Learn what an Assisting Hands franchise owner did to improve an isolated workforce.
A career change at 51 brought Robbie McCullough to his new role as a home care owner and administrator. Since he was new to the home care franchise industry, he experienced his share of mistakes and lessons at the start, with one of the best lessons learned to keep his caregivers engaged and satisfied.
McCullough’s home care franchise journey began after a corporate restructuring at his previous company prompted him to figure out the next step in his career. McCullough worked with a franchise broker friend, took different personality tests, and discovered that many of his skills and interests aligned with caregiving.
McCullough’s first-hand experience with his older sister who was born with Down syndrome, and his care for his mother-in-law for 35 years, also helped with his journey into the home care sector.
McCullough spent a year vetting home care franchises to buy, and in 2015, he joined Assisting Hands Home Care, as a franchise partner in Dallas.
But once he became a homecare owner and hired caregivers, McCullough began to observe an issue with staff engagement: that the work of his caregiver staff is lonely. “The thing that most people underestimate is it's a lonely business because [the caregivers are] out there … isolated,” he says.
McCullough has worked to resolve that issue so his caregivers feel connected to the organization and engaged. To support and ensure caregivers have face-to-face interactions with the company, Assisting Hands holds team meetings in the office and gives out monthly caregiving rewards. Caregivers are also asked to maintain consistent contact with the office via email, text, or phone, says McCullough.
In addition, Assisting Hands invests in caregivers’ career development by offering a suite of modules to assist them in becoming certified as a certified nurse aide (CNA) or home aide. New caregivers are also given the opportunity to sign up for shifts during their initial onboarding to engage employees right from the beginning.
It's critical, McCullough says, that caregivers feel they have a relationship with managerial leadership, emphasizing the importance of leadership collecting and listening to employee feedback.
McCullough has caregivers complete a voluntary monthly survey by phone. Using survey software, they answer questions on a scale of one to 10 about their satisfaction. McCullough’s efforts are paying off as his branch of Assisting Hands won the Employer of Choice Award from Best of Home Care in August. The Best of Home Care Employer of Choice is awarded to home care agencies for outstanding caregiver satisfaction ratings.
The addition to the code set will help remove language barriers to Spanish-speaking patients.
The American Medical Association has released its Current Procedural Terminology (CPT) code set for 2024, now offering Spanish language descriptors.
The new code set, which serves as the nation's leading data-sharing terminology, is a welcome effort to address language barriers to Spanish-speaking patients, with the descriptors for over 11,000 medical procedures and services now available in their language.
"Navigating medical care and paperwork can be especially challenging for Latinx patients who do not speak English as a second language," Lori Prestesater, AMA senior vice president of health solutions, said in a statement.
"Providing approximately 41 million Spanish-speaking individuals in the United States with an easy-to-understand description of medical procedures and services can help build a more inclusive healthcare environment, where language is no longer a barrier and patients can actively engage in their own care."
HealthLeaders has previously reported on the negative effect language barriers can have on patients’ care, particularly in the home health setting.
For Alison Squires, PhD, RN, FAAN, being able to speak Spanish helped her as nurse in that she was better able to determine the treatment or care the patient needed. While interpreters are commonly used to facilitate communication between foreign patients and clinicians, she explained that the information patients share with them can get curtailed or isn't as detailed for the sake of translation and time constraints.
A standardized resource like the code set explaining procedures in a way that's easy to understand, as well as in Spanish, will benefit facilities and practices across the board, according to Squires.
"This would standardize the language used across all facilities, which is a welcome thing," she told HealthLeaders. "The main issue will be whether or not facilities actually use them."
Squires also notes the importance of involving patients in the review process for the code set, adding a failure to do so would be "problematic."
'Goal No. 1 is to get CMS to step back, exercise their authority, and say we don't have to institute these cuts now,' says the president of the NAHC.
At this week’s U.S. Senate subcommittee hearing on the importance of home health, William A. Dombi, president of the National Association for Home Care and Hospice, and Carrie Edwards, RN, BSN, MHA, LSSGB, director of home care services for Mary Lanning Healthcare, were two of the five witnesses who testified in front of the subcommittee.
At issue was the Centers for Medicare & Medicaid’s proposed significant rate cut of 5.653% for 2024—a $870 million cut out of a $16 billion benefit.
