The development of a safe and effective COVID-19 vaccine has always been a matter of “when” not “if.”  Significant advances in vaccine development, a coordinated global response and considerable public/private funding provide hope for individuals in long-term care.

However, the devil lies in the distribution that began this week in some places.

Each state plan for vaccine distribution highlights high-risk older adults as being target populations for Phase 1 efforts. Nursing homes and assisted living facilities will receive “first priority” when initial shipments of the vaccine arrive. Home health and adult day services will hopefully follow.

This is vital as individuals in these settings are most vulnerable to the deadly effects of COVID-19. However, early access to a novel vaccine will create both challenges and opportunities across long-term care settings.

Long-term care settings are chronically understaffed, under-resourced and underfunded; they need resources, beyond the vaccine itself, to ensure an effective roll-out to those who would benefit most. Three key areas that policymakers must pay attention to in long-term care are financing, personnel and mistrust. 

Financial considerations

There are significant costs to launching successful vaccine distribution efforts. Personnel (e.g. nurses) are needed to administer vaccines, additional space and equipment (e.g. laboratory-grade freezers) are required for storage, and significant administrative costs exist (e.g. outreach, patient education, record keeping).

The federal government has committed to covering the cost of the COVID-19 vaccine itself and its distribution. However, there has been little discussion as to how long-term care facilities, which have been operating on “shoe-string budgets” since before the pandemic, will finance other costs. Reimbursements from the federal government should reflect additional expenses.


Staff, especially nurses, play an essential role in vaccine distribution. However, more than one in five nursing homes report severe staffing shortages. During ordinary times, such shortages prevent staff from performing routine responsibilities. This has only been exacerbated by the pandemic.

To ensure effective distribution of the vaccine, staffing will need to be prioritized. Not only do more staff need to be hired as part of the vaccine roll-out, but additional resources are needed to ensure that all staff are educated, equipped, motivated and readied. This includes training staff to communicate effectively about the vaccine, counter vaccine misinformation and confront barriers to equitable distribution such as unconscious bias. Importantly, these mobilizing efforts should not be limited to those responsible for administering the vaccine, but to all staff to facilitate a culture of receiving the vaccine.


Finally, older adults have yet to say “yes” to the vaccine. Concerns about the effectiveness of a rapidly developed vaccine will need to be overcome.

In addition, the legacy of racism and historical abuse may reduce vaccine uptake among the substantial number of racial and ethnic minorities in long-term care settings who have already endured a disproportionate burden of COVID-19 infections and deaths. A recent poll found that nearly 1 in 3 older adults said they were unlikely to get a COVID-19 vaccine, with non-White older adults being the most reluctant.

Among nursing home residents, Black older adults are consistently found to have lower vaccine rates than White older adults. To reduce vaccine hesitancy among the groups most susceptible to the harms of COVID-19, programs in long-term care settings around vaccine education and promotion need to be developed.

These programs cannot take a one-size-fits-all approach. Culturally relevant vaccine programs will acknowledge the public’s genuine fears, connect emotionally with individuals and their caregivers and provide older adults with a forum to discuss their concerns. Long-term care settings must capitalize on their intimate knowledge of persons in their care, and use it to create a dialogue with the communities they serve. This can be done using group education led by nurses in long-term care settings or informal conversations with non-clinician community-leaders who comprise the local “trust network.” 

Importantly, while a vaccine to protect our most vulnerable population is here, its effectiveness hinges on broadly successful implementation. We must offset costs not already covered, build a sizeable and prepared workforce, and confront fears and mistrust to achieve the reach necessary to restore safety across long-term care. 

Tina Sadarangani, Ph.D., R.N.,; Daniel David, Ph.D., R.N.,; and Jasmine Travers, Ph.D., R.N., are assistant professors at the NYU Rory Meyers College of Nursing.