“Fate Worse Than Death”: Long-Term Care’s Independence Crisis: Aging-in-Place Planning Offers Solutions

A recent study highlighted by NBC Right Now, titled “Fate worse than death: Many long-term care residents lose all independence, study says,” paints a grim picture of life in long-term care (LTC) facilities. The headline is attention-grabbing, and for seniors and families planning for the future, the subject study underscores the importance of aging in place strategies to preserve independence and autonomy.

THE STUDY

Published on April 23, 2025, "Cognitive and Functional Decline Among Long-Term Care Residents," is a retrospective cohort study (meaning an observational study that uses existing data to examine individuals by looking back in time to assess how past variables relate to specific outcomes) involving more than 120,000 Canadian residents followed for up to 5 years.  One aspect of the study was interviewing residents to determine their goals in seeking long-term care and their feelings about long-term care. The study provides a compelling glimpse into older adults’ fears of losing independence, and the trajectories of needs while in long-term care. 

Study Results: Some of the key findings of the study include: 

• Many people lose all independence soon after entering long-term care;

• About 20% lose the ability to make everyday decisions within five years of admission, and 13% become totally dependent for all personal care including bathing, toileting and eating;

• Residents living with dementia may be at risk of spending more time living in states of impairment than residents who have no cognitive impairment; the increased survival of residents with dementia may reflect the natural history of dementia as a progressive terminal disease with great variability in survival time, ranging from 3 to 15 years.

• Advance directives may play an important role in reducing time spent living with severe disability; residents with Do Not Resuscitate (DNR) or Do Not Hospitalize (DNH) orders experience shorter periods of institutionalization while suffering profound impairment associated with a loss of all independence.

• The standard care practice of providing longevity can leave residents in states that they consider "worse than death," contradicting the goals that residents view as most important.

• Despite advance care directives, 25% of long-term care residents have at least 1 transfer to the hospital every 6 months, and many die shortly after a hospital transfer. 

Indeed, in the introduction to the study, the authors write:

"Patients, including healthy outpatients and those with serious illness, consider states such as being “unable to get out of bed,” “unable to communicate,” or “unable to reason or remember” as worse than death, and yet these outcomes are rarely explicitly discussed. [citations omitted].  Pursuing longevity-focused care when a person is living in a state they consider worse than death is contrary to resident-centered principles for which LTC homes strive. However, pursuit of longevity against a patient’s wishes may occur because preferences change when death is imminent and because substitute decision-makers and clinicians are partial toward life-prolonging treatment when clinical outcomes or resident preferences are uncertain."

Researcher Assessments: The researchers released statements regarding their findings and assessments:

• Dr. Ramtin Hakimjavadi, lead researcher, a resident in internal medicine at the University of Ottawa in Canada, and one of more than fifteen medical professionals that authored the study, characterized the findings:

"In interviews, long-term care residents have expressed that loss of independence is more distressing to them than the thought of dying. [Residents aren’t receiving the best care] if we don’t talk about the possibility of severe disability and ask about the circumstances when life prolonging treatments would not be acceptable."

• Senior researcher, Dr. Daniel Kobewka, an investigator at Bruyère Health Research Institute and adjunct scientist at the Institute for Clinical Evaluative Services in Ottawa, advised that: 

“[r]esidents, their family members, and care teams should have open discussions about what quality of life means to the resident, considering the possibility of prolonged disability. Planning ahead can help ensure that future care aligns with personal values, including the choice to prioritize comfort and dignity over life-prolonging interventions.” 

Call to Action: The study represents a call to action. 

• The Health Care Industry:  Clinicians and health care professionals are called to consider critically  life-prolonging treatment, appropriate for the healthy and recovering, as being contrary to the wishes and consent of residents that "follow a frailty trajectory with no clear terminal phase...experienc[ing instead] a progressive decline in cognition and physical function after admission due [for example] to the accumulation of chronic conditions." Care for these residents must be guided by their wishes and goals, ensuring dignity and quality of life for residents and care partners. 

• Residents: Residents should make their wishes and goals explicit.  At a minimum that means executing Durable Powers of Attorney for Health Care, Advanced Directives in the form of a Living Will and Advanced Directives for Dementia, and a broad form HIPAA release in favor of trusted health care decision-makers. Residents and their families should consider a DNR, DNH, and where appropriate, Physician Orders for Life-Sustaining Treatment (POLST). Residents should also consider aggressive, comprehensive aging in place planning, and a robust estate plan to protect a resident's independence, decision-making, and dignity.   

