Nursing home staffing levels have not been so low since 1994.
Year-end data from the Bureau of Labor Statistics (BLS) showed that over the course of the pandemic, nursing homes lost 210,000 jobs. As the hardest hit healthcare sector, nursing homes are still struggling with recruiting and maintaining their workforce.
The data further illuminates the healthcare workforce shortage's impact on the sector. Further analysis of the BLS data by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) found that nursing home workforce levels haven't been so low seen since 1994.
While facilities added an average of 3,700 jobs per month over the last nine months, it's expected that at its current pace, nursing homes won't return to pre-pandemic levels until 2027. A previous AHCA/NCAL estimate anticipated the sector recovering by 2026.
"The data doesn't lie. This is not just an exaggerated call for help, and this labor crisis will not go away on its own or through government enforcement," Mark Parkinson, president and CEO of AHCA/NCAL, said in a statement.
"Our nursing homes are struggling to recruit caregivers, and if we do not get meaningful assistance soon, then the consequence will be hundreds of thousands of seniors displaced."
The LTC sector's staffing shortages have forced nursing homes to limit admissions, and hospitals are backlogged with patients ready to be discharged and moved to a facility. In more severe cases, some nursing homes have been forced to close permanently.
While the situation requires immediate support, analysis by AHCA/NCAL suggests long-term investments and programs are needed to help the sector recover. Action from policymakers is needed to alleviate financial challenges as well. Many facilities struggle to cover the cost of care to their residents because of low Medicaid reimbursement rates.
To attract talent, facilities have also begun offering increased wages and bonuses, but with little success. The Biden administration is currently considering implementing a staffing minimum, but without the proper resources it could only worsen the sector's workforce crisis.
Skilled nursing facilities have relied on the staffing flexibilities allowed by the PHE, but what happens after they expire?
President Biden's announcement this week that the public health emergency (PHE) declaration for COVID-19 will end on May 11, may give skilled nursing facilities (SNF) cause for concern that their staffing needs won't be met before the PHE expiration.
The PHE had been renewed last month and was set to end in April, so the May date gives SNFs a little more time.
However, Katie Smith Sloan, president and CEO of LeadingAge, the association of nonprofit providers of aging services, said in a statement, "While we appreciate the administration giving our mission-driven, nonprofit providers some time to plan, our members are severely outstretched and now face a new landscape of funding and rules while simply trying to survive."
Sloan added that outside of staffing waivers and flexibilities afforded by the PHE, there are also questions about policies and how the Biden administration will navigate a "true post-COVID country."
The pandemic caused many challenges to the healthcare sector, with SNFs being impacted the most. After intense media scrutiny at the height of the pandemic, the sector-wide labor shortage has nursing homes across the country struggling to maintain recruit and maintain staff.
A spokesperson for the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) spoke to HealthLeaders about the PHE ending.
"The resources the Public Health Emergency provided were crucial, especially as the pandemic exacerbated the labor shortage and economic crisis," they said. "Providers are now dealing with skyrocketing labor costs to attract workers and soaring inflation."
According to the spokesperson, Medicaid underfunding has always made it difficult for nursing homes to invest in their staff and services and maintain efficient operations. In its May 2021 reform agenda, AHCA/NCAL outlined funding strategies to help improve the sector. One suggestion was that reimbursement rates be updated regularly to keep up with inflation.
While the temporary nurse aid (TNA) waiver program provided some relief to nursing homes, allowing TNAs to work beyond four months with competency checks and training versus certification, the waiver expired in October 2022.
The Building America's Health Care Workforce Act, first introduced to Congress in May 2022 and reintroduced just last month, would extend PHE flexibilities by allowing TNAs to have on-the-job training count toward their certification to help bolster the workforce in nursing homes. In addition to preventing further job losses, the bill would protect seniors' access to care when the PHE ends.
"Hundreds of thousands of temporary nurse aides stepped up to serve vulnerable seniors during this global crisis, supporting residents with nonclinical tasks and offering companionship," the AHCA/NCAL spokesperson said.
"With many states unable to meet current training and testing demands, [the Building America's Health Care Workforce Act] will help temporary aides transition to permanent caregivers while continuing to serve their residents, supporting seniors' continuity of care."
