The Centers for Disease Control and Prevention on Sept. 26 approved a third shot of Pfizer’s vaccine for seniors 65-plus and anyone with underlying medical conditions. It recommended a six-month waiting period. Boosters also were made available to workers in high-risk settings, such as healthcare. 

Still in the balance at press time: how the national staff vaccine mandate might cover adherence to a booster schedule. Most existing provider and state policies call for one or two shots. Also, Food and Drug Administration advisors were set to review whether patients can mix and match shots for booster purposes.

That was in addition to overtime — a factor costing facilities nationwide significant cash in the short-term and increasing the risk of worker burnout in the long-term.

“I don’t know if workers can work that many hours for many months at a time, ” George Linial, president of LeadingAge Texas, told McKnight’s Long-Term Care News in early October. “We’re teetering. We’re surviving, but we’re on precarious ground.”

In hiring categories ranging from administrators to housekeepers, long-term care providers across the nation spent this summer begging for help. Instead, the numbers kept dropping. Skilled nursing shed another 1,500 employees in July, bringing the total since March 2020 to 380,000.

The timing couldn’t be worse, as the long-awaited “silver tsunami” approaches. Accounting for recent turnover, long-term care employers will need to fill 7.4 million direct care jobs to meet patient demand through 2029, according to a September report by workforce advocate PHI.

There have been some scattershot policy efforts to stem the tide. In West Virginia, the governor pledged extra funding, staffing assistance and a 24/7 monitoring system for long-term care facilities facing worker shortages during COVID’s delta surge. In New York, the governor promised to call out the National Guard in response to shortages after a state vaccine mandate kicked in Sept. 27.

But at press time, providers nationwide were waiting for the other shoe to drop: In mid-October, the Centers for Medicare & Medicaid Services was expected to issue an interim rule detailing its national COVID vaccine mandate.

That rule will set in place a harrowing new deadline, one with worrisome staff implications in areas where vaccination rates are lagged the rest of the nation (both in the community and among those working in skilled nursing facilities). Whether or not the mandate allows for test-outs, providers are bracing for more staff losses as vaccine-resistant workers flee for jobs without such rules.

Already, the flight has affected access to care. A September American Health Care Association survey found 89% of providers were experiencing high or moderate staffing shortages. And 58% were so strapped, they limited new admissions. 

A Texas Health Care Association and LeadingAge Texas survey put that “turn away” rate at 30%. Just as alarming: 63% of providers there said they could not fill positions because they have zero applicants.

“That business model is not going to work well when your census is down and your staffing costs are up,” said Linial. “That’s not a good formula for long-term survival.”

How bad will it get?

Two independent surveys have predicted stark consequences of nursing home mandates. In late August, an OnShift survey of more than 2,100 long-term care employees found just 8% of those unvaccinated planned to get a vaccine. In September, Caring.com reported one in three unvaccinated caregivers would refuse shots and quit.

But some providers that have already made vaccinations a condition of employment on their own are reporting far less severe losses.

Lutheran Senior Services operates Life Plan communities and long-term care in Missouri and Illinois. After instituting its policy, effective Sept. 1, the operator reported losing 110 of its 3,200 employees, or about 3%. 

New York may serve as a major test case. The day after its mandate for nursing homes kicked in, officials reported 92% of workers had been vaccinated.

In Texas, where COVID vaccine mandates by local governments or providers are banned, staff members are vaccinated at a rate of 62.32%, below the national average of 65.4%, per data submitted to CMS by Sept. 19.

“We’re so tightly staffed right now that even losing a few workers is devastating,” Linial said. “We can’t afford to lose many more.”

Finding the right fit

Salmon Health and Retirement CEO Matt Salmon told McKnight’s filling the ranks at his Massachusetts locations is like a “battle every day.”

This year, his team has used business intelligence tools to overlay addresses of state-certified nurse aides with communities where current staff live and work. Then Salmon offered employees a bonus to go door to door and encourage qualified neighbors to apply. But Salmon recognized good old-fashioned shoe leather might not be enough as mandates kick in. The company pre-booked travel nurses around key dates.

The threat of losing multiple employees in a single clip adds a new wrinkle to hiring efforts. Even as they recommit to educating about vaccines, providers are busy building databases and employing new technologies to go after job candidates they presume they’ll need. Workforce software companies have seen a major uptick in skilled nursing clients this year.

OnShift’s Peter Corless said providers need a way to quickly communicate needs to staffers who might be willing to pick up or switch shifts. That has led to the creation of internal staffing pools with “flex” positions across settings or shifts. Others are targeting retirees open to part-time work.