Study Limitations: The authors acknowledge key limitations:  

• First, all studies that use administrative data have a risk of bias from misclassification or incomplete capture of variables, which the researchers addressed by using validated definitions when possible and maintaining consistency with previous research. 

• Second, the study did not stratify data by the type of dementia (e.g., Alzheimer, Lewy body, or frontotemporal dementia) given the available data. Although different dementia subtypes carry distinct trajectories and prognoses, the researchers concluded that their findings reflect residents living with Alzheimer dementia given its prevalence relative to other subtypes.

• Third, the length of stay observed in the study is subject to local admission and aging-in-place policies, which vary by jurisdiction.

• Fourth, while the study aimed to inform resident-centered decision-making in LTC through the identification of resident-important cognitive and functional impairments, resident and caregiver perspectives may differ from those of the patient partners who informed this study. The researcher believe that, nonetheless, their data provides a foundation for communication and future studies to consider functional and cognitive impairments as outcomes for prognostication. 

• Fifth, the  study has limitations in generalizability. The findings are generalizable to regions with a similar LTC population of mostly older adults with frailty and chronic conditions requiring continuous care. However, the  population studied may be older and have higher levels of frailty and health burdens at admission because of the prioritization of home care in Canada compared with regions with less emphasis on home care or with more flexible LTC eligibility criteria. Additionally, the publicly funded single-payer system in Canada may result in a more homogenous population compared with regions using a third-payer system, which may have a more diverse LTC population. This difference may limit the generalizability of our results to other regions.

The Study Is Worthy of Serious Considerations Despite the Limitations

There are number of reasons that this study deserves attention despite the acknowledged limitations.

1. Peer Review and Credibility: Published in JAMA Network Open, a peer-reviewed, open-access journal with a strong reputation the study benefits from rigorous editorial oversight. The authors are affiliated with reputable institutions  and have expertise in health policy and aging, enhancing credibility. No funding conflicts are disclosed, reducing bias concerns.
2. Methodology: A retrospective cohort study afforded the researchers an immense sample size, and a fairly long period over which to follow subjects. The weakness of these types of studies, data quality/bias, was addressed by using validated definitions when possible and maintaining consistency with previous research. 
3. Generizability: There are obvious differences between the Canadian health care model and the U.S. model.  Aging in place planning is public policy in Canada and is heavily subsidized.  The concern was that Canadian residents might be older and in worse health than, say, in the U.S.  Although U.S. commitment to aging in place in Medicare  may not be as robust, there is some semblance of public support, for example, in the adoption of alternatives available in Medicare Advantage Plans, the recent "Hospital at Home" initiative of Medicare, and Medicare/Medicaid's Program of All-Inclusive Care for the Elderly (PACE) program for adults 55+ who need nursing home-level care but can live safely in the community, which provides comprehensive services (medical, social, home care) through an interdisciplinary team, centered at an adult day health center, with in-home support.  More importantly, with the risk of asset loss from long-term care spend down, U.S. residents are much more likely to avail themselves of institutional care alternatives, meaning the populations of LTC residents may not differ dramatically.  Moreover, it appears to me that the quality of care in Canada is higher given that the rehospitalization rate described in the study was an average of every six months, while U.S, residents run an almost one-in-three risk of rehospitalization in the first 28 days of care from just medical "mistakes."
4. Is the Headline "Fair?": The headline, “Fate worse than death: Many long-term care residents lose all independence, study says,” is undeniably dramatic. The phrase “fate worse than death” is emotionally charged, invoking despair and finality. While it risks overgeneralizing, implying that all long-term care leads to catastrophic outcomes, the headline isn’t entirely unfair. Loss of independence is a profound fear for seniors, and the study’s emphasis on this issue aligns with documented concerns. For example, a 2023 New York Times article notes that many aging Americans struggle to stay independent due to a fragmented long-term care system, supporting the study’s premise. The hyperbolic tone serves a purpose: it grabs attention and sparks discussion about a critical issue.