Staffing mandates have been suggested as a remedy to the rural workforce shortage, but may actually further their financial strain.
Thirteen U.S. Senators sent a letter on January 20 to the Centers for Medicare & Medicaid Services (CMS), asking the agency to avoid implementing staffing mandates in nursing homes.
"We fear a one-size-fits-all staffing mandate would undermine access to care for patients, particularly in rural communities," the letter said. "Instead, we urge you to work with Congress and rural stakeholders on tailored solutions that address the severe workforce challenges in our states' underserved areas."
A historic workforce shortage has all areas of healthcare stretched to their operational limits, particularly facilities in rural communities. Staffing mandates have been proposed as one method to address the shortage, however, in the letter, the senators state that "strict staff-to-patient ratios and/or minimum hours per resident day requirements may not reflect optimal staffing levels given differences in patients' needs and underlying conditions."
As the hardest hit facilities of healthcare during the pandemic, nursing homes are struggling to recover from the impact. In the letter, the Senators ask CMS to be flexible with providers and their workforce recruitment and retention efforts, expressing a commitment to working together.
"We stand ready to work with your agency on proposals to improve long-term care for patients," the letter stated. "The best way to accomplish this goal is working with Congress and stakeholders to ensure any future actions do not further exacerbate the serious challenges already facing facilities in rural America."
The senators who authored the letter are: John Barrasso (R-WY), Jon Tester (D-MT), Steve Daines (R-MT), John Hickenlooper (D-CO), John Thune (R-SD), Gary Peters (D-MI), Joe Manchin (D-WV), Deb Fischer (R-NE), Kyrsten Sinema (I-AZ), John Hoeven (R-ND), Cynthia Lummis (R-WY), and Mike Rounds (R-SD).
The bill would enhance funding for home care and expand access to services.
Senators Bob Casey (D-PA) and Debbie Dingell (D-MI-6) introduced the Better Care Better Jobs Act this week to expand access to home and community-based services for older adults, individuals with disabilities, and injured workers, and to improve pay and benefits for caregivers.
"I was lucky to have my husband John receive care at home, which showed me the significant fractures in this system, from low wages for workers to … so many people not knowing how to get the care they desperately need," Dingell said in a statement.
The pandemic highlighted many Americans' preference to receive care or "age in place" in the comfort of their home. However, states only provide coverage for some home care services, creating significant gaps for some individuals due to eligibility and benefits standards.
According to a release on the details of the bill, home care workers earn a median wage of $13 per hour, with few or no benefits, and about 18% of them live in poverty, which contributes to the sector's high turnover rates.
"The Better Care Better Jobs Act is a generational investment in home care," Casey, who also serves as chairman of the U.S. Senate Special Committee on Aging, said in a statement. "It's about both caring for our loved ones and making the smart economic choice for families and communities across all levels of the government to strengthen this workforce," he said.
"This is not a Democrat or Republican issue. It's an American issue."
Some key objectives of the Better Care Better Jobs Act include:
States will receive a permanent 10% increase in Medicaid match funding for delivering Medicaid home and community-based services by strengthening and expanding access to them and their workforce
Encourage innovative models that benefit direct care workers and care recipients
Support quality and accountability
Facilitate state planning
Permanent spousal impoverishment protections
Make the Money Follows the Person Rebalancing Demonstration permanent
Bevis spoke with HealthLeaders about the importance of technology and the role branding and messaging plays in private duty marketing.
Caring Senior Service recently announced that Jeff Bevis joined the private duty organization as its chief operating officer. With almost 20 years of experience in the sector, and 10 more in franchise operations, Bevis has a track record for building successful brands. HealthLeaders talks to him about the importance of technology, recruiting the right franchise owners, and private duty agency branding.
HealthLeaders: What from your operational experience did you bring with you to Caring Senior Service?
Jeff Bevis: The power of data, the importance of data in the industry. Brands, operations, and franchise owners, they need to better leverage the data they have or put more importance on it.
From a quality and service standpoint, I continue to be a big believer that we need to get the industry to where we have a JD Power index of satisfaction for clients as well as for caregivers. We've done a pretty good job in the industry over the last several years trying to raise the importance of caregiver satisfaction and employee satisfaction management, but I think we still lag as it relates to client and patient satisfaction.
