Long-term care facilities are likely to face multiple challenges when it comes to inoculating staff members against COVID-19, despite federal efforts to rush any approved vaccine to their doors.

In an article published in JAMA last week, Mary Chris Jaklevic examined many of the issues that skilled nursing facilities could have to grapple with, from the logistical nightmare of shots requiring ultra cold storage to vaccine hesitancy that likely will undermine efforts to mandate shots for healthcare workers.

Long-term care workers had the lowest influenza vaccination rates last season at 69.3%, according to the Centers for Disease Control and Prevention. Although nursing homes are among the facilities least likely to require staff flu shots, CDC Director Robert Redfield, M.D., told McKnight’s earlier this fall that he would encourage nursing home operators to adopt such policies.

Other experts said facilities also need to begin working now to educate employees about the safety standards built into any vaccine eventually approved in the United States.

Christian Bergman, M.D., of Virginia Commonwealth University in Richmond said that educational programs should include a live briefing before vaccinations arrive, allowing workers to ask questions and take home information about safety and efficacy, learn details about adverse effects, and better understand how the vaccine was tested.

But geriatric nurse practitioner Barbara Resnick, Ph.D., RN, said nursing homes are limited in what they can do to prepare until more specific details become available.

ProMedica Senior Care, formerly HCR ManorCare, told Jaklevic that it plans to educate workers in 26 states using virtual town halls. Chief Medical Officer Mark Gloth, D.O., said that employees who refuse the vaccine will be required to acknowledge that they’ve been counseled on the risks and benefits. Gloth acknowledged that “people have concerns. We want to be respectful of that.”

Among the questions remaining: Will states or the federal government issue a federal vaccine mandate for healthcare workers? And should older adults or the caregivers who work with them should be vaccinated first?

The current National Academies recommendations put older adults living in shared facilities behind frontline healthcare staff, but the final rollout could be determined after clinical testing results are shared.