HealthLeaders spoke with Dombi and Edwards ahead of the hearing about how home health and home care continue to struggle to provide the care their clients and patients need and how the rate cut would future exacerbate these struggles.
This transcript has been edited for brevity and clarity.
HealthLeaders: What are the main concerns the home health and home care sector are currently seeing?
William A. Dombi: The word that I'm hearing the most is survival. The providers of care are looking for ways to survive these challenges today. The issues are the workforce crisis and the aspect of payment rates.
We are also struggling with the continued growth in Medicare Advantage, which in most instances pays less than the cost of care.
The Centers for Medicare & Medicaid Services have enough leverage and power to be able to do that, and otherwise what they're trying to do is take advantage of the opportunities for innovative services, whether it be hospital-at-home care or use of technologies to supplement the in-person services.
You've got a tug of war between forward-looking opportunities and backward-looking regulatory actions on payment rates and in the middle of that is, where do you find the staff? It's a combination of are there people to do it and do you have the financial capabilities to get this perspective candidate to say yes, or for current workers to stay onboard.
HL: Carrie, do you think Medicaid will eventually extend its coverage to home care services? If so, how would this remedy some issues in that setting?
Carrie Edwards: In some states the Medicaid program does pay for caregiving and in others it doesn't. My agency provides home health services, covered by Medicare, and then we also do home and community-based care through Medicaid.
People want to stay at home while they're aging and the home health Medicare benefit allows our agency to provide skilled nursing care to keep them at home, and we teach the patients and families to care for themselves at home. Then, if they did need ongoing care after the Medicare benefit ended for that patient with goals met, they could transition to that other side if they had Medicaid services.
There have been efforts over the years to have Medicare take on long-term care but it's failed time and time again because of the cost.
I think the states would love to see Medicare take over the realm of long-term care from Medicaid for a couple of reasons. One is that the states are paying a good portion of the cost of Medicaid, but the other is that people qualify for Medicaid only after they've been hospitalized.
People who are destitute or near destitute from absorbing healthcare costs, it just seems an unfair thing to do, particularly in the last decade of people's lives. But the politics and the financing of it have been tried and so far, have not made it across the finish line to get Medicare to pay for that kind of service.
By 2030, I'm hoping there's enough home health and home care agencies still around. If there's continued Medicare cuts or decreases to Medicaid funding, there's going to be more closures.
HL: If there aren't enough healthcare workers to accommodate the growing demand for these services, how are patients expected to get the care they need?
Dombi: The demand is there for the service among the public, and clinicians see the value of healthcare services at home, and it saves spending, but the buyer, Medicare and/or Medicaid at times, and others either don't have the financing to do it, or don't want to acquire the financing to cover those kinds of costs.
It is a challenge that this country is facing with Medicare and Medicaid. It's a challenge countries all across the globe are facing, too, as we see Europe, Japan, and China aging as well. As someone who is aging himself, I'm concerned personally about where things will be by 2030. Medicare is at risk of bankruptcy even before 2030.
HL: What is it that CMS is hoping to accomplish with the cuts, despite struggles providers are facing because of them?
Dombi: In this case, the cuts are not coming because Congress is saying cut. Congress said a transition from one payment model to another must be budget neutral.
Home health providers and home care agencies agree, we just don't believe CMS has implemented them in a budget-neutral fashion, meaning the amount of money spent today is less than the amount of money spent on care under the old payment model. That does not comply with the laws of Congress.
That's why this hearing is being held, to figure out a way to deliver what they think is necessary care, but to do so has been complicated by CMS' actions. Congress can't simply say, “Well, let's just stop the cuts,” because the Congressional Budget Office will look at that and say, ”How are you going to pay for that?”
What we really need is for Congress to tell CMS to do its job correctly. We're hoping for that kind of action out of Congress and there is legislation pending that would stop the cuts, too.
HL: How informed do you think legislators are about the issues home health and home care are facing?
Dombi: I'll offer this respectfully to Congress: their hands are in too many different subject areas for them to have the depth of knowledge that Carrie has or that I might have. We can't expect them to. At the same time, they're quick learners.
It's clear that home health is not just less costly than a day's stay in an alternative care setting, but studies for several years now have shown that it saves money by preventing people's condition from getting worse and being hospitalized at a huge cost.
In fact, Medicare's invested in a program called home health value-based purchasing, but I would imagine if you were to ask members of this committee who will be holding the hearing, “What does HHVBP stand for?” you would be hard pressed to find someone who knows. So, we're going to tell them about it.
