Jeanne Peters, 95, a resident at The Reservoir nursing home in West Hartford, received a COVID-19 vaccine on Dec. 18. The Reservoir was among the first nursing homes in Connecticut to begin vaccinating residents against coronavirus. AP Photo
Jeanne Peters, 95, a rehab patient at The Reservoir, a nursing facility, was given the first COVID-19 vaccination in a Connecticut nursing home Friday, Dec. 18, 2020, in West Hartford, Conn. Administering the vaccine is Mary Lou Galushko, a CVS pharmacist form North Haven, left. (AP Photo/Stephen Dunn)

In January, Gov. Ned Lamont announced that Connecticut was the first state in the nation to vaccinate all nursing home residents. By the end of that month, the state had even administered more doses than there were residents, in part because some facilities cater to residents discharged from hospitals who enter nursing homes for short periods to recover.

But while the overall rate of vaccination among residents remains extremely high, it’s that kind of turnover that has some facilities now reporting rates as low as 66%. Just under a third of nursing homes reported rates under 90%. “Some facilities might have more recently admitted residents who were not vaccinated upon admission,” wrote Department of Public Health spokesperson Chris Boyle.

“We can’t turn down patients because they aren’t vaccinated,” said Tim Brown, spokesperson for Athena Health Care Systems, which runs 26 nursing homes in the state. “As long as we have it documented that we offered them the vaccine, there is nothing else we can do.”

Nursing home residents have been disproportionately impacted by the coronavirus, from the early days of the pandemic through the delta wave these past few months. As Connecticut heads into the winter, COVID-19 is expected to make a resurgence, as do most respiratory viruses in the colder months. But low resident vaccination coverage in some of the state’s nursing homes is not a problem that has immediate solutions.

In early September, Josh Geballe, the state’s chief operating officer, wrote that the governor’s office was not planning to institute a vaccine mandate for residents in long-term care facilities. The state has mandated that nursing home staff be vaccinated, citing a desire to ensure resident safety.

DPH has also retired “Operation Matchmaker,” a vaccination initiative that specifically targeted short-term residents in nursing homes earlier this year, though nursing homes still have access to vaccines via pharmacies.

Poor data collection on short-stay residents poses another problem in understanding and mitigating the risks posed by those entering nursing homes for short-term rehabilitation. DPH does not have an up-to-date facility-level count of the short-stay residents trekking in and out of the state’s approximately 209 nursing homes.

The agency is reliant on a federal COVID case reporting system called the National Healthcare Safety Network, instituted by the Centers for Medicare and Medicaid Services. CMS does not break out resident coronavirus cases by whether individuals are short-stay or long-term residents, and therefore DPH cannot differentiate between them, Boyle wrote.

Sunil Parikh, an epidemiologist at the Yale School of Public Health, has been studying COVID spread in Connecticut nursing homes in conjunction with DPH.

“We are working with them to understand the factors that are leading to COVID spread in the time of the delta variant and good vaccination coverage,” he said.

Parikh is “definitely interested in this question” of how short-stay residents impact disease spread — but at the moment, “I don’t think we really have this data yet,” he said.

Understanding resident vaccination rates

Data on resident vaccination rates are published by the CMS weekly with a delay of about two weeks. The most recent data available go through Sept. 26. The federal data may contain some reporting errors; DPH conducts a quality check where “outliers and potentially inaccurate data are flagged.”

In addition to being old and error-prone, the public data “show stochasticity,” Boyle wrote in a statement to CT Mirror. That means a nursing home’s vaccination rate today will not necessarily have any bearing on its vaccination rate two weeks in the future, since rates would depend on the vaccination status of discharges and admissions, which may vary widely week to week.

For instance, as of Sept. 12, Arden House in Hamden posted a resident vaccination rate of 76%. Last week, the number rose to 85%, according to a statement provided by spokesperson Lori Mayer. The nursing home has also scheduled a COVID-19 vaccine clinic this week “for any additional residents who want to be vaccinated,” she wrote.

But patterns have still emerged from the data. Brown said that Athena has seen lower resident vaccination rates recently in facilities where short-term rehabilitation is a large focus.

