Nine years ago, when I started writing “The World According to Dr. El,” McKnight’s Editor Jim Berklan reassured me that I’d always find something to say. I was surprised to discover that not only was this true, in fact the opposite was often the case — many weeks I’ve had difficulty choosing between an abundance of intriguing topics.

Over the years, I’ve used the column to explain what psychologists do in long-term care and what they could do if given the chance. I’ve highlighted issues that I thought deserved more attention, and I’ve tried to amplify the efforts of do-gooders in the field. I shared my COVID-19 experiences back when New York City was an anomaly, and I’ve advocated for the growing number of severely mentally ill residents in our midst. 

And while I haven’t run out of material, I’m tapping out my last column because I don’t want to run out of time. If there’s one thing I’ve learned from sitting by the bedsides of elders in the nursing home, it’s that life goes faster than we think it will, and I have other mountains to climb.

I plan to spend more time with the octogenarians in my own family, focus on my New York licensed virtual private practice, and continue with my speaking engagements and other eldercare-related projects. 

My greatest hope, aside from enjoying time without a biweekly deadline, is to publish the novel I started many years ago about a psychologist working in a nursing home. (A stretch, I know.) It’s the undertaking I’d most regret leaving undone if I were talking to my psychologist in my nursing home room at age 85. 

But enough about me. 

The pricey problem I haven’t mentioned before

There’s one thing I haven’t told you in the last nine years, and it’s costing you a fortune. I’m not exactly sure whose fortune it is, given our convoluted system. But “the system” is paying for it, and it’s negatively affecting the physical and emotional well-being of residents.

Not surprisingly, it’s a transition of care, but a more subtle and more frequent transition of care than is usually studied: Off-campus medical appointments are not going well.

Over the last 25 years, I’ve heard the following reasons for an incomplete medical appointment: The resident wasn’t out of bed in time, the staff couldn’t find any clothes and the resident refused to go out in a gown, the ambulette was late, the driver got lost, the ambulette got into a traffic accident, the office address was incorrect, the date of the appointment was wrong, the referral form was missing, the doctor had an emergency, the wheelchair couldn’t fit into the elevator, the doctor needs the old X-ray/Doppler/scan, the wait for the doctor was too long and the aide needed to get back to her family so they left, etc., etc. 

I tell my distraught residents that if anyone actually gets to an appointment on time and returns without a problem, I write it down on my calendar because it’s so rare.

According to this Forbes article, missed medical appointments “cost the U.S. healthcare system more than $150 billion a year,” and the third most common reason that older adults miss appointments is transportation problems. 

Given that nursing facilities are arranging transportation, this should not be a problem. But it is.  

I will leave you with that information in the hope that it will lead to research and self-reflection within the continuum of care and result in savings that benefit everyone in the system, including and especially residents and direct care staff. 

Thank you

I’d like to thank Jim Berklan, John O’Connor, Wayne, and the other folks at McKnight’s Long-Term Care News for the opportunity to write this column and to be a part of their outstanding team. 

Thanks to my colleagues in Psychologists in Long-Term Care, particularly Margie Norris, for their support and encouragement of my efforts to represent psychology in LTC. 

To all the health researchers, organizations and policymakers striving for healthcare justice, the workers doing right by their residents, the families advocating for their loved ones, and the residents keeping the faith — you are inspiring! 

Keep going — it’s making a difference. The system urgently needs change and conditions are riper for it than I’ve ever seen before.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her, visit her at EleanorFeldmanBarbera.com.  

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

These days, mental health in long-term care is getting far more attention than it used to. After 25 years as a nursing home psychologist, it’s pretty exciting to see.

I perused the April print edition of McKnight’s Long-Term Care News and found articles on the impact of nurse stress on quality of care, the connection between nursing turnover and the emotional toll of the job, and the importance of mental health support for staff. 

Last week, McKnight’s Senior Editor Kimberly Marselas wrote about the increased attention being paid by CMS to mental health conditions, and on iCare’s Chris Wright: Seizing on skilled nursing’s behavioral health opportunities.

It’s my hope that this attention generates a shift in the way that psychology services are utilized and reimbursed. 

While it’s valuable to provide individual services for residents with identified mental health conditions, psychologists can and should do so much more.

