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.

The caregiving training codes were proposed this summer as a vehicle that would allow staff in skilled nursing and other settings to bill for time spent training unpaid caregivers, including family members, once a year.

But in its final rule issued Nov. 2, the Centers for Medicare & Medicaid Services said the codes could be used at the “volume and frequency” needed to meet a physician’s treatment plan, as well as changes in condition or to address new or changed diagnoses, or if there’s a change in caregiver.

Caregivers are “critical members of all of our teams, and it’s really critical that they know how to best support all of their loved ones,” Katy Barnett, director of home care and hospice operations and policy at LeadingAge, said on a policy call with members Monday. “Limiting these codes to just once a year just didn’t make sense and wasn’t efficient to meet patient and caregiver needs.”

LeadingAge had urged CMS to expand the caregiver training services codes, noting that one training per patient annually might not be enough to support robust training for at-home care needs. CMS has explicitly said it was adopting the codes to support because they align with principles outlined in a Biden Executive Order on caregiving issued this spring, and because they more broadly support patient-centered care initiatives.

Caregiver training is described as direct, skilled intervention for the caregivers to provide strategies and techniques to equip them with knowledge and skills to assist patients living with functional deficits, Broad River Rehab Executive Vice President Renee Kinder, RAC-CT, explained in a recent guest column for McKnight’s Long-Term Care News.

Training can be billed in time increments for one-on-one sessions or for group training, if multiple patients have similar conditions or therapeutic needs.

“Skilled training supports a caregiver’s understanding of the patient’s treatment plan, ability to engage in activities with the patient in between treatment sessions, and knowledge of external resources to assist in areas such as activities of daily living (ADLs), transfers, mobility, safety practices, problem solving and communication,” Kinder said.

She encouraged therapists and others working in skilled nursing to learn the rules for use when the codes come into play Jan. 1, implement them to ensure regulatory compliance, and “use this opportunity to increase the quality of care we provide daily.”

For its part, LeadingAge hopes CMS will introduce more flexibility in the codes next year. The organization had used its formal comments to call on CMS to allow physicians to delegate caregiver training to non-billing staff, such as nurses, under the supervision of a clinician and to allow clinical social workers to bill for such training. Barnett said CMS did not clarify whether physicians can delegate the training, but said that CMS would consider making future changes in future rule-making.

Barnett added that LeadingAge also has encouraged CMS to add the codes to its covered telehealth care to “support the majority of caregivers who work full-time or part-time jobs” and might not be in a nursing home or other post-acute setting at the same time as a rounding physician. The finalized rule, however, did not include a telehealth option.

These have now officially been finalized for use beginning Jan. 1, 2024 when used according to the following rules.

To begin, let’s review from a regulatory standpoint why these allowances are being made for the first time, allowing reimbursement in the absence of the patient present. 

The Centers for Medicare & Medicaid Services states specifically that they have continued to consider whether the caregiver behavior management training and similar caregiver training services could be considered to fall within the scope of services that are reasonable and necessary under section 1862(a)(1)(A) of the Act, in alignment with the principles of the recent Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers.

Furthermore, and as part of an U.S. Department of Health & Human Services-level review of our payment policies, use was found to identify opportunities to better account for patient-centered care, changes in medical practice that have led to more care coordination and team-based care, and to promote equitable access to reasonable and necessary medical services. 

CMS also states they believe it important for practitioners furnishing patient-centered care to use various effective communication techniques when providing patient-centered care, in alignment with requirements under section 1557 of the Affordable Care Act and in certain circumstances, caregivers can play a key role in developing and carrying out the treatment plan or, as applicable to physical, occupational, or speech-language therapy, the therapy plan of care (collectively referred to in this discussion as the “treatment plan”) established for the patient by the treating practitioner (which for purposes of this discussion could include a physician; NPP such as a nurse practitioner, physician assistant, clinical nurse specialist, clinical psychologist; or a physical therapist, occupational therapist, or speech-language pathologist).

Finally, they believe Caregiver Training Services (CTS) can be reasonable and necessary to treat the patient’s illness or injury as required under section 1862 (a)(1)(A) of the Act, therefore providing an opportunity to consider the best approach to establishing separate payment for the services described by the caregiver training codes, especially as it relates to a practitioner treating a patient and expending resources to train a caregiver who is assisting or acting as a proxy for the patient.

