lose staff amid a crisis. Then Freimark looked around and saw the county’s high rate of community transmission.

“We saw the data,” Freimark said. “We saw what was going on in the state, and more specifically, I had been watching closely what’s been going on in Miami-Dade County, in terms of the double-digit positivity rates. Of course, we’re tightly tied to the hospitals in the community, and they are slammed.

“It’s a brutal environment,” he said, “and we need to be able to keep people safe and healthy.”

Pandemic of the unvaccinated

After months of declining cases, nursing homes reported rising numbers of new COVID-19 infections among residents and staff in July and early August, leading the White House last week to announce a vaccine mandate for all nursing home workers as a condition of participating in the Medicare and Medicaid health insurance programs for elderly, disabled and low-income Americans. The programs are the largest payers for nursing homes and the lifeblood of the industry.

The Food and Drug Administration’s full approval of the Pfizer-BioNTech vaccine this week has led to more mandates from private employers, though most new vaccinations will not be completed in time to stem the current surge in cases, hospitalizations and deaths.

The most dramatic COVID-19 case increases this summer have occurred in states with low rates of vaccinated workers, such as Florida, where an estimated 47.5% of nursing home staff were fully vaccinated as of Aug. 15 — lower than the national average of vaccinated staff per facility (61.1%) and the lowest of any state, according to the most recent data reported by the federal Centers for Medicare and Medicaid Services or CMS.

About 70,000 people live in a nursing home in Florida, where the rate of fully vaccinated residents per facility — 73.1% — is lower than every other state except Nevada, which reported a resident vaccination rate of 71.7% per nursing home as of Aug. 15. The national average of vaccinated residents per nursing home is 83.1%.

As Florida nursing homes lag behind their peers in resident and staff vaccination rates, the number and rate of new COVID cases for residents and staff of the state’s more than 700 nursing homes spiked in July and early August.

Centers for Disease Control and Prevention nursing home data reported 1,011 confirmed COVID-19 cases among Florida nursing home residents for the week ending Aug. 15 — a 683% increase from the 129 cases reported during the week that ended July 4.

CDC also reported a spike in confirmed cases among Florida nursing home staff during the same time period, with a total of 1,095 COVID-19 infections for the week ending Aug. 15, or a 715% increase from the 134 cases reported during the week that ended July 4.

Deaths often occur two to eight weeks after the onset of COVID-19 symptoms. A Miami Herald analysis of federal nursing home data found that the number of COVID-related resident deaths per week in Florida facilities has risen significantly since late July.

During the two-week period that ended Aug. 15, Florida nursing homes reported 106 resident deaths due to COVID-19 — almost as many as the 110 total resident deaths reported by facilities during the months of April, May, June and July.

Nursing home resident deaths due to COVID-19 have ticked up in other states, too, with facilities reporting a total of 511 deaths during the two weeks ending Aug. 15, according to CMS data, which is updated each week.

CMS reported 3,615 new COVID-19 cases among nursing home residents nationwide during the week that ended Aug. 15, a 645% increase over the 485 cases reported for the week that ended July 4. Nursing home workers saw a bigger spike, with 5,855 cases during the week that ended Aug. 15, compared with 750 cases during the week that ended July 4 — a 680% increase.

Brian McGarry, a professor and nursing home researcher with the University of Rochester Medical Center in New York, said the recent spike in cases is a telltale sign of a resurgence among the most vulnerable populations.

“What you’re seeing is the potential start of another wave of COVID outbreaks in nursing homes, and that’s super disheartening at this point in the pandemic,” McGarry said.

Cases are rising at the same time that CDC public health and medical experts are recommending booster shots of the Pfizer-BioNTech and Moderna vaccines eight months after the second dose, with priority given to nursing home residents and seniors — many of whom were inoculated early in the vaccine rollout and continue to be at higher risk for severe disease.

Adding to the urgency to protect nursing home residents from COVID-19 is the predominance of the delta variant, which has fueled the recent resurgence.

A CDC study published last week found that the Moderna and Pfizer-BioNTech vaccines were about 75% effective against infection among nursing home residents but that protection “declined significantly” — to about 53% — when the delta variant predominated in June and July. Delta’s grip has gotten stronger, making up 9 in 10 of all virus samples sequenced by CDC during the week that ended Aug. 14.

Healthcare worker mandates

Like many hospitals, most nursing homes have been reluctant to mandate vaccination of employees because they don’t want to lose workers to a competitor that does not require inoculation or see more staff leave for work in other industries.

The federal government vaccine mandate for nursing homes, which could take effect as soon as mid-September, would apply to more than 15,000 nursing homes and 1.3 million workers. By mandating shots for all nursing home staff, it will be less likely that employees opposed to the vaccines will leave for a competing facility, which makes it easier for administrators, McGarry said.

But Florida’s nursing home industry pushed back on the Biden administration’s vaccine mandate for workers. The Florida Health Care Association, the state’s largest nursing home lobby, said in a public statement that the order is unfair because it excludes other healthcare workers at hospitals. FHCA also argued that the order will exacerbate staffing shortages.

“By the federal government singling out nursing homes with a vaccination requirement that does not apply to healthcare personnel at other locations and in other healthcare sectors, we fear that our already critical workforce shortages will worsen,” said Emmett Reed, FHCA chief executive.

The federal government has used the threat of removing Medicare and Medicaid to overcome seemingly insurmountable obstacles in healthcare before. Most notably, the government used the threat of stripping Medicare payments to desegregate American hospitals in the 1960s.

Over the last two months, the Biden administration and several states have increasingly adopted vaccine mandates for federal workers and other public employees, beginning in July with the Department of Veterans Affairs, which employs more than 115,000 front-line healthcare workers at government-run hospitals, and including the Department of Defense, which has made vaccination mandatory for all 1.3 million active-duty service members.