Aging-in-Place Solutions to Preserve Independence

The study’s findings underscore why many seniors prefer to age in place—remaining in their homes or communities with support tailored to their needs. Aging in place planning, a cornerstone of this blog, empowers seniors to maintain independence, dignity, and control. Below are solutions commonly explored here, designed to address the risks highlighted by the study:

• Home Modifications for Safety and Accessibility: Modifying the home to accommodate mobility or health challenges is a proactive step. Common upgrades include installing grab bars, widening doorways, adding ramps, or creating single-level living spaces. These changes reduce reliance on institutional care by enabling seniors to navigate their homes safely. For example, a walk-in shower can preserve independence in bathing, directly countering the loss of control noted in the study. 

• Multigenerational Living: Multigenerational living is a powerful strategy for aging in place, offering financial savings, emotional support, and caregiving flexibility. By reducing reliance on institutional care, families can avoid spend-down and preserve assets, aligning with elder law goals. However, success requires planning. For more see the article: Aging in Place: Multigenerational Living as a Strategy to Avoid Institutional Care and Support Family Caregiving.

• Deploy Technology for Safety, Health, and Communication: Technology serves two purposes.  First, technology use supports cognitive health. Second, technology offers solutions to challenges faced when aging in place that otherwise might demand institutionalization. 

• Revocable Living Trusts for Asset Protection: A revocable living trust, as discussed in our recent article “The Dangers of Last-Minute Estate Planning.” ensures assets are managed and distributed per the senior’s wishes, even if they become incapacitated. Unlike wills, trusts are transparent in asset titling (e.g., on deeds or accounts), deterring manipulation and supporting financial independence. Trusts can also fund home care or modifications, avoiding the asset depletion that forces some into long-term care, and protect against guardianships, and abusive guardians.

• General Durable Powers of Attorney (GDPOA): A GDPOA appoints a trusted agent to handle financial and healthcare decisions if a senior becomes incapacitated. This prevents the need for court-ordered conservatorships, which can strip autonomy, as seen in the Autry case. By ensuring a trusted person manages their affairs, seniors maintain control indirectly, aligning with the study’s call for personalized care.  Structuring trusts to prevent third-party guardians access to trust assets disincentivizes guardians, and helps prevent control of assets being wrestled away from trusted advisors and agents.  

• Aging-in-Place Care Coordination:  In-home care, such as nonmedical caregivers or telehealth services, allows seniors to receive support without leaving home. Emerging technologies like tele-dentistry or remote monitoring, noted in LTC News, enhance access to care for mobility-challenged seniors. Coordinating care through family, agencies, or professionals ensures needs are met without the institutional routines criticized in the study.

• Guardianship Protections and Nominations: Nominating a guardian in a GDPOA or trust ensures that, if guardianship is needed, a trusted individual is appointed. Structuring trusts to limit guardian access to assets, as discussed in “The Dangers of Last-Minute Estate Planning,” preserves the senior’s plan. This protects against the loss of control highlighted by the study, as seniors retain influence over their legacy.   Structuring trusts to limit guardian access to assets, as discussed in “The Perils of Last-Minute Estate Planning,” preserves the senior’s plan. This protects against the loss of control highlighted by the study, as seniors retain influence over their legacy.

• Medicaid Planning for Long-Term Care Costs:  Strategic Medicaid planning, using trusts or asset transfers, can preserve resources for in-home care rather than nursing home costs. Unlike the hasty Medicaid attempts in the Autry case (Dangers of Last Minute Estate Planning), a well-crafted trust allows crisis planning without disrupting the estate plan, supporting aging in place. Consideration of and implementation of asset transfers permissible to qualified family members under Medicaid are more certain and less expensive and disruptive than either monolithic irrevocable transfers so common from trust mills, or crisis planning planning.

• Lifestyle Changes: Simple lifestyle changes can support, protect, and improve cognitive and physical health as well as  emotional and psychological well-being, and build a broader community and social safety net thereby removing barriers and creating opportunities for home and community based care. 

These strategies and solutions, regularly featured on this blog, empower seniors to avoid the institutional settings critiqued in the study. By planning proactively, families can create environments where independence thrives, reducing the risk of a “fate worse than death.” 

Home Health Care Staff Shortages Threaten Health- Frustrates Aging in Place

This Blog has reported the threat staffing shortages pose to the long-term institutional care industry, its residents, and its patients.  Staffing shortages in the home health care industry present similar threats, both to the industry and to actual and prospective customers.  