Many continue to throw money at the problem in the hopes of driving up applications. In New York City, ArchCare at Carmel Richmond Healthcare and Rehabilitation Center was offering signing incentives of up to $10,000 for RNS, LPNs and CNAs. But it is also offering expanded fringe benefits intended to get those new workers to stay.

Amy Goldsmith, senior vice president for Sava Senior Care, said providers need to do more than just entice workers with wages. After having its image tarnished by COVID, it’s critical the industry focuses on building supportive workplaces.

“What makes a nurse want to work in your center?” she asked during a September webinar. “What are you going to do for them that someone else is going to do? Yeah, we all pay about the same. Yeah, it’s the same work. But showing some of that culture that you have within your center (can) make someone want to be there.”

The issues won’t quit

Even if the labor pool grows and COVID finally settles back into something manageable, providers will be stuck with higher pay rates and an expectation of better benefits.

“It’s difficult to imagine how the long-term care sector will meet demand for direct care workers without dramatically improving their jobs,” Kezia Scales, director of policy research at PHI, says.

And for that, providers say they need more than strike teams and subsidies.

Linial, for instance, has asked Gov. Gregg Abbott (R) for $400 million of the state’s American Rescue Plan funds to help strengthen the long-term care workforce. But he also continues to advocate for solutions that could draw workers and make the industry more stable: student loan repayment programs for nursing school graduates who choose long-term care; state-reimbursed training and certification testing for CNAs; financial backing to help move pandemic-era temporary nurse aides into permanent CNA positions; and new career ladder incentives.

“Those things are going to take a little bit of time to implement and reap the rewards of,” Linial says. “But we do need to have some sort of long-term strategy for the workforce situation.”

He’d also like to see Medicaid rates increase, and has long asked his state to fund a program that dedicates extra dollars to frontline staffing improvements.

In a similar vein, national advocates have urged Congress to include Federal Medical Assistance Percentages provisions in a budget reconciliation bill still being debated at press time. Under the Nursing Home Improvement and Accountability Act, states would receive a higher federal match to expand efforts to improve nursing facility staffing, such as improved wages and benefits. 

Removal of related but costly programs for the caregiving industry from President Biden’s Build Back Better agenda would be bad news for the three-quarters of nursing homes who told AHCA they are unsure if they’ll last another year.

“The consequences of letting this crisis go unsolved are significant,” AHCA leaders say. “The long-term care labor crisis ultimately limits access to care for vulnerable seniors. Without help from lawmakers, more workforce-related closures could occur.” 

Foundations Health Solutions, the largest provider of post-acute services in Ohio, owns 59 properties in the region and utilizes staff expertise to build and improve facilities in its portfolio.

“Having our own construction team affords us a unique opportunity to learn from our prior projects to ensure that we deliver the best product for our customers,” says Jim Park, Foundations’ regional director of operations. “We lean heavily on our front line staff to challenge us with our new designs, as they know what truly works best.”

Developer Brian Colleran saw a substantial need for skilled nursing care in Belpre, near Parkersburg, WV. The nearly 52,000-square-foot, 84-bed facility held a grand opening in July. Park says the property fulfills the needs of the community, doing so with the latest, efficient technology and consumer-driven features that can enhance clinical outcomes.

Colleran reflects on the Rockland Ridge project as an example of how long-term care design has advanced in recent years: “We recognize a correlation between the physical plant and clinical outcomes. A facility with private rooms, outdoor spaces, modern lighting, work-safe surfaces, and 21st century technology leads to higher employee morale. By building a home where residents thrive, staff become more engaged and proud of the care being provided,” he says.

Inside & out

Administrator Chelsea Holsinger calls Rockland Ridge “a nice place to live and to heal.”

An outdoor courtyard serves as a centerpiece for the facility, providing a welcoming atmosphere for socializing, lounging and activities.

“Along with being beautiful and providing social interaction, there is a physical therapy aspect to it,” Holsinger says. “There are walking paths with steps, ramps, curbs and different ground materials to help residents maintain balance while getting their exercise.”

An adjacent sunroom provides natural light and brings the outdoors in during winter,  and a spacious gym is available for all residents. Eco-friendly infrastructure and energy-saving features are also key.

“We are passionate that form needs to continue to match (industry) advancements,” Park says. “A main goal of the design was to create both an internal and external environment that encourages physical and mental development, stress relief and an overall desire to be well. We feel we accomplished this goal.”

