In Texas, one long-term care facility spent more than $70,000 extra on staffing in August, much of it to cover exorbitant agency rates or give a $100 bonus each time an in-house nurse picked up an extra shift.
That was in addition to overtime — a factor costing facilities nationwide significant cash in the short-term and increasing the risk of worker burnout in the long-term.
“I don’t know if workers can work that many hours for many months at a time, ” George Linial, president of LeadingAge Texas, told McKnight’s Long-Term Care News in early October. “We’re teetering. We’re surviving, but we’re on precarious ground.”
In hiring categories ranging from administrators to housekeepers, long-term care providers across the nation spent this summer begging for help. Instead, the numbers kept dropping. Skilled nursing shed another 1,500 employees in July, bringing the total since March 2020 to 380,000.
The timing couldn’t be worse, as the long-awaited “silver tsunami” approaches. Accounting for recent turnover, long-term care employers will need to fill 7.4 million direct care jobs to meet patient demand through 2029, according to a September report by workforce advocate PHI.
There have been some scattershot policy efforts to stem the tide. In West Virginia, the governor pledged extra funding, staffing assistance and a 24/7 monitoring system for long-term care facilities facing worker shortages during COVID’s delta surge. In New York, the governor promised to call out the National Guard in response to shortages after a state vaccine mandate kicked in Sept. 27.
But at press time, providers nationwide were waiting for the other shoe to drop: In mid-October, the Centers for Medicare & Medicaid Services was expected to issue an interim rule detailing its national COVID vaccine mandate.
That rule will set in place a harrowing new deadline, one with worrisome staff implications in areas where vaccination rates are lagged the rest of the nation (both in the community and among those working in skilled nursing facilities). Whether or not the mandate allows for test-outs, providers are bracing for more staff losses as vaccine-resistant workers flee for jobs without such rules.
Already, the flight has affected access to care. A September American Health Care Association survey found 89% of providers were experiencing high or moderate staffing shortages. And 58% were so strapped, they limited new admissions.
A Texas Health Care Association and LeadingAge Texas survey put that “turn away” rate at 30%. Just as alarming: 63% of providers there said they could not fill positions because they have zero applicants.
“That business model is not going to work well when your census is down and your staffing costs are up,” said Linial. “That’s not a good formula for long-term survival.”
How bad will it get?
Two independent surveys have predicted stark consequences of nursing home mandates. In late August, an OnShift survey of more than 2,100 long-term care employees found just 8% of those unvaccinated planned to get a vaccine. In September, Caring.com reported one in three unvaccinated caregivers would refuse shots and quit.
But some providers that have already made vaccinations a condition of employment on their own are reporting far less severe losses.
Lutheran Senior Services operates Life Plan communities and long-term care in Missouri and Illinois. After instituting its policy, effective Sept. 1, the operator reported losing 110 of its 3,200 employees, or about 3%.
New York may serve as a major test case. The day after its mandate for nursing homes kicked in, officials reported 92% of workers had been vaccinated.
In Texas, where COVID vaccine mandates by local governments or providers are banned, staff members are vaccinated at a rate of 62.32%, below the national average of 65.4%, per data submitted to CMS by Sept. 19.
“We’re so tightly staffed right now that even losing a few workers is devastating,” Linial said. “We can’t afford to lose many more.”
Finding the right fit
Salmon Health and Retirement CEO Matt Salmon told McKnight’s filling the ranks at his Massachusetts locations is like a “battle every day.”
This year, his team has used business intelligence tools to overlay addresses of state-certified nurse aides with communities where current staff live and work. Then Salmon offered employees a bonus to go door to door and encourage qualified neighbors to apply. But Salmon recognized good old-fashioned shoe leather might not be enough as mandates kick in. The company pre-booked travel nurses around key dates.
The threat of losing multiple employees in a single clip adds a new wrinkle to hiring efforts. Even as they recommit to educating about vaccines, providers are busy building databases and employing new technologies to go after job candidates they presume they’ll need. Workforce software companies have seen a major uptick in skilled nursing clients this year.
OnShift’s Peter Corless said providers need a way to quickly communicate needs to staffers who might be willing to pick up or switch shifts. That has led to the creation of internal staffing pools with “flex” positions across settings or shifts. Others are targeting retirees open to part-time work.
Many continue to throw money at the problem in the hopes of driving up applications. In New York City, ArchCare at Carmel Richmond Healthcare and Rehabilitation Center was offering signing incentives of up to $10,000 for RNS, LPNs and CNAs. But it is also offering expanded fringe benefits intended to get those new workers to stay.
Amy Goldsmith, senior vice president for Sava Senior Care, said providers need to do more than just entice workers with wages. After having its image tarnished by COVID, it’s critical the industry focuses on building supportive workplaces.
“What makes a nurse want to work in your center?” she asked during a September webinar. “What are you going to do for them that someone else is going to do? Yeah, we all pay about the same. Yeah, it’s the same work. But showing some of that culture that you have within your center (can) make someone want to be there.”
The issues won’t quit
Even if the labor pool grows and COVID finally settles back into something manageable, providers will be stuck with higher pay rates and an expectation of better benefits.
“It’s difficult to imagine how the long-term care sector will meet demand for direct care workers without dramatically improving their jobs,” Kezia Scales, director of policy research at PHI, says.
And for that, providers say they need more than strike teams and subsidies.
Linial, for instance, has asked Gov. Gregg Abbott (R) for $400 million of the state’s American Rescue Plan funds to help strengthen the long-term care workforce. But he also continues to advocate for solutions that could draw workers and make the industry more stable: student loan repayment programs for nursing school graduates who choose long-term care; state-reimbursed training and certification testing for CNAs; financial backing to help move pandemic-era temporary nurse aides into permanent CNA positions; and new career ladder incentives.
“Those things are going to take a little bit of time to implement and reap the rewards of,” Linial says. “But we do need to have some sort of long-term strategy for the workforce situation.”
He’d also like to see Medicaid rates increase, and has long asked his state to fund a program that dedicates extra dollars to frontline staffing improvements.
In a similar vein, national advocates have urged Congress to include Federal Medical Assistance Percentages provisions in a budget reconciliation bill still being debated at press time. Under the Nursing Home Improvement and Accountability Act, states would receive a higher federal match to expand efforts to improve nursing facility staffing, such as improved wages and benefits.
Removal of related but costly programs for the caregiving industry from President Biden’s Build Back Better agenda would be bad news for the three-quarters of nursing homes who told AHCA they are unsure if they’ll last another year.
“The consequences of letting this crisis go unsolved are significant,” AHCA leaders say. “The long-term care labor crisis ultimately limits access to care for vulnerable seniors. Without help from lawmakers, more workforce-related closures could occur.”
From the November 2021 Issue of McKnight's Long-Term Care News
