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Hundreds of Thousands of Nursing Home Staff Are Going to Leave’ Without Reasonable Vaccine Mandate Implementation

While the skilled nursing industry awaits further guidance on what the Biden administration’s vaccine mandate for nursing home staff will entail, Mark Parkinson, president and CEO of the American Health Care Association (AHCA), is calling on government officials to not only mandate the vaccine for all health care settings, but to provide an alternative to the vaccine — such as regular testing or additional PPE — at least for some time.

“We need to have some continued period of time to work with staff to get the vaccine where they’re not just all terminated immediately,” Parkinson told Skilled Nursing News.

About 83.1% of residents and 61.1% of staff per facility are vaccinated, the Centers for Medicare & Medicaid Services (CMS) reported as of the week of Aug. 15.

During a call with nursing home stakeholders, CMS said the regulation is expected in late September. 

While CMS officials did not provide much detail during the call on what the regulation could look like, they did indicate the mandate would be enforced in the same manner as other issues of compliance in that termination would not be the first enforcement step taken.

Parkinson spoke with SNN last week to further discuss the vaccine mandate, the Provider Relief Fund (PRF) delay and the delta variant, among other topics.

This interview has been edited for length and clarity.

How specifically do you think the Biden administration’s vaccine mandate will impact an already challenging staffing situation for skilled nursing facilities?

If the vaccine mandate is implemented poorly, hundreds of thousands of nursing home staff are going to leave. If it’s implemented thoughtfully, we can avoid that. And, I think, still achieve the objectives that the administration wants to achieve.

When you say thoughtfully, what do you mean by that?

There are a few things that the administration can do to make this work. The first is that it needs to mandate the vaccine for all health care settings. If they just mandate the vaccine for nursing homes, we’re going to see an exodus of unvaccinated workers going to other health care providers continuing to work. So the first thing is they need to mandate it for everybody.

The second thing that they need to do is that they need to provide an alternative to the vaccine, at least for some period of time. We hope that they do what a number of other states have done, which is that they’ve mandated the vaccine but they’ve also allowed an opt out for staff that are willing to be frequently tested, utilize more PPE, or go through some education.

At least for some period of time there’s going to have to be an alternative to the vaccine, or we’re simply going to lose too many workers. 

The third thing we think that they should do is increase their education efforts. There have been some promotional campaigns but we’re advocating for promotional campaigns, directed specifically at our staff to educate them on the safety and the effectiveness of the vaccine.

Finally, they’re going to need to provide some funding with this. No matter how successful the effort is, we’re going to lose employees and we’re going to be required to hire agency people and other more expensive staffing and without the funding to do that, they’re just aren’t going to be the workers that are needed to take care of the residents in the buildings.

I would also add, they need to apply the vaccine mandate to other folks that are in the buildings, the surveyors, the ombudspeople, the other health care providers that come in and out of buildings.

The Pfizer vaccine recently received full approval from the FDA. Do you think we see the administration start to require other healthcare settings to require vaccinations with this?

I don’t know. I do know that there was a reluctance on their part until the Pfizer vaccine was fully authorized and so our hope is that now that there’s been full authorization, they will make this mandate consistent across all provider types.

What do you think is delaying the administration’s release of the remaining provider relief funds?

The administration has told us that they want to make sure that the remaining funds go to providers who need them the most, rather than just sending the funds out to every single provider. So we know that they’ve taken some time in developing an application process that would target the funds. We understand that reluctance and that desire, and we think that plenty of time has passed to get it right and to get the funds out.

What we want to have happen is what we’ve now been asking for for a matter of months, which is for them to open up the portal and release that final amount of funding.

Do you think delaying the release of the remaining Provider Relief Funds and the staffing mandate is going to put operators under economic pressure going forward?

Absolutely. If the vaccine mandate happens overnight without any additional funding and without exceptions, there will be tens of thousands or hundreds of thousands of workers that will leave, there will be hundreds, perhaps more, buildings that will close wings and possibly completely close. We are at a precipice where, if they don’t make the right decisions, hundreds of buildings, maybe more will be dramatically impacted and possibly close.

What have you been hearing and seeing from operators on how the delta variant has impacted occupancy recovery and admissions in general?

When you look at occupancy data, it continues to be OK. Not great, but not terrible. We follow the NHSN [National Healthcare Safety Network] data as it’s released every week. For most weeks since early January we’ve had a slight increase in occupancy. We’re still about 8% below where we were before the pandemic, which is not sustainable. We need to get back to where we were before the pandemic for this to ultimately work out. But at least for now, census has not collapsed despite the delta variant. We continue to see a slow recovery in occupancy.

What are some of the biggest issues facing nursing homes today?

The first of course is staffing. We face a staffing crisis that is unprecedented. Staffing has always been a problem in long-term care — it has never been this bad. Operators that never used agency in the past are now using agency. There are some parts of the country where agency workers are not even available. It’s just impossible to overstate the severity of the staffing crisis.

The second big challenge is keeping COVID out of buildings, even though it is spreading rapidly in the general population. That’s an area where nursing homes are doing great. We’re now at about two-thirds the number of cases in the general population that we were at the peak back in December. At nursing facilities we are still 90% lower than we were at the peak back in December in terms of new cases and in terms of deaths, so they’re doing a fantastic job. 

Finally, just keeping the doors open financially because of the challenges both with occupancy and increased costs.

Every operator out there, regardless of the success that they’ve had in the past, is really worried about what the future is going to bring and whether they’re going to be able to make it or not.

I just don’t think there’s ever been a time in the history of the sector where we’ve faced these huge monumental problems all at once, and it’s made it very challenging.

Where do you see the skilled nursing industry headed?

In the very short term my hope is that we’re able to work out with the administration a reasonable implementation of the vaccine policy, and that very quickly they release the additional Provider Relief Funds so that we can get through the remainder of 2021. Once we get past that date, I think that we’re demonstrating that we’re getting really good at keeping this variant out of buildings and so there is some hope that we can return to some level of normality in our buildings.

Even if COVID is endemic in the general population, the new normal may just be, OK there’s COVID out there, we’re going to keep it out of buildings, we’re going to make sure everybody’s vaccinated, we’re going to make these safe havens for older people — and I think that’s a very real possibility.

If we can succeed in doing that, I think that occupancy will continue to creep up and it will take some time because the return in occupancy is excruciatingly slow, but by the time you get to the middle part of 2022, we would hopefully be back to pre-pandemic occupancy levels and just the new normal in dealing with infection control.

How dire is it that these facilities get the remaining Provider Relief Funds, how much longer do you think operators can wait?

As I’ve talked to providers across the country, the amount of funds they have left to survive the pandemic depends a lot on what state they’re in.

There are some states that have provided more funding to providers than other states, but in the states that have provided almost no funding, or a limited amount, I’m talking to providers that are going to start running out of money in 60 to 90 days.

For others it’s longer than that, maybe in the six month time frame, but the challenge is that once the Provider Relief Fund announces a new payment it’s going to be a portal and an application process — which itself is going to take some time. Even if they would announce the new program today, they’d have to really make it quite efficient in order to have checks out in the next 60 to 90 days.

We’re entering this really dangerous period of time where people are going to be running out of money. There’s $43 billion still sitting there at the Provider Relief Fund which for some reason is not being paid out. That’s why we think a very simple thing that the administration can do that would help immediately is to open up the availability of those funds, otherwise folks are just going to run out of money.

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