Multiple factors make it likely that the trend of rising labor activity in long-term care will continue in 2024, experts say.

In 2023, care workers and others across the US — from writers and actors, to auto workers — launched high-profile strikes, often successfully bargaining for higher pay and improved working conditions. 

These strikes capitalized on shifting workforce conditions and public opinion, Adam Dean, PhD, associate professor of political science at The George Washington University, told McKnight’s Long-Term Care News. 

Only 16% of nursing homes currently have workers that are represented by a union, but that number is likely to increase if today’s trends hold, he added.

“There’s enormous potential for the growth of unions in that sector and I think that the big labor wins that people have been following in the news … set the stage nationally for what’s possible when workers unionize,” he said. “I think that will set the stage for 2024. I expect to see more organizing and more strikes to come.”

Striking a good balance?

Dean was optimistic that such labor activity would benefit both workers and the long-term care industry as a whole.

“I expect that it will improve the quality of healthcare that residents or patients receive,” Dean noted, citing a study he coauthored that found unionized nursing homes were 78% more likely to comply with illness and injury reporting regulations. 

In skilled nursing, pressure from organized labor has been mounting since the early days of 2020, when workers threatened to strike over pandemic working conditions and the availability of safety equipment.

October 2023 saw the largest strike ever recorded in the healthcare sector as 75,000 Kaiser Permanente workers walked off the job for three days. That strike culminated in a 6% pay increase and promises of additional action to address staffing shortages.

Going into 2024, pay and staffing continue to top the list of labor issues that could become the spark for organized action

“The SEIU and other labor unions that represent healthcare workers have been pushing for higher nurse-to-patient ratios,” Dean noted.. “I expect those kinds of fights to continue.”

One key factor in the current labor upswing is the low rate of unemployment. 

Broad forces in play

“We have a low unemployment rate currently in the United States, which gives workers greater bargaining power with their employers,” Dean noted.

That rate sits at only 3.7%, giving workers the confidence to make demands of their employers since they are likely to be able to change jobs quickly if necessary. 

“It gets [workers] into a position of relative security,” Jason Resnikoff, PhD, assistant professor of contemporary history at the University of Groningen told NBC Washington. “It makes it much easier for them to go on strike.”

During 2023’s increase in strikes, public opinion shifted in favor of unions, especially among young Americans, some feel. 

“There’s a growing public support for unions and strikes,” Dean said, citing a study from the American Federation of Labor and Congress of Industrial Organizations. “88% of Americans 30 and younger have a favorable view of labor unions.”

The AFL-CIO study found that 71% of Americans supported unions overall. 

These measures are aimed at addressing one facet of the ongoing nursing home staffing crisis in the US, as administrators face similar burnout and shortages that care workers are experiencing.

By the midpoint of 2023, Wisconsin’s Department of Safety and Professional Services had already issued more licenses to nursing home administrators than in recent full years, according to DSPS Secretary-designee Dan Hereth. That coincided with a 44% year-over-year increase in new licenses for all healthcare professionals issued by the department. 

To achieve these results, the department focused on streamlining its licensing workflow and added both new avenues and clarity to existing paths for those seeking licenses. 

“We’ve been able to improve our processes and invest in technology to speed up our department’s role in licensing,” a representative from DSPS told McKnight’s Long-Term Care News. “We’re licensing more professionals more quickly than ever, and we’re hopeful to keep those numbers up in 2024.”

To that end, the department also is working to clarify which classes and programs help candidates meet the requirements for licensure. It is partnering with the University of Minnesota to have some of its classes pre-approved for the licensing process. 

Welcome changes

The new policies will help nursing homes address an increasingly worrisome turnover rate of nursing home administrators, according to Rene Eastman, vice president of financial and regulatory services at LeadingAge Wisconsin.

“LeadingAge Wisconsin members are extremely grateful that the state DSPS has made new paths to licensure available,” Eastman told McKnight’s. “Our state experienced 148 nursing home administrator turnovers in the first five months of 2023, and that’s in a state with only 336 licensed facilities — so we were on pace to a bad place.”

The new policies should be a significant help for people working in long-term care as they seek to advance through the profession and further their career goals, Eastman said. 

