Building a successful vaccination program for long term care providers is a mix of deploying both new and tried-and-true strategies and practices to ensure vital immunizations take place. Nursing staff in care communities are putting the COVID-19 vaccination debate to rest as much as possible and focusing anew on giving residents and staff of skilled nursing facilities (SNFs) and assisted living communities the support they need to get “shots in the arm” and hopefully avoid outbreaks of flu, RSV, pneumonia, and yes, COVID-19.
Running every year from approximately October to February, the vaccination season exists in conjunction with the respiratory virus season and marks an annual test for clinical staff in nursing facilities to prevent infectious disease outbreaks. For assisted living communities, the season can be more about streamlining access for residents, often through pharmacies operating clinics on campuses.
In speaking to vaccine delivery experts, a leading national pharmacy, and two operators experiencing higher than average vaccination uptake rates, it is clear there are lessons to be learned for all caregivers. Whether you are a community, vendor, resident, staff member, or family member, the fundamental goal—especially after the COVID-19 pandemic—is for residents to stay updated on their vaccinations for the big infection threats such as COVID-19 and flu. Other non-annual vaccine programs cover RSV, pneumonia, tuberculosis, Tdap, and shingles, among others.
The Basics
SNFs traditionally offer two paths for fulfilling residents’ vaccine needs. The first is on admission, when needs are identified and vaccine supplies are ordered from the pharmacy. The second is via a clinic, which is the most popular model for flu and COVID-19 vaccination.
To be considered fully vaccinated against COVID-19, an individual must have received one shot of the updated COVID-19 vaccines.
According to public health experts, an individual must receive the flu vaccine once a year, ideally in September or October, to be considered vaccinated against the flu.
Finally, the CDC recommends an RSV vaccine for everyone ages 75 and older and adults ages 60 to 74 at increased risk of severe RSV, which includes residents of nursing homes or other long term care facilities.1 The RSV vaccine is not currently an annual vaccine, which means residents who have received the RSV vaccine do not need another one.
The pneumonia vaccine recommendation for adults is that the vaccine be administered to those over age 65 or to adults ages 19 to 64 with certain risk conditions. Specific recommendations for the type of vaccine hinge on prior vaccination history and can be found at https://www.cdc.gov/vaccines/vpd/pneumo/index.html.
The Tdap booster is given once every 10 years,2 and the shingles vaccine is for those over age 50. Experts recommend vaccination with the recombinant zoster vaccine (Shingrix) in two doses given two to six months apart.3
The Good Samaritan Way
To understand what works and what does not, DeeAndra Sandgren, chief nursing officer at Evangelical Lutheran Good Samaritan Society, explains how the nonprofit’s successful vaccination efforts, particularly in SNFs in North Dakota and South Dakota, demand a building-wide effort built on trust and communication.
Overall, Good Samaritan serves more than 5,000 skilled nursing residents daily and approximately 2,000 assisted living residents, primarily in rural locales. Of the dozens of communities in Good Samaritan’s portfolio, the standout SNFs for vaccinations outperform the national averages for vaccinations by a wide margin.
“We really try to make the vaccine clinics a big day. We are in rural locations, and we work with the local pharmacy to help and do these shot clinics,” Sandgren said. The buildings that have had more success than others at vaccination uptake are usually reflective of staff efforts to engage residents, families, and team members on the importance of getting vaccines, she explained. An 80 percent flu vaccine uptake for residents is the norm for Good Samaritan.