The mental health challenges in nursing homes would be better served if psychologists were involved in programming, such as the STAR-VA model for dementia-related behaviors, or the Eldercare Method, developed by senior living consultant Kelly O’Shea Carney, Ph.D., ABPP to address the behavioral health needs of long-term care residents.

She and Margaret Norris, Ph.D., wrote “Transforming Long-Term Care: Expanded Roles for Mental Health Professionals,” which “shows how mental health practitioners can use their full range of skills to create systems that are more supportive and engaging for residents, while also providing the staff with greater opportunities for professional growth and meaning.”

As I’ve written about in the past, psychologists can be instrumental in a wide variety of currently problematic areas such as:

• Staff training, including education on mental health basics and psychiatric illnesses, how to work with families, stress management techniques, and other issues that typically arise for staff in the nursing home setting.

• Team building, which focuses on addressing the specific needs of units and departments, such as conflict resolution, communication skills, etc.

• Morale boosting, utilizing psychologists’ training and awareness of the emotional climate of the facility to devise interventions that can improve facility culture, such as enhancing staff common areas or collaborating with the recreation department on activities that inspire community.

• Improved onboarding, addressing often undiscussed but vitally important topics such as coping with the loss of residents or dealing with challenging families. 

• Behavioral rounds, to assist staff with interventions to reduce problematic behaviors in residents or families.

• Open office hours, where residents, workers and family members can drop in for a quick chat to address concerns and get direction for further services if needed.

• Systems interventions where psychologists collaborate with facility leaders to streamline systems and resolve problems, often between departments, such as communication glitches or turf disputes. 

• Group sessions for residents that cover topics such as how to make the most of rehab or psychoeducation about illnesses like diabetes, and which foster connections and reduce isolation.

• Group sessions for families, to reduce their anxiety, increase their ability to manage their loved ones’ health challenges, improve their understanding of how to partner with the team, and to decrease the amount of staff time spent dealing with family concerns.

• Family psychotherapy sessions, since admitting a loved one to a nursing home can be very distressing.

• End-of-life support, because we should be experts in acknowledging when residents are nearing death and helping them, and their families and team members, cope with the process and with their grief.

• Individual psychotherapy for residents because, yes, this is important too.

A few years ago, I got a referral for a very anxious 90-year-old rehab resident. She was initially extremely reluctant to speak with me but she eventually became a fan of psychotherapy. 

The morning before she was to return home, she called me over to her spot in the day room and told me, “I wish I’d talked to you when I was a young woman. The work you’re doing is so important, just as important as the cardiologist or the surgeon.” 

“I know,” I replied. 

Long-term care is like this woman, who could have benefitted from psychological services decades ago. 

I’m pleased that greater mental health awareness has entered the LTC zeitgeist and I’d like to think that columns like mine have contributed to this recognition. 

The work continues, but I wanted to let you know in advance that this is my penultimate “World According to Dr. El” column. More on that next time.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements, visit her at EleanorFeldmanBarbera.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

I have to admit that when I saw the news headline last week, “BREAKING: CMS cuts SNF pay rates by net $320 million,” I felt a kick-’em-while-they’re-down discouragement.

I’m concerned, like others, about how facilities currently struggling financially are going to make it to the anticipated period when demographic shifts will lead to full beds and thriving enterprises.

As a psychologist, I’m also mindful of the emotional impact of these news stories. The nursing home business has never been easy, but since the pandemic, it’s been vastly more difficult, with facility closures, large numbers of staff members departing, and new recruits hard to come by. 

It’s telling and unsettling that my most popular column in 2021 was titled, “How to keep working in LTC (when you’re not sure how much more you can take).”

A recent headline, “BREAKING: U.S. nursing home system ‘ineffective,’ ‘unsustainable,’ National Academies report says,” succinctly summarized the vast challenges of the field. While I agree with what I read of the quoted report (I got about 400 pages in and then my flight landed), I wish for news that offers encouragement and support for weary long-term care providers. 

It’s likely that different titles would spark hope regarding the direction of the field depending on what role one has in the industry. 

