Long-term care providers were intent on dismissing undesirable memories of the COVID-19 pandemic as much as possible in 2023, but the year’s top stories revealed there were still remnants of it to deal with — and plenty of other issues to fill the gaps.

From unprecedented, increased regulatory pressures to newly introduced legislation, ongoing workforce challenges, image problems and more, there was a lot to digest.

Here are the top stories that grabbed our readers’ attention in 2023, the top handful of them inevitably related to the staffing mandate and the sector’s ongoing workforce challenges.

Federal minimum staffing proposal dominates

By the time the Centers for Medicare & Medicaid Services finally issued its first-ever rule to set nursing home minimum staffing levels, the sector had experienced a roller-coaster of tense emotions. The Sept. 1 announcement put providers and their advocacy counterparts in labor and consumer groups in an uproar.

Operators called the proposal an impossible, unfunded mandate, if not because of the estimated $4 billion or greater price tag, then because there simply aren’t currently enough registered nurses to satisfy the tripling of current mandated levels.

‘Accidental’ early study release, Biden unloads on providers

President Biden added fuel to the fire when he unloaded on nursing operators just days after the staffing mandate was proposed.

The administration, however, was undercut a few days before the proposed rule’s release, when a “draft” of it was briefly posted online before being pulled down. That gave outsiders an early look at study findings saying it’s impossible to settle on a specific staffing level(s) that would serve the White House’s desired goal. Despite officials calling it a “draft” study report, it was nonetheless included in the same form when the proposal was released later that week.

The intrigue persists: Was it truly an accidental early posting, or was it the purposeful act of an insider sympathetic to providers’ year-long criticism that an unprecedented staffing mandate would be a bad idea?

Staffing mandate’s costs greatly underestimated: report

Three weeks after the staffing mandate was officially proposed, a respected third-party analyst hired by providers found that its cost would be nearly 60% higher than the $4 billion annual cost estimated by the Centers for Medicare & Medicaid Services.

Nursing homes would need to spend more than $6.8 billion annually and hire more than 102,000 new workers under its proposed form, said an updated analysis issued by accounting and consulting firm CliftonLarsonAllen.

Bills would block federal staffing mandate

Within five weeks of the staffing rule’s proposal, Republican House members proposed legislation to block it. A similar Senate bill, this one bipartisan, was proposed in December. 

The legislative efforts are being led by lawmakers in rural states, which figure to be most severely hurt by any new staffing standard.

CMS delivers 4% Medicare pay raise

Nursing homes received a higher-than-expected 4.0% increase to their Medicare Part A payments for fiscal 2024. The July 31 final rule from CMS added 0.3% — or $200 million — to the agency’s original April proposal. Inflationary costs were deemed responsible for the largest annual increase in recent memory.

In addition, most of the recommended vast changes to CMS’ quality reporting and value-based purchasing programs were retained in the final rule.

Biden plan would tie pay rates to staff turnover rates

In mid-April, President Biden signed a massive executive order that included several measures intended to improve access to long-term care and bolster job protections for skilled nursing workers. Among them were calls to expand on the then-undisclosed staffing mandate and to tie Medicare payments to staff retention.

The White House called the 50-plus elements the “most comprehensive set of executive actions any President has ever taken to improve care for hard-working families while supporting care workers and family caregivers.”

Nursing home ownership transparency pushed

Federal authorities made good on their promise to increase transparency from anyone owning a stake in nursing homes, or doing top business with them, with a rule finalized Nov. 15.

The rule imposes many of the ownership transparency measures outlined in a February proposal and defines both private equity and real estate investment trust owners. A coalition of 18 attorneys general fueled aspects of the rule with a plea for more ownership information.

Feds lift COVID-19 vaccine mandate that Supreme Court upheld

Regulators made big news in late spring when they announced they were acting to COVID-19 vaccination requirements for healthcare workers. The mandate had been upheld by the Supreme Court in a historic court decision in January of 2022.

Other vaccine requirements also were lifted with the end of the public health emergency on May 11. Booster shot rates have plummeted since.

