COVID-19 vaccination rates increased among nursing home employees across the US after the Biden administration announced a COVID-19 vaccination mandate last August for staff working in facilities receiving Medicare and Medicaid funding, according to a new report by KFF (Kaiser Family Foundation) researchers. Their analysis also found that despite concerns that the mandate might spur nursing home workers to quit or be fired for noncompliance, the requirement does not appear to have worsened staffing shortages.
To date, at least one-quarter (23%) of US deaths from COVID-19 have occurred among residents or staff at long-term care facilities. The toll was even higher early in the pandemic, with COVID-19 deaths at such facilities comprising nearly half of all US COVID-19 fatalities.
The KFF researchers analyzed nursing home–level data for some 14 700 nursing facilities, about 97% percent of all US nursing facilities. They found that COVID-19 vaccination rates among nursing home staff increased nationally by 25 percentage points (from 63% to 88%) between the August 2021 mandate announcement and March 27, 2022, after the vaccination deadlines for health workers had passed in all states. Because of litigation challenging the new rule, facilities in different states had different deadlines for compliance.
As of March 2022, 12% of nursing homes nationally reported that 100% of their staff were fully vaccinated. Among states, the share of facilities with universal staff vaccination ranged from 0% in Wyoming facilities to 56% of facilities in Rhode Island. Another 39% of nursing homes nationally reported staff vaccination rates of 91% to 99%, whereas the remaining 49% reported that 90% or less of their staff had been fully vaccinated.
Although the Centers for Disease Control and Prevention said that booster shots offer substantial protection—with adults who received 3 doses of a COVID-19 vaccine being 94% less likely to be put on a ventilator or die from the infection compared with unvaccinated adults—the Centers for Medicare & Medicaid Services does not require nursing home staff to receive booster shots.
The national booster rate for nursing home employees increased 17 percentage points (27% to 44%) between mid-January 2022 and March 2022, after vaccination deadlines had passed. However, the booster rates for nursing home staff varied widely across states, ranging from 93% in Massachusetts to 24% in Florida, Mississippi, and Missouri.
Nationally, about 31% of facilities reported that more than half of their employees had received a booster shot, another 31% reported rates below 25%, and roughly 37% reported that 25% to 50% had been boosted.
Some states had booster mandates that likely resulted in greater uptake of booster shots by nursing home staff. This included 5 states (California, Connecticut, Massachusetts, New Jersey, and New York) reporting increases of more than 30 percentage points in booster shot rates between January 2022 to March 2022.
Although a number of factors may have contributed to boosting staff vaccination rates, “the mandate did likely play a role in increased vaccination rates from August 2021 to March 2022,” the researchers said.
Despite warnings by some nursing home operators that the vaccine mandate might lead to a shortage of staff at long-term care facilities, data suggest that this did not happen. The KFF analysis found that on average, 28% of US nursing homes nationally reported staffing shortages as of March 2022, a slight decrease from the peak in January 2022 after vaccination deadlines in all states had passed.
“Data suggest that the vaccine mandate has not exacerbated staffing shortages to the extent initially hypothesized since shortages have actually fallen nationally since January 2022,” the KFF researchers said. The share of nursing facilities reporting a staff shortage peaked at 34% in the week ending January 23, 2022—during the wave of infections caused by the Omicron variant—and then fell slightly and remained relatively stable through March, even after the vaccine mandate went into effect.
In February, the Biden administration announced several policies to address staffing issues in nursing homes. These include establishing minimum staffing levels for Medicare and Medicaid-certified nursing facilities; supporting state efforts to tie Medicaid reimbursement rates to increases in clinical staff wages and benefits, including additional pay for experience and specialization; and launching a national nursing career pathways campaign.
In addition, a recent report from the National Academies of Sciences, Engineering, and Medicine on nursing facilities recommended enhanced and updated federal staffing standards as one of a number of components in recommended reforms. At the state level, some states have taken steps to boost minimum staffing requirements since the onset of the COVID-19 pandemic.
“It will be important to watch whether and how lessons from the pandemic are integrated into new federal and state policies to improve nursing facility care quality and protect residents and staff,” the KFF researchers noted. “As new COVID-19 variants emerge and make their way into nursing facilities, maximizing vaccination and booster rates among facility staff will help protect against illness and death of residents and staff, and help maintain sufficient staffing levels.”
Published: May 24, 2022. doi:10.1001/jamahealthforum.2022.2069
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Stephenson J. JAMA Health Forum.
Corresponding Author: Joan Stephenson, PhD, Contributing Editor, JAMA Health Forum (Joan.Stephenson@jamanetwork.org).
Conflict of Interest Disclosures: None reported.