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.

The government’s promise to impose federal staffing standards could happen any day now. Talk about staffing challenges.

This pending mandate has the provider community on edge. For a couple of good reasons.

One is that little matter of how to prep for the heightened table stakes.

Another, related concern, is that the directive is arriving while nurses are becoming increasingly scarce.

In some ways, RNs divesting themselves of their careers is actually the more ominous concern. Those actions are far different than pending rules that can be delayed, reduced or perhaps even rejected. No, nurses are leaving, period. And the reality becomes more obvious by the day.

For the latest proof, please direct your attention to a fresh analysis by the National Council of State Boards of Nursing.

Roughly 100,000 RNs have left the field since the arrival of COVID-19, authors found. Worse, still, is that another 900,000 are likely to depart by 2027.

If anything close to that million nurse march plays out, long-term care won’t have to deal with a staffing challenge. It will have to deal with a staffing nightmare.

The report’s authors pointed to stress and burnout as key defection catalysts. There’s little doubt that’s true. But I think there is another factor at play in long-term care.

It’s one that tends to get overlooked: The all-too-common dysfunctional relationship that exists between administrators and DONs. And here, it must be said, it’s the administrators who are largely to blame.

In far too many facilities, DONs are not getting the tools or support they need to do their jobs, much less grow.

At the NADONA show in June, I will be joining some leading DONs and TJ Griffin from PharMerica, for what promises to be a lively podcast. We hope to explore the challenges in this often fractured partnership — and propose ways to fix it. (Full disclosure, PharMerica is sponsoring this presentation.)

We don’t simply want to hold a gripe session — although it’s a safe bet that a few of those will be shared. Rather, we are hoping to raise awareness among administrations about ways to mend and improve the working relationship they have with DONs.

We will air a recording of the podcast in July, so please look for it. I think you’ll find it’s a real eye-opener. More to the point, it might just help improve your staffing situation.

And it’s probably safe to say this field is going to need all the staffing help it can get.

John O’Connor is editorial director for McKnight’s.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

Having fewer dominant players in the skilled nursing sector  — and room for quality improvements in many markets — will continue to fuel the chain’s growth beyond its current 177 skilled nursing facilities, said Jason Murray, CEO of Providence and PACS, the Providence Administrative Consulting Services arm.

“This notion that we can take these struggling assets, that for years, for a variety of reasons have struggled clinically, financially, this idea that we can take these distressed assets and breathe new life into them with a new care model, new leadership, and then to see the results of that over time … that is rewarding for us,” Murray told McKnight’s Long-Term Care News earlier this month.

“There’s a lot of opportunity out there for us to replicate what we’ve done year over year and with every acquisition. We will continue to grow because there are 15,000 nursing homes across the country and by my last count, the largest provider has 250 or something,” he added. “It’s very fragmented and there’s a lot of opportunity for continued growth in our sector.”

Providence Group roared onto the national stage in 2021, when it acquired Plum Healthcare Group, then California’s second-largest nursing home operator. At the time, the company reported it had picked up operations at all 58 facilities it acquired and bought the real estate for 10.

Today, Providence continues to operate a mix of its own buildings and those leased from real estate investment trusts. Most recently, its nine-state portfolio has added new facilities in Colorado and Arizona.

All of those facilities have access to back-office services and clinical support from PACS, which uses a regional model to deliver training and expertise. But Murray insists that it’s the administrators in each of those buildings who determine how much involvement they want with PACS.

In turnaround projects, Providence closely examines the ability of an existing administrator to lift a building’s performance. Regional executives can help with recruiting those more in line with the chain’s approach to becoming indispensable post-acute partners and elevating care standards.

The ‘secret sauce’

That often means grooming a new building leader through PACS’ six- to nine-month administrator-in-training program for recent college graduates or a training and support program for experienced administrators who want to transfer into the company. 

Once administrators are working in the system, they are empowered to tap resources and institute local policies that make the most sense for their region and for their workers. Murray says that the decentralized model has been a major contributor to administrator turnover rates that continuously beat national averages.

Last year, he said, Providence turned over 2% of its administrators. By comparison, a major consumer group recently reported that roughly half of US nursing homes reporting administrator data to federal regulators lost at least one administrator in the previous 12 months.