Here are some breaking news headlines I’d like to read:

“CMS appoints psychologist to monitor emotional impact of policies on providers”

“Billionaire donates fortune to study cost-effective ways to offer quality eldercare services”

“Research reveals psychosocial focus key to LTC financial success”

“CMS mandates Chief Experience Officer position for all LTC homes”

“Review: 95% of nursing home management companies operate in good faith”

“Owners with criminal convictions prohibited from further facility ownership”

“Community rallies to save local nursing home”

“Innovation Center establishes ‘Family Caregiver School’ to improve collaboration between families and healthcare providers”

“Thinktank finds government-sponsored end-of-life family counseling cuts costs, leads to ‘better’ deaths”

“Initiative to study needs of seniors with severe mental illness”

“New program for elders with physical and mental illness significantly reduces health expenses: ‘We’re finally getting the support we need,’ thriving members say”

“CNA training and salary advances improve staff retention and care quality, reduce rehospitalizations and costs”

“Career ladder for CNAs now LTC norm”

How likely is it that we’ll be seeing any of these headlines any time soon? Perhaps if that 600-page report from the National Academies of Sciences, Engineering, and Medicine is followed, and backed up by funding, some of these headlines might come true. 

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements, visit her at EleanorFeldmanBarbera.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

As I reviewed the many recent long-term care happenings and articles to select a topic for this week’s blog, my mind kept returning to the fascinating column by researchers Lindsey Creapeau and Jennifer Johs-Artisensi, “Nursing assistants’ perspective holds the key to solving your staffing woes.” 

Their study asked nursing home administrators, directors of nursing and certified nursing assistants their perspectives on the staffing challenges in the field. While they all agreed upon the need to raise wages, there were significant discrepancies between nursing home leaders and staff members. 

While the administrators and DONs pointed to “competition (other long-term care sites or even those in other industries), low wages, shortages of candidates to apply, the physically and emotionally demanding nature of the job, and low federal/state reimbursement” as the main factors affecting recruitment and retention, CNAs focused on dissatisfaction with job training and the work environment. 

In addition, CNAs wanted more emotional and practical support in their jobs but didn’t express as much distress regarding workloads as the leadership groups anticipated. The aides had many suggestions for improving the work environment, such as increased control over their schedules, onsite childcare and assistance with transportation to work.

I was struck by the disparities between leaders and workers. 

It was as if the groups spoke different “love languages,” leading me to imagine this scene:

Administrator, thinking staff spoke the love language akin to “receiving gifts”: “I thought you left me because you could get more money for easier work at the fast-food place down the block.”

CNA, valuing the love languages akin to “quality time” and “words of affirmation”: “No, I was devoted to my residents, but I left because you never listened to me.”

The study shows the value of asking and listening to staff, illuminating areas where administrators and DONs could direct their time, attention and funding to make the greatest impact. 

For those who don’t have the opportunity to be part of a similar research study, there are many other ways to get feedback from workers, including the ideas below:

• Survey employees: Hire a consultant to solicit and compile worker perspectives. If tackling this in-house, bear in mind that the way in which questions are asked can affect responses and that staffers will feel more open about sharing their thoughts if some level of anonymity is assured.

• Use a suggestion box: This could include a means of anonymously submitting electronic comments, or an actual box near the administrator’s office, complete with paper and pencils to facilitate commentary. Staff feedback and suggestions could be encouraged in meetings and with reminders in paystubs, with the best encouragement being publicly following through with suggestions.

• Conduct exit interviews: Staff members often show their dissatisfaction with the facility by walking out the door. Before they depart, glean valuable information about their perceptions by asking why they’re leaving and what might have been done to keep them on staff. 

• Ask your consulting psychologist: The psychologist has a role and education unlike other staff members — trained in interpersonal dynamics, they spend their days moving from unit to unit, talking with residents and staff and observing day-to-day interactions. Chances are that they could offer suggestions about how to better meet staff needs. 

• Sleep over: As I wrote in “LTC leaders gain remarkable insights from the Sleepover Project,” leaders who spent the night in their facility learned dramatic and unexpected lessons about their work culture, reporting that the culture of their high-quality facilities wasn’t as good as they’d thought it was — and that the needed changes were easily within their power to manifest.

• Create an Experience Officer position: Some hospitals have a Chief Experience Officer whose role centers on improving the experiences of patients, families and staff; nursing homes could do the same. 

This study and the experiences of leaders who participated in the Sleepover Project indicate that there’s a disconnect between management expectations and what staff would actually find helpful in maintaining their employment. The best way to bridge this disconnect and save time and money on well-meaning but misdirected efforts is to ask staff members what they need. 