Standout Good Samaritan locations for COVID-19 vaccine uptake include the following:
- Ottumwa, Iowa: 80 percent
- Parsons, Kans.: 79 percent
- Lakota, N.Dak.: 77 percent
- Canistota, S.Dak.: 75 percent
Sandgren said uptake for the pneumococcal vaccine is around 60 percent for Good Samaritan residents, which is in line with the national average. On this metric, these Good Samaritan locations stand out:
- Battle Lake, Minn., and Canton, S.Dak.: 96 percent
- Ottumwa, Iowa: 94 percent
- Bismarck, N.Dak.: 88 percent
- Hays, Kans.: 80 percent
“These locations have really built trust with residents and families over the course of the pandemic and now. They strive to be the one voice for families, who rely on the staff to get them information,” Sandgren said. “We are also part of a larger health care system, Sanford Health [the largest rural health system in the United States]. And they notice when patients need updates on their vaccines and inform us as they are sent out.”
Some reasons residents and staff choose not to get vaccinated are the same as for the general population, she said, citing vaccine fatigue and a plethora of misinformation circulating on social media and other outlets about vaccines, notably COVID-19 shots. “It is unique to each individual, but we do our best to give them information and answer their questions,” Sandgren said.
Smaller SNF Takes Team Approach
Larae Dixon, director of nursing services, and Samantha Katz, assistant director of nursing services and infection preventionist at Pinnacle of North Berwick in Maine, said the positive results they record for their vaccination efforts stem from an all-hands-on-deck approach. Katz points to a team effort, starting at admission, to get the intended uptake of vaccines.
“On admission, we get prior blanket consent, so we don’t have to chase anyone around for consent forms when the time comes for the shots. We also get prior immunization records, which helps to know the resident’s history of what they need or don’t have,” she said.
The resident population at Pinnacle of North Berwick is 60. Out of that total, only eight people have refused vaccines, mostly due to religious beliefs or opposition to getting another COVID-19 shot. “Overall, we don’t get too much pushback,” Dixon said.
For 2024, the facility is going to initiate the RSV vaccine after not doing so in 2023 due to supply and cost issues. With a number of vaccines to deliver, Pinnacle has identified a way to avoid doing too much at once.
“We are a little concerned, with the flu and COVID shots out there already, to introduce RSV and possibly get some resistance. We are going to introduce that vaccine earlier so it won’t seem overwhelming to have all of them at once,” Katz said.
COVID-19 and flu vaccines are given at the same time, a process that will kick into high gear this fall. The facility saw no flu cases last year as a result of the vaccine being mandatory for residents and staff. It is free for everyone, as well.
After the pandemic, there is more attention paid than ever to quickly identifying and addressing any illness outbreaks, the nursing leaders said. “We really move fast on early testing of symptoms and administering COVID tests. We are current on guidelines on when to test and mask,” Katz said.
Other common-sense practices are also helping to keep the spread of viruses to a minimum.
“I also always tell people to keep their windows open as much as possible. We are a smaller and older building, and the ventilation is a priority. We are strict on limiting activities with other residents when anyone is showing signs of illness, and we keep people in small groups when it is the cold and flu season. It is the routines that matter, encouraging outside visits, washing hands, and those things,” Katz said.
In the end, the success or failure of vaccine efforts and a broader infection-control program comes down to the clinical staff being proactive and armed with personal relationships that have built trust. “Honestly, I think the reason we do such a good job is that we do it together. It is not just on one person, and the same message is validated though each channel over and over. We also have a laid-back approach; we are not pushing anything on anyone. Our goal is to give information and provide facts,” Dixon said.
Katz added, “We are both very hands on with residents, and they feel comfortable talking with us. I think that helps. The personal relationship is what it is all about.”
Pharmacy Forging Ahead on Assisted Living Clinics
From the long term care pharmacy point of view, the task for helping improve vaccination uptake has become a do-it-yourself endeavor, according to T.J. Griffin, chief clinical officer of PharMerica. In what he describes as an out-of-the-box idea for the 2024 vaccination season, the pharmacy will be standing up vaccination clinics at strategic assisted living partners so they do not have to rely on large retail pharmacy chains.
“We have more than 400 clinics scheduled already for the fall for flu, COVID, pneumococcal, and RSV vaccines. Our nurses and pharmacists will be managing the clinics,” Griffin said.