HL: Carrie, how do you plan to use your perspective and knowledge from being in the field to paint a picture for the committee?
Edwards: By sharing my personal experience with my home health and home care agency that was at risk of foreclosure earlier this year. We've been working hard and have made significant changes to stay open at this point. That's why I hope they don't have further cuts, because I know we will probably close if they do go through.
We used to serve 13 counties in our part of rural Nebraska, which was about 42,000 Medicare beneficiaries. Now we serve one county and about 7,000 Medicare beneficiaries. A lot of those previous 13 counties don't have other any other options for care.
Staff have left because they were fearful of the agency closing. We're not replacing those positions, so with less staff we're trying to take care of the clients and patients we can.
We've had to turn down referrals, some of which we previously serviced, but live in those outlying counties that we no longer serve. This year to date we've turned away 55 referrals.
HL: What outcomes are you hoping will come from your testimony?
Dombi: Goal No. 1 is to get CMS to step back, exercise their authority, and say we don't have to institute these cuts now to give us some breathing room to find more long-term solutions.
There are issues out there and what Carrie told you can be extrapolated nationwide. The data shows that over the last five to six years, half a million fewer Medicare beneficiaries are accessing home health services.
There's a Medicare-eligible population that wants home health services and we have gone from 3.5 million Medicare beneficiaries using home health in a year, to 3 million beneficiaries now. Half a million people are either in higher cost settings or they're trying to deal with their healthcare needs without support.
Edwards: We just want to be able to take care of the patients in their home, the ones that need it.
Dombi: The truth is that we've been through this before in the late 1990s.
The payment model was changed, and they instituted something called the interim payment system. Fewer Medicaid beneficiaries received services, 40% of home health agencies closed, and spending on the Medicare skilled nursing facility benefit went up from $11 billion a year to $24 billion a year. Right now, it's at $27 billion.
We're spending nearly twice as much on skilled nursing facilities for less than half of the population of people receiving care.
Some people need a skilled nursing facility, and they can't be safely cared for at home, but to see this happen before and on the verge of it happening again, sometimes it takes the sky falling and crashing on the ground before Congress acts.
We're hoping to prevent that from happening this time around.
Editor's note: This story was updated at 5pm on September 21, 2023.
The proposed federal mandate has been largely opposed, and state mandates haven't fared much better.
The proposed federal staffing mandate has been hanging like a dark cloud over the nursing home sector. Providers, who are already struggling to maintain staff amid a workforce crisis and financial strain, are largely against the mandate, many going so far as to advocate to their local and federal legislators against it.
The standards of the staffing mandate were released September 1, and are notably more strict than current states’ mandates. While there hasn't been a decision made yet, with the workforce crisis and funding struggles, there doesn't seem to be a silver lining for nursing homes.
Here are some previous HealthLeaders stories that detail how the sector has reached this point, the issues providers are struggling with, and how some states are currently managing their own staffing mandates.
Nursing homes saw a substantial portion of its workforce leave during the pandemic, and continue to struggle to recruit and retain workers. Additionally, the Medicare reimbursements that fund these facilities often don't cover the full cost of residents’ care, putting even more strain on their resources.
Facilities would need to hire over 191,000 nurses and nurse aides, estimated to cost $11.3 billion annually, to accommodate the minimum staffing mandate proposed by the Biden administration, according to a report by CliftonLarsonAllen LLP, an accounting and consulting firm.
At the time of the report's release, skilled nursing facilities were unable to accept new residents and concerned about potentially having to shut down due to the workforce crisis and increasing operating costs.
In July, the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) sent a letter to the president with their suggestions on how improve the long-term care space. The suggestions included adding a customer satisfaction rating to the Five-Star rating system and Care Compare data, along with making efforts to supply, attract, and retain workers to long-term care by leveraging federal, state, and academic entities.
Since the state implemented its own staffing mandate in January 2022, New York nursing homes continue to struggle to hire staff, particularly due to the state's low Medicaid reimbursement rates. Until 2023, facilities had seen only a 1% rate increase, forcing facilities to lower their occupancy to maintain operations.
The state of Pennsylvania implemented its staffing mandate in July, with the state's nursing homes negotiating with legislators on the minimum staffing requirements in exchange for a $300 million increase in Medicaid funding.