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements, visit her at EleanorFeldmanBarbera.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

I had the pleasure of being interviewed recently by Susan Ryan, senior director of The Green House Project, for her Elevate Eldercare podcast. As I remarked to her, what could be better than talking with someone kind and knowledgeable about something I’ve been obsessed with for more than 20 years?

We spoke about the experiences that inform my thinking about long-term care, and we addressed topics such as the disconnect between mental and physical health, the moral injury and staff burnout exacerbated by the pandemic, and ways of better supporting staff, families and facilities in their efforts to provide quality care.

Readers can listen to the podcast here, and I’d like to expand in this column on some of the points discussed in the conversation.

First, let me call attention to the fact that there are not a lot of mental health professionals in long-term care; it’s first and foremost a medical setting.

The voices that we hear from regarding care tend to be physicians and nurses, and increasingly, nursing aides. On the business and policy side, we’re informed by CEOs, heads of trade organizations, healthcare economists and policymakers. Families and resident advocates have a place at the table. 

But there’s less often a mental health perspective on long-term care, especially from those embedded in nursing home teams.

Many of the problems facing LTC, however, can be mitigated by using a mental health lens: staff burnout, unappealing facility cultures, family distress, subpar end-of-life care, the increasing population of residents with severe mental illness, etc.

One of the subjects we addressed in the podcast, for instance, were my efforts to overcome post-traumatic stress disorder after working in the pandemic epicenter. Whenever I write or speak about this, someone tells me afterward, “I just realized I have PTSD,” or, “I feel seen. Thank you.” As facilities seek to address continued staff burnout, keep in mind that acknowledgment and witnessing are a vital part of how people heal from trauma and how they regain trust in leadership. 

Susan Ryan and I also discussed ways to overcome the information disconnect between leaders and employees, which can affect quality, cost of care and staff retention. Bridging the hierarchy and incorporating “worker voice” can lead to improved and streamlined processes.   

One of the techniques I mentioned was The Sleepover Project, where leaders spend a night in their facilities, interact with residents, staff and families, and see what’s happening on the front lines of their organization. A psychological question for any leader who hesitates to do this might be, “What am I afraid of?” 

This is a legitimate query that deserves exploration. Is it the amount of time it would take? The loss of control? Is there fear that the facility is so dreadful that one night would be unbearable? Is there a wish to avoid knowing that this is the case? 

Dig deep and then weigh these factors against the benefits of sleeping over, such as morale building and discovering needed changes that only leaders are in the position to make. For a facility to run successfully, it’s vital that there’s a flow of information from leaders to the front lines and vice versa. Develop as many ways as possible in which to communicate with and learn from employees. 

Our discussion touched on incorporating a psychological approach into working with teams and families with the goal of reducing turnover, family distress and problems with communication, with many suggestions offered. We also mentioned the limitations of a punitive approach to nursing home reform.

If the ideas on the Elevate Eldercare podcast intrigue you, note that I’ll be delving into some of them further in the free April 5 McKnight’s Long-Term Care News webinar, “Creating wellness, reducing costs: Targeting the emotional health of residents, staff and families.”

As the industry undergoes a period of change, I hope readers take opportunities to hear from direct care workers and to consider the benefits of better integrating mental health supports into every aspect of long-term care. 

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements, visit her at EleanorFeldmanBarbera.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

President Biden’s State of the Union address last week targeted several aspects of the long-term care industry, most of which have received more attention than his mention of reducing the inappropriate use of antipsychotic medications.

As a long-term care psychologist who has closely observed the trend of increasing numbers of residents with severe mental illness who require antipsychotic medications, I’m concerned that attempts to reduce antipsychotics might disregard the needs of these residents.

An effort to comply with, and enforce, regulations around antipsychotic use must be conducted with a recognition that there are many residents who need these medications in order to maintain their emotional stability, with an emphasis on the term, “inappropriate use,” rather than on “reducing antipsychotics.”

My concern is heightened because the industry and its regulators can appear to have a lack of awareness about, or a plan to manage, this growing population. Ironically, this echoes a frequent feature of mental illness — anosognosia, or the lack of awareness of having a mental illness. (Though by the time they arrive at our doors with several decades of experience with mental health problems, these residents are generally long past anosognosia and can often tell us how to manage their own illnesses.)