Making such new paths available will become increasingly vital across the country, as will ensuring reciprocity between states, according to Doug Olson, president and CEO of Vision Centre. 

“One of the things that the Vision Centre is interested in is making the career pathway more seamless and transparent so people can understand how they can move into that next level of practice,” Olson told McKnight’s. 

He emphasized that states across the country should focus on increasing the reciprocity of their licensure policies, including recognizing the qualifications of health services executives certified by the National Association of Long Term Care Administrator Boards. Without such measures, long-term care could be staring down a serious administrator shortage by the end of the decade, he added.

Measures to increase clarity, transparency and inter-state reciprocity for licensing nursing home administrators will be vital to removing the existing barriers to the profession, Olson said.

Residents and their families were treated to tours around the 184-bed Cheektowaga, NY, facility — fully decked out with holiday lights and decorations — courtesy of a horse-and-carriage team brought in from nearby Banner Farm.

“I thought it would be wonderful for the families and the residents to get together during the holidays,” said Rhonda Gorman, activity director at Garden Gate. “A lot of times we do a tree lighting or something like that, but this time we thought it would be nice to do something different.” 

She was inspired to organize a carriage ride activity after the success of festive fall hayrides earlier in the year. 

The event — which Gorman is calling “Country Christmas” — drew quite a crowd. Gorman estimated between 50 and 75 residents, family members and staff came to hang out with the horses.

Residents who were physically able were whisked away on the carriage ride, but even those who weren’t able to access the ride itself got to participate in the highlight of the event.

Even more than the holiday spirit-boosting ride, the horses were clearly the star of the show. The team showed up early and stayed late, Gorman said, ensuring that everyone got to spend time with and even pet the enormous Clydesdales. 

“It really adds a wonderful quality of life for the residents to get outside in the wintertime and see horses and be with their families,” Gorman said. “It’s something that we strive for with our staff.”

The Banner Farm Clydesdales don’t only go out for Christmas events, but the horse breed has become synonymous with Christmas ever since it was featured in an iconic series of holiday Budweiser ads. 

This is the first time that Garden Gate has run the carriage ride event, but it will not be the last.

“This will definitely be an annual tradition,” Gorman stated.

And the holiday season is just getting started for Garden Gate’s residents, as the facility has more Christmas events lined up, including three days of lunch and gifts with Santa later this week.

The Center for Medicare Advocacy shined a spotlight on a 2017 rule that makes it possible for some facilities to maintain nurse aide training and competency evaluation programs through waivers from CMS even after those NATCEPs would have been suspended due to regulatory penalties or extended surveys. 

The Trump-era rule gave CMS the discretion to use case-by-case judgment to allow facilities to maintain their training and evaluation programs — a power which has proved contentious. 

“[CMS] has largely ignored the directive to strengthen the enforcement of standards of care for nursing facilities,” wrote Toby Edelman, Senior Policy Attorney at CMA, in a Dec. 14 article for the organization. “Instead, it has allowed Trump administration policies which explicitly overturned Obama administration policies and otherwise reduced enforcement, to remain in place. The Center for Medicare Advocacy calls on CMS to strengthen enforcement and protect residents.”

But staffing shortages across the country have left many in the long-term care sector frustrated by regulations that suspend the programs working to bring more care staff into the workforce. 

“In the midst of a historic labor crisis, allowing facilities the ability to offer CNA training programs to train crucially needed caregivers is exactly the type of workforce solutions we need,” wrote the American American Health Care Association in a statement to McKnight’s Long-Term Care News. “Now is not the time to take away critically important workforce development resources and programs, such as in-house CNA training.”

Some policymakers sympathize with that sentiment. A bipartisan House bill currently in committee would remove NATCEP suspensions for facilities that didn’t endanger residents, and also offer facilities more and simpler ways to reinstate their programs after correcting deficiencies.

AHCA and LeadingAge have endorsed the bill as a way to improve workforce numbers and quality of care nationwide.

Some experts have gone so far as to suggest CMS should stop suspending NATCEPs entirely until the staffing crisis has been adequately addressed.

