How a Vaccine Mandate Could Worsen a Shortage of Home Care Aides - The New York Times

Some 250,000 home health care workers must get the coronavirus vaccine by Friday, but tens of thousands of them have yet to receive it.

In the upstate city of Johnstown, north of Albany, two-thirds of the home health aides at one small agency have notified their director that they intend to quit rather than get vaccinated against the coronavirus, as they are required to do this week under a state mandate.

At the Visiting Nurse Service of New York, the state's largest home health care organization, about 400 workers are expected to be unable to work after the mandate takes effect. And in the New York City area, a union leader for home health care workers says he expects thousands of his members will be put on leave.

"We need more time," said Joe Pecora, the vice president of Home Healthcare Workers of America, a union that represents about 32,000 home health care workers in New York City and its suburbs. "It's unrealistic to get all these people vaccinated by the deadline."

One week after requiring more than 650,000 hospital and nursing home workers to get at least one dose of the vaccine, New York State's pioneering mandate for health care workers is moving into a second and likely more difficult phase: requiring at least 250,000 home health care workers to get at least one dose of the vaccine before Friday or face the threat of losing their jobs.

While the first phase of the mandate was widely viewed as successful in pressuring thousands of nurses, doctors, technicians and orderlies to get the vaccine, many industry officials say they fear this second phase will result in thousands of workers simply quitting their jobs and finding new work in restaurants, retail or other industries. Most home health care aides, many of them immigrants, are paid about minimum wage and could find jobs paying similar wages elsewhere.

Without enough workers to go around, patients recovering from stints in the hospital or elderly New Yorkers who rely on long-term aides for assistance with everything from grocery shopping to bathing could find their care reduced or ended. The shortage could also exacerbate patient backlogs at hospitals, which often discharge patients with the support of in-home care.

"Even a small percentage of home care workers no longer working will impact thousands of homebound individuals," said Dan Savitt, the president and chief executive of the Visiting Nurse Service of New York. "The rough math here is for every 1 percent of full-time aides unavailable, there are about 1,500 Medicaid members that will be impacted."

Some industry officials estimate that only seven of 10 home health care workers in the state are vaccinated, causing many of the agencies that employ the workers to brace for staffing shortages starting Friday. Many leaders are also calling on Gov. Kathy Hochul to extend the deadline.

"We think we can continue to build those numbers, but there needs to be an appropriate recognition of a runway for this mandate," said Al Cardillo, the president of the Home Care Association of New York State, an industry organization. Noting that the industry is already facing staffing shortages, he added: "Even to dismiss 5 percent of staff is catastrophic in this field."

An association survey of 189 of the state's 1,500 home health care agencies, taken in mid-September, found that almost 900 nurses would quit rather than get vaccinated, affecting the care of nearly 18,000 patients. The survey found that about a third of home health aides, who do the bulk of daily care, had not been vaccinated.

By contrast, at least 84 percent of hospital and nursing home workers had received at least one dose a week before the mandate took effect for them, on Sept. 27. By the day after the deadline, that number had risen to 92 percent.

The state does not yet have data on the vaccination rates of home health workers, a Department of Health spokeswoman said, making it difficult to judge exactly how much disruption would take place.

The department said that it was sticking to the deadline and had offered grants to home health agencies for emergency planning. "The state believes it's important to balance the risk of disruption in care with the risk to patients of having unvaccinated personnel in their homes," the department said in a statement.

Ms. Hochul, a strong proponent of the mandate, which she inherited from her predecessor, Andrew M. Cuomo, has already declared a state of emergency in health care staffing in New York, which allows her to deploy the National Guard and permit student nurses and out-of-state and foreign workers to temporarily fill staffing gaps at "hospitals and other health care facilities."

But those actions would probably not be suited for home health patients, who require specially trained nurses and prefer aides they are comfortable with, Mr. Savitt and other agency directors said.

Not all industry officials were pessimistic about the mandate. Helen Schaub, director of policy and legislation at 1199SEIU, which represents some 70,000 home health workers in the state, said that many of the large agencies that employ its workers now have vaccination rates over 90 percent.

JASA, an organization serving older adults in New York City, said that its staff members had rushed to be vaccinated this week after an all-out push by the agency. Among its 660 home health aides, some 94 percent are now vaccinated, up from 20 percent who had submitted proof by August, said Kathryn Haslanger, the organization's director. Five people resigned over the mandate.