Notably, many of Pennsylvania's nursing homes are having to turn away hospital transfers, causing an increase in the average length of a hospital stay, which is already costly.
The COO of Caring Senior Service shares how incentivizing career development has been a successful way to keep caregivers from leaving.
Private duty agencies are struggling to retain workers once they've been hired. A recent report found that 57% of caregivers quit within the first 90 days. Caregiver wages are typically low, many work several jobs at different franchises to make enough income, and career development opportunities are not always available.
Jeff Bevis, chief operating officer at Caring Senior Service, a private duty franchise, shares how he is working to retain his caregivers through a career development rewards program.
Caring Senior Service launched its Caring Rewards program to incentivize and reward caregivers for completing training modules and being actively involved in their work. The points earned from completing each module can be redeemed in an online store of over 10,000 items. But better yet, this program helps caregivers to advance in their skills and wages.
HealthLeaders spoke with Jeff Bevis to learn more.
The following transcript has been edited for brevity and clarity.
HealthLeaders: How was Caring Rewards developed?
Jeff Bevis: A lot of us in the home care space have a learning management system or at least an online learning platform. What we do is marry the reward system to the LMS modules and try to incentivize and reward the caregiver for taking additional training.
What caregivers have been telling us in the industry for years and years is that they want more training, they want more structure, they want more professional development.
HL: How do you think the program is developing quality caregivers?
Bevis: A big piece of Caring Rewards is our GreatCare operating platform. The GreatCare Method is built around what Caring Rewards is all about: trying to make sure that we maintain a high level of onboarding and experience with our caregivers. We're giving them tools to enable active involvement much better or to a higher level than what you see in the rest of the industry.
Because they're caregivers with enhanced training, are more actively involved, and have better tools, we're able to deliver a higher quality of care or higher level of service.
HL: How does the program work?
Bevis: Let's say I'm a caregiver that is hired by a Caring Senior Service office. I'll complete my onboarding and orientation before I ever go out into the field to serve a client. The training is explaining and showing me that we have certified, advanced, and master-level certification if I have aspirations of additional training, professional development, or want to learn more to enhance my overall skills.
We make that clear up front so that caregivers take advantage of it right away, and because it sets us apart … in the industry.
Bevis continues with his example: As I continue to serve clients with Caring Senior Service, I decide that I want to participate in opportunities to learn more. My care manager can start assigning me online modules in our learning management system and for each of those that I take, I earn Caring Reward points. In addition, for each of those that I take, I'm working up to GreatCare Certified Level One.
Once I achieve that, I continue to take courses, all online, and I can become GreatCare Advanced Level, and then Master Level. Not only does that enhance the level of training, but it also drives a higher hourly wage for me.
Already we've seen in the last several years that it can even lead to becoming a manager in the office. About a third of our managers, nationwide, started as caregivers with us, so they've seen the benefit of this type of program.
HL: Tell me about the modules that caregivers can take.
Bevis: [The modules start with basics]: what's the difference between companion care services and personal care services, how to transfer someone effectively, etc. This will also vary by states because they have different training requirements.
We have courses for meal preparation, cooking, how to clean a house effectively, what to provide when we take someone to a physician's appointment. The memory care side is even more specialized to make sure that the caregiver is properly trained in helping people with dementia.
HL: What kinds of rewards can caregivers redeem their points for?
Bevis: There's all kinds of retail merchandise. We've accessed an outside third party and [the caregivers] redeem for furniture, sporting goods, clothing, household goods.
HL: How does the program affect employee turnover within the first 90 days?
Bevis: From a metric standpoint, the first 90 days is pivotal for turnover. Our system turnover is just under 41% right now, and the latest industry benchmarking report had the industry at 77.1%. We're better than the industry number by quite a bit, but in the first 90 days, our caregiver turnover runs about 27%
HL: Considering the national turnover rate, how important is it for agencies to invest in their caregivers in similar ways to equip them with the tools that they need from day one?
Bevis: I've been tracking caregiver turnover and retention for the last 20 years. It's always been kind of a ticking time bomb to home care brands. I don't think we pay enough attention to it as an industry, quite honestly.
That's why [Caring Senior Service pays] even more attention to that. We think that's the metric that measures the effectiveness of Caring Rewards and the GreatCare offering, as well as just the retention rates. We've had over 1,000 caregivers redeem their Caring Reward points.