There is a legal maxim that "Justice Delayed is Justice Denied."  In the long-term care and the health care industry there is no simple maxim that  warns that "freedom delayed is freedom denied," but there should be.  A shortage of home health care workers means that some seniors may be unable to safely return to their homes, and may, instead, be forced into institutional care alternatives otherwise avoidable.  This may seem an anomalous result, but it is real.  Seniors are transferred to institutions that are woefully understaffed every day.  

There is no compromise possible, however, for a family seeking return of their mother or father to a home when they cannot demonstrate adequate and sufficient support services.  The systemic choice is clear; it is unacceptable for a senior to be at risk in their own home, but acceptable if that risk is institutional.  The Trump Administration learned, for example, that there were nursing homes opened and operating, without a nurse.  Medicare did not, and to this day, does not prohibit the transfer of a patient from a hospital to a poorly staffed nursing home or assisted living facility!     

Aging in Place Planning is specifically designed to reduce the risk of unnecessary and avoidable institutional care.  Unfortunately, many seniors may need home health care workers for short periods of time following acute needs or hospitalizations in order to rehabilitate safely at home.  "Freedom," may be denied these seniors if there is no choice but institutional care.   

Kaiser Health News, published a story about the on-going shortage, entitled, "Desperate for Home Care, Seniors Often Wait Months With Workers in Short Supply."  Using Maine as an example, the article explains:

"The Maine home-based care program, which helps....more than 800 in the state, has a waitlist 925 people long; those applicants sometimes lack help for months or years, according to officials in Maine, which has the country’s oldest population. This leaves many people at an increased risk of falls or not getting medical care and other dangers.  The problem is simple: Here and in much of the rest of the country there are too few workers. Yet, the solution is anything but easy."

Katie Smith Sloan , CEO of Leading Age, which represents nonprofit aging services providers, told Kaiser that the workforce shortage is a nationwide dilemma:

 “Millions of older adults are unable to access the affordable care and services that they so desperately need,” she said at a recent press event. State and federal reimbursement rates to elder care agencies are inadequate to cover the cost of quality care and services or to pay a living wage to caregivers."

This shortage was not unexpected.  Kaiser reported that "[f]or at least 20 years, national experts have warned about the dire consequences of a shortage of nursing assistants and home aides as tens of millions of baby boomers hit their senior years." President Biden even included funding for home and community-based care in the infrastructure bill ("human infrastructure").

And here we are. 

Picture Credit: Photo 19608638 / Help Wanted © Martinmark | Dreamstime.com

Staff Shortages Worsen in Long-term Care Industry

Among the many reasons supporting the decision to age in place is a worsening staff shortage in the long-term care industry.  A survey published by the American Health Care Association revealed 94% of long-term care facilities are struggling to hire staff. 

The U.S. faces a certified nurse aide shortage of about 200,000, with the situation made even more dire by a surging number of unvaccinated aides being forced to quarantine as cases of variant COVID-19 cases threaten to surge.  Regional variations make this shortage more or less extreme for the industry and residents.

There are many reasons that contribute to cause these shortages, but among the most surprising is the effect of workplace violence. Violence in all healthcare settings plays a role in the nursing shortage, with the "ever-present threat of emotional or physical abuse adding to an already stressful environment." 

Staff shortages, of course, negatively affect health outcomes. Nursing shortages lead to errors, higher morbidity, and higher mortality rates. 

Lori Porter, founder and CEO of the National Association of Health Care Assistants, is sounding the alarm.  "Bemoaning the twin crises (shortages and vaccinations) won’t resolve them. But neither will throwing just money at potential employees," Porter said, according to McKnights Long-term Care News, adding that "Medicaid pressures continue to make routine higher pay and better benefits elusive for many."

“Pay is one of the scariest things,” she said. “I’ve seen facilities giving up to $20 and hour … I’m not certain how you make that happen in today’s world.”

Porter suggested providers need to look at their individual recruitment efforts to address oversights and messaging, but she also suggested a federal recruitment campaign could be part of the solution.

“People want to be part of a team,” Porter said. “We want to blame the millennials because they don’t want to work. But I would hire millennials all day long because they don’t want to make a job. They want to make a difference.”

Some sociologists and economists have taken to calling the current labor challenge "The Great Resignation." Porter noted that it’s important to consider the cultural shift spurred by COVID-19 and seize on the industry’s intangible benefits to shift momentum.

“Pay and benefits (are) things we’re very weak on as a profession,” she said. “But the second thing we have to sell are emotional benefits, and we’re very high on emotional benefits if care centers and employers will learn how to articulate it in a way that resonates with ‘I want to be part of something that makes a difference.’”