Unlike at SNFs, streamlining access is a key factor in whether assisted living residents can and will get the vaccines they need. Residents will see their vaccines paid for mostly under Medicare Part B, but by doing the clinics at strategic partners, PharMerica will ensure the cost is free for the care community.
As far as uptake, the flu vaccine gets much more business than the COVID-19 shot, Griffin said. Communities have budgeted for around 95 percent to 100 percent uptake for the flu shot and around 40 percent for the COVID-19 vaccination. There has been no hangover from the COVID-19 pandemic for residents getting the flu update, he noted.
Pilot Assesses Vaccine Programs
Outside of the care communities that are on the front lines of vaccination efforts, there are programs and studies in place to examine how to get better uptake among residents and staff in the long term care setting. Consider, for example, the work of Elizabeth Sobczyk, who is the associate executive director at AMDA – The Society for Post-Acute and Long-Term Medicine, and the project director for the Moving Needles program (movingneedles.org), funded by the Centers for Disease Control and Prevention (CDC).
She said Moving Needles is all about improving immunization rates in post-acute and long term care (PALTC), with the goal of making routine adult immunizations a standard of care for PALTC residents and an expectation for employees.
Sobczyk said the main parts of the program seek to align existing immunization policies and procedures in PALTC to make the system work better. To do this, Moving Needles has conducted pilots to test routine, standardized adult immunizations across PALTC settings, for both residents and staff. This allows researchers to establish baseline data and measure improvement, integrate routine immunization and reporting to state authorities into workflows and electronic health record systems for both staff and residents, and demonstrate both clinical benefits and operational/cost benefits to implementation.
“We want to create a permanent resource on PALTC immunization,” she said.
As part of the effort, a round-one pilot at nine long term care facilities from three chains occurred in Pennsylvania and North Carolina from July 2022 to June 2023. A round-two pilot in twelve facilities from four chains saw data collected from July 2023 to June 2024 in Alabama, California, Colorado, Iowa, Minnesota, Nebraska, Pennsylvania, and Washington State.
The study tracked COVID-19, influenza, pneumococcal, Tdap, and shingles vaccines for residents. Staff vaccinations focused on COVID-19, influenza, and hepatitis B.
Success and Challenges in Vaccination Efforts
What the pilots discovered, according to the Moving Needles program, is that staffing turnover can impair vaccination uptake for residents, akin to what the providers discussed in reference to the need for nursing staff to have relationships with residents and their families in order to build trust.
The pilots also showed the need for assigning a vaccine team in a facility and creating a vaccine calendar to spread out offerings and planning time, using state data for finding resident histories, reviewing data at quality assurance and performance improvement meetings, and introducing a multivaccine consent form on admission.
“Consent requirements vary by facility and can be challenging, particularly when residents cannot assent for themselves,” Sobczyk said.
A challenge related to vaccine fatigue in resident uptake centers, the pilots showed, is that more residents are asking why they need more shots with the latest COVID-19 vaccine. A barrier to making vaccine programs operate smoothly is that Medicare Part A stay residents can have Part B vaccines billed only by the facility, not the pharmacy, which some providers struggle with. This nuance can create workflow challenges to offering vaccines on admission for maximum protection.
As for staff, standard operating procedures to check vaccination status on hire seems to work well, as does having a peer champion, researchers said. Offering vaccines outside of normal clinic times, more than once, to all shifts of staff also gets more positive uptake, as does offering shots to the resistant staff multiple times.
A roadblock to driving staff immunizations higher is the inability of many facilities to offer vaccines on-site. “LTC [long term care] pharmacies contract with Medicare, and staff who have insurance are considered out-of-network. Facilities that absorb the cost of the flu vaccine cannot do so with the price of COVID. The end of Bridge Access further complicates access,” Sobczyk said.