A: We are examining if the antiviral medication baloxavir (Xofluza) is non-inferior to, i.e., at least as good as, oseltamivir (Tamiflu) to limit outbreaks of influenza. Each nursing home will be given a kit containing baloxavir or oseltamivir. When an index case of influenza-like illness occurs, the home will ‘activate’ the kit and administer it to all residents in that ward or facility, at the discretion of the facility. The primary outcome will be the number of lab-confirmed influenza cases. In other words, does using baloxavir early in an outbreak prevent at least as many subsequent cases of influenza as using oseltamivir?

Q:How could the results influence future patient care? 

A: If nursing homes suspect an outbreak of influenza … the typical response is to administer oseltamivir prophylactically to all residents. Oseltamivir must be given every day for up to two weeks and requires monitoring renal function. Baloxavir, if effective for prophylaxis, only needs a single dose and has simpler dosing recommendations. If we show baloxavir is non-inferior but more convenient to use, it may become an attractive alternative.

Q:Is enrollment ongoing? 

A: Our study timeline goes until the end of 2023, but we hope to complete enrollment before the next influenza season. See join.nhflurx.com for more information

The Phoebe Richland Health Care Center in Richlandtown, PA, set up Fosbenner’s ride to fulfill her wish after she told staff about a childhood experience when she witnessed a hot air balloon flight. She had never had a chance to take a ride herself.

Staffers were committed to making the dream happen but soon realized that finding a hot air balloon pilot “was harder than [they] thought” since they needed a pilot who could accommodate wheelchairs, according to AnnMarie Pettito-Thomas, community life lead at Phoebe Richland. 

Luckily, they found Lehigh Valley Hot Air, a family-owned hot air balloon company operated by local pilot Will Randell. 

“We love making wishes come true,” Randell said.

Fosbenner’s trip on the hot air balloon went off without any problems and allowed her to float above the local community while friends, family and staff cheered her on. 

“I could see all of you waving up at me,” Fosbenner said after the ride. “It was great!”

How did that ambitious young radio host end up as the chairwoman of the board of directors for LeadingAge and president and CEO of New Jersey-based Jewish Home Family? Through her gift for communication, drive to connect and natural abundance of energy.

“My husband would tell you I never met a microphone I didn’t like,” she says. “I think it’s true. At my core, I am a communicator. This is who I am and what I do.”

When Elliott was working her first hospital job in Wisconsin back in the early 1980s, she met a local public relations executive, Tom Jones, through the United Way. With his encouragement, Elliott became the youngest, and first female, chair of the Greater Beloit United Way at age 28. 

“His constant support, encouragement and good humor helped me to see how someone’s interest and commitment can help you grow, and that same level of interest and commitment can be reflected throughout your career,” recalls Elliott, who holds a bachelor’s degree in TV-radio and a master’s degree in communications.

Forty years later, Elliott is still paying it forward. Her management philosophy to this day is simple: Life is about relationships.

In Elliott’s line of work, that philosophy plays out in hundreds of ways. Whether she’s resolving timing issues with her local utility, mentoring younger colleagues, or sourcing PPE during the early days of COVID-19, Elliot relies on the strength of her relationships to get things done.

“This work takes a lot, and she has a lot,” says Don Shulman, president and CEO of AJAS, where Elliott serves on the executive committee and board. “She has a high energy level and a powerful battery that keeps her going in her own community, at LeadingAge, at AJAS and, not to mention, in her devotion to her residents and mission.”

That high energy level is evident as you look at Elliott’s incredible career, which includes writing a biweekly column in The Times of Israel, and plenty of doting on family — which comprises six sons, a daughter and nine grandchildren — and their assorted activities. 

Never one to sit still, Elliott used the pandemic quarantine routine to attain a lifelong goal: She earned her yoga instructor’s certification. She spent her days coming into the office in full PPE, then signing on for yoga instruction training through Zoom every evening for three hours, and for six hours again on Sundays, with practice in between. Now, she leads biweekly chair yoga classes for residents on each campus and a weekly class for managers. 

“Yoga is about so much more than movement, or asana,” she observes. “It’s about centering and grounding. Teaching yoga has been a way for me to channel some of that energy. With the elders, I focus on opening our chests, being able to expand, so we have prana, that breath of life.”

And as everyone quickly learns, wherever Elliott goes there is always plenty of life.