Millennials are, though, among the most unlikely to want a COVID-19 vaccine, another issue that continues to plague providers. Porter told LeadingAge members that vaccine coverage among her membership remains her top concern. She has worked to counter hesitancy with information from AMDA, rather than the Centers for Disease Control and Prevention or the Centers for Medicare & Medicaid Services, and appealing with direct messages about the responsibility to residents.

But Porter said many of the workers her organization represents are still reluctant, at least until the vaccines receive full FDA approval.

“Many of their arguments are becoming weakened. More vaccines have been taken and no one has grown a third arm yet,” said Porter, who noted the rate of unvaccinated people in her area of Missouri recently led two major hospitals there to reopen their COVID units. “Now is the time to push harder than ever.”

Esther's Law Protects Ohio Seniors in Nursing and Rehabilitation Institutions by Permitting Cameras and Monitoring

Residents of Ohio’s nursing homes are permitted to place electronic monitoring devices in their rooms. “Esther’s Law” went into effect on March 23, 2022, after passing unanimously through the Ohio House and Senate and being signed by Governor Mike DeWine on December 22, 2021. This bipartisan legislation demonstrates that ridding Ohio is committed to reducing elder abuse generally, and particularly in institutions charged with caring for Ohio's vulnerable elderly residents. 

The genesis of Esther’s Law (Ohio Revised Code § 3721.60, et seq.), was a shocking video depicting the abuse of the bill’s namesake, Esther Piskor, at the hands of her nursing home care providers. Esther’s son Steve Piskor suspected his mother was the victim of abuse in an Ohio nursing home. In September 2011, Steve placed a hidden camera in his mother’s room which caught and documented six weeks of abuse. Nurses and aides threw Esther around the room, sprayed her in the face with unknown substances, and yelled at and neglected her. Mr. Piskor has since worked to ensure Elder Abuse will be driven out of Ohio’s nursing homes.

The law allows a nursing home resident, the resident’s guardian, or the resident's agent under a power of attorney, to authorize the installation of an electronic monitoring device in the resident's room under the following conditions: (1) the resident or the resident’s representative completes and submits a form to the facility, if the facility prescribes a form for the device and (2) the resident pays for the cost of the device and its upkeep. A resident may withdraw authorization at any time.

If the resident has a roommate, the consent of the other resident is required before any monitoring device may be installed. The roommate may consent based on certain conditions, such as agreed upon angling of the device, or limitations as to the use of the device. Devices must be installed and used in accordance with the consent of all residents residing in the room.

Nursing home operators and their staff should also be aware that the law requires reasonable attempts to accommodate residents to be made where a resident wishes to install an electronic monitoring device, but a roommate refuses to consent. Reasonable accommodation expressly includes moving the resident to another room where installation would be permitted if available.

The scope of Esther’s Law is currently limited to “long-term care” facilities defined as nursing homes and skilled nursing facilities and currently does not extend to assisted-living accommodations that do not meet the “long-term care facility” classification.  State legislators have indicated, however, that the scope of Esther’s Law may expand to other types of facilities in the near future.

Steve Piskor and the State Senators sponsoring Esther’s Law state that the goal of the law is to prevent abuse in the first instance, and not to be a reactive tool after abuse has occurred. This goal is made clear and is served by the law permitting long-term care facilities to place notices outside of the resident’s room to notify others that electronic monitoring is taking place.  In other words, the law is not intended to encourage secretive monitoring merely to encourage or facilitate litigation.

The law also prohibits any denial of admission, discharge, discrimination, or retaliation based on a resident’s decision to exercise the right to install an electronic monitoring device.  

Obviously, seniors and family members should seriously consider the use of such devices.  Keep in mind that even inexpensive and relatively unreliable devices will result in the placing of a notice that a device is electronic monitoring is taking place. Many home residents and merchants purchase signs advising that security systems and electronic surveillance exists, even where no such systems or devices are employed; deterrence is the first goal of any security or safety system or plan. 

Vaccine Mandates Threaten Viability of the Long-term Care Industry

Some long-term care facilities are mandating  COVID-19 vaccines among staff.  Mandates divide the industry in profound ways, and threaten a myriad of legal challenges.

Lauren Clason has penned an excellent article for Congressional Quarterly Roll Call, warning that vaccine mandates "have sparked ethical and legal concerns and [already] prompted some nursing home workers to quit."