According to data tracked by LTCfocus.org, the number of severely mentally ill residents has more than doubled in almost every state between 2000 and 2020. Given the changes wrought by COVID-19 (i.e., empty beds), that number will likely be higher once the 2021 data comes in.

Necessary, but insufficient

Maintaining the use of antipsychotic medications is essential for this group of residents, for them as individuals and for the safe management of the living environment, but in and of itself, it is not sufficient care.

As I’ve written about in the past (see “Severely mentally ill residents: A ‘perfect storm’ creates a SNF wave”), these residents generally arrive at nursing homes following a health crisis but are frequently difficult to discharge even after they’re medically stable, due to the need to manage concomitant medical and mental health problems. 

Ideally, there would be more community resources for this group, such as care homes that can manage comorbid physical and psychiatric health problems, paid family caregiver programs to encourage the help of their relatives, and psychosocial supports for individuals who could potentially manage in the community with assistance.

Given that these resources are not yet available to most, and that nursing homes are increasingly filling their beds with this cohort, acknowledging this reality will allow us to better deal with the challenges and the opportunities of the situation.

The challenges

I noted some of the care issues in “Severely mentally ill residents: Staff training, teamwork needed” — such as the need for increased staff training and support in managing individuals who tend to be younger, more physically imposing, and have mental health issues that can compromise their compliance with medical treatments. 

For instance, a recently admitted resident with a diagnosis of paranoid schizophrenia might resist taking medications from a new nurse in an unfamiliar setting, and the nurse might recognize that their usual encouragement tactics could exacerbate the paranoia but not know what alternatives to use. This is not an individual nurse problem, or an individual resident problem, but a systems problem. See the above-mentioned article for some systems solutions.

The opportunities

If we properly manage their wellbeing, we can reap the benefits of having this population in our buildings.

For example, some of these residents are high utilizers of care, going back and forth to medical and psychiatric hospitals. If we can stabilize them psychiatrically and physically, this would be a boon to insurers and increase the value of the nursing home as a partner in a continuum of care.

In addition, this cohort tends to be relatively young and able. Once stable, it would be beneficial to them and to the older, more frail residents to participate in activities that require someone who can walk or see or hear. Picture them reading a book to older residents, handing out bingo cards, or helping a visually impaired resident play a game. In the psychiatric hospital, patients could earn a small stipend for such assistance. We’ll have to be more creative in LTC since regulations currently prohibit “work.”

Another benefit of stabilizing this population is that we may be able to reconnect families that have been torn apart by the societal lack of support for those with severe mental illness. The closing of psychiatric hospitals and the deficit of community services have strained families trying to manage an extremely challenging lifelong illness. 

The safe haven and care of the nursing home might be the first time in decades that these residents and their families have gotten the support they needed to manage their mental and physical health. Reconnecting estranged families is the kind of service that makes frontline workers feel really good about their jobs. (Conversely, admitting psychiatric patients without proper staffing, training and support does not.)

Ideally, there would be better options and assistance for residents with both physical and mental health problems, but since these are currently lacking, the industry would benefit from greater acknowledgment of this cohort, maintenance of needed medications, and increased efforts to provide services appropriate to this population. 

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements, visit her at EleanorFeldmanBarbera.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

With worker shortages at critical levels, long-term care leaders are undoubtedly looking for creative solutions to their staffing woes. 

There have been excellent suggestions from within the LTC world, but I recently came upon a journal article from the National Academies of Sciences, Engineering, and Medicine that outlined short-term strategies in the general workforce that might be helpful. It was geared towards women and government policies, but many of the workforce participation recommendations could be adapted to the LTC environment and are applicable to both male and female employees. 

As facilities struggle with staffing and salaries, these ideas offer good value for the investment of time and money, enhance the culture of the organization, and create jobs that fit with the lifestyle of employees.

What follows are the recommendations of the “rapid expert consultation team” — a group composed of an economist, a policy researcher, a sociologist, and a psychologist — and customized by me as needed to fit the circumstances of long-term care workers and facilities.

Supporting caregiving responsibilities

• Provide direct financial support for workers and their families: While long-term care companies wouldn’t be expected to offer the same types of support as the government, they could take a variety of financially helpful actions. For instance, they could make it easier for workers to access government support by keeping abreast of opportunities and assisting employees in applying for them. Food stamps/SNAP, scholarships for students, and local subsidized housing options immediately come to mind. They could also offer emergency funds, which could be generated by holding fundraisers to replenish the coffers, perhaps with matching funds from the company, giving the sense that the company is there for workers in times of hardship. Offering take-home meals at a discount would be an indirect financial help, as well as a time saver, for busy employees.