Now let’s move on to how the codes are defined!

Caregiver Training Without the Patient Present:

Caregiver training is direct, skilled intervention for the caregiver(s) to provide strategies and techniques to equip caregiver(s) with knowledge and skills to assist patients living with functional deficits. 

Codes 97550, 97551 are used to report the total duration of face-to-face time spent by the qualified health care professional providing training to the caregiver(s) of an individual patient without the patient present. 

Code 97552 is used to report group caregiver training provided to multiple sets of caregivers for multiple patients with similar conditions or therapeutic needs without the patient present. 

During a skilled intervention, the caregiver(s) is trained using verbal instructions, video and live demonstrations, and feedback from the qualified healthcare professional on the use of strategies and techniques to facilitate functional performance and safety in the home or community without the patient present. Skilled training supports a caregiver’s understanding of the patient’s treatment plan, ability to engage in activities with the patient in between treatment sessions, and knowledge of external resources to assist in areas such as activities of daily living (ADLs), transfers, mobility, safety practices, problem solving and communication.

97550 Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face to face; initial 30 minutes.

97551 each additional 15 minutes (List separately in addition to code for primary service).

97552 Group caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face to face with multiple sets of caregivers. 

In closing, let us first understand the rules for use, implement them to ensure regulatory compliance, and use this opportunity to increase the quality of care we provide daily.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at rkinder@broadriverrehab.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.

Have a column idea? See our submission guidelines here.

Launched in October 2022, the statewide Gateway-In Project so far has graduated more than 1,200 CNAs and has a goal of developing a total of 2,700 CNAs by 2026. The California Department of Health Care Access and Information awarded the state’s LeadingAge affiliate more than $25 million for the project.

“I am thrilled with the remarkable outcomes made by The Gateway-In Project just one year after its launch,” said Jeannee Parker Martin, CEO of LeadingAge California, in a press release touting the program’s success. “This visionary recruitment, training and retention initiative is designed to help tackle California’s pressing healthcare workforce shortage head-on while also creating new opportunities for residents across the state.”

The association noted that there has been high demand throughout the state for CNA training, and there are training programs in 29 of the state’s 58 counties, with students ranging in ages from 19 to more than 56 years old. The goal is to send as many students as possible into the long-term care pipeline, which is struggling with a national, historic staffing crisis. 

In addition to ensuring students are proficient in nursing responsibilities, The Gateway-In Project provides wraparound support services such as childcare, transportation, scrubs and classroom materials. The press release noted that 62% of students earn less than $25,000 a year and 73% say their highest level of education is either high school or a GED. 

The state has the largest number of older adults in the country and an additional 275,000 direct care workers will be needed by 2026 to meet care needs, according to LeadingAge California. 

“The Gateway-In Project serves as a crucial intervention measure to create a new workforce pipeline to prepare for this growing population and avoid a crisis in the provision of care,” the group’s release said.

A: You don’t have to do it all alone!

Think about some of the best training you have received, and try recreating some of it. Skills labs are popular with staff. Set up a room with blood pressure stations, a weigh station and more. and have nurse aides go through the stations.

Set up a room with 10 things that are wrong — maybe a frayed call light, items on the floor, pills on the bedside table — and have staff list the items that should not be there or are dangerous. Or send emails to your consultants, medical director, dietitian and social worker, and give them a month during the year that you would like them to conduct an in-service. 

For instance, perhaps ask the dietitian to talk about proper seating and feeding of the resident. Ask podiatry to speak on care of the feet. A pharmacy consultant can perhaps address flexible medication times. Also involve the social worker, funeral director, local politician and administrator.

Do you have nurses who are certified in wound care or infection prevention? Include them, too. This way, lots of people make your work lighter. 

Activities can get involved, too, talking about activities and how they involve residents and perhaps their family members in selecting appropriate activities for the specific residents. These session can provide new lessons for consultants too, as the staff know their residents well and can make suggestions to improve the quality of life for those under their care.

Make it fun. Serve refreshments when you can, and more will attend! Oh, and don’t make all of the training at 2 p.m. just to make it easy for the consultants. Juggle the times so all shifts have equal opportunities to attend during their waking hours.