The Brief History of the Vaccine

It is important, in considering the impact of the vaccine and associated mandates, to appreciate the brief history of the vaccine.  Bluntly, it is neither normal nor organic.  On December 11, 2020, the FDA issued an Emergency Use Authorization ("EUA") for the Pfizer-BioNTech COVID-19 vaccine. Two days later, the first shipment of the vaccine left the manufacturing plant. Vaccinations began on December 14, 2020. Subsequently, on December 18, 2020, the FDA issued an EUA for the Moderna COVID-19 vaccine. The first shipments of the Moderna vaccine left a distribution center on December 20, 2020. An FDA report issued on December 8, 2020, highlights the unknowns that exist when a vaccine receives an EUA, including the limited amount of data to support the effectiveness of the Pfizer-BioNTech vaccine against asymptomatic infection and its unknown effect against transmission of COVID-19 from individuals who are infected despite vaccination. 

While many articles implicitly or explicitly assail workers (or anyone) who expresses doubts or concerns regarding the vaccine, these authors ignore the the "unknowns" that inherently exists when a vaccine receives an EUA.  Whether these "unknowns" merit refusal or delay, is not an objective fact, notwithstanding the narrative of most authors.  Worse, failure to acknowledge rational concerns only substantiates irrational concerns;  the motives of vaccine proponents are more readily assailable when they are not truthful about "unknowns."    

Regardless, long-term care workers have not rushed to receive the vaccine as public health experts battle everything from unsubstantiated conspiracy theories to the simple fears that come with a novel virus and a more novel vaccine. In context, however, the historical success with vaccination utilization by long-term care industry staff is poor; nursing homes historically trail other health care institutions in vaccinations (see CDC Reports That SNF Workers Most Likely Among Health Care Workers to Forego Recommended Vaccinations). 

The Law

At the federal level, the Equal Employment Opportunity Commission ("EEOC") has determined that COVID-19 meets the direct threat standard, meaning that "a significant risk of substantial harm would be posed by having someone with COVID-19, or symptoms of it, present in the workplace at the current time."   The Equal Employment Opportunity Commission (EEOC) issued guidance in December clearing COVID-19 vaccine mandates in accordance with laws like the Americans with Disabilities Act. 

The EEOC's guidance acknowledges without explanation that the FDA has an obligation to "[e]nsure that recipients of [a] vaccine under an EUA are informed … that they have the option to accept or refuse the vaccine." Based on the EEOC's guidance to date, "a mandatory vaccination policy, with appropriate carve-outs for individuals with disabilities and sincerely held religious beliefs, may be permissible under federal law," according to the excellent analysis of one of the most respected firms in America, Jones Day..  

But, even if it is lawful, there are problems: 

"Namely, no federal agency has endorsed employer-mandated COVID-19 vaccinations explicitly, and historically these agencies have stopped short of endorsing mandatory vaccinations outside of certain industries; courts may disagree with a conclusion by the EEOC that mandatory vaccination is lawful; and there is a lack of legal precedent supportive of across-the-board mandatory vaccinations for all job positions in all industries. Moreover, even if mandatory vaccination is found lawful under federal law, such a policy carries additional risks, including potential liability under state law and damage to employee relations. And notwithstanding workers' compensation exclusivity, there is an open question whether tort or similar liability could attach to an employer, and under what circumstances, if employees are harmed by an employer-mandated vaccine.  

Simply, the law pertaining specifically to emergency use authorizations, which require less efficacy and safety data than a full approval, is unclear.  Dorit Reiss, a professor at University of California, Hastings College of the Law told CQ RollCall:

The law requires that recipients be informed of the right to refuse a vaccine under emergency authorizations, but also that they be informed of the consequences. Whether the consequences can include losing one’s job is unclear.  If it goes to court, I think it’s a 50-50." 

While incentives for mandating the vaccine in elderly care setting are strong, so are the disincentives and potential disadvantages.  Employers might expose themselves to tort and negligence claims if something goes wrong, Robin Shea, a Constangy Brooks, Smith and Prophete partner told CQ Roll Call, adding:

“I would be concerned about that, and in a non-health care workplace, I would be thinking about that really hard before mandating it.”

Conclusion?  There is risk everywhere.  

