Experts estimate that herd immunity for COVID-19 will be reached when 75–85%  of the U.S. population has received the COVID-19 vaccine. 

But long-term care — including nursing homes and assisted living communities — form a distinct population that should be considered separately. These are congregate settings, where residents are largely confined onsite and whose caregivers have demonstrated significant vaccine hesitancy. 

For example, many reports tell us that more than half of long-term care staff  refuse COVID-19 vaccinations. And this is a very difficult population to manage because of the pressures of chronic staff shortages, high staff turnover, staff concerns about vaccine safety, and because many staff have several jobs with different employers. 

So this raises a disturbing dilemma: If only a fraction of residents and staff are vaccinated, herd immunity can’t be achieved in their community, even if it IS  achieved in certain states or nationwide. 

Some additional hard questions also present themselves: 

• Should new residents be required to have received the COVID-19 vaccination prior to admission? If so, should they be required to have  BOTH injections, or is just a single injection sufficient for admission? 

• Should newly admitted VACCINATED and NON-VACCINATED residents be  quarantined in their rooms the same way? Temporarily cohorted within a  section of the community the same way? 

• Should COVID-19 vaccination be mandated in long-term care? If so,

o For residents only? 

o For staff only? 

o For both residents and staff? 

o For visiting family members and other loved ones? 

o For vendors? 

• Before the crushing mitigation procedures that are currently in place are  relaxed, should each long-term care community be required to prove that 75–85% of its residents and staff are vaccinated and have therefore achieved herd immunity? 

And finally … is the long-term care industry willing to publicly state its communities are safe as long as they meet the 75-85% vaccination threshold for herd immunity? 

In a community with 100 residents, this would mean 15-25 residents are still susceptible to getting the disease as they congregate among themselves and others in hallways, dining rooms, activity rooms and other communal places. 

These are only some of the difficult yet essential questions we must answer before realizing the hope and promises of a better 2021 in long-term care. 

To paraphrase Robert Frost, “We have miles to go before we sleep.” 

Steven Fuller, Ph.D., D.O., is a physician and entrepreneur who supports an integrated care model of senior housing. He is president of Illumination Analytics and a Six Sigma Green Belt. The former Presyterian Senior Living executive continues to write on timely topics concerning long-term care.