Morningside of Belmont

Tennessee nursing homes have a long-term care problem: 18 months after the COVID-19 crisis began, their staffs are shrinking faster than ever.

Last month, Tennessee nursing homes and residential care facilities reported the largest drop in employment in state history, according to statistics from the Tennessee Department of Labor.

Tennessee Health Care Association spokesperson Jay Moore has attributed the staffing spiral to newly instituted COVID vaccine requirements for long-term care workers. Since July, more than 60 percent of Tennessee nursing homes have issued vaccine mandates for their employees. Administrators began handing down requirements after rumors of impending federal regulations began to swirl throughout the sector.

Aug. 18, the rumors became reality. President Joe Biden said his administration will require nursing homes to vaccinate their staff against COVID-19 or risk losing Medicare and Medicaid funding.

Nursing homes were long the deadliest place for COVID-19 outbreaks, with facilities accounting for more than one fourth of all COVID-related deaths last fall in Tennessee. Severe outbreaks continued even through lockdowns that barred family members from visiting, often mirroring surges in the broader community. Staff were a key way the virus got inside because they come and go daily and work so closely with residents. 

Some administrators feel like the looming regulation has put them in a no-win situation. The threat of losing Medicare and Medicaid funding is a potent one. Roughly 80 to 85 percent of nursing-home operators’ revenue comes from the two programs, according to David Grabowski, a professor of healthcare policy at Harvard Medical School. However, the risk of losing staff to vaccine requirements could be just as costly. More than half of all Tennessee nursing homes are already operating with a staff shortage of 20 percent or greater, according to THCA.

Two weeks ago, administrators of Morningside of Belmont, a nursing home in Nashville, gave employees a choice: Get vaccinated or find somewhere else to work. The entire cleaning staff and its sales director chose the latter and walked out, leaving the residency without a single cleaning crew member and administrators scrambling to hire new staff. The building’s handyman has been charged with cleaning the rooms during the interim, according to one of the residents.

What’s to come

Bill Schaffner, a veteran professor of infectious diseases at Vanderbilt University Medical Center, said he fears walkouts in nursing homes could foreshadow what's to come, now that Pfizer’s vaccine is fully FDA approved.

“I think we are watching the tide before the tsunami hits,” Schaffner said.

Schaffner said once a vaccine receives full FDA approval, the barriers to mandate it become lower or nonexistent. He foresees the government enacting similar vaccine regulations that would make federal funding “vaccine-conditional” for a number of entities such as public schools and hospitals. Schaffner said while he would support the decision to connect funding to employee vaccine mandates, he fears the fallout.

“Many institutions that don’t have vaccine mandates in place have opted out of doing so for two reasons: The vaccine wasn’t fully FDA approved and/or they are already facing staff shortages and fear a significant portion of their staff will quit rather than get the vaccine,” he said.

He pointed out that there are different levels of enforcement and exceptions to mandates. He said it’s impossible to draw a completely hard line on a federal level, but the “power of the purse” has a lot of influence.

“We are fighting a war against COVID,” Schaffner said. “To date, the army has been composed of all volunteers, people voluntarily receiving the vaccine. However, with Delta numbers climbing, we’ve realized a ‘volunteer army’ is not enough. We have to start drafting people to get the vaccine.”