“Providers need to embrace this idea that your administrators and the teams at your buildings need to be high-performing people,” Murray said. “That is our secret sauce: the ability to attract and retain the best talent not only in our industry, but I would put our talent against any industry. We have prior professional athletes, prior attorneys, prior business owners who are running nursing homes as administrators and who are part of the clinical teams.”

While the PACS team also provides legal, clinical and marketing support, it’s been the ability to help recruit that individual facilities lean on most, Murray says.

“The recruiting of staff, the training of staff and making sure we can keep our facilities staffed, that is the main driver behind our success,” Murray said, noting a relatively good turnover rate of 40% among CNAs, LPNs and RNs.

Consistency of administration leads to happier staff, and those higher staffing levels have helped keep beds open in Providence facilities even as others may have struggled. Murray said census today averages around 90% outside of new acquisitions.

Most of the group’s facilities experienced a dip of about 5% during the early COVID days, but many quickly created support systems for hospitals to anchor referrals.

“Our trajectory out of that was much quicker and steeper than some of the national averages,” Murray noted. “Over a two-quarter period,  we came back close to historical census levels… We felt like we were very good partners in the markets we were in … and secondly, we worked very hard to keep our buildings staffed.”

An in-house staffing agency endeavor also helped to help normalize the cost of staffing in some markets and circumvent at least some agency price-gouging.

More growth ahead?

Moving forward, where and how Providence charts its growth largely will be dictated by recruitment potential, especially for administrators, and the ability to build up a geographic area that can pool recruiting resources and share staff as needed. 

“We’ve become much more sophisticated in how we do acquisitions now. In the early days, it was kind of a finger in the wind sort of approach to see if it made sense,” Murray said. “But over time, we’ve created a scorecard that measures many of the things we’re talking about: reimbursement, that’s important; Medicaid, how is it funded in the state? We look at occupancy percentages [and] we look at the competitive profile. We also look at the regulatory environment and how much traction the local associations have. Is there any legislation that is pending that we need to consider? Those are all components to this scorecard.”

Providence-owned facilities are expected to meet certain clinical and quality metrics, and those goals are set out in a clear framework. But how administrators get there is up to them. 

In taking over distressed assets, PACS works with the new administrator to understand where a given facility needs to improve and how it might get there. Yet Murray said leaders above the regional level try to stay out of the fray.

“The metrics are readily available and shared amongst our affiliates so that they can benchmark themselves and understand how they benchmark themselves against their peers, and not just our peers within our company, but also local as well as national metrics,” Murray said. “But we try to empower the administrator to make as many decisions locally as they can. The moment we try to take decisions away from the administrator is the moment we start to see things change and not for the better.”

One tool Providence Group hopes to bring to its affiliates is a more robust care continuum. As with other management decisions, determining home care and hospice partners falls to local managers. Dashboards allow some visibility into how well those partnerships are working and whether patients who need step down care get what they truly need.

But a more aligned strategy might be possible through ancillaries, which Providence currently does not own or manage.

“It is something that Providence Group is contemplating: Are there opportunities on the ancillary side to provide additional support?” Murray said. “We feel very strongly that we are as good as any provider out there in our space in doing what we do. So the idea of bringing verticals within Providence Group and bringing that same level of expertise and commitment to excellence in those verticals, … would [give us] as much touch on that patient post-acute as we can get.” 

But again, Murray insisted, the decision to use those ancillary, co-owned partners would be left to in-building leaders.

“When you lose your identity, when you lose your culture, when you lose your operating model that made you successful, you’re too big,” he said. “We’re not interested in trying to become the largest provider in the country. We’re interested in looking at opportunities where we can provide that new life. As we continue to successfully do that, we will let the numbers take care of themselves.”

No big deal, you say? Well, let me tell you what these individuals have endured and continue to endure to this day. 

Our nation’s long-term care leaders have led the way in the battle with the pandemic that continues even today (despite the impending end to the public health emergency). The physical and emotional toll has placed undue strain on us and our profession. We have been thrust into an unwanted spotlight and often vilified in the mainstream media (even more than before the pandemic).