Among the other big story lines

As the referring examples in this sentence indicate, the skilled nursing sector saw a growing number of providers shedding or closing facilities, or filing for bankruptcy as access worries mounted.

Meanwhile, as Medicare Advantage plans passed the 50% market share level for the first time, regulators made moves to impose more standards on them, with providers appealing for even more.

On Oct. 1, the largest overhaul to the Minimum Data Set in years became effective, capping a hectic year of planning and worrying.

Also on the federal regulatory front, authorities quietly put into place new, stricter measures regarding infection control and general vaccine immunization matters. They also continued to increase scrutiny of the use of antipsychotics and schizophrenia medications.

In other pandemic-related matters, a federal jury found that the nursing home that was the site of the first major COVID-19 outbreak in the US was not liable for the deaths of two residents. It signified one of a number of heartening court victories for providers accused of wrongdoing in the early days of the public health emergency.

Every long-term care resident deserves to enjoy these festivities to the fullest without the risk of acquiring a respiratory virus that may land them in the hospital, or worse. As highlighted during the pandemic, what happens in the outer community is the major driver of viral spread into long-term care centers. So, it is incumbent upon all of us to ensure that our population is equipped to fight off common respiratory viruses, such as influenza, RSV and COVID-19; however, the challenge lies in convincing our nation’s seniors, healthcare workers, and the general public to roll up their sleeves and get vaccinated. 

As a geriatrician and current chief medical officer at the nation’s largest organization representing long-term and post-acute care centers, I have witnessed both the devastating impact these viruses can have and the incredible strides the global medical community has made in developing effective vaccines. We know that these vaccines may not necessarily prevent infection, but they do reduce the risk of severe illness and a potential trip to the hospital or worse — death. 

A need to double-down

Despite these major advancements and historic milestones, we are seeing a decline in the number of individuals willing to receive these vaccines. “Vaccine fatigue” and hesitancy are rampant throughout our society but especially when it comes to the COVID-19 and RSV vaccines. 

A recent KFF survey found that more than half (51%) of all adults say they “definitely” or “probably” will not get the latest COVID-19 shot and two-thirds of the general public are not worried about getting the virus. Meanwhile, only 16% of adults 60 years and older report having received the RSV vaccine. These surveys are consistent with what we’re seeing unfold. 

Recent data from the CDC shows low vaccination rates in the community. While we are seeing the same trends in long-term care settings, it is encouraging that our uptake is higher than in the community. Nonetheless, we need to double-down on our efforts to increase those numbers. 

Much has been written about challenges with vaccine availability or why we should hold more clinics to vaccinate our residents. These are not the reasons we’re seeing slow uptake. While initially the new COVID-19 vaccine was hard to access because it was first sent to commercial pharmacies serving the general public, the vaccine is now more widely available through the pharmacies serving nursing homes. National regulations require nursing homes to educate and offer every resident and staff member the COVID-19 vaccine. 

Harmful ripple effects

The primary issue is that the majority of residents or their family members who are making decisions for them either no longer believe the COVID vaccines are necessary or express fear and skepticism about getting the new shots. We are hearing similar concerns related to the RSV vaccine, despite evidence that it is most effective among the elderly, individuals with chronic diseases, and those who live in a long-term care setting. 

I’m also concerned that this vaccine fatigue and hesitancy is impacting interest in the influenza vaccine, which is lower this year than in pre-pandemic years. 

In addition, there are administrative and insurance reimbursement challenges that need to be addressed. In long-term care, we need vaccines to be readily available to order when a current resident or new admission wants the vaccine. Additionally, those orders need to come with a guarantee that we, as providers, or the pharmacy receives reimbursement from all insurance providers — not just Medicare. Cutting the red tape around reimbursement can help ensure that long-term care providers have access to the vaccine and remain focused on encouraging uptake. One way federal policymakers could take this a step further would be to offer a pool of free vaccines available to long-term care providers. This would eliminate the administrative burden and streamline access to vaccines for residents and staff. 