Under legislation signed this week by Gov. Kathy Hochul (D), nursing students in New York state will be able to complete up to one-third of their clinical training through simulation experiences, up from a quarter. The state is among 31 others that currently use some form of this training, Hochul’s office said.

Keeping the pipeline moving

The idea is to keep the workforce pipeline moving by preventing a wait for the limited supply of student clinical placements necessary before licensure. Stakeholders said expanded use of simulation training will also allow nursing programs to grow, adding more clinical training to meet demand.

Simulation training for future nurses tests clinical and critical thinking skills in a classroom or lab setting rather than a healthcare setting. It became a pandemic stop-gap for many states as schools suspended their in-person training due to COVID-19-related restrictions, threatening to delay graduations. California, for example, temporarily allowed students to receive 50% of their clinical training in certain areas (geriatrics and medical-surgical classes) via simulation.

Replacing lost staff

“I give New York state credit for doing this,” said Shari Carson, RN, BSN, LNHA, regional clinical coordinator of Ciena Healthcare in Michigan and vice president of The National Association of Directors of Nursing Administration of Long-Term Care. There are not enough nurses graduating to replace those that will soon be lost to retirement, let alone those lost to attrition during the pandemic, she said. 

In fact, New York’s post-pandemic clinician workforce crisis looks bleak. It will be short an estimated 40,000 licensed nurse employees by 2030. “[E]xpanding simulated training will help clear the logjam, address the shortage and ensure high quality care for millions of New Yorkers,” Hochul’s office said.

Bigger investments needed

Yet, simulation training is only “a partial solution” to the problem of building back the workforce, Carson said. Much bigger investments are needed to attract nurses where they are most needed, she added.

For example, student loan forgiveness programs could work to entice nurses to work in underserved areas such as long-term care and rural care, just as they do for physicians, she said. 

Meanwhile, training in a simulated scenario can help boost critical thinking skills, Carson said. The National Council of State Boards of Nursing has found that up to 50% simulation can be effectively substituted for traditional clinical experience. And the learning experience has become more realistic as technological features improve. But there are some skills that nurses in training need to learn hands-on, she said. Intubations can be a different experience in each patient, for example. And when a patient goes into cardiopulmonary arrest, “you need to learn how to respond, how to be part of a team and do CPR.”

Up to speed for LTC

During the pandemic, Carson’s home state of Michigan temporarily allowed simulation for much of its pre-licensure nurses’ training, she noted. As newly licensed nurses moved into jobs, Carson and her peers in the field quickly recognized that orientation programs would need to be expanded and enhanced to be sure the new hires were up to speed.

When it comes to long-term care staffing, if simulation training is geared more towards specialty clinical areas, such as medical-surgical, psychiatric and skilled nursing, it could be helpful, she noted. “We could then teach them what they need to know,” she said.

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“It’s impossible to exaggerate the challenges that providers face in providing care because of the inability to hire workers,” said Mark Parkinson, president and CEO of the American Health Care Association/National Center for Assisted Living.

While doctors’ offices, and the home health and hospice sectors have recovered to pre-pandemic employment levels, skilled nursing facilities are short almost a quarter-million employees. In addition, assisted living facilities remain down by approximately 40,000 workers, Parkinson said during a media call Wednesday. And those are the numbers the long-term care industry needs to hire just to reach parity with pre-pandemic staffing levels. 

“It is unique to long-term care that we face this crisis,” Parkinson said, adding that 96% of providers report that they cannot hire workers. “This is not a normal type of labor situation that we have seen in the past. There’s been challenges, but it has never been like this where we’ve had a material reduction in the workforce and an inability to admit people because of the loss of workers.”

The association launched a job education website called Careers in Caring, which gives providers tools and resources to aid in hiring. They include research-tested methods to reach job candidates, informational videos about working in the industry, messaging materials, social media tools, and templates for press releases. The site also includes a template for Myth-Fact documents to help push back against disinformation. 

Among the myriad challenges the sector faces are low wages and Medicaid rates that do not reflect the real costs with which providers are dealing, AHCA leaders explained. 