Subject to a conflicting and changing regulatory environment, without adequate staffing and with ever-changing directives from local, state and national agencies, leaders have been on the job throughout it all. Administrators are key players in the care team and are entrusted with the responsibility of managing the care of our loved ones.

We touch the lives of residents and families, and, most importantly, ensure that staff provides the highest level of quality care to a vulnerable population.

To become an administrator takes commitment and dedication. Upon becoming an administrator, we continue life-long learning to assure we stay abreast of the changing landscape in aging services. We are masters of multi-tasking, considering every aspect of a person’s life, not just their medical needs, while building a sense of home and community.

Administrators are the counselor to the employee who is enduring financial hardship, the anchor of stability for elders who too often see different faces caring for them each day, and the voice in the community who tells the stories of inspiration, achievement and hope that occur every day.

Each day, these heroes give their all to assure their communities are equipped to provide high quality care and services to the elders in their care. They embody servant leadership by putting the needs of their patients, residents, families and co-workers ahead of their own. No, this career is not at all for the weak!

March 13 to 17 is National Long Term-Care Administrator’s Week. During this week, fellow staff, residents, families and volunteers have an extra opportunity to say, “thank you” and honor the administrators who lead our nation’s long-term care communities. 

The nation owes our long-term care administrators a debt of gratitude. Please join me and the American College of Health Care Administrators as we take some time to show our appreciation to these selfless leaders! 

Robert Lane, MA, CNHA FACHCA is president and CEO at The American College of Health Care Administrators (ACHCA). Based in Oklahoma, he has spent 39 years an administrator, field trainer, Quality Improvement Organization (QIO) project manager, speaker, and consultant. 

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.

The claims come from the Long-Term Care Community Coalition, which used federal payroll-based journal data to extrapolate  that the average amount of time administrators spent at SNFs dropped from 8.44 hours per day in the third quarter of 2019 to 6.17 hours per day in the same quarter in 2022. 

In addition, at least half of all US nursing homes lost at least one administrator over the previous 12 months and at least 2,100 facilities lost at least two administrators, the group said.

“Nursing homes are rarely held accountable when they put profits over the safety of their residents and staff,” the coalition said in its email announcing their Q3 Staffing Report. It included an “important note” that pokes at industry lobbyists for claiming they need additional resources to meet staffing minimums when “inadequate staffing has been a persistent problem for decades.”

But Bob Lane, president of the American College of Health Care Administrators, said the report is based on self-reported provider data, which opens the door for reporting inconsistencies that can paint an inaccurate picture.

“The data reported may not be entirely accurate,” Lane told McKnights Long-Term Care News Friday. “The report notes that inadequate staffing has existed for decades, which is true, however I would argue this is not attributable to providers putting profits over residents and staff, but chronic underfunding of Medicaid in virtually every state.”

Lane also pointed to administrator burnout from the last three years as a possible reason for why there are staffing vacancies. Some 52% of administrators considered leaving their jobs in the three months prior, according to the McKnights’ 2022 Mood of the Market survey, which gathered info in July and August and was published in September. 

“The physical and emotional toll has placed undue strain on them and our profession,” Lane said. “They have been thrust into an unwanted spotlight and often vilified into the media … Subject to a conflicting and changing regulatory environment, without adequate staffing and with ever-changing directives from local, state, and national agencies, these leaders have been on the job throughout it all.”

A December study from researchers at Brown and Harvard universities found that administrators were “fully committed” to their facilities but the pandemic created significant levels of stress managing restrictions, new government rules, and the sector’s viability. 

An executive staffing recruiter who works with providers also disputed the numbers and reminded that even when there’s administrator turnover, facilities must have licensed administrators.“ In no way do I think administrators are or can even think about, spending less time in their buildings,” said Kate Piperata to McKnights Friday, adding that the hours aren’t decreasing but rather being spread out over more residents as facility populations increase.

National Long-Term Care Administrators Week kicks off Monday and lasts through Friday, a period during which appreciation and special thanks can be given to those running the country’s nursing homes.

“Our nation’s long-term care leaders have led the way in the battle with the pandemic. The physical and emotional toll has placed undue strain on the profession,” noted the American College of Health Care Administrators, the week’s sponsor, in announcing the observance.