While free vaccines would be ideal, most importantly we need effective and consistent public health messaging, which is the major driver of the current vaccination rates. We need every provider in every healthcare setting — from the physician’s office, commercial pharmacy, adult day care, hospital and beyond — to discuss the importance of the vaccines with the elderly and their family and address each person’s concerns. 

We’ve come a long way, but … 

Unfortunately, many new admissions arrive to a nursing home or assisted living community without having been offered or received the vaccine during their encounters with clinicians in other healthcare settings. 

Using nursing homes as a stopgap to vaccinate all individuals is ineffective and insufficient. Seniors and families need to be offered the vaccine before they’re admitted to a long-term care facility — and at every subsequent interaction, especially since primary healthcare providers are seen as trusted advisors. Long-term care staff can then help pick up those missed or continue to work to convince hesitant or skeptical residents to get vaccinated. By increasing our education efforts throughout the healthcare community, we can work together to encourage more individuals — residents and staff alike — to get vaccinated.

We’ve come a long way since 2020: COVID-19 is no longer a pandemic, and the mortality rate among nursing home residents remains at record lows. Vaccines are a major reason why, but after three years of battling this virus, Americans have a hard time acknowledging vaccines are still necessary. 

Nursing home providers cannot shoulder the responsibility of combating these deeply held beliefs all on their own. As a country, we need to focus on collectively increasing vaccination rates among the general population and avoid isolating or placing blame on specific communities or individuals. 

Long-term care providers should be applauded for achieving higher vaccination rates than in other settings, but we need a collective endeavor to take this further. 

By having the entire healthcare community and public health system collaborate, we can overcome vaccine skepticism and hesitancy and achieve even better vaccination rates among our residents. In turn, we can better protect our most vulnerable community members. 

David Gifford, MD, M.PH, is the chief medical officer of the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL). 

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

The CDC said that low uptake of vaccines for COVID-19, respiratory syncytial virus (RSV) and flu are to blame for putting Americans at risk for severe illness and hospitalization this winter. 

“Low vaccination rates, coupled with ongoing increases in national and international respiratory disease activity caused by multiple pathogens, including influenza viruses, SARS-CoV-2 [the virus that causes COVID-19], and RSV, could lead to more severe disease and increased healthcare capacity strain in the coming weeks,” a CDC statement said. “In addition, a recent increase in cases of multi-system inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection in the United States has been reported.”

Compared to last year, about 7 million fewer adults were vaccinated this year. The vaccination rate is 36% for adults and children. In terms of the COVID-19 shot, 17% of adults (and 36% of them older adults) and 8% of children received their latest shots. About 16% of people over the age of 60 have received the RSV shot.

“We are seeing too few folks get vaccinated this season,” CDC Director Dr. Mandy Cohen said during a briefing this week with the American Medical Association, CNN reported. “The voice of the physician matters so much in whether or not folks decide to get vaccinated.”

The CDC cited a survey in their advisory to explain why people aren’t getting vaccinated in large numbers. Survey data said that doctors aren’t recommending the shots enough, and there are concerns about side effects from vaccines, while others forget to get vaccines. 

“About 70 to 80% of American adults over the age of 18 have at least one condition that puts them at higher risk of a bad outcome,” Cohen said. “Getting vaccinated decreases your risk of hospitalization and death at every age, including 18 to 64, but it also decreases your risk of long COVID.”

Emergency department visits and hospitalizations for respiratory diseases are increasing among all groups of people, the CDC said.

In the past four weeks, hospitalizations increased 200% for flu, 51% for COVID and 60% for RSV, according to the CDC advisory. There have also been 30 reports of MIS-C, a rare complication in children infected with COVID that typically surfaces a month after infection.

“These tools that protect us — vaccines … testing and treatment and washing hands and ventilation and masks — all of these things are layers of protection that help make sure that we can weather this season,” Cohen said.

Using data from the Centers for Disease Control and Prevention, the analysis found that deaths over the four-week period ending Nov. 19 were more than four times higher than those recorded during a four-week period ending June 25.

About 1,000 residents died from the virus in the fall time frame, bringing the year-to-date total to roughly 9,000 residents, AARP reported. Since the start of the pandemic, more than 185,000 nursing home patients have died of COVID.

