Florida’s omicron winter hit nursing homes hard, with the number of weekly infections reported among residents and staff reaching record highs in mid-January.
But despite reporting more cases for a single week in mid-January than at any other point in the pandemic, Florida nursing homes are not seeing a corresponding spike in deaths — the cumulative effect, experts say, of immunity from vaccines and prior illness with COVID-19, hard-won experience with infection control, and new therapies that reduce the severity of disease.
“The fact that there were not more deaths is probably due to vaccination and the fact that many people had it before, and the nursing homes knowing what to do, having procedures they didn’t have when this started concerning PPE [personal protective equipment] and who to isolate and when and how,” said Lindsay Peterson, a researcher with the University of South Florida’s School of Aging Studies.
“They maybe deserve some credit for figuring out how to keep people alive, if not preventing them from getting COVID,” she said of Florida nursing homes.
Florida prioritized nursing home residents and staff for vaccination in December 2020, and Peterson said that policy helped to build immunity among some of the state’s most vulnerable residents.
Nearly 82% of people who live in a Florida nursing home were fully vaccinated against COVID-19 as of Jan. 30, according to the Centers for Disease Control and Prevention’s data dashboard. Among nursing home workers in Florida, about 79% are fully vaccinated, meaning they have received at least two doses of the Pfizer or Moderna or one shot of the Johnson & Johnson vaccines.
A low uptake of boosters
But vaccine immunity wanes after about five months, and more than a year after the state prioritized them for vaccination an even smaller share of Florida nursing home residents and staff have received the recommended booster or third dose.
The CDC recommends a booster at least five months after completing vaccination with the Pfizer or Moderna shots and two months after receiving the Johnson & Johnson vaccine.
As of Jan. 30, about half (52.4%) of fully vaccinated people living in a Florida nursing home have received a booster dose, according to CDC data. Among fully vaccinated staff, about one in five (21.5%) have received an additional dose.
That may help explain why nursing homes reported record-high cases in mid-January.
Cindy Prins, an epidemiologist and assistant dean for educational affairs at the University of Florida’s College of Public Health and Health Professions, said having four of five nursing home residents and workers fully vaccinated may sound good. But it’s not enough to protect those who are at greatest risk of severe illness and death from COVID.
“Eighty percent vaccination rate among Florida nursing home residents. That sounds great, but it leaves you with a significant number of people who are very vulnerable, people who are older and have underlying conditions and then are not vaccinated,” she said. “People are still dying from it.”
Even for those who survive, COVID-19 is not without risk.
“We need to remember that there are many factors that go along with getting infected, besides hospitalization and death,” Prins said. “This may still lead to other outcomes ... They may have lingering issues from having been infected.”
Record-high cases
New cases in Florida nursing homes peaked in mid-January, about a week after new cases crested statewide.
More than 3,400 people living in a Florida nursing home tested positive for COVID-19 during the week ended Jan. 16 — about three times the number of cases reported during the peak week of the delta wave in mid-August, according to CDC data.
Florida nursing home workers also had record-high infections, with more than 4,500 cases reported during the week ended Jan. 9, about a fourfold increase over the highest week in August.
Nursing homes reported 50 deaths per week during the two weeks that ended Jan. 30, a significantly lower number than the peak of every prior wave of the pandemic.
That doesn’t mean omicron hasn’t hurt nursing homes.
The highly contagious variant infected so many residents and staff in January that many facilities had to stop admitting new residents, leaving some hospitals unable to discharge patients to facilities for rehabilitation or long-term care, said Mary Mayhew, president of the Florida Hospital Association.
“We have definitely seen a delay and an increase in the number of patients who are awaiting discharge,” Mayhew said in late January.
The FHA surveyed its member hospitals recently and, with about 40% responding, found that, “There were over 1,000 patients who were in need of a bed in a skilled nursing facility and no longer required hospital level of care,” Mayhew said.
Empty beds mean financial pain
Throughout the pandemic, nursing homes also have reported lower occupancy due to patients declining to be admitted to a facility or family members taking out loved ones to live at home.
Kristen Knapp, director of communications for the Florida Health Care Association, a nursing home industry advocacy group, said most of the FHCA’s members were forced to limit admissions in mid-January due to staffing shortages attributable to the omicron wave.
Empty beds cause more financial pressure for nursing homes, and it’s coming at a time when the FHCA estimates that facilities are experiencing an average 12.6% increase in costs, including testing, infection control supplies and PPE, Knapp said.
Most nursing homes receive the majority of their revenue through fixed rates from Medicaid, the public health insurance program for low-income and disabled Americans, which limits their ability to spend more, whether its on wages or other fixed costs, Knapp said.
“When you’re limiting admissions, your lease payment doesn’t go down. Your fixed payments don’t go down,” Knapp said. “If you’re a 120-bed building and you only have 80 beds filled. That’s typically how facilities are able to recover. They’re able to fill their beds. But you can’t fill your beds when you don’t have the staff.”
To shore up their workforce, nursing home administrators have used signing bonuses, pay raises and temporary staffing agencies, Knapp said.
The FHCA intends to help the industry by asking legislators to raise the Medicaid rates for nursing homes, she said. The group also helped draft a legislative proposal that would loosen restrictions for certifying workers — making it easier for nursing homes to admit more residents without having to hire additional staff.
Changing the job requirements
Florida law requires a nursing home to provide a minimum of 2.5 hours of direct care per resident per day by a certified nursing assistant or CNA. In addition, each facility is required to staff at least one CNA per 20 residents and at least one licensed nurse per 40 residents.
Under the proposal supported by FHCA, Senate Bill 804, nursing homes that do not meet the state-mandated staff requirements would no longer be barred from admitting new residents.
