As COVID-19 began its death march through long-term care facilities early last spring, Principle LTC President and CEO Lynn Hood opened a Special Care Unit to treat infected patients from many of her chain’s 46 facilities.

The building concentrated resources, including an infectious disease consulant, infusion nurses and equipment needed to fight the disease. It also allowed administrators to quickly move sick patients out of buildings where they had been living, decontaminate their rooms and minimize spread.

As of February, Principle had four Special Care Units encompassing 300 beds.

In a sure sign that the pandemic is far from over, the North Carolina-based nonprofit planned to open two more units this month.

The move not only centralizes care of stricken residents, it protects the reputation of individual Principle facilities as they begin the quest to win back referrals and fill beds. It also serves as tacit acknowledgement that, despite progress on vaccinations, COVID-19 isn’t done targeting seniors and those who care for them.

After a year of constant crises and pivoting, experts say now is not the time to relax.

“We have a big cliff coming up,” Hood said. “First of all, we don’t know how long the vaccine protection is going to last, and we haven’t had a big holiday since Christmas. We don’t know what the next gatherings are going to look like. I’m also concerned about communities’ complacency once they start seeing early positive signs emerge.”

As of Feb. 1, the federal government reported 77.8% of skilled nursing residents in the Pharmacy Partnership for Long-Term Care program had received at least one dose of a COVID-19 vaccination.

In smaller pockets across the nation, a majority of residents had already gotten both shots and time to build immunity. In some cases, that meant a return of indoor visits (with continued precautions) and some daily activities.

But the Centers for Medicare & Medicaid Services had yet to revise last fall’s visitation guidance, even as families clamored for access.

“It’s too early,” Evan Shulman, director of the agency’s Division of Nursing Homes, told LeadingAge members in mid-February.

Chief among the agency’s concerns: whether the Pfizer and Moderna vaccines actually stymie transmission. An analysis by the American Health Care Association found vaccinated nursing homes experienced a 48% decline in new resident cases three weeks after the first clinic. AHCA asked the Centers for Disease Control and Prevention to “rapidly evaluate the vaccines’ effectiveness among the long-term care population in both preventing spread and in reducing morbidity and mortality.”

For now, Shulman urges patience, noting issues around vaccine protection length and effectiveness against emerging variants. she said.

Vaccine unknowns

“We have outstanding questions on the vaccines,” he said. “Everyone needs to keep doing what you’re doing: Adhere to all infection control guidelines; when it’s your chance to get vaccines, get vaccinated; and as more people get vaccinated, then more visitation will occur.”

Ruth Katz, senior vice president of policy for LeadingAge, agrees “now is not the time” to let up.

“We need to double-down on the mitigation strategies that we have been using and that we know work: masking, social distancing, screening and testing, with immediate action taken when symptoms develop or asymptomatic cases are identified. We need to continue facilitating access to PPE, testing, and vaccination for residents and staff,” she said.

At the Maryland Baptist Aged Home in Baltimore, conditions are still far from routine.

The 29-bed facility has had zero COVID-19 cases, according to the Rev. Derrick DeWitt, director.

“We acted early,” DeWitt said during a LeadingAge update. “We were excessive. We were extreme. We were emotional.”

The emotion ratcheted up when DeWitt, the first on his team to be vaccinated, found out only 11 of 42 employees followed his lead during the first on-site clinic.

“I was shocked,” DeWitt said. “It never crossed my mind we would have that type of hesitancy.”

He redoubled his efforts, appealing to his employees as a boss, as a pastor who prayed over vaccination, and as someone who valued science over rumor. He took a hard line when some staff members seemed to buy into conspiracy theories about the shot, telling them, “I can’t guarantee your job here if you don’t take the vaccine.”

DeWitt said his building doesn’t have the luxury of isolating patients by wing or floor. If staff members complain about mask wearing weeks after their second doses, he points out that six employees remain unvaccinated.

“Not being at 100%, we’re stuck in this COVID status quo environment,” he said. “To me, 86% is equivalent to 0% … It’s only going to take one person to infect everybody else who’s not had the vaccine, and then the vaccine is only a percentage (of risk) that I won’t get severe disease.

“Until we get to 100%, it’s going to have to be business as the new normal.”

Infinite vaccine wave

In larger facilities, 100% vaccination rates may be even more challenging to attain and sustain.

As federal officials encourage more Americans to get vaccinated on a quest for national herd immunity, Steven Fuller, D.O., Ph.D., said nursing homes should not think of themselves as fully protected by high compliance.

“Herd immunity cannot be achieved in a congregate setting,” said Fuller, a former executive and medical director with Presbyterian Senior Living. “After the third wave of vaccinations, (residents) continuously come in. What about them? What about staff members? Turnover is about 15%.”

He’s calling for an “infinite wave” of vaccines, and for individual nursing homes to establish policies that ensure access to vaccinations for months to come.

Ohio officials in February were the first to outline a plan requiring providers to begin that process by picking a pharmacy partner and having new staff and residents vaccinated before admission.

Fuller said it’s critical for providers to consider how they will treat residents or staff or who are partially or not-at-all vaccinated.

“Do you force the unvaccinated to be stuck in their rooms while the vaccinated can roam freely and take advantage of everything?” he asked. “That’s a battle that will be temporary … But at least they know they’ve defined the battle, and they know the fight ahead.”

Return on investment

At Principle, Hood and her team have developed 80 COVID-19 policies, which they continue to rely on as North Carolina allows small group gatherings for meals, group therapy and activities.

Compassionate care is allowed for end-of-life situations and for residents experiencing social isolation or depression. Visitors must undergo symptom checks and wear PPE on isolation units.

Principle spent more than $2 million on PPE and “multi-millions” on testing and other interventions.It installed technology such as cold plasma air purification in all buildings. And working with a hospital infection preventionist, Hood also purchased extra PCR tests and screening panels that could better identify patients at risk of severe disease because of clotting issues or dehydration.

State priorities key

Hood said innovation was possible only because North Carolina prioritized nursing homes for federal matching funds. Principle also operates in Kentucky and Virginia, where nursing homes got considerably less financial help.

As the chain continues to vaccinate and offer monoclonal antibody treatments and Special Care Units, Hood is “cautiously optimistic.”

By press time, 92% of residents had accepted at least their first vaccination, and about 60% of full-time employees had done the same. In the first week of February, the entire chain had just 12 new positive patients — 85% from a small group that had not yet been vaccinated. At Special Care Units, the COVID-19 survival rate was 95% to 97% compared to 80.5% among U.S. Medicaid or Medicare beneficiaries.

Amid these successes, many nursing homes are struggling with access to supplies and cash flow in the face of unprecedented occupancy declines.

A proposed $35 billion Provider Relief Fund boost would fall short of the $100 billion AHCA wants. LeadingAge’s Katz added that COVID costs “will continue for the foreseeable future, as will reduced revenues.”

Hood wants permanent Medicaid funding increases that recognize today’s nursing homes are caring for some of the nation’s sickest patients.

“For me, the way forward has to be through funding and a commitment from the industry to deal with what’s upon us,” she said. “I don’t think we need a way back. We need a way forward.”