Tearing Apart the Industry

As a result, the vaccine threatens the industry with workforce uncertainty and public mistrust, all amid threats of legal disputes as institutions contend with union agreements, state laws, and the vaccines’ lack of full Food and Drug Administration approval.  A vaccine mandate also raises ethical issues. Clasen writes:

"Distrust in the government is widespread among low-income communities of color, which make up a disproportionate share of the long-term care workforce. Undergoing a mandatory vaccination from whiter, wealthier bosses seems disrespectful of their historic marginalization, worker advocates say. Distrust among white staffers is also widespread."

“Our members deserve to be heard on why they’re hesitant, and there are many reasons for it that aren’t ridiculous,” Lori Porter, CEO of the National Association of Health Care Assistants, which represents 26,000 certified nursing assistants, or CNAs, told CQ RollCall.  

National polls show that as many as 70 percent of long-term care staff are still wary of the vaccine, Porter told CQ RollCall. Polling among NAHCA members is better, with about 50 percent of workers saying they’d take it.

Many CNAs are leaving the centers that are mandating vaccines.  No nursing center in America today can afford to lose CNAs.  According to Porter, there are "more than 170,000 openings for certified nursing assistants in skilled nursing facilities alone. The annual turnover rate stands at 120 percent."  Locally, the Ohio National Guard was dispatched to help staff a nursing home when staff simply failed to show up for work.  The Ohio National Guard served capably in that role, having in certain instances assisted with staffing institutions reeling from infection and self-quarantines.    

Clasen interviewed Shanna Lacy, a 38-year-old nursing assistant at an Iowa nursing home, who is, according to Clasen "opting out of the vaccine over concerns about unknown long-term effects, driven by the vaccine’s fast-tracked timeline coupled with her distrust in government."

“I don’t feel like any corporation or government or whoever should make somebody do something to their body that they don’t want to,” Lacy told CQ Roll Call.

Lacy reportedly enjoys working at her facility and told CQ RollCall that she gets the flu vaccine every year. But, she said, the pandemic is not severe where she lives, and her belief in former President Donald Trump’s claims that he won the 2020 presidential election further undermines her trust in the government’s vaccine operation. 

Lacy’s nursing home offers prize drawings to employees who take the vaccine, she said, while those who don’t are tested three days a week. She has not been told the facility would require her to take the vaccine, but if that happens, she told CQ RollCall she would find work elsewhere, or maybe even leave the field:

“I could work at a McDonald’s flipping burgers, making the same amount and not being made to take this vaccine,” she said. “Do I want to work at McDonald’s? No, I don’t. But if I had to, I would.” 

Mandates for other vaccines like the flu are common, but requiring a vaccine authorized on an emergency basis is new ground. The Atria Senior Living chain is requiring all 14,000 of its staffers to be vaccinated by May 1:  

“We’re very strong in the belief that our residents deserve to live in a vaccinated environment, and our staff deserves to work in a vaccinated environment,” CEO John Moore told CQ Roll Call. “And it’s a privilege to have access to the vaccine early.” 

Moore reported that the number of staffers who had quit since implementing the mandate was low, but that staffers who ultimately refuse the vaccine will be let go.  What constitutes "low" in an industry with 120% turnover, with a deadline still months away is unclear in the CQRollCall article. 

According to Moore and CQ RollCall, dozens of other facilities are implementing vaccine mandates: 

“No one wanted COVID. No one chose COVID,” Moore said. “There are no perfect answers. There’s only the next best answer, and that’s what we keep searching for."

In Pennsylvania, a vaccine mandate in a nursing home operated by Bucks County sparked a union dispute. The American Federation of State, County and Municipal Employees (AFSCME) filed a grievance with Neshaminy Manor, arguing that changes to employment terms are a bargaining issue under state law.

“I really feel as though this is something that can be worked out,” AFSCME District Council 88 Director Tom Tosti told CQ RollCall. “The workers there in that manor — and across every nursing home facility and every facility, whether it has mental health patients or whatever — have been working tirelessly since this pandemic hit. And to turn around and say now you’re mandated to put something into your body or you’re getting terminated isn’t fair at all for what they’ve done this past year.”

Bucks County says the mandate is on solid legal footing, pointing to the toll the coronavirus takes on the elderly. The facility lost 86 patients to the virus.

“Any staff that has not been vaccinated by the end of March could be laid off,” the county said in a statement.  