Students are paid for the time they spend training and getting hands-on experience in Loretto facilities.
As the largest regional long-term care provider in their area, the Loretto, a nonprofit organization of skilled nursing, memory care, and assisted living facilities that has served the central New York community for almost 100 years, has felt the pressure of the current workforce crisis.
Now, the Loretto is taking matters into its own hands. By expanding its paid training program, the organization is creating a pipeline of talent for its facilities and introducing individuals to career pathways within healthcare.
HealthLeaders spoke with Loretto's chief marketing and engagement officer, Julie Sheedy, and chief people officer, Nancy Williams about how the organization has approached the workforce crisis, its training program, and how other nursing home providers can implement similar programs.
The following transcript has been edited for brevity and clarity.
HealthLeaders: How has the program alleviated the strain of the workforce crisis on the organization and its facilities?
Julie Sheedy: With the shortage, hospitals are trying to hang on to the staff that they have. We have made a significant commitment to training programs and are the only provider in this area that provides both certified nurse aide (CNA) and home health aide trainings. We also have the first federally recognized and approved licensed practical nurse (LPN) apprentice program in New York state.
That speaks to the commitment that Loretto has made to grow our own, and we've had success with that, which has perpetuated our expansion into Cuba County.
HL: When did the organization decide to try and find its own solution to the workforce crisis?
Sheedy: We've had the program in the Syracuse area and Onondaga County for several years based on a successful model called Health Train, to try to provide healthcare career pathways. We established our own certified nurse aide training program in Syracuse, and we now train on average, over 100 individuals a year through that program.
Loretto was asked to step in and assume responsibility for a large skilled nursing facility in Auburn, New York in Cayuga County, which is a very different market and very hard to recruit in. It's a much more rural community and it's surrounded by a lot of farmland, so it's even more difficult to find qualified individuals in that market.
As we continue to assess the challenges we're facing with staffing, we recognize the value of our training program here and started to take steps to do that which starts with building a plan and getting state approval.
We also needed to make sure we had the space available to train and educators available, so we also had some changes in that facility which freed up space that was repurposed into a classroom which was a benefit as well.
We have a class running every month and that's where the 100 average comes from, and then we just had our first inaugural class graduate in Auburn, with six individuals.
We've got a little bit of a slower roll there in Auburn. We have one educator, and we also have to meet mandatory state requirements for a teacher-to-student ratio.
HL: Are the students completing the program with the promise of employment after?
Nancy Williams: Students go through the five-week program, and they get great hands-on experience through it. It takes them through to the preparation for sitting for the New York state examination. Once they've successfully completed that exam, they're able to work and function as certified nursing assistants and they're able to have full employment at Loretto, along with benefits.
The intent is to provide a great level of support to them through the program. There's also the benefit of it being an earn-as-you-learn program, so there's that support that comes along with it as well.
Then at the end of the educational experience, they're working as CNAs within our facilities.
Sheedy: Loretto is paying them to be trained so they become an official employee of Loretto when they're accepted into the class. They're paid a wage while they're in that class.
HL: What does the training consist of as far as modules?
Williams: The first couple of weeks is classroom learning and training, and then they have clinical training that occurs in the Loretto units. They're with our staff and residents gaining hands-on experience and honing the skills that they've learned over those first few weeks as they get started.
Then as they get to the tail-end of the program, it includes comprehensive reviews of their skills that they've learned and different types of mock testing to prepare them for the state CNA exam that they'll be sitting for.
We've been doing this for a long time at our Syracuse site, so with the expansion to the Auburn site and Cuba County, we have this successful template to draw from. They mirror one another and take a comprehensive approach to prepare the students to be successful when they sit for their exam and then when they're taking care of our community members thereafter.
HL: How important is it for organizations to make the effort to address the workforce crisis as they wait for more to be done at the state or federal levels?
Williams: We know from the success that we've had with the investment of our career paths for our employees that it's important for us to be growing our own, especially in the face of the nursing and healthcare staffing shortage.
The pandemic added many layers of complexity to that and we're going to continue to face the impacts of the staffing shortage as we move toward the future.
It will be great as other things come into play to provide support for us as an organization and for healthcare in general, but we find it to be very important for us to be proactive and investing in the careers and the learning and development of our employees, and we know that this is important to them, both professionally and personally.
Sheedy: Loretto has several successful partnerships in this community. We've been talking to our community college recently about how to support them in growing some nontraditional career pathways through their programs.