Currently, Medicaid is funding only 84% of the operating costs for rural facilities, said another media call participant, Phil Fogg, the president of the AHCA/NCAL board of directors and the president and CEO of Marquis Companies. Providers need reimbursement stability, so states might need to look at a critical access designation, similar to that given to hospitals in similar areas, to provide a steadying financial hand, Fogg asserted.

Reforms needed to increase staffing capacity

Providers also face the specter of a promised first-ever federal minimum staffing mandate.

“Our current workforce is tired and burned out,” Fogg said, noting that his company has the largest number of job openings in its 33-year history. “The workforce shortage is creating serious access issues. In rural communities, you’re literally seeing facilities close because they cannot get the staff to meet not only their state and federal requirements but to care for the people in that community.”

The sector is pushing various policy reforms, such as increasing workforce visas in the immigration system, boosting capacity in education and jobs programs, and promoting long-term care careers in high school, and getting licensing agencies to be quicker and more efficient. 

The campaign to recruit new employees — or win back former workers — will focus on two broad message areas: long-term care is a calling through which people can find fulfillment; and it offers professional job advancement that can see a worker go from a nursing aide to an administrator to even an owner/operator. The association conducted focus groups and surveys with former and current workers to determine what motivates employees to stay or leave. 

“There are very few occupations where you can provide the type of satisfaction to a person who has a real desire to help other people,” Parkinson said. “They don’t come into the space for money; they really see it as a calling.”

They met during a bipartisan committee hearing last week to address skilled nursing staffing shortages, a major culprit causing strife and facility shutdowns in Kansas and many other states.

The hearing specifically dealt with a domino felled by staffing shortages, use of agency staff. Last year, nursing homes nationwide saw an 83% increase in their median contract labor use compared to 2020, according to a report issued in October by accounting firm CliftonLarsonAllen.

Advocates complained that agencies were price gouging to take advantage of providers’ dire needs, and they were making it difficult for agency nurses to leave for more stable opportunities.

Staffing agencies include large buyout clauses in their employee contracts in order to discourage facilities from hiring nurses and aides who may want to leave an agency and work for a facility, Rachel Monger of LeadingAge Kansas told McKnight’s Long-Term Care News.

“Some staffing agencies are even known to put non-compete restrictions in their contracts with nurses to prevent them from going to other agencies or facilities in the area,” she said.

Staffing companies were charging Medicaid providers more than triple the typical rate for essential workers, Monger told Home and Community Based Services and KanCare Oversight Committee. 

Prohibit restrictive agency clauses

One solution is for the state to pass legislation that prevents staffing agencies from using buyout and non-compete clauses in their contracts with facilities and nursing staff, Monger said. 

“Nurses and nurse aides are free to go work for a temporary staffing agency any time they’d like,” she said. “Our state cannot afford to have nurses and nurse aides held hostage so that staffing agencies can demand thousands of dollars more on top of the extortionate charges they are already demanding from nursing homes and hospitals.”

Committee members didn’t show much enthusiasm for government intervention in market-based business, and were reminded that the government funding aspect made the agency-provider relationship unique, according to a media report.

Cutting the number of training hours needed for CNA certification was a move supported by Rep. Brenda Landwehr (R-Wichita). Kansas currently requires 90 hours, but the federal Centers for Medicare & Medicaid Services requires 75.

When another legislator said 75 hours of training might deliver unprepared workers to critical environments and duties, Landwehr countered, “It doesn’t mean we’re losing quality. It means Kansas was sitting too high. Why in the world are we sitting here at 90 hours with the feds at 75?”

“People are going to have to get off their turf-battle stances,” Landwehr said. “We’ve got to make changes because we’ve got to figure out how to increase this workforce. We’re going to have this discussion in every area of health care whether people like it or don’t like it.”

‘Miles away from the ideal’

Monger said she doesn’t love the reduction of training hours, but there’s little room for luxury. Her organization has been pushing for staffing agency oversight legislation since 2020.

“Our state legislature has challenged all of us to look at licensure and certification training through the lens of wants versus needs,” she said. “In an ideal world, we would include as many training hours and topics as possible for certified nurse aide programs.  

“But we are miles away from the ideal, with no relief in sight. If the federal government believes 75 hours of training is an adequate and safe amount of clock time to cover the federally required curriculum, we are willing to have a public and multi-stakeholder conversation around adopting the CMS standard in Kansas.”