This week's vaccine deadline, set in an Aug. 26 emergency regulation by the Department of Health, covers certified home health agencies, long-term home health care programs, hospices and adult care facilities.

What to Know About Covid-19 Booster Shots

The F.D.A. has authorized booster shots for millions of recipients of the Pfizer-BioNTech, Moderna and Johnson & Johnson vaccines. Pfizer and Moderna recipients who are eligible for a booster include people 65 and older, and younger adults at high risk of severe Covid-19 because of medical conditions or where they work. Eligible Pfizer and Moderna recipients can get a booster at least six months after their second dose. All Johnson & Johnson recipients will be eligible for a second shot at least two months after the first.

Yes. The F.D.A. has updated its authorizations to allow medical providers to boost people with a different vaccine than the one they initially received, a strategy known as "mix and match." Whether you received Moderna, Johnson & Johnson or Pfizer-BioNTech, you may receive a booster of any other vaccine. Regulators have not recommended any one vaccine over another as a booster. They have also remained silent on whether it is preferable to stick with the same vaccine when possible.

The C.D.C. has said the conditions that qualify a person for a booster shot include: hypertension and heart disease; diabetes or obesity; cancer or blood disorders; weakened immune system; chronic lung, kidney or liver disease; dementia and certain disabilities. Pregnant women and current and former smokers are also eligible.

The F.D.A. authorized boosters for workers whose jobs put them at high risk of exposure to potentially infectious people. The C.D.C. says that group includes: emergency medical workers; education workers; food and agriculture workers; manufacturing workers; corrections workers; U.S. Postal Service workers; public transit workers; grocery store workers.

Yes. The C.D.C. says the Covid vaccine may be administered without regard to the timing of other vaccines, and many pharmacy sites are allowing people to schedule a flu shot at the same time as a booster dose.

As with the hospital mandate, limited medical exemptions are permitted. The regulation does not allow religious exemptions, but workers whose employers have approved their religious exemptions may be permitted to work for now while the issue is challenged in court.

The state's hundreds of thousands of home health care workers have been largely out of the spotlight during the pandemic, despite the work they have done to care for high-risk patients. Home health workers were not initially included in New York's highest priority category for vaccination, for example, though after lobbying efforts, they were added.

Most home health aides — the bulk of the home health work force — make close to the state minimum wage of $15 an hour. The home health care system, largely funded by Medicare and Medicaid, also relies on a smaller number of nurses, who help oversee care of homebound patients. Agencies also employ therapists and social workers.

Already facing an industrywide staffing crunch, agencies have begun to implement emergency staffing plans, which include limiting new admissions, asking family members of home care recipients to shoulder more of the burden, and authorizing overtime. The Visiting Nurse Service is asking to have until the end of the year to comply with the mandate.

Assemblyman Richard Gottfried, who chairs the health committee, said in an interview that "a short delay might well make sense," given the ongoing staffing crisis in home care. He also suggested that the state use federal money to offer enhanced salaries and overtime incentives to help hire and retain home health aides.

"Home care is a different situation for workers and patients," he said. "If a hospital has 95 percent of its staff, you can move people around and survive. But if a home care patient's home health aide doesn't show up, it's a 100 percent shortage for that patient."

Some home health aides — those directly employed by patients — are not covered by the current mandate, meaning that they could still work even if unvaccinated. Still, Bill Hammond, an expert on health policy at the Empire Center for Public Policy, a think tank in Albany, said he remained concerned that vulnerable patients could fall through the cracks.

"You have to hope that the certified agencies will prioritize the people who are most desperately dependent on care, but that is asking a lot of a system to make that decision reliably in that crisis situation," he said.

The Community Health Center of St. Mary's Health Care and Nathan Littauer Hospital in Johnstown takes care of about 140 home care patients a week in seven rural counties north and west of Albany. The agency has already been severely taxed during the pandemic, dropping to six full-time nurses from 16, said Millie Ferriter, its executive director.

Now, four of her six home health aides, and two of her remaining nurses, say they don't want to get vaccinated.

"The crux of the matter is they feel that they want to make their own choice about the vaccine, and a lot of them don't feel they have that opportunity to do so right now," she said. "I'm hoping I can keep talking with them to change their minds, but they are steadfast."

Ashley Wong contributed reporting.