HL: What are ways you anticipate technology and the use of data coming to the forefront for the private duty sector?
Bevis: I think it's pushing a couple of things for us as an industry, leveraging technology as it relates to staffing or augmenting the staffing challenges. We're all aware that we can't seem to recruit enough quality staff members fast enough. Whether it's through telehealth or remote patient monitoring or other ways we can use technology when we have a staffing shortage or when they're [working] around the clock.
I also think [we can expect changes in] the use of technology as it relates to trying to deliver more services into the home. One example would be using a tablet-based platform and having apps or services on the tablet that the client or client's family could tap into that would increase their quality of life, overall service delivery, or their needs for different services. I don't think we're there yet, but I think we need to work on delivering more services into the home using technology and I'm just thinking that a tablet-based platform is going to be key to being able to do that.
In our case here at Caring, one of the big draws is working alongside the founder, Jeff Salter, and elevating this brand, as we already have a tablet-based platform. We've had it in place since 2015, and I think that's kind of a best-kept secret in the whole industry, because when I built FirstLight with my son, we had 200 iPads out in the field as a test. We thought we were trailblazers in the home care world and that was the first true tablet platform that was out in the field and turns out that we were doing that at Caring years ago.
HL: How important is branding and messaging for agencies?
Bevis: I think, unfortunately, most of the brands in our space have not established themselves as a solid brand. They don't have quality metrics to measure awareness or market share, brand presence both online and locally. A lot goes into branding to do it well. I'm not saying all the home care brands have to be like Coke, but from a brand awareness standpoint, I think that's one of the big differentiators that you see in the franchising world.
You see probably a small handful of home care franchises that get it; they focus on branding, they're consistent in messaging. Most of those are the larger networks, so they have multimillion dollar advertising funds and that's a big part of that branding position because it's not cheap. I think the larger networks are doing a good job of branding themselves in a dominant way in the home care franchising space. Everybody else, I think there's some room for improvement.
I don't think it's a matter of who has the largest checkbook. I do think there's some efficiency, some proactive branding steps that even smaller brands can take to look as big as the rest of the industry and to do a good job. I think a lot of it comes down to the messaging and content online, the online positioning of your services and your successes and your consistency in caring for your clients and having great caregiver retention numbers.
HL: How do you recruit franchise owners?
Bevis: The most successful brands are selective in their recruiting, so they're always looking for and marketing towards, in what's called the franchise development side of the business, the right fit of person with experience, background, working capital, culture, ethics, and integrity that matches what the brand is looking for. That, to me, is a big differentiation point.
In other franchise systems and businesses, there are some that have zero qualifications, so if anyone reaches out and says they want to be part of a franchise, some franchises will take that person. The better franchise systems, and this goes for home care because we provide such a personal service, have a well-defined qualification process. Their franchise development recruiting budget is well established, the criteria is consistent. That's also how you build stronger brands because your brand is only as strong as your weakest franchise.
To pay close attention to the criteria and qualifications, you're making sure you're bringing in strong candidates— strong franchise owners that meet your requirements [and] have the same vision, mission, focus as the franchise has. That makes a big difference.
Staffing mandates that have been proposed to remedy the workforce shortage may cause more financial problems for skilled nursing facilties.
Thirteen U.S. Senators sent a letter on January 20 to the Centers for Medicare & Medicaid Services (CMS), asking the agency to avoid implementing staffing mandates in nursing homes.
"We fear a one-size-fits-all staffing mandate would undermine access to care for patients, particularly in rural communities," the letter said. "Instead, we urge you to work with Congress and rural stakeholders on tailored solutions that address the severe workforce challenges in our states' underserved areas."
A historic workforce shortage has all areas of healthcare stretched to their operational limits, particularly facilities in rural communities. Staffing mandates have been proposed as one method to address the shortage, however, in the letter, the senators state that "strict staff-to-patient ratios and/or minimum hours per resident day requirements may not reflect optimal staffing levels given differences in patients' needs and underlying conditions."
As the hardest hit facilities of healthcare during the pandemic, nursing homes are struggling to recover from the impact. In the letter, the Senators ask CMS to be flexible with providers and their workforce recruitment and retention efforts, expressing a commitment to working together.
