In the wake of a historic shortage of nurses and assistants, America’s nursing homes have been forced to get creative when it comes to hiring, scheduling and retaining workers. 

Now many are pushing lawmakers and state regulatory agencies to respond to the ongoing workforce crisis with a similar openness, one that in some ways reenvisions the sector’s professional landscape.

Emerging is a patchwork of new-to-skilled nursing positions that vary from state-to-state, with some designed to attract a fresh crop of entry-level workers, and others made to help providers target increasingly complex patient populations while also enticing workers to remain in the field.

Temporary nurse aides in 18 states will be allowed to continue to work under federal waivers through the end of the public health emergency. Some states have already developed a state level alternative in the form of personal care attendants, and skilled nursing medication technicians are now allowed in some 38 states. Increasingly, nursing homes are bringing in behavioral health technicians, too.

While it’s unclear how such roles will fit into any minimum staffing requirements proposed by federal regulators, individuals filling these jobs are already making a difference in their employers’ ability to provide quality care and keep their doors open. That’s a factor state and federal rule makers ought to consider as they review new requests from providers, several providers said.

“Those types of things will be really helpful to the industry,” Ciena Healthcare Senior Vice President Amy La Fleur told McKnight’s Long-Term Care News. “When you dovetail it with some of the career paths and some of the workforce grants out there, it gives us a pretty robust set of offerings for people that are considering coming into long-term care.”

And the sector still badly needs more people — maybe even those who’ve never considered a job in healthcare — to walk through their doors. In a February report, the American Health Care Association said a major obstacle in filling the 210,000 jobs vacated through December 2022 is a lack of interested or qualified candidates.

Florida developed its personal care attendant program as a temporary COVID-19 patch, but after initial success, the state legislature made it permanent in 2021. State skilled nursing facilities have placed thousands of frontline workers through the program. At least 3,000 have gone on to site for the certified nursing assistant exam, with about three-quarters passing, according to the Florida Health Care Association.

Just as important as the numbers, says Senior Vice President of Quality Affairs Deborah Franklin, are the types of people who have applied for these very hands-on, critical roles since they were first created under emergency conditions.

“All these people who’d never thought about healthcare, because they needed a job, they saw the ads for the PCA and answered it,” Franklin told McKnight’s. “They found out they loved healthcare. Now they’ve enrolled in nursing school. We’ve just kept hearing over and over again these great stories.”

Franklin considers it a “wonderful, unintended consequence” that by making the program permanent, lawmakers essentially created an apprenticeship that allows workers to sit through eight hours of classroom training and competency testing then get immediate, daily exposure to the skilled nursing setting without spending thousands on a private certification course.

“This removed those barriers for those who didn’t have the money or the means to get to CNA school,” she said.

Med techs moving forward

Tackling a perceived inability to move up is a critical difference-maker for those who view CNA work as a dead-end job.

Robert Vande Merwe, executive director of the Idaho Health Care Association, has spent 15 years trying to convince various state agencies to remove hurdles to offering medication technician positions in nursing homes. A bill allowing facilities to offer the training needed for CNAs to take the med tech exam was expected to pass the legislature this spring.

Vande Merwe expects each of the state’s 80 nursing homes might hire only one tech, but that would have a ripple effect.

“This gives CNAs a true ladder. Sometimes, it’s really hard to see: What’s the next step? Be a shift manager? We’re trying to find other intermediate steps for them. I think this will help us find more CNAs too, to help them see their options.”

Med techs have found solid footing in many nursing homes nationwide, and more states appear poised to approve them. La Fleur was hoping Michigan would pass legislation last session, but it died in the lame duck period.

“We were ready to wrap up getting our temp nurse aides tested and trained and then quickly move into medication assistant training, but now we’re on hold,” she said.

That was a defeat because operators need the help, but also because some CNAs might lose interest while awaiting entry into that opportunity. Med techs, tasked with passing non-dangerous meds that don’t need an assessment or a nurse’s review, earned an average of $18.27 hourly, vs. $16.87 for CNAs, according to the 2022-23 Nursing Home Salary & Benefits Report.

The next frontier?

Providers in several states also are looking at how they might incorporate behavioral health techs, or mental health specialists, into their workforce.

These techs can be CNAs with advanced training or hold a standalone certification, which many already use to work in similar hospital roles. In either case, they are prepared to help develop care plans for, and ensure daily interactions align with, treatment for patients with psychiatric or psychological needs. They also are trained to de-escalate problematic behaviors and can identify patients for medication reductions.

Given a Centers for Medicare & Medicaid Services push to accommodate more skilled nursing patients with behavioral diagnoses and substance abuse disorders, hiring more behavioral health workers makes perfect sense to providers like Amina Dubuisson, DNP, vice president of clinical services at Florida’s Ventura Services.

Dubuisson recently hired two behavioral health techs for one of the chain’s 12 skilled nursing facilities. She’s started with buildings with the highest concentration of relatively young, ambulatory patients with significant behavioral diagnoses such as bipolar disorder or major depression.

“Those facilities have a higher rate of return to hospital and also, they’re using psychotropics,” Dubuisson said. “And we know there is more in treating patients with mental disorders than just medications … so in an effort to try and do that, we’re going to hire these mental techs.”

Under Florida’s minimum staffing rule, revised last year, nursing homes can include services provided by behavioral techs in a flexible category calling for 0.6 hours daily of any hands-on care. 

In a short time, she has already seen the way the additional role helps relieve other staff. Just as PCAs support CNAs and med techs reduce burden on licensed nurses, behavioral health techs relieve aides and nurses from time spent on managing behaviors — and they give behavioral patients a dedicated resource to help manage their condition and liaison with families and other members of the care team.

She hopes to eventually advance existing CNAs into behavioral roles through in-house training.

“They’ve been in the building. They know the residents. They know the long-term care setting,” Dubuisson said. “And it will be another motivation on the career ladder for them, and I think as far as hiring, we’ll probably have a higher chance of retaining our own staff.