But vaccinations, at first widely embraced by residents and later mandated for healthcare workers, drove infection and deaths rates down dramatically starting in 2021.

The uptick in deaths last month, accompanied by a quadrupling of infections of both residents and staff compared to this summer, comes as vaccine coverage is way down compared to the last two winters.

But there is some reason for optimism. The AARP analysis reported about 25% of nursing home residents were considered up-to-date on COVID shots, though that figure was based on Nov. 19 reporting. As of Dec. 3, according to Centers for Medicare & Medicaid Services data, the resident up-to-date figure had climbed to 30.7%, with 7.2% of staff covered.

Resident deaths peaked at 338 the week ending Nov. 26, then fell back to about 260 per week for the first two weeks of December, according to a review of CDC data by McKnight’s Long-Term Care News on Thursday. That’s still on pace to record another 1,000 deaths by year’s end, however.

Providers have continued to encourage vaccination, but in many states they reported early challenges with accessing shots, paying for them and getting enough for all of their people. More broadly, aging services providers said they are facing the same challenges public health officials are: a lack of interest in yet another round of vaccines.

“Long-term care providers are making every effort to encourage residents and staff to get vaccinated, and we are confident we will continue to make progress in the face of cold and flu season,” David Gifford, MD, chief medical officer at the American Health Care Association/National Center for Assisted Living told McKnight’s in late November.

“While nursing home residents are more than three times as likely to be up to date on their COVID vaccinations compared to the general public, nursing homes do not operate in a vacuum,” he added. “Unfortunately, we face the same challenges that we’re seeing across the US population at large: vaccine misinformation, hesitancy and fatigue. We need a collective approach to boost vaccine access and uptake, and AHCA/NCAL will continue to seek support of public health officials and the broader health care community.”

In November 2021, AARP reported, almost 90% of residents were vaccinated and roughly 40% had received a booster shot. Staff vaccinations had also hit the 80% mark just ahead of the Supreme Court approving a federal mandate. That mandate was ended along with the expiration of the public health emergency earlier this year.

Kimberly Marselas

With updated COVID vaccines expected to be widely available by week’s end, providers are ramping up efforts to get shots into arms as nursing home cases remain elevated compared to the last six months. 

The American Health Care Association/National Center for Assisted Living on Wednesday launched its 2023 #GetVaccinated Toolkit, with resources designed to equip providers with the tools and information needed to encourage “critical vaccinations among residents and staff.”

“Long-term care providers are making every effort to encourage residents and staff to roll up their sleeves,” AHCA President and CEO Mark Parkinson said in announcing the updated tools. “We remain focused on ramping up those education efforts this fall and partnering with Administration officials and other stakeholders to streamline access to vaccines.”

US nursing homes have reported more than 10,000 resident COVID cases in each of the last three weeks, according to the Centers for Disease Control & Prevention. That’s a level not seen since March, and it has sparked some concern given that cases have tended to climb in winter months as more people move indoors.

Notably, as mask requirements and visitation limitations are largely gone, the share of nursing home residents “up to date” on their COVID shots has fallen to 62.1%. And staff coverage lingers around 25%, according to Centers for Medicare & Medicaid Services dated Aug. 27.

The head of the CDC on Tuesday evening approved the rollout of a new shot, the first to target a common post-omicron variant known as XBB.1.5. The agency recommended the shot for anyone 6 months and older.

The last shot recommended was for seniors and the immunocompromised, who were advised in April that they could receive a second booster at least four months after their last shot.

But some nursing homes faced challenges in encouraging their patients to accept new boosters, given less urgency around the disease this spring and summer..

Nursing home resident deaths, however, have more than doubled from an average around 80 nationally in mid-July to 199 for the week ending Sept. 3.

Increasing cases and more serious outcomes among the senior population are good reminders that, for some, COVID may be forgotten, but for most it is not gone, a pair of infectious disease doctors wrote in a JAMA viewpoint Wednesday.