It’s not uncommon for a short-term rehab facility like Middlesex Health — which reported the lowest DPH-verified resident vaccination rate — to have four or five discharges or new patients in a day, he said. Northbridge Health Care Center in Bridgeport is in a similar situation and under 80% of residents there are vaccinated, according to the most recent data.

Despite the random variation that any individual nursing home might see over time, the range of resident vaccination rates posted by all nursing homes has remained relatively constant over the past few months. In other words: Though individual nursing homes may move up or down in a ranking based on resident vaccination rates, the range of rates reported has remained fairly broad, between 60-100%. The median rate has hovered between 91-94%; half of nursing homes report rates under the median, and half over.

By contrast, the range has narrowed for staff vaccination rates since the state announced that it would mandate vaccinations for staff in the first week of August. The median rate of vaccination has also increased significantly, though latest figures still had it lower than residents at 90%. The most recent data available show rates just before Sept. 27, the state’s staff vaccination mandate deadline.

The state is not currently imposing a similar mandate for resident vaccinations.

No other states in the country have announced such a mandate. Arthur Caplan, professor of bioethics at NYU Langone School of Medicine, did not believe that there was precedent for a resident vaccination mandate for other illnesses such as the flu either. “Residents who are elderly tended to be more highly vaccinated so mandates focused on staff bringing in flu and also being sick and absent from work.”

Nevertheless, Michelle Mello, professor of law at Stanford University, said the state had the ability to impose a COVID mandate if it chose, provided that it allowed for religious, disability-related and medical exemptions.

But such a mandate could do more harm than good.

“Resident vaccination rates are already extremely high, we ensure there is regular testing to identify and mitigate outbreaks, and many residents have no alternatives about where to live,” Geballe said.

Current disease mitigation strategies

CT DPH follows CMS policies and CDC guidance, which is based on the latest evidence for effective disease prevention and control measure,” Boyle wrote.

Several long-term care providers said DPH has suggested testing new residents when they arrive, quarantining them and testing them again after five days to ensure the virus hasn’t surfaced, and again after 12 days when it is likely a resident is close to getting ready to go home.

The state has retired a program where pharmacies and other providers were “responsible for immunizing new residents and staff, especially the revolving door of short-term residents, who typically stay for a month or less for rehabilitation services,” The Mirror previously reported.

“Operation Matchmaker was an initiative that took place during the spring to ensure that each nursing home had a pharmacy that could offer COVID vaccines to residents who were admitted after the initial round of clinics that were done by CVS and Walgreens,” Boyle wrote. “Since that time, DPH has worked to ensure that all facilities are partnered with a long-term vaccine provider to conduct continued resident vaccination as needed – including for booster doses or other needs that arise.”

“Facilities report to the federal government and the state weekly through the CDC’s National Healthcare Safety Network if they are having trouble accessing vaccine. The Connecticut Department of Public Health monitors this reporting closely and reaches out to facilities that may have issues,” Boyle wrote.

There are four pharmacies in Connecticut that do most of the business with nursing homes and that are now providing them vaccines when they need it. The four pharmacies are Omnicare, Pharmerica, Partners Health and Procare. In some cases, the pharmacies are sending staff to the facilities to administer shots, but most facilities are having their own staff administer the vaccine at this point.

Several providers said that if someone isn’t vaccinated by now it’s likely they won’t get the shot, no matter what.

Vaccinations have been very successful at reducing illness and death in nursing home settings in Connecticut.

Nevertheless, nursing home residents continue to be at high risk of contracting and dying from COVID-19. A national study by the Kaiser Family Foundation found that nursing homes witnessed a “steeper increase in COVID-19 cases and deaths in August 2021 than the rest of the country.”

“Without vaccinating people and as many people in our state as we can, we run the risk of COVID-19 surging its ugly head,” said DPH Commissioner Manisha Juthani during a COVID briefing last month. “It is the winter months when respiratory viruses circulate in general, so we have to be prepared for that. We have to be prepared for the worst. But I am cautiously optimistic.”