“NATCEP programs are sometimes a key lifeblood for facility operations, providing needed advertising of the profession to potential CNAs,” wrote attorney Neville Bilimoria in a blog post for McKnight’s Long-Term Care News. “Taking that crucial program away from nursing homes is especially onerous for facilities trying to improve their staffing numbers in the midst of the very real shortage of CNAs.”
Staffing shortages and proposed regulation are set to continue as vital issues for the skilled nursing sector next year. Whether CMS continues to offer some leniency on NATCEPs or follows advocates’ suggestions and takes a firmer hand could have consequences for already struggling facilities.

Researchers found that scheduling CNAs regularly with the same group of teammates reduced turnover by nearly 25%. 

If nursing homes capitalize on the results of the study, it could go a long way toward cheaply and effectively addressing the nursing home staffing crisis, according to lead author Kevin Mayo, PhD, assistant professor of finance and management science at Washington State University. 

“These findings suggest that managers may be able to leverage part-time CNA scheduling to reduce turnover,” the study asserts, “improving both the quality and cost of care.”

The study also found that giving part-time CNAs one additional hour of work per week could reduce turnover by about 2%. Turnover was increased both by too few hours worked and too many, however, so facilities need to be more cautious in this regard. 

Building cohesive, consistent teams is the most important factor to consider, Mayo said, but nursing homes should consider all aspects of the study to achieve the best results. 

“By both balancing working hours and maintaining consistent teams, healthcare facilities can greatly reduce staff turnover,” Mayo told Newswise. 

Between greater scheduling consistency and tweaking hours worked, the authors estimate that facilities can save 7% of their operating costs with greater employee retention. 

Nursing homes have already felt the pressure to employ more flexible, worker-focused scheduling in response to the staffing crisis. The results of this study suggest that there are large benefits to be gained from this approach, and at very low cost.

Greater retention should also lead to higher quality of care for residents. After analysis of their data, the researchers concluded that CNA turnover had measurable negative effects on care quality that could be eliminated by increased retention. 

The study, published in the journal Manufacturing & Services Operations Management, analyzed data for more than 6,000 part-time CNAs from 157 facilities. 

Other authors included University of Cincinnati Assistant Professor Eric Webb, PhD, as well as Indiana University’s George Ball, PhD, and Kurt Bretthauer, PhD.

The identical measures would require nursing homes and any related business entities operating in New Jersey to file consolidated financial statements to be audited at their own expense.

The laws are aimed at curbing a method some industry critics say nursing home owners have used to hide their profits. In related party transactions, nursing home owners may pay well above market rate for rent and management services to third-party companies that are also owned by the same person or group. That makes it hard for state and federal officials to determine owners’ true operating costs. 

Not all agree that these requirements are necessary. Nursing homes already disclose related party transactions and related financial details and have done so for years, according to Andrew Aronson, president and CEO of the Health Care Association of New Jersey.

Consumer advocates cheered the bills on Thursday. Sam Brooks, ​​director of public policy for The National Consumer Voice for Quality Long Term Care, said the long-term care sector would ultimately benefit from states stepping up to fill a gap in transparency. 

“The industry should welcome these reforms,” Brooks told McKnight’s Long-Term Care News. “Just this year, MACPAC issued a report stating that the use of related parties made determining the actual care costs impossible. Increased transparency and accountability could help facilities allegedly struggling to cover costs demonstrate the need for increased funding.”

Brooks emphasized the need for financial accountability, citing a New York Times article that claimed up to 70% of for-profit nursing homes were funneling money through private companies in 2017, leaving $11 billion dollars beyond public scrutiny.

Clarifying finances for policymakers

The bills’ advocates in New Jersey are pushing for a vote in both the state Senate and Assembly by the end of the current legislative session on Jan. 8, according to Laurie Facciarossa-Brewer, New Jersey’s long-term care ombudsman.

“Advocates and regulators need consolidated financial statements to properly evaluate nursing home operations and foster quality care and better conditions for the residents,” Facciarossa-Brewer wrote in an article for northjersey.com. “The current disclosure requirements make it too easy for nursing homes to hide profits and resist calls to improve conditions. We see this clearly when it comes to staffing rules.”