They pointed out that while hybrid immunity — vaccination combined with a past infection — appears to be offering much of the US population added protection against COVID, seniors are less likely to experience that. They have the lowest levels of hybrid immunity, and the immunity afforded them by vaccines also decreases faster.

“As the US continues to emerge from the pandemic it is essential that clinicians and patients keep SARS-CoV-2 on the list of viral pathogens that cause major respiratory illness,” write Carlos del Rio, MD, of Emory University School of Medicine and JAMA Deputy Editor Preeti N. Malani, MD, of the University of Michigan, Ann Arbor. “Protecting the most vulnerable populations should be a priority. This includes making vaccinations, high-quality masks, testing, and antivirals easily available.”

The AHCA toolkit includes campaign resources for multiple vaccination types, including influenza and a new RSV shot available to seniors.

“Older adults and immunocompromised individuals are at higher risk of becoming seriously ill from these viruses,” AHCA reminded. “Vaccination remains one of the most effective, safest ways to build immunity and prevent serious illness, hospitalizations and death.”

The 2023 #GetVaccinated Toolkit includes:

• A checklist for providers with suggested best practices in order to prepare for fall vaccination season;
• Poster graphics to raise awareness about the importance of getting vaccinated;
• Social media posts and graphics;
• Template letters to residents and family members; and
• In-depth resources for providers about recommended vaccines for residents and staff, documenting vaccines, frequently asked questions, and more.

The investigation included data from 8,402 outpatients treated in Quebec province, Canada, between March 15 and Oct. 15, 2022. Researchers analyzed the risk of COVID-19-associated hospitalization occurring within 30 days of followup, compared with risk among untreated controls.

Regardless of vaccination status, Paxlovid treatment was associated with a 69% reduced relative risk of hospitalization, they found. And the benefits were even more pronounced (96%) in patients who had not completed a full primary COVID-19 vaccination course. 

Older adults and vaccine timing

In contrast, there was no protection against hospitalization for patients at high risk of severe disease who completed their primary vaccination series of shots less than six months ago. The latter finding suggests that a booster dose at six months “remains an effective method for preventing severe illness,” the researchers wrote.

But when patients who had a full primary series of vaccinations were sorted into groups, two subgroups stood out. High-risk patients aged 70 years and older were significantly protected when their last vaccine dose was received at least six months beforehand.

In addition, severely immunocompromised patients also received significant protection, no matter their vaccination status, the researchers reported.

Omicron surge

Notably, the study took place during the omicron variants BA.2 and BA.4/5 surge. The results “are consistent with previous studies that demonstrated nirmatrelvir/ritonavir treatment and COVID-19 vaccination improve clinical outcomes of SARS-CoV-2 infected patients,” the researchers concluded.

Full findings were published in Clinical Infectious Diseases.

Related articles:

​​FDA advisers support full approval of Paxlovid for at-risk older adults

Large EHR study confirms Paxlovid works best within 5-day time window

Paxlovid effective against omicron variants, new research finds

Paxlovid cuts risk of COVID hospitalization, which may leave older adults weakened

Investigators examined electronic health records and immunization data from adults in the United States, aged 18 years and older. Social vulnerability was calculated using a standardized index from the Centers for Disease Control and Prevention across four themes: socioeconomic status; household composition and disability; minority status and language; and housing type and transportation.

“Initial COVID-19 vaccination coverage remains lower in communities with higher social vulnerability and booster rates are even lower,” Brian Dixon, PhD, MPA, of the Regenstrief Institute and the University of Indiana reported. At the same time, he and his colleagues found no differences in vaccine effectiveness between those who are socially vulnerable and those who are not.

In addition to being less likely to be vaccinated, socially vulnerable people also may have higher odds of contracting COVID-19 because they are more likely to live within dense populations, travel via public transportation and hold jobs with face-to-face interaction, the researchers said. What’s more, fewer resources to seek medical care ups the chances of experiencing adverse COVID-19 outcomes, said researcher Katie Allen, BS, a data scientist with Regenstrief Institute.

The results highlight the need for continued public health efforts that focus on vaccine coverage as well as vaccine effectiveness, Allen and colleagues concluded.

