The biggest nursing home chain in the US is sounding off about a potentially messy COVID-19 vaccine rollout for seniors, as a patchwork of state vaccination plans emerges

• Under a federal program, pharmacy giants CVS Health and Walgreens will give COVID-19 vaccines to residents and staff at more than 50,000 long-term care facilities. 
• Dr. Richard Feifer, chief medical officer of the country’s largest nursing home operator, Genesis HealthCare, sounded off about West Virginia’s decision to devise its own strategy for vaccinating long-term care facilities.
• The adjutant general of the West Virginia National Guard and a leader in the state’s pandemic response said the federal program would limit West Virginia’s ability to vaccinate long-term care residents quickly.
• CVS and Walgreens and preparing to vaccinate millions of vulnerable nursing home residents. The pharmacy chains said they would be ready to give shots at long-term care facilities within 48 hours of receiving Pfizer’s COVID-19 vaccine.
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The chief medical officer of the largest US nursing home operator, Genesis HealthCare, said the federal government’s decision to give states the final say in COVID-19 vaccination plans is complicating efforts to ensure the country’s most vulnerable people are vaccinated.

Dr. Richard Feifer, chief medical officer of Genesis, which operates more than 325 long-term care facilities in 24 states, said that while most states have agreed to allow pharmacy chains CVS Health and Walgreens to vaccinate their nursing home residents as part of a federal program, at least one state – West Virginia – is mulling its own strategy.

That could create problems for Kennett Square, Pennsylvania-based Genesis, which has 34 nursing homes in West Virginia. Nearly half of deaths from COVID-19 in the state are among nursing home residents.

“We’re concerned that they’re trying to reinvent the wheel and we don’t have time to waste,” Feifer said. “We’d much prefer fully leveraging the national model and we’re expressing those concerns in West Virginia.”

Residents and staff of long-term care facilities will be some of the first in the US to get a COVID-19 vaccine once it’s approved, a decision that’s expected to come in a matter of days for Pfizer and BioNTech’s vaccine. Large chain pharmacies CVS and Walgreens are preparing to vaccinate more than 50,000 of those facilities as part of the federal program, called the Pharmacy Partnership for Long-Term Care.

Long-term care facilities opted into that federal program, which is meant to relieve those facilities of the burden of storing the vaccines, giving the shots, and reporting vaccination data. But states ultimately decide where the first vaccines go and whether to stick with the federal government's approach.

While state's playbooks are evolving by the day and coronavirus vaccines have not yet gotten emergency clearance in the US, it's clear that their strategies are diverging, creating a patchwork of vaccination plans across the country.

Inconsistent state approaches to managing the pandemic have complicated COVID-19 testing and efforts to source personal protective equipment, causing confusion and inefficiencies, Feifer said, adding that he worried variation among states would hinder efforts to vaccinate Americans quickly and end the pandemic.

"We have needed a more deliberate centralized model of managing the pandemic all along," he said. "We can't afford to make the same mistakes again around state-by-state variation." 

West Virginia is developing its own plan for vaccinating long-term care residents that don't rely on CVS or Walgreens, in hopes of doing it faster than the federal government

Maj. Gen. James Hoyer, the adjutant general of the West Virginia National Guard who is head of a task force leading the state's pandemic response, told Business Insider that the state has decided to delay full implementation of the federal program to vaccinate nursing homes.

Instead, West Virginia is developing its own strategy to best fit its population. The state is prioritizing nursing home and assisted living residents and staff for the first vaccine shipments, along with healthcare workers that work with patients with COVID-19.

West Virginia placed an initial order to the US Centers for Disease Control and Prevention of 16,575 doses of the Pfizer vaccine.

Because many of the largely rural state's pharmacies are not part of big chains, "we felt from a state perspective that we were limiting the ability to very rapidly, logistically distribute and administer vaccines to that population," Hoyer said.

West Virginia's goal is to vaccinate all nursing home and assisted-living residents and staff in less than 30 days of receiving the vaccines at five designated hospitals in the state. Hoyer said the state pharmacy board has put out a call to pharmacists in the state that want to participate in vaccinating the nursing homes.

Those pharmacies would include those that already have relationships with nursing homes or assisted-living facilities in their communities. They could include CVS and Walgreens.

"We believe that based on our primarily rural nature that pharmacies are going to be key to our distribution to our general citizen population, so this is helping us build the infrastructure long-term to vaccinate all West Virginians," Hoyer said.

"We are using the approach that we think best fits us in West Virginia" he said. "I think everybody's going to have a different approach based on idiosyncrasies and differences."

Rebecca Snead, executive vice president and CEO of the National Alliance of State Pharmacy Associations, said there may be other states in addition to West Virginia that are opting out of or delaying implementation of the federal government's program to vaccinate long-term care facilities. There will be variation not just among states, but also between each national partner and each facilities' capacity and and requirements for t he clinics.

"Success will depend on meeting the needs of the individual facility, no matter if it is a federal partner or the state facilitating the vaccine distribution/administration," Snead wrote in an email.

Read more: 'This is game time': Hospitals across the country are gearing up to give the first COVID-19 shots to millions of healthcare workers

US officials said 36 states want vaccines shipped to long-term care facilities

The FDA could give emergency approval to a vaccine from drug company Pfizer within days. An expert panel is meeting Thursday to review the drug company's application for emergency-use authorization.

A week later, it will review Moderna's request for emergency approval of its vaccine. Both require two doses given weeks apart.