Some states, including California and Washington, have already issued vaccine mandates for all healthcare workers, including nursing home staff.

McGarry said vaccine mandates make sense for all nursing home employees because his past research has shown that the number of unique individuals who come in and out of a nursing home greatly affects the risk of an outbreak.

With many nursing homes temporarily stopping visitations for residents during the current resurgence, that leaves employees as a key vector for the virus to enter the facility, McGarry said.

“There’s definitely a smoking gun there. ... These facilities that have low staff vaccination rates are going to be susceptible to higher case rates,” he said. “It’s a frail, older population who we know is very susceptible and vulnerable to bad outcomes as a result of COVID.”

Pressure on nursing homes

Making employee vaccination a condition of receiving Medicare and Medicaid funding is expected to put more financial pressure on nursing homes, however.

Many nursing homes have reported losing workers to pandemic exhaustion and to jobs in other industries, said Jeff Johnson, president of the Florida chapter of the American Association of Retired Persons or AARP.

“The majority of people who work in nursing homes are hourly wage workers who are making now about what McDonald’s and other fast food establishments are offering and there’s no time off,” he said.

Time off for getting vaccinated is important because nursing home workers may need a day or two to recover if they experience side effects, Johnson said.

“Losing a day of work may not sound like a big deal, but when you’re living economically on the edge it can be,” he said.

But nursing homes do not have the same flexibility as other employers to raise wages or offer other economic incentives because they cannot negotiate reimbursement rates with their biggest payers, Medicare and Medicaid.

Most nursing homes rely on revenues from both programs, but the reimbursement rate and coverage requirements differ. Medicaid pays lower rates than Medicare but covers long-term stays. Medicare caps nursing home coverage at 100 days, and only after a minimum hospitalization of at least three days.

“The thinking here is that nursing homes make a profit on short-stay Medicare patients and hope to break even on long-stay Medicaid patients,” McGarry said.

But the pandemic forced many hospitals to postpone non-emergency surgeries, and many patients deferred care because they did not want to be exposed to the coronavirus at a healthcare facility.

With fewer Medicare patients in nursing homes, the facilities have had to rely more on the lower-paying Medicaid program.

“There’s been some bail-out funds to help them weather the storm,” McGarry said, “but it’s very uncertain what the nursing home landscape is going to look like and what their revenue streams are going to look like going forward.”

Worker retention is a constant challenge for nursing homes, with one study finding that the median annual turnover rate for total nursing staff at most facilities was 94%.

The pandemic also has changed the way nursing home workers do their jobs, McGarry said. As nursing homes isolated patients and restricted family members from visiting during pandemic surges, they also required residents to be fed one-on-one as opposed to communal dining halls. That helped reduce the spread of COVID but also created more work and responsibilities for nursing home workers.

“They need more people now than prior to the pandemic,” McGarry said. “The amount of labor per resident has gone up.”

After the FDA authorized the first COVID-19 vaccine for emergency use in December, Gov. Ron DeSantis issued an executive order prioritizing seniors, long-term care residents and healthcare workers for the shots.

At Miami Jewish Health, which has a nursing home and independent and assisted living facilities on campus, the first doses of Moderna began to arrive about a week after it became the second vaccine to be authorized by the FDA. Freimark, the CEO, said administrators went “on a full-court press” and started administering the shots on Christmas Eve.

Since then, about 78.1% of an estimated 315 nursing home residents at Miami Jewish Health had been vaccinated as of Aug. 15, according to federal data. The staff vaccination rates is higher, nearly 82% or about 985 employees as of Aug. 15.

Freimark said he relied on an employee physician and other healthcare workers to help educate staff about the vaccine, and he has brought in a little help from outside the organization, too.

“We have brought in local, community-based physicians and local clergy,” he said, “people of influence from the community that we felt would be helpful in terms of working with our team.”

Freimark said more employees have signed up to get the vaccine in recent weeks as they’ve seen the cases and hospitalizations soar in Miami-Dade and elsewhere.

He would like to reach 100% vaccination rate for employees, especially given the risk of so-called breakthrough cases among vaccinated individuals.

Nursing home residents often have chronic medical conditions that raise their risk for severe disease, hospitalization and death from COVID-19, Freimark said, but there’s no way to guarantee that they will never contract the disease.

“There is no way to just put ourselves into a bubble and completely protect the environment,” he said. “It’s just not possible.”

‘Like guinea pigs’

Vaccine hesitancy among nursing home workers was shaped, in part, by their experience during the pandemic. Throughout 2020, as outbreaks occurred, nursing home workers were not first in line for much of anything they needed that was in short supply — not for N95 respirator masks or rapid testing kits or other tools to keep them safe from the virus.

Hospitals were prioritized for supplies and their workers celebrated as healthcare heroes, McGarry said, while nursing home workers were largely overlooked.

When Florida and other states prioritized nursing home staff for vaccination, some of those workers felt “like guinea pigs,” he said.

Another explanation for the low vaccination rate among Florida’s nursing home employees may be attributed to the high turnover rate among workers, said Johnson, with the Florida chapter of the AARP.

“It’s possible that some of the low vaccination rates are from people who weren’t around in January,” he said, “which raises other concerns because generally speaking, high turnover of staffing is a general warning sign about the overall quality of a facility.”

Then there’s what Johnson called “the general gamut of concerns” about the vaccine, including whether the shots are safe and effective, political opposition, mistrust of government and lack of access to healthcare.

“All those things are the same in a nursing home as they are in the community,” Johnson said. “But you would think in a nursing home the folks who work there would get how important it is to be vaccinated.”

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