One of the challenges that this industry faces is the lack of available educators, so the more that we can do collaboratively to share resources and offer opportunities to our community, the better. We're trying to do that all the time by working with different organizations.
HL: What are some steps other organizations should take to implement similar training programs?
Sheedy: For peers and leaders, a place to start is to understand what the regulations are in your state.
When we wanted to expand into Auburn, we put together a plan and put it in front of our State Department of Health to get approval. Learn about the regulatory requirements for being an educational provider versus a healthcare provider.
You also need to understand what resources are available to you, either within your organization or your community, to find qualified educators that meet the requirements. There are specific requirements to offer this type of training in the post-acute market. Also look at that model of paying a wage while they're training because that is an incentive for the population that we're recruiting.
For many of these individuals, this is their first exposure to healthcare. They might have had a family member or a loved one in healthcare, but now they're looking at a professional path into employment and career development.
Williams: We have a union environment here within our organization, so make sure to work collaboratively with your union representatives and ensure that they have a say and that you're including all the stakeholders that need to be involved in the process.
Sheedy: You should also have a student profile criterion for who should be in these training programs. Part of the key to success is that these individuals are prepared to be in a learning environment and that they can meet the criteria to be in the program, to commit to the class and the hours, have transportation, and other things to ensure their success.
The proposed staffing minimum exceeds the existing standards in most states.
The Centers for Medicare & Medicaid Services' newly released proposed rule for minimum staffing standards for the nation's nursing homes could further exacerbate the long-term sector's workforce struggles.
Meant to be the Biden Administration's ongoing solution for nursing home quality, the Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Report has raised concerns among the post-acute sector as a "one-size-fits-all" approach that would not guarantee quality care and could negatively affect operations.
Under the proposed rule, it requires nursing homes to implement specific nurse staffing levels to provide care for residents:
Facilities would be required to provide a minimum of 0.55 hours of care from a registered nurse (RN) each day
Another 2.45 hours of care from a nurse aide, per resident per day (PPD)
CMS has noted that these standards are higher than existing standards in almost every state, and it will mean that 75% of nursing homes will have to strengthen their current staffing. It has been estimated by critics of this proposal that the costs for raising staff levels will be in the billions.
For skilled nursing facility administrators who are already experiencing workforce shortages and recruitment and retention challenges, this standard could cause undue burden for the nation's nursing homes. Administrators will have to find ways to squeeze money from already tight operational budgets to hire nurses or find alternative means of funding. Finding and hiring nurses post-pandemic is also a difficulty as many nurses retired or left the nursing profession altogether. Not having enough staff could also mean nursing homes would have to shut down their operations.
CMS attempts to resolve these issues in a few ways. To support staffing, CMS also announced a nationwide campaign that is designed to create better career access for those interested in pursuing a nursing position in long-term care. CMS, working alongside the Health and Human Services Workforce Initiative and Department of Labor, will invest $75 million in financial incentives, including scholarships and tuition reimbursement.
Also, recognizing that the staffing minimum may be more difficult for facilities in rural and underserved community, CMS said it would take these difficulties into consideration through "staggered implementation and exceptions processes."
Paying post-acute nurses and nurse aides a competitive wage is also an issue. Direct care workers in nursing homes are vastly underpaid for the type of work they do.
CMS responded to this pain point by proposing in the rule that states will be required to collect, report on, and publish their compensation as a percentage of Medicaid payments for those who working in skilled nursing or intermediate care facilities.
Publishing the compensation of direct care workers is one step toward addressing their pay inequity, but it will require actual policy change or action from Medicaid to see results.
With the criticism that the proposed rule is “unfounded, unfunded, and unrealistic,” the nation’s long-term care administrators will be closely following how CMS listens and responds to their concerns about staffing minimums and if it truly is the answer to bettering the quality of nursing homes.
Editor's note: This article was updated on September 13, 2023.
Improving pay and working conditions will go further in staffing home healthcare, expert says.
At the beginning of the year, many in healthcare were looking to foreign healthcare workers as a potential solution to the nation's workforce crisis, particularly for the post-acute care sector.
That initiative was upended last spring when the U.S. State Department announced a green card freeze, which allowed only green card petitions filed earlier than June 2022 to proceed to the interview stage.