• Invest in the childcare infrastructure: One of the biggest challenges in retaining workers during the pandemic has been related to childcare problems, but with a young, mostly female workforce, childcare has always been an issue. A nursing home with an on-site children’s day care program, or with a reduced fee voucher for a nearby day care service, would enhance the attractiveness of the job. Another creative idea is facilitating the sharing of informal day care resources or transportation to such resources, perhaps by having an internal message board where workers could find each other and meet each other’s needs.

• Introduce family-supportive policies: Family-supportive policies allow those with caregiving responsibilities in the home to continue or return to work. Suggestions in this area focus on paid sick leave, flexible work schedules, and other protections such as “advance notice of work schedules, additional compensation for unexpected schedule changes or on-call hours, the right to accept or decline added or lengthened shifts, mandatory rest periods between shifts, and the right to request scheduling accommodations.” The experts suggest that these policies be coupled with an organizational culture that supports using them without fear of repercussions. 

Supporting workforce participation and career development

• Invest in workforce development and education: Implementing these recommendations would include contributing to or covering the cost of training or courses for employees wishing to expand their skills or move into a new position within the organization, as well as offering “returnship” programs that allow people to come back to work after some time away (like an internship, but one focused on returning workers).  

• Provide access to mental health services: This recommendation echoes one I’ve written about many times in the past (for example, “5 strategies to promote mental health in long-term care” and “BBB Act provides opportunity to address LTC mental health needs”). Offering mental health supports, the authors note, may be a tool for retaining staff members who are thinking about dropping out of the workforce due to mental health concerns. 

Long-term care is in the midst of profound changes that necessitate rethinking not only how services are provided, but how staff members are recruited and retained. 

I’m reminded of the Oldsmobile advertisement from the late 1980’s, “This is not your father’s Oldsmobile.” Marketing for the nursing home of the future might emphasize, “This is not your grandmother’s nursing home.” 

Perhaps we’ll attract staff to these upgraded facilities with the tagline, “This is not your parents’ nursing home job.”

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements, visit her at EleanorFeldmanBarbera.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

I was tempted to listen to the STAT News event, “The exhaustion epidemic: Examining the COVID-19 burnout crisis in health care,” while lying prone on the couch.

Instead, I took notes and considered how this hospital-heavy analysis might apply to the long-term care industry.

Two physicians, one nurse and one psychiatrist/researcher discussed at length how the pandemic has worsened what was already a dysfunctional and understaffed healthcare system.

In hospitals, they noted, the initial feeling during the pandemic was, “We’re all in this together,” with hospital workers considered healthcare heroes. This has given way to exhaustion, burnout and departures from the field.

For long-term care workers, there was never a feeling that we were all in this together. Aside from individual facility or team cohesiveness, nursing homes were ignored, disparaged and largely cast adrift to fend for themselves in the beginning of the pandemic.

LTC staff began the pandemic without societal support, risked their lives in the face of an unknown virus, and suffered tremendous losses of often beloved residents. From this lowpoint, facilities now have even fewer staff, with omicron-related absences increasing the burden on already overwhelmed workers.

It’s no wonder we’ve reached historic levels of staffing shortages.

Burnout and moral injury

Psychiatrist Wendy Dean, M.D., discussed her research on moral injury, observing that it’s a frequent precursor to burnout. As described on her Moral Injury in Healthcare website, “Moral injury occurs when clinicians are repeatedly expected, in the course of providing care, to make choices that transgress their longstanding, deeply held commitment to healing.”

This includes situations where aides are expected to care for far too many residents than they’re able to, nursing supervisors are asked to manage too many units, and other circumstances where staff are being put into positions where they cannot conduct their jobs in a safe and professional manner.

While burnout casts the problem as that of an individual having difficulty managing stressors, moral injury recognizes that the system itself is the problem.

Panelists encouraged listeners to engage in self-care practices that reduce the likelihood of burnout, while also advocating (together!) for changes within the healthcare industry. They advised workers to find others who are feeling similarly stressed in the workplace, talk with them, come up with solutions and bring them to management.