The CDC’s Bridge Access Program ended in August 2024. It provided free COVID-19 vaccines to adults without health insurance and adults whose insurance does not cover all COVID-19 vaccine costs.
Mandates Are Out, Leadership Is In
Post-pandemic, the pilot programs revealed a need for a mindset change on vaccination efforts. The culture during the pandemic centered on mandates and what people had to do to keep jobs (staff) or to remain in place (residents).
With the emergency over, the mandates for staff are mostly out, and the need for leaders to lead by example and go outside the box, such as by offering incentives for getting vaccinations, is in. “Through the pilots, we saw the importance of building trust and community,” researchers said. “Incentives work in the context of building community and shifting to positive associations, like with t-shirts, barbecues with the night shift before a vaccine clinic, etc.”
Strong leaders at the chain level produced good results, as well. This came in the form of vision-setting, acknowledging and encouraging efforts, providing operational and problem-solving support, being visible and supportive to facility staff related to the project, developing standardized guidance and processes, and supporting use of data in decision-making and quality meetings.
Prevention Forum Stakes Out Key Role
There is a fresh resource available to long term care stakeholders to keep current with the latest federal updates on vaccines. The National Infection Prevention Forum (NIPF) is a national forum for any infection preventionist or for infection prevention champions in long term care to share lessons learned and resources and get answers to questions.
NIPF’s Cathy Ciolek, a consultant and project manager for the American Health Care Association (AHCA), said the forum provides a mechanism to rapidly disseminate federal updates as they become available from the CDC, Centers for Medicare & Medicaid Services (CMS), or Occupational Safety and Health Administration (OSHA).
AHCA partnered with the Association for Professionals in Infection Control and Epidemiology (APIC) with funding from CDC Project First Line to set up the NIPF, which is open to all long term care professionals focusing on infection prevention, regardless of their membership in AHCA or APIC, Ciolek said.
NIPF’s collaborative nature is augmented by APIC and CDC subject matter experts who are available to address questions the group are unable to answer. Ciolek said updates are provided through Hot Topics, Ask the CDC Expert, and clinical skills tests using clinical-based scenarios.
Hot Topics Focus on Safety, Administration
Examples of recent vaccine updates that received NIPF attention include one from the CDC in late 2023 recommending that all residents in long term care facilities be vaccinated against COVID-19, flu, and RSV, which raised the issue of co-administration, or simultaneous administration, of all three vaccines.
Ciolek said a study found that co-administration of the COVID-19 vaccine with the seasonal flu vaccine did not raise any red flags, thus making it safe to give both at the same time. An NIPF Hot Topic update noted that giving the vaccines at the same time prevents the need for multiple clinics and can help stem an infection if waiting to get one vaccine or the other.
“That Hot Topic was all about what’s safe and who can administer the vaccines. We want the forum to stand out as an information resource, and that is what we do, bringing CDC experts and others to explain new guidance and requirements, in addition to the updates,” Ciolek said.
According to NIPF updates, SNFs should provide a vaccine information statement (VIS) to recipients in their native language whenever possible, but they should not delay a vaccination while waiting for a VIS.
Noting that uptake of the RSV vaccine is low, the CDC said there is nonetheless a need to protect nursing home residents against severe outcomes of respiratory illnesses.
The CDC found that co-administration of the RSV vaccine with other vaccines is acceptable. “The vaccines should be administered in different body locations at least one inch apart based on the individual’s physical condition and specific needs. Frail residents of nursing homes with advanced age or those with certain chronic or underlying medical conditions are identified as likely to benefit from receipt of the RSV vaccine,” the CDC said.
For more information on the NIPF and additional vaccination resources, visit AHCA/NCAL’s #GetVaccinated campaign at http://getvaccinated.us.
Patrick Connole is a veteran journalist and a former senior writer and editor for Provider, where he gained experience reporting on the long term care profession. Connole previously worked for Dow Jones, Reuters, and McGraw-Hill covering business news.