Some problems are so pervasive that even well-intentioned efforts to solve them feel overwhelming and inadequate. The staffing crisis is one of them. Workforce shortages jeopardize the health and safety of both long-term care residents and the staff who care for them. Staffing challenges are intertwined with long-standing issues, including wage levels and stigma, which are exacerbated by incredibly difficult working conditions created by the COVID-19 pandemic.
The Biden-Harris administration has announced plans to “ensure that every nursing home provides a sufficient number of staff who are adequately trained to provide high-quality care…”, and described reforms powered by many sticks with just a few carrots to help. In this third installment of the Advancing Excellence Policy Series, Board member Tracey Moorhead and Board Chair Barbara Bowers reflect on the announcement. They describe some of the nuances that make staffing problems so pervasive and share additional recommendations for policymakers to make nursing homes better places to live and work.
We welcome you to use this content and reference our complete set of recommendations to help promote change.
–Theresa Schmidt, for Advancing Excellence
Late last month, President Biden announced a set of reforms aimed at improving the safety and quality of nursing home care, including establishing a minimum nursing home staffing requirement. The proposal notes that CMS will conduct research to determine the level and type of staffing needed to ensure safe and quality care and will issue proposed rules within one year.
The Administration’s focus on the need for staffing reform presents a long-awaited opportunity to make lasting, meaningful change, but any reforms must recognize and address factors that have caused current staffing shortfalls while also establishing realistic goals. Absent significant payment reforms directly focused on resolving staffing challenges, PALTC providers will continue to struggle in their efforts to recruit and retain staff.
We have long known that insufficient staffing jeopardizes residents’ quality of life and quality of care and negatively impacts clinical outcomes through delays in care and the inability of staff to provide care that is responsive to resident preferences. Staffing shortages are tied to difficulties recruiting and retaining qualified staff that are also well known to post-acute and long-term care providers.
Nationally, the average annual turnover for CNAs is 80% (or higher) in long-term care settings, while average nurse turnover rates consistently exceed 50%. Staff turnover is also closely associated with increased hospitalization, poorer outcomes, and increased cost. Higher rates of staff turnover have also been linked to greater likelihood of infection control citations.
The staffing crisis has a variety of causes. Compared to hospital staff, registered nurses and nursing assistants working in long-term care settings have lower wages. Nurses also frequently lack access to high-quality training programs, such as residency programs, which have been shown to improve both retention and quality of care. Because working in a nursing home compares so unfavorably to working in a hospital, this contributes to challenges recruiting and retaining advanced practice nurses and registered nurses.
The COVID-19 pandemic exacerbated staffing challenges and raised awareness among both members of the public and policymakers about the impact of staff shortages on care quality. In the early waves of COVID-19, CNAs were celebrated as the “unsung heroes” of long-term care. But as the pandemic progressed, CNAs who worked in more than one nursing home were blamed for spreading the virus. This was a necessity for many CNAs, however, whose poverty level wages required them to work multiple jobs in multiple nursing homes. One in three CNAs qualify for public benefits, and 42% are without health insurance, often due to an inability to afford the employee portion of plans offered by their employers.
Recruiting nurses and CNAs to replace those who have left during the pandemic is increasingly difficult and expensive, requiring costly marketing and staff replacement programs. Communities may also find it challenging to recruit and retain qualified CNAs because of poor working conditions, lack of advancement opportunities, insufficient training, and lack of a broader U.S. culture that values and explicitly acknowledges their work. Research suggests that improving the work environment for both CNAs and nurses may lead to both improved retention and improved care quality.
Recruitment and retention efforts are also undermined by the stigmas associated with caring for older adults. Common perceptions that nursing homes are undesirable places to live and work persist and are compounded by media coverage and policy mandates impacting providers. Stigmas may be an especially powerful deterrent for students who believe working in this environment is less prestigious than working in acute care.
Minimum staffing requirements alone will not solve the problems of rapidly rising wages in competing employment sectors, and existing payment models limit the ability of providers to improve wages and working conditions. Reimbursement rates for Medicaid, in particular, contribute to the ongoing lack of parity with competing employment sectors in wages and working conditions. The Administration described their intention to provide a template encouraging states to tie nursing home Medicaid reimbursement to wages and benefits, but current rates only cover 70-80% of the actual cost of care. Increases in public funding for nursing homes would help fill this gap, but must be coupled with robust transparency and accountability measures to ensure that the funds go to staff wages and resident care.
The Advancing Excellence in LTC Collaborative, in an Open Letter to the Biden-Harris Administration, advocated for increased support and reimbursement to improve compensation, benefits, and educational opportunities for staff (see Figure 1).
Additional recommendations include:
- Offer incentives, or directly support increased wage. Promote wage parity with hospital and other post-acute care settings for skilled nursing staff, including CNAs, through wage pass throughs, state pay for performance programs, and other incentives.
- Consider including an element related to environment and workplace quality in a nursing home quality program. Recommend a minimum level of health insurance benefits offered by long-term care employers.
- Develop educational content and modes of delivery for nursing home staff development, including person-centered care principles and competency-based professional leveling criteria for staff. Use CMP funds to support training programs. Evaluate the alignment between available training programs and the training needs of skilled nursing staff, including CNAs.
- Incentivize meeting training thresholds. Establish training thresholds and develop a mechanism to tie these thresholds to reimbursement increases. Include meeting training thresholds in survey criteria.
We believe that by pursuing and supporting these recommendations, policymakers can help make long-term care communities better places to work for staff, and sufficient staffing will also make them better places to live for residents and achieve the safety and quality improvements envisioned in President Biden’s proposals.
Tracey Moorhead, MA, is President and CEO of the American Association of Post-Acute Care Nursing (AAPACN). She serves on the board of the Advancing Excellence in Tong Term Care Collaborative.
Barbara Bowers, RN, FAAN, is the current chair of the Advancing Excellence in Long Term Care Collaborative and is Professor Emerita at The University of Wisconsin-Madison, School of Nursing.
Theresa Schmidt, MA, was the 2021 Secretary of Advancing Excellence and has served on the board since 2014. In this role, she led the development of the open letter to the Biden Administration. She is a Vice President at Discern Health, part of Real Chemistry.
The Advancing Excellence in Long-Term Care Collaborative is a not-for-profit entity that creates a forum for organizations and individuals committed to the needs of long-term care residents and staff to discuss policies that affect these vulnerable populations.
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.