Squires spoke with HealthLeaders about how the workforce crisis can be alleviated, instead, by addressing low wages, reimbursement structures, and lack of accountability at the managerial and executive levels.
The following transcript has been edited for clarity and brevity.
HealthLeaders: When did you first hear about the idea of using foreign healthcare workers to alleviate the workforce crisis?
Alison Squires: When I first started as a nurse in the mid-90s to early 2000s, it was very commonplace.
In the U.S., we have been recruiting internationally educated nurses for many years. It made a lot of people a lot of money from 2000 to 2008. But then the global economic crash hit, and what the U.S. started doing was fix its own production issues. We graduate a significant number of nurses every year thanks to that.
After that, the conversation around internationally educated nurses sort of died down. When the pandemic hit, we knew that it was going to have devastating effects on the healthcare workforce. For some people, that was going to be leaving the profession or their bedside role, and for others that meant that they might be leaving their countries to go work elsewhere.
My argument is that it will solve a part of the shortage, but when we look at the overall vacancy rate and the number of nurses who pass clinicals and are able to get a working permit to be able to come to the U.S. to work, that number is phenomenally small and doesn't address the core issue around retention.
The assumption is the internationally educated nurses will stay working for a long time in this one place and the reality is they will probably stay for two years and then they'll move on to a different place to practice.
HL: What should providers and executives look for within their own organizations to address the workforce crisis?
Squires: To be fair, home healthcare nurses should get paid more. They don't get paid at the level that they should, given the complexity of the patients that they're dealing with.
There's both a need for home healthcare agencies to lessen their administrative roles and pass some of that money on to nurses.
Home health could be an attractive place for people to work, especially experienced nurses from the hospital setting.
Accountability in terms of addressing the issues in the sector that dissuade people from wanting to work in it is just not there. The federal government could also do better with reimbursement for home care services, but it should make that reimbursement conditional on the home care agencies shifting those funds to hiring more nurses.
HL: During the pandemic, we saw the biggest exodus of workers leaving their roles in the post-acute care sector. With more workers leaving acute care and hospital settings, how can post-acute attempt to draw them in?
Squires: With home healthcare you have more autonomy and flexibility with your schedule.
It would be less intense than the acute care environment these days, which is incredibly intense. I hear about it from my former students that are currently working as staff nurses, and it's just a completely different animal compared to when I started working, even compared to when I left in 2008.
With home health, you're also able to foster a better connection with the patient than you would in an acute-care setting. It's a different kind of patient, and I think people who need a break from the intensity of the hospital environment would be drawn to these settings.
HL: Do you think there's a degree of separation between organizations who do or don't have clinicians in the upper and C-suite levels of their organization’s leadership?
Squires: It depends. The old school thinking is “great clinicians make great managers,” which is not really the case.
In terms of organizational leadership, management is how well you deal with people, but also how well you understand your industry. In the U.S., the reimbursement systems are the things that drive how many people you can hire, or how many residents and clients you can take on.
Where I think the failure happens is that even though it's a people-centered industry, healthcare sometimes forgets about the people who are involved. Nurses are notoriously left out of decision-making across all levels in a lot of organizations, and they're the ones who could tell you how to fix the system issues.
They live the system. They know how to work around the system. They're masters at it.
The county partnered with Rowan College of South Jersey and Rowan University for the grant-funded training program.
In Gloucester County, New Jersey, where there are over 1,000 roles available for certified nurse aides (CNAs) alone, the county's board of commissioners has partnered with Rowan College of South Jersey (RCSJ) and Rowan University to launch a program to train CNAs and licensed practical nurses (LPNs) at no cost.
"Through extensive conversation with our nursing home administration coming out of a post-COVIDworld, staffing shortages have had a major impact on us," Gloucester County Commissioner Jim Jefferson told HealthLeaders.
In the past, hospital systems would hire only four-year graduate BSNs, which made two-year RNs, LPNs, and CNAs readily available to work in nursing homes, he explained. Now, with hospital systems once again hiring two-year RNs, LPNs, and CNAs, all areas of healthcare are struggling to hire.
This program enables the county to develop its own talent pipeline, while also introducing residents to a career pathway in healthcare.
"CNAs are the backbone of a nursing home, and our county college, RCSJ, trains them. By engaging our county administration with our nursing home administration, workforce development, and our county college, we were able to utilize grant-funding opportunities for those who qualify."
The program is free with the promise of employment for students after satisfactory completion.