The identical bills would require that new nursing home owners in New Jersey submit applications to the state Department of Health — including, among other details, a list of all parties assuming ownership, an organizational chart disclosing any related entities under the same parties and a consolidated financial statement with a projection of profits or losses for the next three years.

Transparency at a high cost

Without objecting to greater transparency in principle, association leaders in the state sounded the alarm over the additional regulatory burden the requirements could place on providers.

“The issue that we have with the bills is they require audited financial statements,” Aronson told McKnight’s. “The audits would add significant costs to the facilities. They’re very expensive.” 

Aronson cast doubt that the new requirements would provide meaningful information that the government doesn’t already have access to through cost reports. He also projected the costs of audits to be over $100,000 per building, per year when factoring in all involved parties.

“We think that cost is excessive to require information frankly that the state already has,” Aronson said. 

Jim McCracken, president and CEO of LeadingAge New Jersey & Delaware, expressed similar hesitation.

“Nonprofit nursing homes file 990s, so there is financial transparency regarding their operations,” McCracken told McKnight’s. “The bill … would create duplication and result in increased administrative costs for nonprofits. If the proposed bill becomes law, administrative costs would increase, diverting resources that would otherwise be available to improve patient care.”

Advocates, on the other hand, claim the bills are necessary to provide clarity on nursing home finances in the state. They could impact how New Jersey’s facilities are regulated for staffing and how they are reimbursed for the care they provide, according to Facciarossa-Brewer.

A proposed staffing rule from the Centers for Medicare & Medicaid Services would raise minimum requirements for facilities across the country. Opponents say most nursing homes do not meet those requirements, are already struggling financially and would be heavily burdened by extra operational costs without corresponding reimbursement adjustments to cover losses.

Meanwhile, some advocates for the proposed staffing rule argue that it does not go far enough in regulating care quality. 

Facciarossa-Brewer asserted that these transparency bills would allow lawmakers to see the full picture of nursing homes’ financial status and, therefore, make more informed decisions about regulations and how to allocate government resources.

“Nursing home owners and their lobbyists argue that many cannot afford to recruit and retain additional staff,” Facciarossa-Brewer said. “Greater financial transparency would go a long way toward proving — or disproving — those claims.”

Policymakers and consumer advocates are beginning to push for similar transparency measures across the country, including recently in California, according to Aronson.

This article has been updated to add clarifying language and also correct a misstatement to properly note that providers would have to pay for the new audits.

The study evaluated states on a scale of 100 based on a variety of factors, such as the number of nursing homes per 100,000 residents, occupancy rates, cost of residency and the percentage of nursing homes with no deficiencies. 

Iowa topped the list with a score of 70.67. Iowa was not a leading state in the individual categories, but was consistently in the top third of each category. Around 10% of Iowa homes had no deficiencies, which was well above the national average of 6%. 

Despite a top-five occupancy rate, California was the bottom-ranked state, with an 18.61 rating. This was partially because of its high cost. Private nursing home rooms in the state cost more than $12,000 per month, among the highest in the nation. The state also has the 2nd most deficiencies per facility on average.

Providing insight into nursing home care in the US is only growing more important as the population ages, said SonderCare CEO Kyle Sobko. 

“This data provides a clear insight into which states currently offer the best access to elderly care and outlines the factors contributing to this,” Sobko stated. 

Rural Southern and Great Plains states consistently received high scores in the study. The top 10, in order, were:

• Iowa
• Oklahoma
• Missouri
• Louisiana
• South Dakota
• Kansas
• Montana
• North Carolina
• Wisconsin
• Nebraska

Among more populous states, Texas, Pennsylvania, and Illinois ranked highest, at 11th, 15th and 16th, respectively. 

Sobko noted that there were some notable outliers in the SonderCare study.

“The most surprising finding from this study is that Alaska ranks overwhelmingly as the most expensive state for elderly care, both semi-private and private,” he said. “The cost of a room in a private nursing home in Alaska is $31,512 per month, this is more than $16,300 more than the second most expensive state, Connecticut.”

Those costs helped drag Alaska down to a ranking of 46th, rounding out a bottom five that also included the 2nd most expensive state, Connecticut, as well as West Virginia, Hawaii, and California. East coast states made up nine of the bottom 15.