"We stand ready to work with your agency on proposals to improve long-term care for patients," the letter stated. "The best way to accomplish this goal is working with Congress and stakeholders to ensure any future actions do not further exacerbate the serious challenges already facing facilities in rural America."
The senators who authored the letter are: John Barrasso (R-WY), Jon Tester (D-MT), Steve Daines (R-MT), John Hickenlooper (D-CO), John Thune (R-SD), Gary Peters (D-MI), Joe Manchin (D-WV), Deb Fischer (R-NE), Kyrsten Sinema (I-AZ), John Hoeven (R-ND), Cynthia Lummis (R-WY), and Mike Rounds (R-SD).
LeadingAge, the nonprofit organization of aging services providers, has created Opening Doors to Aging Services to change public perception and the lack of understanding about post-acute services.
With older adults expected to make up 20% of the nation's population by 2030, the healthcare sector must prepare for the increasing demand of aging services. The sector must also inform and change public perceptions of aging services, says the director of public messaging for LeadingAge, Gwen Fitzgerald.
Research by LeadingAge, a community of nonprofit aging services providers, has found that the public lacks awareness about the full continuum of care services available to older adults and their families, meaning most U.S. adults think mostly of nursing homes when they think of aging services. To increase understanding of the breadth of aging services, the organization developed the Opening Doors to Aging Services initiative. This initiative offers original research, communications, and campaign resources that helps "reset the narrative" of aging services.
"LeadingAge members and other aging services professionals can access the research, strategies, and communications assets to introduce older adults and families to the array of aging services," Fitzgerald told HealthLeaders.
The initiative's assets are available to providers, agencies, and nursing homes free of charge.
According to an executive research summary authored by LeadingAge, public perceptions of aging services are mixed. Forty-five percent of Americans have a positive view of them, 20% have a negative view, and 35% don't know how they feel.
"That neutral opinion, in our view, is very positive in the aftermath of the early pandemic tidal wave of negative publicity," Fitzgerald said. "In fact, we see an opportunity to inform those who say they don't know, as well as the rest of the general public, about the quality care and services available while the spotlight remains focused on our field."
COVID-19 also had influence in the way aging services—particularly nursing homes—are viewed by the general population. In the first year of the pandemic, nursing homes were subjected to heavy media attention due to the high number of resident deaths and strict social distancing and lockdown guidelines.
However, she says providing authentic information about aging services can boost consumer awareness and confidence about aging services.
"No doubt the one-off, bad apple stories can raise concern for some consumers. But the Opening Doors research provides the road map to resetting the narrative," she continued "[Such as] telling authentic stories about aging services, especially about the quality care and services, the extraordinary professionals who commit themselves to older adults, and the enormous benefits aging services deliver to older adults."
Post-acute workers have an important role to play in helping with public perception and understanding.
"Aging services professionals have an important story to tell: that with extra help from aging services, older adults can keep contributing and enjoy a better life. … It is essential direct care professionals speak out and share the love of their chosen calling and how they make a difference in others' lives," said Fitzgerald.
The research executive summary concludes: "While [aging services are] not well-understood by the general public, the sector has potential for meaningful support, according to research." Through LeadingAge's research they listed five factors that already help the initiative's goal of changing understanding and perception of aging services:
Those who have experiences within the post-acute sector have had positive experiences
There is already admiration and support for those who work in the post-acute sector
The time is ripe for learning about aging services
The public expects policymakers to invest in and support aging services and the elderly population
Due to the growing elderly population, there is a spotlight on post-acute care, and the sector can showcase what it has to offer
To avoid paying employees proper overtime, the company lowered the employees' regular rates when employees worked over 40 hours in a week, paying overtime compensation according to those rates.
A consent judgment obtained by the U.S. Department of Labor is requiring TriMED HealthCare LLC to pay $1.9 million in back wages to 433 employees, including an equal amount in liquidated damages, and a civil money penalty of more than $180,000 for willful violations.
TriMED HealthCare provides home care services in Bucks, Montgomery, Northampton, Delaware, Chester, Lehigh, Philadelphia, and surrounding counties in Pennsylvania.
An investigation by the DOL's Wage and Hour Division found that TriMED HealthCare and its owner violated the Fair Labor Standards Act. To avoid paying employees proper overtime, the company lowered the employees' regular rates when employees worked over 40 hours in a week, paying overtime compensation according to those rates. In a press release statement, it explained, "By lowering the rates, the employer concealed the fact that they paid all hours as straight time."