The study was published in Clinical Infectious Diseases.

Related articles:

CMS: Lapses in vaccine compliance to trigger ‘aggressive’ enforcement

Investigators analyzed infection prevention data, such as vaccine type and number of shots in 17 Canadian nursing homes and eight retirement homes between March and November 2021. All study participants had received at least three mRNA vaccinations.

Data show strong protection

In total, 17% of residents had a presumed omicron-related SARS-CoV-2 infection between the local start of the first omicron wave in December 2021 and May 2022. Infection risk decreased by 47% with three doses of Moderna’s vaccine compared with Pfizer’s vaccine. In addition, infection risk fell by 81% with any fourth mRNA vaccine dose.

Hybrid immunity, defined as a prior SARS-CoV-2 infection plus vaccination, was also highly protective. An infection sustained within three months before the omicron wave began lowered subsequent infection risk by 48% in the vaccinated study subjects.

The risk of becoming infected with omicron did not differ by age or sex.

The results underscore the importance of vaccine type and the number of vaccine doses in maintaining protective immunity, lead author Jessica A. Breznik, PhD, of McMaster University in Canada reported. These factors are also key to reducing the risk of breakthrough infections, she and her colleagues added. 

“These findings promote continued public health efforts to support vaccination programs and monitor vaccine immunogenicity in older adults,” the researchers concluded.

Full findings were published in JAMDA.

Related articles: 

Study: Some 56% of people don’t know they are contagious, omicron study finds

CDC: Seniors receive 80% protection against severe omicron illness with fourth vaccine dose

CDC: LTC residents account for many omicron hospitalizations among the vaccinated (2022)

Best bet against omicron? Prior infection or a booster shot, early research suggests (2021)

In a Tuesday update, the United Nations agency underscored what it said was the importance of vaccinating people who remain at risk of severe disease. The recommendations reflect the influence of the omicron variant and high levels of population immunity from infection and vaccination, the WHO stated.

Along with older adults and healthcare workers, its highest priority group for vaccination includes younger adults with significant comorbidities, immunocompromised people and pregnant people.

“Updated to reflect that much of the population is either vaccinated or previously infected with COVID-19, or both, the revised roadmap re-emphasizes the importance of vaccinating those still at-risk of severe disease, mostly older adults and those with underlying conditions, including with additional boosters,” said Hanna Nohynek, MD, PhD, chair of the WHO’s Strategic Advisory Group of Experts on Immunization (SAGE).

Booster recommendations

For the high priority group, SAGE calls for an additional booster dose at six to 12 months following the recipient’s last shot. The timing within that window should be based on factors such as age and health issues such as immunocompromising conditions, it said.

Notably, it does not recommend additional booster vaccinations beyond a primary series plus a first booster shot for adults aged 60 years and younger or children who do not have compromising health conditions. 

CDC’s guidance

In the United States, the Centers for Disease Control and Prevention recommends that all eligible people aged 6 months and older receive “the most recent booster dose recommended for them by CDC” at least two months after completion of an initial series of shots, with some exceptions for small children. 

The CDC’s independent advisers decided in February that the current evidence does not support more than one yearly dose of the currently recommended COVID-19 bivalent booster vaccine for older adults and other groups vulnerable to severe disease.

Notably, the effectiveness of COVID-19 mRNA vaccines is thought to decline significantly at about four to six months after the shot is received. With this and other potential issues in mind, the Advisory Committee For Immunization Practices (ACIP) also called for vaccine policy flexibility, allowing for more frequent doses for people who are vulnerable to severe disease.

Nursing home rates

In U.S. nursing homes, about 53% of residents are up-to-date on their COVID-19 shots, having received the current recommended booster, a bivalent shot designed to target the omicron variant, according to CDC data from March 19.

About 42% of the overall U.S. population aged 65 years and older has received the bivalent shot.

Related articles:

Evidence supports only one yearly COVID-19 booster shot for seniors, CDC advisers say

FDA authorizes omicron-targeting vaccines as preferred COVID booster shots

CDC: Two booster shots cut severe COVID risk in nursing home residents by 74%