Saving Money and Saving Lives in Nursing Homes


Mar 30, 2007

This commentary originally appeared in on March 30, 2007.

While more than 3,200 Americans have died in Iraq since the United States invaded that nation in March 2003, about 120,000 Americans have died in their own country during the same period after losing battles to a microscopic enemy — the influenza virus.

More than 90 percent of Americans who die from the flu are 65 and older, and many of them live in nursing homes, where flu outbreaks are common. In fact, one study found that nursing home residents 65 and older are three times more likely to be hospitalized for influenza than people of similar ages who do not live in nursing homes.

Many of these nursing home victims could be saved from illness and death — not as a result of some expensive high-tech medical procedure, but by a campaign that would focus on persuading more nursing home employees to get flu shots.

It is time to begin that campaign.

But wouldn't shots for the estimated 1.7 million people who work in nursing homes in the United States cost a lot of money? And don't many of the roughly 1.4 million residents of America's 16,000 nursing homes already get flu shots, protecting them from catching the flu from the people who care for them? The answer to both questions is no.

No one can put a price on a human life or human suffering. But in strictly dollars and cents terms, the price of a flu shot is about $10. The cost of stopping a flu outbreak can be $200 to $250 per resident in a nursing home. The bill can run up to several thousand dollars for an elderly person hospitalized with the flu. Funeral bills cost thousands of additional dollars.

Because many elderly nursing home residents are in poor health and have weakened immune systems, they are vulnerable to getting the flu when exposed to the influenza virus — even if they have already been immunized. While the flu vaccine can be 86 percent effective for healthy adults when the vaccine matches the prevailing influenza strain, in nursing homes it is estimated that the vaccine is only 23 percent effective for residents.

The flu virus can spread easily in a nursing home, where many people live in close proximity to each other and residents come in close contact with employees who provide personal care.

A study I led for the RAND Corporation, a nonprofit research organization, looked at influenza immunization rates at 301 nursing homes around the United States.

My research team found that nursing homes were 60 percent less likely to have a cluster of influenza-like illness cases if more than 55 percent of the employees and more than 89 percent of the residents were vaccinated for influenza. We defined clusters of influenza-like illness as more than three cases with influenza-like symptoms reported within 72 hours in close proximity within the nursing home.

While it is true that more than 75 percent of nursing home residents get flu shots each year, only about 40 percent of nursing home employees get the shots.

Nursing home residents spend most of their time in the homes. But nursing home employees go to their own individual homes each day, exposing themselves to the flu virus that may be carried by their children, spouses and other people they encounter. That makes it easy for these employees to bring the virus into nursing homes as an unwelcome guest.

Currently flu shots can't be mandated for nursing home employees, but they can be strongly encouraged. The following actions would be both cost-effective and relatively easy to implement.

  • Free flu shots for nursing home employees. Insurance companies and nursing homes would spend a lot less paying the $10 cost of a flu shot for each employee than they would pay to stop the resulting outbreak and treat nursing homes patients who contract the flu.
  • Payments to nursing home employees who get flu shots. One nursing home recently offered $150 to each employee who received a flu shot and achieved very high rates of immunization very quickly. This is a lot cheaper than treating residents who contract the flu.
  • Vaccinate employees first, before nursing home residents get the flu shot. Employees are harder to get to when it comes to arranging the flu shot, so the effort to immunize always takes longer for them than for residents. Employees also keep their immunity much better and longer than residents, so immunizing employees early is acceptable if supplies arrive on time.
  • Employee education. Many nursing home employees are afraid that the immunization will give them the flu or cause other health problems. A well-directed education campaign can alleviate these fears and help employees understand the benefits of immunization.
  • Requiring that the level of employee immunization for each nursing home be publicly reported, so that prospective nursing home residents and their families could use this knowledge in selecting a safe nursing home to live. Currently, only the level of immunization for residents is publicly reported. In an effort to attract more residents, nursing home owners might seek to boost employee immunizations if that statistic was also reported.

For many young and middle-age Americans, the flu is an unpleasant inconvenience. A stuffy nose, fever, headache, stiffness, perhaps a few days missed from work or school. But for many vulnerable older Americans in nursing homes, the flu is a killer. Too many are dying needlessly.

Programs to create incentives for more nursing home employees to get flu shots can save thousands of lives and save money at the same time. The families of nursing home residents, nursing home owners, employee representatives, insurance companies and government officials should unite to create such incentives in time for the next flu season.

Lisa Shugarman is a health policy researcher at the RAND Corporation, a nonprofit research organization.

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