As of Monday, only about 22 percent of the covid-19 vaccine doses that have been distributed for use in long-term care facilities have made their way into the arms of residents and staff.  As has been well documented, these residents—nearly all with pre-existing medical conditions and functional and cognitive impairment– are the most vulnerable to serious illness and death from the virus. And staff are at extremely high risk of contracting and spreading the disease.

Yet, vaccine rollout has been slow. And at some facilities that have vaccine, staffers have been unwilling to get immunized. To learn more about how to accelerate the process, I asked four experts. While some favor mandating staff vaccinations and others prefer using incentives to encourage participation, all agree that the real key is education and staff engagement.

Chaotic distribution

Part of the problem is the chaotic distribution of the vaccine. Just this week, the Trump Administration significantly revised its guidelines, further confusing states, which have the final decisions on how the shots are distributed. One result of this confusion: Some facilities say they are getting the vaccine they expected while others are frustrated by slow deliveries.

Operators of long-term care facilities also complain that the roll-out is being slowed by an enormous amount of paperwork. Residents need to sign authorization forms and if a resident has limited cognitive function, a relative has to agree to the vaccine. All this takes time and adds to the confusion about who can get a shot, and when.

Reluctant staffers

But what about those reluctant staffers?

A December survey by the Kaiser Family Foundation finds that 29 percent of health care workers, including those working in long-term care, were hesitant to take the vaccine.

Among the overall population, resistance is spread among many subgroups. For example, the unwilling include 42 percent of Republicans, 35 percent of rural residents, and 35% of Black adults.

The survey found that Black adults are mostly worried about side effects and the newness of the vaccine while Republicans are more likely to refuse because they believe the risks of COVID-19 are exaggerated. We don’t know if these patterns apply to long-term care workers. Yet addressing this range of concerns makes encouraging compliance even more difficult.

There also appears to be wide variation in vaccine acceptance among long-term care staff. The newspaper Crains New York reports that about 15 percent of aides in its market are refusing the vaccine. But in Ohio, Gov. Mike DeWine says as many as 60 percent of nursing home staff were declining.

Susan Whery, Chief of Geriatrics at the University of New England College of Osteopathic Medicine, says acceptance can vary widely even on the same campus: At one facility in Maine, 93 percent of staff in one unit were willing to be vaccinated compared to only 29 percent on another unit.

What are facilities doing?

Juniper Communities, a highly regarded operator of senior living communities in Colorado, Pennsylvania, and New Jersey, is mandating vaccines for all its staff, just as many facilities do routinely for seasonal flu. CEO Lynne Katzmann says, “Our job is to protect people so they can be as healthy as possible. It is who we are. And vaccines are the ultimate form of protection.”

Mandates can create problems. They may worsen employee relations at facilities that have been under enormous stress. And making compliance a requirement of employment may accelerate turnover and magnify already-severe staff shortages.

At Juniper, which encouraged peer support and engaged in an intense education campaign for staff before imposing the requirement, there have been only a handful of resignations, Katzmann says.

Still, December surveys by the trade publication McKnight’s Long-Term Care News and by LeadingAge, a trade group that represents mostly not-for-profit facilities, found that fewer than 15 percent had mandated vaccines for their staff. However, nearly 40 percent in the McKnight’s survey were not sure if they would mandate the vaccine in the future.

Other facilities are trying a wide range of alternative strategies. Some are offering cash bonuses or days off. Others are using intensive education programs to convince staff that the covid-19 vaccine is both safe and effective.

Dan Reingold, CEO of Riverspring Health, which operates a continuing care community and home care service in Riverdale NY, is combining small incentives with education and encouragement by peers. Among the incentives: Lotto tickets for everyone who receives a vaccine and entry in a raffle to win a $50 gift card.

Whery suggests these small “thank you” gifts can be more effective than large bonuses. But the real key she says, is “making it the norm to take the vaccine.”

Riverspring shows short videos in multiple languages, identifies staff influencers who can encourage colleagues, and holds discussions led by its medical director. And, says Reingold, “Every time I walk around, I ask staff if they have gotten the shot. If they do, I say, “thanks so much.” If not, I say, ‘please get it.’”

Robert Espinoza, policy director at PHI, a group that advocates for direct care workers, says the question of mandates is “a hard one.” But adds that education is key: “Do they have the proper information? Now, workers are getting conflicting information.”

How much compliance?

Reingold has set a goal of about 60 percent compliance, roughly in line with his experience with the seasonal flu vaccine. “I don’t think anybody imagines that 100 percent would accept” covid-19 vaccinations, he says. Katzmann, however, says her facilities are close to that.

Whery is more optimistic too: “It is early on in the rollout and we are predicting based on what people say they will do, not what they really do.”

She believes that the covid-19 vaccines will be mandated for health workers once the government formally approves them (they currently are permitted for emergency use only). But, until then, she says employers should focus on staff dialogue and education.

Convincing staff to take the vaccine is tough work, but operators of long-term care facilities and home care agencies need to keep at it.  Lives literally are at stake.