“They have been thrust into an unwanted spotlight and often vilified in the media. Subject to a conflicting and changing regulatory environment, without adequate staffing and with ever-changing directives from local, state, and national agencies, these leaders have been on the job throughout it all,” organizers continued. “The nation owes our long-term care administrators a debt of gratitude.”

Administrators are licensed professionals and a building’s chief leader. They touch the lives of residents and families, and, most importantly, are responsible for ensuring their staff provides the highest level of quality care to a vulnerable population, ACHCA notes.

“They embody servant leadership by putting the needs of their patients, residents, families and co-workers ahead of their own,” said Bob Lane, CNHA, FACHCA, president and CEO of ACHCA. 

The college extends the week’s observance to salute administrators in nursing homes, assisted living residences and other post-acute and aging service settings.

Suggestions on how to honor and recognize an administrator can be found on the group’s website.

As is fitting this time of year, when many people are exchanging gifts and then making New Year’s resolutions, I’ve come up with my wish list for key long-term care players and stakeholders.

For directors of nursing in the nation’s skilled care facilities

The gift of bunches of eager, resolute staff members. It’s hard to keep the boat moving when somebody’s always handing back her or his oar, or there simply aren’t enough people rowing.

The resolution they should make: To develop more patience for those whom they may hire. And remember: No snacking on young staff members allowed. It’s been acknowledged many times by nursing leaders that for some reason, experienced nurses tend to treat newcomers brusquely, to put it politely, or that they tend “to eat their own” to phrase it not so politely. Play nice. Period.

For building administrators

The gift: A lasting supply of directors of nursing, probably the most pivotal leader in your buildings.

The resolution: To become better communicators. The only way to make sure gossip or unfounded speculation ruins morale and sometimes the reputation of your facility is to let it go unchecked, or get started in the first place. 

For the residents

The gift of consistent assignment of their direct caregivers. There is no way this gift can be overvalued. Ever.

The resolution: To keep your family members in line, and fully appreciative of those who diligently take care of you 24/7/365.

For unscrupulous contract nurse agencies

The gift: A big lump of coal. You’re right up there with the gas stations who charge $10 a gallon or more after a hurricane ravages an area.

The resolution: To develop some kind of conscience to help the industry you profess to be saving while lining your own pockets to excessive levels.

For nursing home owners

A gift of lower inflation rates, while also being able to harvest some of the value that higher interest rates bring. But mostly lower inflation. 

The resolution: To be more transparent about who you are and what you’re doing. Then again, the feds say they’ll be helping you with this one so hopefully you see fit to play ball. Let the disinfectant of sunshine shine on whoever’s running the show in town.

Private equity investors

The gift of a decent crystal ball so you can figure out who really needs you most. Then behave appropriately.

The resolution: A tempered appetite. They may be just Hollywood examples, but if you want to see how a business leader can modify ravenish financial desires while still keeping hold of a pretty good buck, check out the classic “It Happened on 5th Avenue” or, heck, even “Pretty Woman.”

The states

May they all enjoy the gift of a burgeoning economy in 2023.

The resolution: To share the wealth from a healthier economy with their Medicaid programs, and therefore, skilled nursing stakeholders.

LeadingAge

May it enjoy the present of another technology executive like Majd Alwan. His long-time second-in-command, Scott Code, could be just the guy.

The resolution: To never give up the good fight. Advocacy statements out of President and CEO Katie Smith Sloan and the rest of her leadership team during the pandemic have been powerful, pointed and unapologetic. Shockingly so in some cases. Good for them.

The American Health Care Association

May 2023 bring the gift of another quality, fun annual conference, like the one in Nashville in October 2022. (Minus, ahem, the case of COVID-19 that some of us arrived home with.)

The resolution: More national news show appearances for President and CEO Mark Parkinson, who’s never been better than in the early days of the pandemic, when he let the nation know that long-term care providers were victims as much as anybody since their patients were most susceptible to the most dangerous public health scourge in at least a century. Double down on that with more public exposure for gifted speaker AHCA Senior Vice President of Government Affairs Clif Porter, too.

The Centers for Medicare & Medicaid Services

Let CMS have the gift of wisdom when it unveils its promised nursing home minimum staffing standard early in 2023. The absolute right way to do this may not be known yet, but there are definitely easily recognized wrong ways to go about it.