US health officials have said millions of vaccines could be shipped out within 24 hours of one getting emergency approval. State governors and their health departments have been busy planning where COVID-19 vaccines will go.

Army Gen. Gustave Perna, who oversees the logistics of delivering COVID-19 vaccines to states, said during a media briefing Wednesday that 36 states had so far told the US Centers for Disease Control and Prevention that they want initial vaccines to ship to long-term care facilities.

North Carolina is one state relying on the federal government's approach for vaccinating those facilities. Dr. Mandy Cohen, secretary of the NC Department of Health and Human Services, said during a media briefing Thursday that while vaccines for nursing homes will come out of the state's vaccine allocation, Walgreens and CVS will be doing all the work of getting shots in arms.

Cohen said she expects the pharmacies to begin vaccinating long-term care facilities in the second week of the vaccine rollout, once the Moderna vaccine is authorized. Healthcare workers in contact with COVID-19 patients would be prioritized during the first week.

Most big long-term care companies are working with either CVS or Walgreens to vaccinate their residents and staff.  Signature HealthCare, which has 109 facilities in 10 states, is working with both CVS and Walgreens. Atria Senior Living, Sunrise Senior Living, Brookdale Senior Living are partnering with CVS.

Deaths in long-term care facilities, which include nursing homes, skilled nursing and assisted living facilities, account for 40% of all COVID-19 deaths in the US, though in some states that figure is much higher, according to the Kaiser Family Foundation.

Genesis, which reported $4.57 billion in revenue in 2019, chose to work with CVS to vaccinate its nursing homes in most states where it operates. But Feifer said it's unclear if CVS would be able to vaccinate Genesis' nursing homes in West Virginia, as that would require the state's approval and "CVS supporting that outside of their direct contract with the CDC," he said.

A spokesman for CVS said the company is unaware of any state opting out of the federal program, but said if a state were to opt out, CVS' ability to vaccinate a long-term care facility in that state would depend on the state.

A CDC spokeswoman said that all states have opted into the federal pharmacy partnership for long-term care.

Read more: Pharmacies, doctor's offices and hospitals are gearing up to give coronavirus vaccines to millions of Americans. Here's how they're preparing and how much they stand to profit along the way.

CVS and Walgreens will vaccinate at more than 50,000 long-term care facilities

Chris Cox, a senior vice president at CVS and the company's liaison to Operation Warp Speed, said Friday that the pharmacy chain would vaccinate more than 30,000 long-term care facilities, which he estimated include roughly 3 million residents and staff.

The company is coordinating with the facilities while it waits for each state to decide where to send the first vaccines.

Walgreens, meanwhile, is planning to vaccinate more than 27,000 long-term care facilities, said Rina Shah, the pharmacy chain's Group vice president of pharmacy operations and services.

Both CVS and Walgreens said they'll be ready to give shots within 48 hours of receiving the vaccines at their designated hubs.

"When a vaccine is available, the state will let us know which are the priority groups within that population, and then we'll begin the administration of those facilities," Shah said.

A CDC committee recommended that states prioritize healthcare workers and nursing home residents for the first doses, but timelines could vary by state. Cox said the CDC is allowing states to "turn on" the federal program for all of long-term care, or they can start with vaccinating skilled-nursing facilities first and move to other facilities later.

Cox said some states may also choose to start vaccinating healthcare workers in hospitals before turning to long-term care facilities, for example. Others may opt to vaccinate long-term care settings right away.

Pfizer will ship its vaccines, which must be kept at a temperature of negative 70 degrees Celsius, directly to roughly 1,000 CVS pharmacies that are acting as "hubs." Those hubs were chosen because of their proximity to the long-term care facilities that CVS will visit. Supply chain company McKesson will ship CVS the Moderna vaccines, which can be kept at regular freezer temperature.

Similarly, Walgreens will have vaccines shipped to certain stores that will then take the vaccine to long-term care facilities. Walgreens is working with the facilities now to understand how many patients and staff want vaccines ahead of setting up on-site clinics.

Cox said CVS intends to vaccinate all residents and staff in a single facility in one visit, rather than prioritizing who within the facility should be vaccinated if there's limited supply. But if a state directs CVS to vaccinate all long-term care facilities, and there are limited vaccines, CVS plans to prioritize skilled-nursing facilities over other types of long-term care settings, as the patients are generally sicker. CVS will also take population size into account.


CVS will return to set up a second vaccine clinic a few weeks later to give the second dose, and will set up a third clinic for any new residents.

"We expect to get to all of them within three to four weeks of whenever the jurisdiction turns it on, so it's not going to be a long wait for any of them," Cox said.

Genesis' Feifer said he's concerned that vaccinating all nursing home staff on the same day could create staffing shortages if a large number of workers get side effects. Genesis has urged the federal government and CVS to consider staggering the vaccinations to reduce that risk.

The CVS spokesman said that for facilities concerned about staffing, CVS is willing to stagger dosing among its three clinics. Half the staff would receive the first dose on the pharmacy's first visit, with the rest of the staff receiving it on the second visit, for example.

• Read more:
• Pharmacies, doctor's offices and hospitals are gearing up to give coronavirus vaccines to millions of Americans. Here's how they're preparing and how much they stand to profit along the way.
• 'This is game time': Hospitals across the country are gearing up to give the first COVID-19 shots to millions of healthcare workers
• These are the states that have announced how many COVID-19 vaccine doses they will receive in the first round of distribution
• The US will give Americans paper cards to remind them of their second COVID-19 vaccine dose, but will leave further messaging to states and pharmacies