The pay range for direct care employees at TriMED HealthCare is $7.25 to $14 an hour.
"This is a significant recovery of back wages and liquidated damages for people who typically work for low wages and often struggle to make ends meet," Principal Deputy Wage and Hour Administrator, Jessica Looman said in a statement. "Employers must understand that federal law requires them to respect workers' rights to be paid all of their earned wages, and that we will investigate those who fail to meet their obligations."
In addition to back wages, TriMED HealthCare will also have to pay an equal amount in liquidated damages to employees, along with a civil money penalty of $180,141 due to the "willful nature" of its violations. The Wage and Hour Division also found that employers paid some administrative employees straight time when they'd worked overtime, failed to pay direct care workers for travel between clients' homes, and didn't keep records as they're required to do.
"Employers who intentionally disregard the law and fail to pay workers their hard-earned wages will find that we will use every tool available, including enforcement actions in federal court, to hold them accountable," Seema Nanda, the department's solicitor of labor, said in a statement.
The California Attorney General alleges that Mariner Health Care Inc. violated California's Unfair Competition Law and False Advertising Law.
California Attorney General Rob Bonta secured a preliminary injunction against 19 skilled nursing facilities (SNF) under Mariner Health Care Inc. earlier this month. The facilities were found to have violated federal and state laws and regulations over five years.
Mariner Health Care is alleged to have violated the state's Unfair Competition Law and False Advertising Law, by understaffing its facilities and neglecting their residents' care. It is also alleged that the facilities were inflating their ratings submitted to the Centers for Medicare & Medicaid Services (CMS).
"Mariner and its skilled nursing facilities violated both the law and the trust of our communities by failing to protect the safety and well-being of its residents," Bonta said in a statement. "Mariner understaffed its facilities and left residents vulnerable to assault, illness, and harm."
According to Bonta, the preliminary injunction will allow for an independent monitor to oversee the 19 facilities to ensure SNF compliance and resident safety.
On April 8, 2021, the Division of Medi-Cal Fraud and Elder Abuse, along with the district attorneys of Alameda, Los Angeles, Marin, and Santa Cruz counties, filed a civil complaint against the 19 skilled nursing facilities and Mariner Health Care. The complaint claimed that as a result of the SNFs' understaffing violations, residents were left vulnerable to the spread of diseases like lice, and amputations resulting from inadequate care. There were also a high number of unreported sexual assault cases.
"It is disappointing that facilities like Mariner's fail to protect and provide services to one of our most vulnerable groups. Our elderly population deserves the best care and they should never be neglected," George Gascón, Los Angeles country district attorney, said in a statement.
"This injunction will make sure that residents at these facilities are given the proper care they need in a safe environment."
The home healthcare company was previously investigated in 2014 for violating the Fair Labor Standards Act.
Kynd Hearts Home Health Care, a home healthcare company, has been ordered to pay over $1.5 million in back wages and damages to its employees.
The summary judgment, obtained by the U.S. Department of Labor (DOL), comes after the department filed a complaint against the company in September 2020. An investigation by the department's Wage and Hour Division found that Kynd Hearts failed to pay certain non-exempt employees proper overtime.
Employees' hourly rates were reduced with the more hours they worked, and overtime was then calculated according to the reduced rate. The company also failed to show total premium pay for all overtime hours in a workweek in its payroll records.
In addition to the 2020 complaint, the Wage and Hour Division previously investigated Kynd Hearts in 2014 for pay practices violating the Fair Labor Standards Act.
"The employers knew their obligations to pay proper overtime rates and yet, they willfully disregarded the law and denied workers all of their hard-earned wages," Jessica Looman, principal deputy Wage and Hour administrator, said in a statement.
The DOL has also ordered the company to pay a civil money penalty of $226,512. The judgment permanently forbids Kynd Hearts Home Health Care from future FLSA violations.
"Hardworking healthcare workers will choose to work for employers who value them, pay them full wages and respect their rights," Looman said. "Employers who comply with labor law and appreciate the dignity of work will have a clear advantage when it comes to recruiting and retaining workers."