The resolution: To consistently listen more and act for the good of the entire system that the agency is both patron and overseer to. The circumspect decision-making that went into switching from a drastic funding pay cut in the proposed Fiscal 2023 SNF PPS rule to a more moderate package that also phased in funding take backs was a welcome breath of fresh air and clearheadedness.

And to all of our readers, as always, I wish you good health and outstanding days ahead.

James M. Berklan is McKnight’s Executive Editor.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

Investigators observed operations and conducted interviews with 169 staff members in 14 nursing homes across four states. The facilities that practiced low-intensity care for residents with advanced dementia had more pleasant physical environments and more standardized advance care planning processes, reported senior author Susan L. Mitchell, M.D., of Hebrew SeniorLife in Boston and Harvard Medical School. These facilities also had greater staff engagement in shared decision-making, and staff members who did not value tube feeding.

Yet in all of the nursing homes, staff members expressed assumptions that “proxies for Black residents were reluctant to engage in advance care planning and favored more aggressive care,” Mitchell and colleagues reported. 

It’s a bias that must be addressed, the authors concluded.

“Given pervasive staff biases toward proxies of Black residents, achieving health equity for nursing home residents with advanced dementia must be the goal behind all efforts aimed at reducing disparities in their care,” they wrote.

The 169 staff member participants included administrators, directors of nursing, nurses, certified nursing assistants, social workers, occupational therapists, speech-language pathologists, dieticians, medical clinicians and chaplains.

The study, titled ADVANCE (Assessment of Disparities and Variation for Alzheimer Disease Nursing Home Care at End of Life), was conducted between June, 2018 and July, 2021. 

Full findings were published in JAMA Internal Medicine.

The free online resource tool, “Infection Prevention Compendium For Long-Term Care Facilities,” was developed in collaboration with the New York Academy of Medicine, Saraya Co. Ltd. and Best Sanitizers Inc. It contains links to key information in four categories, including:

• Infection prevention tools and resources for direct care providers, administrators and managers, and support staff;
• U.S. and international infection control resources;
• A summary of New York Academy of Medicine (NYAM) reports; and 
• Teaching tools

The teaching tools include five PowerPoints, one each for administrators, family members, nurses, residents and specialized contract providers. These are designed to test individual knowledge and promote shared core principles regarding infection prevention and control.  

The resources will serve as a time-saver for staff and hopefully help them to feel less alone as they continue to navigate the pandemic, the authors say.

“The impact [of the compendium] is to provide the tools and resources in an easy-to-understand and easily accessible format that can make these staff’s lives a little bit easier,” said Elana Kieffer, acting director of the NYAM Center for Healthy Aging. 

The Yale School of Nursing and the New York Academy of Medicine have formed a coalition to address infection prevention in long-term care facilities worldwide.

Covid vaccines have provided the light at the end of the tunnel that we have been waiting for. Everyone cannot wait to “return to normal.” Not that “normal” was a day at the beach for those of us in long term care.

Already some large nursing home companies have declared the pandemic is over and it is time to focus on census building once again. Slow your roll, I say.

For many nursing home administrators and other long term care leaders, this has been the hardest year of their careers. A year on from the start of the pandemic, many have not even had a day off or been able to take a vacation. What was a 24/7 job to begin with became a 24/7 job on steroids.

We need a break. We need to stop and catch our breath before we try to return to normal. Consider just the number of deaths we have experienced. Death became routine. In our business, we come to expect death as part of life. But we don’t usually expect it to visit our employees and their families. Many employees and more than a few administrators died from the virus.  

Before we try to move on, we need to take time to acknowledge those we have lost to COVID-19. We need to grieve. We have been under a lot of emotional and sometimes physical stress. Grief is necessary to allow our brains to recuperate after this experience. We need to come to terms with our emotions and the reality of our situation.

I suggest a formal process for this. Hold a memorial service. Get the entire team together to acknowledge what they have been through. Remember those that have been taken from us. Say their names. Have a group hug.

Unless we stop to remember there will be no return to normal.

Bill McGinley, CNHA, is president and CEO of the American College of Health Care Administrators.