They also had advice for healthcare leaders.

Direction for leaders

The experts stressed the importance of leadership engagement at all levels, with an emphasis on communication. This includes having a clinician present during business discussions, trailing clinicians on the units to increase understanding of the day-to-day challenges of the job, and creating venues where staff can offer feedback, including anonymously for those who don’t feel comfortable speaking up publicly.

Good communication, they said, involved not assuming, but instead asking employees what they need to get their jobs done right and then getting it for them. Not surprisingly, this led into a discussion of the moral injury facing managers who know what their workers need but are unable to procure it due to financial, political or other constraints.

Other suggestions included offering paid time off for staff to prevent or recover from burnout, as well as acting as an advocate for staff by speaking up for their needs. As an example, they referred to hospital system leaders asking the larger community to wear masks to help contain the virus, even though it was an unpopular ask in their locale.

Perception of being valued

In his introduction as sponsor of the event, Mark Reisenauer, president of Astellas Pharma US, noted that healthcare workers were 40% less likely to feel burned out if they felt valued by their organization.

Given how unvalued nursing home workers felt at the beginning of the pandemic, this is an essential component in rebuilding our workforce.

Even if older adults are considered less worthwhile by some in our society, even if nursing homes are considered awful, dangerous places, even if working in a long-term care facility is considered somehow inferior to other jobs — nursing homes themselves can show workers that they are valued and important.

In relationships, we show people we care about them by being present, listening to them, and giving them what they need to be happy and successful. To retain and attract workers, facilities can do the same. This is the bedrock upon which we can rebuild the field.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements, visit her at EleanorFeldmanBarbera.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

As I stated in my last column, improving the emotional tenor of the facility can decrease staff turnover. In this piece, I’ll offer additional ideas to achieve that goal. 

Most organizations have a consulting psychologist on the team who can spearhead or contribute to the recommendations below. Psychologists are capable of far more than providing direct services to residents. 

Psychologists are in a unique position not only by virtue of their understanding of research and their extensive training in individual and group behavior, but also because they spend most of their time on the units, moving from floor to floor talking to residents, staff and family members. 

This allows them to see patterns from unit to unit and to observe interactions usually hidden from those in leadership positions. Their expertise can improve the functioning and atmosphere of the nursing home.

Staff support

Even under conditions where there are reasonably paid and sufficient staff, the nursing home is a stressful environment. As noted in this STAT first opinion piece, “We all need help working through grief and hardship,” staff members may be coping with their own personal losses while trying to care for others. Given COVID-19’s impact on long-term care facilities, virtually every worker is dealing with grief and a “minefield of triggers” on the job.

The authors suggest enhancing policies to provide “systematic supports and anticipatory guidance.” Psychological knowledge would be valuable in formulating these systemwide strategies. Employee assistance programs, support groups and psychologist open office hours are other means to help workers manage common stressors such as team conflicts, difficult residents and family problems.

In addition to direct emotional support, there are many other ways to mitigate stressors on the job.

Restructuring and education

As I wrote in “Post-pandemic population may require higher staffing levels,” the population of nursing home residents has changed. With the decrease in elective surgeries and the increase in avoidance of nursing home rehabs, the remaining residents are more likely to be a demanding mix of people who are unable to be managed at home due to medical acuity, behaviors and/or a lack of available, supportive family. There are also more residents with comorbid severe mental illness and medical problems.

Staff members are therefore required to simultaneously manage very different and urgent needs, such as a wheelchair-bound resident with dementia about to stand up from his chair, a recent admission with alarming vital signs, and a comparatively young woman with bipolar disorder loudly demanding immediate attention.

As part of ongoing staff training to address these and other common challenges, the psychologist can contribute expertise in behavior management, critical thinking skills, the understanding of mental illness and techniques to become more proactive than reactive on the units. 

Teamwork

Staff conflict is another frequent difficulty in the nursing home setting. Not only can psychological training be used to mitigate and prevent disagreements, but it can also be used to examine and change systems that are contributing to problems. 

For instance, in the example above with diverse resident needs, perhaps the solution is not just training staff members to be better at triaging care, but in establishing floors or neighborhoods that focus on particular types of residents. 

Psychological expertise can be useful in team building, making facility-wide transitions, and in training teams to work with specific populations. Especially if a nursing home has residents with severe mental illness, mental health experts should be used to educate staff and create systems that address the needs of this population, such as working on appropriate programming with activities professionals and engaging in behavioral rounds with the team.

