Care homes’ logistical questions

Issues include consent, number of doses available, cognition

As the network of federal and state officials, pharmacies and health care facilities prepare for the complex distribution of the first COVID-19 vaccines, plans for giving the lifesaving doses to nursing home residents are taking shape, but patient advocates still have concerns about the difficult question of consent and what to do if there is not enough to go around.

Under California’s guidelines, staff and the residents of long-term care facilities are among the first groups to get the vaccines, along with workers at hospitals and health care facilities who are most at risk of exposure to the coronavirus. While it’s unclear how many doses will be initially available for the state’s care facilities, the state’s directive spells out a hierarchy of prioritization based on types and locations of facilities, and then individuals’ attributes, including age and underlying medical conditions.

At long-term care facilities, which have had more than 7,000 COVID-19 deaths among patients and staff since the beginning of the pandemic, the vaccines will be given through a federal partnership with CVS and Walgreens, which also have contracts with local pharmacies to vaccinate at those locations.

Nursing homes and other long-term care facilities have had to sign up directly

with those pharmacies, which will administer the vaccines. While some hospitals and counties throughout California are expected to get first shipments of the vaccine this week, CVS spokesperson Monica Prinzing said the Centers for Disease Control and Prevention has told states the earliest they can start vaccinating in long-term care facilities is Dec. 21.

“For states that want to start then, we’ll be in facilities that day,” Prinzing told this news organization in an email.

She added that they’ll use a “hub- and- spoke” model in which about 1,100 CVS Pharmacy locations will store vaccines, and the company’s pharmacy teams will pick up the doses on their way to long-term care facilities that signed up for the program.

T. J. Griffin, chief pharmacy officer for PharMerica, a pharmacy that works with long-term care facilities, and a member of the federal government’s vaccine program Operation Warp Speed, said he expects that most residents of such facilities across the country will have the opportunity to get the vaccine by the end of January.

His company is advising Walgreens about vaccinating elderly residents — how to approach someone with dementia, for instance — and will have several hundred staffers on hand to help Walgreens with the inoculations. Each facility will get three vaccine clinic days, he said, and staff and residents can be vaccinated at the same time.

In some ways, it’s not totally new territory for CVS, Walgreens and other pharmacies.

“We run seasonal flu clinics in thousands of these locations every year, which means our health care professionals are very familiar with this population,” Prinzing said.

But with a brand-new vaccine aimed at relieving a pandemic that has ravaged senior care facilities, a slew of logistical questions and concerns remain.

Chuck Cole, the chief financial officer for nonprofit skilled nursing facility Chaparral House in Berkeley, said that among those concerns is how any side effects from the vaccine might impact the staff’s ability to care for patients.

Studies so far have shown that in some cases, patients have had mild to moderate reactions to the vaccine, including fatigue, headaches and sore muscles. Any adverse reactions among residents or staff could further strain facility resources, which are already stretched thin across nursing homes throughout California.

“We’re using every bit of staff we have,” Cole said. “There’s no more staff available.”

There’s also the matter of getting consent from residents and their family members. The state is not requiring people to take the vaccine, and some residents may be leery about it since the long-term effects are not yet known.

Cole said the severity of the disease might override some concern. And seeing on TV the first inoculations of elderly residents in the United Kingdom could also help.

“In our population, people are used to getting vaccines for pneumonia, vaccines for shingles, vaccines for flu,” he said. “I think there’s less hesitancy toward vaccines because they’re so much more common in the age group we work with.”

Mike Dark, a staff attorney with California Advocates for Nursing Home Reform, said because of the pandemic, long-term care residents have been isolated from information and from family members and advocates who can help them make informed decisions about consenting to the vaccine.

Then there are the residents who lack the cognitive ability to make informed decisions about whether they want the shots. While a fairly easy fix for that is having a durable power of attorney to make health care decisions, Dark said what often happens is that people become incapacitated before they make formal arrangements.

For residents with no family members or legal surrogates to make decisions, it’s often up to facilities to decide.

Anand Chabra, section chief of the COVID-19 Mass Vaccination and a medical director at San Mateo County Health, said the state is working on a “comprehensive education campaign that will include answers to frequently asked questions and other vital information, which will help family members, caregivers, and legal guardians make decisions on behalf of their loved ones.”

The state did not respond to questions about whether it plans a similar effort to educate nursing home patients.

With a limited number of doses and cases surging, it’s crucial that decisions are made soon, advocates say.

“These logistical plans are a matter of life and death,” Dark said.