The emotions of the decision for workers are often overlooked, Pennsylvania COVID-19 task force member Joshua Uy, medical director at Renaissance Healthcare and Rehabilitation Center in Philadelphia told CQ RollCall. Explaining the mechanics of the vaccine doesn’t necessarily erase fear. According to the CQ RollCall article, all of Renaissance’s residents were vaccinated compared with only 50 percent of its staff. Uy focuses on highlighting positive emotions that the vaccine can bring, such as ending isolation. 

“I’ll try to remind them not to ignore what they’re feeling, but to sort of add other emotions, like this vaccine is hope,” he said. 

Porter said NAHCA is considering a project to leverage the families of long-term care patients. 

“CNAs don’t trust government. CNAs don’t trust their employers,” she said. “CNAs trust CNAs. Those two obstacles in the trust run deep.” 

Relying on personal doctors, whom polling shows are a trusted source for many people, doesn’t always work. In Missouri, where NAHCA is based, many doctors weren’t wearing masks as recently as December, she said.

Porter also stresses that receiving priority for a vaccine with the potential to end a pandemic is an unprecedented industry victory:

“We continue to tell our members that this was a win for us,” she said. “Don’t let it be in vain.”

The public watches intently as the drama unfolds.  Perhaps, rather than just feeding a collective fear of institutions, the public will orient its planning toward aging in place, thereby relieving stress upon both the long-term care industry and families seeking to cope with short and long-term care. 

Only 37% of Long-term Care Facilities Staff Vaccinated for COVID-19

While residents of nursing homes and their caregivers have been considered a top priority for COVID-19 vaccination, only 38% of nursing home staff accepted shots when they were offered.  This according a survey conducted by the Centers for Disease Control and Prevention (CDC). 

Anecdotal reports have been circulating for weeks that nursing home staff members were turning down vaccination offers, but these are the first national-level figures.  Of course, historically, nursing homes trail other health care institutions in the staff penetration of vaccines (see CDC Reports That SNF Workers Most Likely Among Health Care Workers to Forego Recommended Vaccinations). 

Dr. Radhika Gharpure, lead author of the study and a member of the CDC’s Vaccine Task Force wrote, "These findings show we have a lot of work to do to increase confidence and also really understand the barriers to vaccination amongst this population." The report cited previous polling data to suggest why employees have been declining vaccines. Many raised concerns about vaccine side effects. Others said they didn't want to be among the first to receive the vaccines, which were first authorized in December. Some said they didn't trust the government, or referenced false claims about the shots.

Residents, meanwhile, have been much more accepting of vaccines, with 78% receiving at least one shot, according to the new report, which examined vaccination rates at more than 11,000 long-term care facilities nationwide between Dec. 18 and Jan. 17.

Source, "Roughly one-third of long-term care staff vaccinated through federal program: CDC," The Hill (2/1/21).

Long-term Care Industry Forecast to Lose $94 Billion Amid Pandemic

The long-term care industry will lose $94 billion over a two-year period as a result of COVID-related costs and revenue losses, according to a new forecast from the nation’s largest nursing home association. 

The American Health Care Association/National Center for Assisted Living detailed its projections Tuesday. Its analysis found that providers spent an estimated $30 billion in 2020 on COVID-related costs, such as hiring more staff members and purchasing personal protective equipment. That number is projected to be $30 billion again for 2021.

In terms of revenue, nursing home operators have lost $11.3 billion in 2021. Provider losses are projected to rise to $22.6 billion in 2021, according to AHCA/NCAL.  

The combination of revenue declines and increased costs resulted in 143 facility closures and mergers in 2020, the report stated. That’s projected to reach 1,670 closures/mergers in 2021 if business conditions do not change. 

AHCA/NCAL is an industry advocate, of course, but it claims the findings justify the need for additional and immediate support for long-term care. The association called for allocating $20 billion to the long-term care industry through enhanced Federal Medicaid Assistance Percentage (FMAP) for long-term services and support, or through a dedicated portion to the Provider Relief Fund, top priority for vaccine distribution and access to testing and supplies. 

“Congress and the Biden Administration must prioritize the long-term care industry and ensure the dedicated front-line workers of these facilities have the necessary resources to protect their residents and themselves,” AHCA/NCAL warned.

Of course, consumers, in the end have the most to lose.  Concerns regarding quality care, security, and staffing, for example, are only heightened when the industry is not profitable.  

Source:  D. Brown, "Long-term care to lose $94 billion due to pandemic: forecast," McKnight's Long-term Care News.