 — Nicole Bowman

Resume: 1979-1987, Works in community relations and public relations at hospital systems in Wisconsin and Illinois; 1987-2000, Holds executive communications roles at Stamford Health System and Unity Health Foundation; 2000, Becomes CEO at Career Development Services in Rochester, NY; 2005-2014, Returns to human services with Jewish Senior Life in Rochester and Cedar Village in Ohio; 2007, Joins Association of Jewish Aging Services board; 2012, Joins LeadingAge board of directors; 2014, Becomes president and CEO of Jewish Home Family; 2015, Earns elder law certificate from University of Toledo; 2016, Joins New Jersey elder abuse task force; 2017-2021, Serves as chairwoman of LeadingAge.

A: Section I of the MDS captures a patient’s active diagnosis, which must be documented by the physician within the last 60 days and directly relate to the patient’s status during the 7-day look-back period. I0020 and I0020B are typically completed only on the 5-Day or interim payment assessment (IPA), but may also be required on OBRA assessments if the state opted to collect PDPM billing codes. I0020 indicates the medical condition category that best describes the primary reason for admission, then I0020B reports the ICD-10-CM code for that condition. 

The primary diagnosis is the main reason why the patient requires skilled care in the nursing home. It is the one used to drive the care plan during the stay. The skilled nursing facility Medicare interdisciplinary team should meet to discuss the resident’s diagnoses, information from the acute-care hospital, and physician documentation to determine which diagnosis best explains the reason for medically-necessary skilled services in the SNF. The SNF team may need to query the physician for a more specific diagnosis. 

Some patients may have several diagnoses that could be primary. If that is the case, the team must determine which one will be considered primary and document its process and rationale. Consider a long-term care resident originally admitted to the SNF with a diagnosis of Parkinson’s disease who later fell and fractured his hip. When readmitted to the SNF for rehabilitation, the primary reason for his skilled stay becomes aftercare of the fracture, not Parkinson’s disease. 

Establishing a team process for review and selection of the primary diagnosis will help to align care plans across clinical and therapy teams and ensure that I0020 is coded correctly.

A: According to the National Consumer Voice, 38 states have introduced emergency orders or enacted laws to immunize healthcare companies and providers from liability for COVID-19 related injuries and deaths.

Early on, these protections were seen as a reasonable way to address long-term care providers’ concerns when little was known about the disease and the proper methods for decreasing exposure risk. As deaths and infections grew, family members of deceased and infected residents began to file lawsuits against the facilities, including management and owners.  

Generally, the statutes and emergency orders confer protections against civil tort liability theories at the state level where most of the claims are filed. On the federal level, the Public Readiness and Emergency Preparedness, or PREP, Act provides some immunity to healthcare providers.

It is important to note that these protections are not without limits. There are  exceptions for gross negligence as well as intentional or reckless conduct. One can easily imagine plaintiffs’ lawyers will look to invoke gross negligence and intentional misconduct by arguing that infections and deaths from COVID-19 were caused by or exacerbated by issues like understaffing. 

But gross negligence and intentional conduct represent high bars for plaintiffs to clear to maintain the lawsuit. Immunity conferred by statute is much more likely to withstand the inevitable constitutional challenges that will be brought by the plaintiffs’ bar.

However, immunity granted by executive orders from governors may be more susceptible to constitutional challenges.

But COVID-19-associated problems run long and deep, with the potential to influence how well and for how long providers  remain financially viable. One challenge that will require immediate — and expensive — attention: Shared rooms.

“How do you make capital investments up front? Then how do you pay for the care on an ongoing basis? And pay staff a living wage and offer a non-double occupancy living environment?” asks Harvard Medical School’s David Grabowski, Ph.D. “Operators tell me all the time, if they had single occupancy, they couldn’t make this work.”

Another problem: A huge expected influx of baby boomers who could instead head toward lower-acuity settings.

“There’s great interest in the ‘less care’ driven market, whether you call it ‘active adult’ or truly independent living,” says Robert Kramer, co-founder and strategic advisor for the National Investment Center for Seniors Housing & Care (NIC).

But the mother of all challenges is a bruised and battered workforce with more support for better wages and benefits.

“Labor shortage issues continue to be a challenge throughout the industry posing pressure on operating margins,” says Bianca Andujo, senior director at Berkadia. “We expect that the recent Provider Relief Fund Phase 4 will grant some additional relief to operators. However, it will not be a permanent fix.”

Unsettled workforce crises very well could permanently alter the face of long-term care in the coming years. 

To Grabowski, labor issues and their causes are just begging to be fixed.

“Nursing home financing has long been broken and the pandemic showed just how much,” he says. “Moving forward, we need to redesign the nursing home payment system to encourage greater value, equity and accountability. Without these types of reforms, I am worried that we will see an exit of high-performing providers and a number of residents unable to obtain high-quality care.”