For the nation’s nursing homes, the first three years of the 2020s have presented one peril after another. From facing down the COVID-19 pandemic on the front-lines, to navigating a sweeping staffing crisis, simply doing business has proven physically, operationally and financially complex. 

Against this backdrop, the recently proposed Centers for Medicare & Medicaid Services staffing mandate feels, to many industry leaders, like insult after injury. I interact daily with skilled nursing operators and the majority share the goal of improving staffing ratios – yet find themselves struggling to find, hire and retain the right personnel, particularly in rural geographies. 

One major concern is that aspects of the mandate, such as the requirements that a registered nurse be onsite 24/7, will simply lead to the closure of smaller sites. This is not a trivial problem. Shutting down facilities will widen gaps in care for those who can’t afford alternatives, and will place burden on hospitals and emergency room facilities by limiting discharge options.

Real and damaging impact could come from a poorly-structured mandate, so it is critical to engage to ensure that any final legislation be carefully amended. And yet, a broader point remains.

Mandate or no mandate, staffing is already a challenge with existential stakes for U.S. nursing homes. And mandate or no mandate, the imperative to innovate – now – remains the same.

The daily reality is that there are not enough nurses and CNAs in most geographic areas to meet demand for these roles. Meanwhile, competition for these roles has intensified – from hospitals and from venture-backed staffing marketplaces – both of which often pay more than skilled nursing facilities. 

The only real fix is to get creative with staffing – and fast. Business leaders do not have the luxury of waiting to see what happens with state and federal regulation over the coming years.

Fortunately, a clear playbook has emerged for staffing success – informed in part by other industries (hospitality, trucking, airlines) that have substantially evolved their staffing practices and technology over the past two decades. By learning from case examples, and capitalizing on new strategies, industry operators can set their organizations up for success and growth, no matter what policies come out of Washington.

Staffing is an existential problem, mandate or no mandate

There is no one-size-fits-all-solution, and staffing challenges will persist for at least the next 10 to 15 years for a number of reasons. 

Talent wars and worker shortages have been hallmarks of the healthcare labor market for decades. Almost half of all employees working at state and local public health agencies left their jobs between 2017 and 2021, according to an analysis published earlier this year. And a hefty portion of staff still report wanting to quit.

As a result, competition for talent remains fierce among nursing facilities – as well as with “substitute” care models like home-based care. With more and more adults preferring age in place, and with Medicaid now paying family members to care for their loved ones, finding sustainable models that provide more robust care support is genuinely a make-or-break challenge for many care facilities.

There is no guarantee that demand will persist for nursing homes that can’t clearly demonstrate their value proposition – and shoring up staffing ratios are becoming an increasingly non-optional aspect of operations, as well as sales and marketing efforts. 

What providers can do to fortify staffing

Nursing home and post-acute providers need to get creative. Simply put, the operational status quo won’t cut it. Fortunately, many providers also have low-hanging fruit innovations in front of them – operating changes that hold significant promise for shoring up staffing. 

I want to challenge providers to think differently, and here’s how:

  • Identifying clear goals. As a starting point, individual facilities and broader operating companies will need to determine more precisely what they are optimizing for. Is your primary objective growth? Or cost containment? Or specific clinical outcomes and/or patient satisfaction metrics in the context of value-based contracts? Each of these objectives will imply differences in how an organization defines its optimal staffing strategy.  
  • Consider staffing mix. Most facilities operate several implicit “pools” of workforce – even within a specific practitioner type (e.g., RNs). For example, just within RNs a single facility might have: 1) full-time on-staff employees, 2) employees on overtime, 3) employees subject to a wide range of union staffing rules, 4) per-diem workforce, 5) hourly workforce, 6) travel nurses, 7) other forms of contract workforce, 8) synchronous telemedicine engagement (i.e., video), 9) asynchronous telemedicine engagement (i.e., messaging), etc. Each of these pools implies different cost dynamics, and each implies different degrees of clinical efficacy. With a clear set of objectives in mind, an organization can take the critical step of defining a targeted “staffing mix” – i.e., targeted percentages against each of the pools outlined above, which may vary by region/facility, given local staffing dynamics. 
  • Establishing flexible staffing operations. Having established a clear view on objectives and desired staffing mix, organizations must consider the interplay across and among individual facilities. Oftentimes, a parent organization will see wildly divergent staffing KPIs across different facilities and regions. Enabling flexible modes of sharing staff across and among geographically proximate facilities – and setting up float pools to flexibly support several facilities at once – can often mitigate staffing pain for the worst-off facilities, while simultaneously providing flexible working opportunities much appreciated by a stretched workforce. Such innovations are particularly helpful in scenarios where staffing demand is highly variable, and facilities need flexibility to operate efficiently during spikes and troughs alike.
  • Getting in place the right tech. Finally, with the right goals and right staffing structures in place, operators require technology that enables schedulers to manage seamlessly and in real-time across different pools of the workforce. A human scheduler, tasked with filling a last-minute shift, cannot reasonably be expected to optimize in real-time across the many pools of workforce in the context of a business strategy. Technological evolution is required, and advanced technology will have a critical role to play. 

What staffing excellence enables

My strong belief is that providers who modernize their staffing strategies now will thrive, while those adopting a “wait and see” mentality will mostly be left behind. I encourage all facilities to start experimenting as soon as possible – taking first steps that can be expanded across a broader organization with time. 

While changing staffing operations can feel like a daunting task, the benefits are real. Better staffing operations enable lead generation by ensuring capacity and cementing a facility’s positive reputation among hospitals, ER units and other discharge entities. 

Additionally, strategic staffing models unlock opportunities to explore alternative reimbursement models such as value-based care. Oftentimes exciting new payment models only become possible with tighter control on staffing operations – which directly promote better clinical objectives, patient satisfaction, and practitioner satisfaction.

While the federal staffing mandate currently being debated poses a major challenge to long-term care providers, facilities can’t assume a reactive stance. The only real option is to  seize this opportunity as a catalyst for positive change.

Lee Hudson Teslik is the founder and CEO of Reverence. Lee launched Reverence after observing both the beauty and the challenges of long-term and end-of-life care models – and particularly the criticality of stable staffing models – directly within his own family.

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.

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