The urgency to vaccinate nursing home residents is evident in the numbers. The COVID-19 pandemic has already claimed the lives of more than 136,000 residents and employees of long-term care institutions in the US alone, accounting for almost 40% of all U.S. deaths related to the disease.
Echoing this urgency, Health and Human Services Secretary Alex Azar declared in mid-December: “We can vaccinate all patients in a nursing home in the United States by Christmas.” However, by Christmas, most states had barely started.
Other states were still far behind when West Virginia became the first state to finish the first round of the double dose vaccine series in nursing homes on December 30.
What did West Virginia do differently?
The numbers tell a story. As a professor specializing in health operations management, I believe they contain some important lessons for other states and the rest of the vaccine distribution.
The math problem of the pharmacy
The first important point is that West Virginia chose not to participate in a federal partnership program that relies on the giant pharmacy chains CVS and Walgreens to deliver vaccines to nursing homes. Instead, the state has a network that consists mainly of local pharmacies.
West Virginia was also praised for how it used the time between when the authorization for the first vaccines became evident and when the first doses arrived to plan the launch.
The big difference is in the numbers. Under the federal partnership program, CVS planned to have around 1,000 of its pharmacies as vaccine centers to serve nearly 25,000 nursing home facilities across the country, a CVS official told The Wall Street Journal early in December. Likewise, a Walgreens employee said his company would have 800 to 1,000 Walgreens pharmacies to serve as centers for some 23,000 nursing home facilities.
This meant that each CVS and Walgreens pharmacy planned, on average, to serve about 25 nursing homes.
West Virginia chose to mobilize independent, networked pharmacies, rather than relying solely on CVS and Walgreens. More than 250 pharmacies have offered to help vaccinate people in 214 nursing homes. In other words, each nursing home, on average, is served by more than one pharmacy.
Vaccination in nursing homes is a very laborious operation. Obtaining consent from residents and employees is time-consuming and confusing. Some people also refuse the vaccine. On January 14, only about a quarter of the vaccines distributed to nursing homes through the federal program reached the people, while West Virginia started vaccinating new groups and administering second doses.
Incentives are another problem
In addition to unbalanced mathematics, there is a history of incentives.
Under contracts signed with the United States Department of Health and Human Services, CVS and Walgreens essentially won the right to vaccinate about 99% of the United States’ nursing homes registered in the program. They had little incentive to commit a large number of pharmacies and employees to the difficult task of vaccinating people in nursing homes.
In West Virginia, however, hundreds of local pharmacies and other pharmacy chains were involved, and each had every incentive to provide fast services so that nursing homes did not give up on the vaccination business. Local pharmacies also often have existing relationships with nursing homes – relationships they want to maintain.
AP Photo / Stephen Dunn
Lessons for the rest of the country
What can other states learn from West Virginia’s success story?
First, to accelerate the vaccine’s launch, the United States must deal with bottlenecks – the scarcity of resources, especially personnel and distribution points, needed for vaccination.
Second, incentives are important. When designing vaccination programs, it is important to ensure that providers are motivated to commit resources to accelerate vaccination. Market competition is a powerful mechanism for this.
Third, state and local leadership can make a difference. Although the lack of federal leadership was cited as a reason for the slow launch of the vaccine, West Virginia was successful in vaccinating asylums because it could be more agile outside the federal program. State and local leaders can succeed when they are held accountable and proactively manage the process.
The US is just beginning the COVID-19 vaccination process. Just over 3% of the country’s population had been vaccinated by January 13 and there are many challenges ahead. The complex cold storage requirements of mRNA vaccines can hamper access to rural areas without careful planning and logistical support. More health professionals and residents also refused to receive the vaccine than public health professionals would like to see. In West Virginia, about half of the nursing home staff refused. All of this has implications as vaccination proceeds.