The county's hope for the program is that it will stabilize its nursing home workforce—and they're beginning to see results, according to Jefferson. With the recent graduating class, the county was able to increase nursing home capacity by 32 residents to 48.
"In a nursing facility, staffing ratios for care is everything," he said. "Lack of staff translates into lack of availability to place residents."
Jefferson predicts that they should be able to reach full capacity—60 residents—once the next cohort of students graduates.
'I'm not sure if what future generations are going to need in terms of senior care is the same as what my grandparents needed.'
If you ask Adrienne Green, MD, it's natural that she's found herself at an organization like the San Francisco Campus for Jewish Living.
Prior to joining the organization, the recently appointed CEO served as the chief medical officer for the University of California San Francsico Medical Center. Early in her career, she worked in skilled nursing, and later as a hospitalist, working often with elderly patients.
HealthLeaders spoke to Green about her journey with organization, her goals as CEO, and what the future holds for post-acute services like skilled nursing facilities.
The following transcript has been edited for clarity and brevity.
HealthLeaders: Prior to becoming CEO, you served as a trustee for the Campus for Jewish Living. How did you initially get involved with the organization?
Adrienne Green: I've always held this organization in high regard. For many years it was referred to as the Jewish Home and, while I was working with the hospital, we sent many patients here and I had the opportunity to work with them often.
I'd been out to the campus on a couple of visits and worked with some of the team on some collaborative programs, and it was through those collaborations that people got to know me and invited me to join the board in 2019.
My time on the board was clouded by COVID, so I had a slightly different board experience than others. What I brought to the board, though, was a clinical perspective, the ability to think about new clinical programs and partnerships, and a framework for how the organization could think about quality and ensure they were providing high-quality care.
Those are things that I get to continue doing as CEO.
HL: What are other goals you hope to accomplish as CEO?
Green: In my mind, the first order of business is to provide stability for the organization. We need a stable staff to ensure that we live up to our reputation of providing the highest quality care for seniors.
After this stabilization phase, we get to do the fun work of doing some strategic planning and thinking about our community needs and wants for the future. We've got a 152-year-old organization with an amazing reputation in the community. I want to sustain that and innovate to make sure that the organization continues that reputation and thrives.
I'm not sure if what future generations are going to need in terms of senior care is the same as what my grandparents needed. For example, more people are going to be cared for in their homes, and there may be less demand for the typical long-term care nursing home. We will still need it, but maybe we need less of that and more that happens in the home.
There are patients coming out of our hospitals that are far more complex than they were 25 years ago, so making sure that our short-term skilled nursing services can provide care for those patients, and that we have the skill sets we need to care for these very complicated patients is another important challenge for us.
Technology will also come into play somewhere in terms of eldercare. I'm not quite sure how it fits yet, but I want to make sure that we're thinking about that as we're thinking about what our organization looks like for the future.
HL: How important is it for post-acute services like skilled nursing to be elevated or emphasized for the public?
Green: Most people wait until it's too late to start thinking about it. With the baby boomer generation coming of age, we are going need to be able to, first, accommodate the volume of elders who need a wide array of care.
Some of that care lies in our traditional models of long-term care in the skilled nursing setting, the short-term care with the increased complexity that I mentioned. We also need to think about the different models we might need.
I know people are already electing to age at home and engage either family or caregivers to allow them to be at home at the end of their life. We need to think about what that looks like and how some of our traditional skilled nursing facilities might interface with that.
The other piece is senior living communities—whether they have independent care, assisted living, more advanced memory care, or hospice services—and how it will accommodate the growing number of elders.
HL: Post-acute providers are struggling to recruit young healthcare professionals due to lack of interest or bias with working with the elderly. What would you say to change their minds or offer a different perspective?
Green: This isn't the most glamorous area of healthcare, but it's necessary. It's incredibly rewarding hearing patients’ and residents’ stories. Providing the respectful, dignified care that they deserve at this critical time in their lives is really a privilege.
While full-time work in this area isn't for everyone, I highly encourage health professionals across all disciplines to, at a minimum, get some experience and spend some time in nursing homes or observing home visits with a home health nurse, so that they can at least understand the environment and what their elderly patients might need, as well as advocating for what they need.
There will be a handful of people who make this their everyday life, but I hope that from an educational perspective, we can encourage students and training programs to make sure that there are training opportunities in this environment.