Families

Psychologists could run educational and support groups for families, participate in end-of-life planning discussions, and work with disgruntled family members, relieving much of the time spent by other professionals (and probably reducing litigation costs).

Onboarding

Psychologists can help review and adjust the onboarding process and the support given to new workers to increase the likelihood that newbies will become old-timers (directly reducing turnover).

Obstacles

The biggest challenge to harnessing psychological expertise outside of direct resident care is that there’s no payor source. My hope is that grants and studies for providing these services will show cost mitigation to lead more organizations to fund them or CMS to consider widening the scope of payable services for psychologists. 

The pandemic has revealed how broken our long-term care system is and how much need there is for mental health services. Fixing the former involves better utilization of the latter.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements, visit her at EleanorFeldmanBarbera.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Late last week, the Centers for Medicare & Medicaid Services announced that they will begin to post staff turnover data on the Medicare.gov Care Compare website. 

In July, turnover will be incorporated into the Five Star Quality Rating calculations. 

While this is bound to cause immediate alarm among providers, in the long run this is a positive development for the industry.

Staff turnover is an excellent way to measure what’s going on inside a facility. If the staff is fleeing, there’s a problem. 

As the CMS memo on the subject put it, “lower turnover is associated with higher overall quality.” It offers several hypotheses why this might be so, including improved leadership by a consistent administrator, increased efficiency by staff familiar with policies and procedures, and the prevention of adverse outcomes through early recognition of changes in medical condition by staff who know their residents.

Attending to turnover has the potential to improve quality, reduce certain expenditures, and rehabilitate the public’s image of nursing homes. The asterisk on the title of this column, however, reflects the fact that the adjustment to this newly public data point is bound to be bumpy.

The reporting is starting in the middle of a pandemic that has had an outsized effect on residents and workers. The “problem” that employees are fleeing might be omicron as much as it is management and general working conditions. And the handling of COVID-19 has been dependent on numerous factors outside of facility control.

We can surmise that, initially, the published turnover rates will be astronomically high, such as those reported by Ashvin Gandhi, Huizi Yu, and David C. Grabowski in Health Affairs. 

The only good news, from an industry perspective, is that virtually everyone’s numbers are going to be abysmal, particularly in areas with widespread illness in the community. The consumer will have little choice but to select among homes with poor staff retention.

Going forward, however, facilities that distinguish themselves from their competitors will have an edge.  

Increasing wages and benefits has been recommended as a first step towards retaining staff. I’d also suggest attending to the emotional tenor of the nursing home. To swiftly stem the tide of departures of pandemic-weary staff, review and enhance the level of emotional support they’re being offered. 

Provide employee assistance programs (EAP), services, support groups, psychologist open office hours and other venues so that depleted staffers have places to refill the well and continue in their work.

Such supports will not only help employees overcome pandemic-related trauma but can also assist them in dealing with a host of problems usually unaddressed by long-term care employers, such as the loss of beloved residents, team conflicts, difficult families and dealings with residents who are challenging in a variety of ways. 

I’ve provided these services informally and gratis throughout my career. I’ve seen how they’ve improved staff retention and quality of care and I know how much more could be done if they were covered services provided on a regular basis.

I’ve been writing about turnover for a long time. See my 2014 piece, “The keys to reducing turnover in long-term care.” Or my 2018 post, “Dr. El’s ‘Quality of Life’ star ratings are the way to go,” in which I proposed a supplemental five-star rating system, with the first star measuring staff turnover. 

Now that turnover is being added to Nursing Home Compare, I’m feeling more optimistic. 

I started my biweekly McKnight’s column on LTC mental health issues in March 2013 with, “Inside the mind of an LTC shrink.” Surely it can’t be long now before someone at CMS recognizes that expanding mental health training and support for staff will improve care quality. 

Of course, it would help the cause to have a study of the subject by David Grabowski, Ashvin Gandhi or another of the many illustrious healthcare researchers who are investigating our oft-disregarded field. 

Until then, partner with a university psychology department, use your own pre- and post-intervention measures, or take my word for it: attending to the emotional tenor of the nursing home will reduce turnover and increase care quality.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements, visit her at EleanorFeldmanBarbera.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.