But patient advocates oppose the proposed changes, saying that nursing home residents will lose restrictions designed to ensure patient safety and quality of care.
Jeff Johnson, state director of AARP Florida, said many long-term care residents need help brushing their teeth, getting dressed, eating and performing other daily activities — and he worries that no one will help patients with those tasks if no one is explicitly assigned to do so.
“That care needs to be provided by somebody, and somebody who’s trained to do it and whose job assignment is that,” Johnson said. “Unless they’ve got robots who are changing people’s diapers, that part hasn’t changed.”
‘A nervous breakdown’
Most nursing home staff who miss work with a COVID-19 infection have mild to moderate illness and many return to work after five days as recommended by the CDC.
Prins, of the University of Florida, said the CDC’s revised guidance helped ensure that healthcare facilities could still function but likely left some vulnerable patients and nursing home residents at risk.
“Obviously that was important to make sure that we have a workforce in place, that we don’t have shortages,” she said. “But I think we also have to acknowledge that we probably also had people coming back who were still spreading COVID.
“If they come back to an environment like a nursing home and long-term care,” she said, “that can be problematic.”
Infected nursing home patients not only risk severe illness and death, they also require more attention and more resources to isolate and prevent the virus from spreading.
And nearly two years after the pandemic began, industry experts say many nursing home workers are burned out or leaving for jobs with similar pay but fewer responsibilities and requirements.
“Everybody is on the verge of a nervous breakdown right now because of the accumulation of things that have been going on since early 2020,” said Peterson of the University of South Florida’s School of Aging Studies.
Vaccine mandate for healthcare workers
Some fear that a federal mandate for healthcare facilities, including nursing homes, to ensure workers are fully vaccinated by Feb. 28 will only worsen a staffing shortage that predates the pandemic.
Prins said it’s critical for nursing home workers to get vaccinated to protect vulnerable residents, especially because they work very closely with them. But many have been hesitant to get the shot, and the pay generally isn’t high enough to discourage some of them from leaving.
Soon there won’t be a choice, though. The Supreme Court has upheld the Biden administration’s vaccine mandate for healthcare workers, and the deadline for facilities in Florida to comply with the rule is Feb. 28.
Facilities that fail to fully vaccinate 100% of their workers risk being terminated from the Medicare and Medicaid public health insurance programs, the biggest payers in the healthcare system. But federal regulators have said that nursing homes, hospitals and other healthcare facilities that do not meet the requirement by deadline will be given a chance to comply.
Prins said it’s important for nursing home workers to get vaccinated in order to protect vulnerable residents, but she worries that the mandate will drive away employees in an industry that has long struggled with staffing shortages.
“I worry that because of an overall shortage of healthcare workers, these are people who are going to decide that they’ll go elsewhere rather than get vaccinated,” she said. “It’s a concern to me whether or not we’re going to lose some of that workforce.”
Exodus of nursing home workers
A mass exodus of nursing home workers is already happening, according to Bureau of Labor Statistics jobs data cited by the American Health Care Association and the National Center for Assisted Living.
The industry organizations report that nursing homes have lost at least 234,000 employees since the start of the pandemic, more than hospitals, doctors’ offices and other healthcare facilities.
Florida nursing homes employed about 150,000 people before the pandemic, the FHCA’s Knapp said, but the industry has lost about 10,000 jobs since March 2020.
The University of South Florida has surveyed nursing homes during the pandemic, Peterson said, and part of the challenge with staffing is that many CNAs and other employees have young children at home and they’re struggling to balance work and family lives.
Given the chance, she said, many nursing home workers are taking jobs with more predictable schedules or leaving the workforce altogether.
“A lot of the nursing home workforce are women of child-raising age, and they feel like they need to be home with their kids,” Peterson said. “So they’re doing what they can to stay home.”
There’s also the challenge that the more understaffed a nursing home is, the more difficult the job becomes for the employees who remain — a frustrating dynamic that leaves some feeling exhausted and frustrated, she said.
“It’s almost like nothing is going to get back to normal until everything is back to normal,” she said. “It’s extreme fatigue in the nursing home business. ... I don’t know how to fix it. You can give people more money but it’s hard, hard work, and it’s hard to make the work any easier except when you do have adequate staff.”
Johnson of the Florida AARP agrees that nursing homes are facing some of the same labor challenges as other industries, though staffing shortages in long-term care predate the pandemic.
But he also believes that working in a nursing home is a calling.
“It’s true that CNAs are making about what they could make working at fast food,” he said. “That also means they’re doing this work because they love it. It’s hard work and they have other options.”
Planning for the future
As Florida enters a third year of the pandemic in March, Johnson said nursing homes will need to develop long-term solutions for staffing shortages without compromising quality of care for residents.
“We ought to be focused on how we prioritize home and community-based care,” he said, “because it tends to be what people want more, and it’s more affordable.”
Long-term care facilities will also need to remain alert for future surges of COVID-19, said Prins with the University of Florida’s College of Public Health. She said in addition to encouraging vaccines and boosters for residents and staff, nursing home administrators should be looking at ways to increase testing, improve air circulation inside facilities and provide high-quality respirator masks that fit properly.
She also believes that messaging is key.
Prins said the record-high cases that nursing homes reported in January reflect a broader and somewhat dismissive attitude about the omicron variant, which was widely reported to be less severe than previous versions of the virus.
“It’s discouraging to have seen this level of transmission with omicron. I feel a little discouraged that the message that got out is, ‘Don’t worry about it. It’s mild. Go get it over with,’ is what people got in their heads, and I don’t think that needed to be the case.
“That part to me is discouraging, especially when you think about people who are vulnerable.”
———
