Nursing homes struggle to fill staffing shortages, even as new ratios loom

CMS mulls new staffing recommendations as the industry struggles to recruit and retain direct care workers.
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Dianna “Mick” McDougall

5 min read

Staffing shortages have rocked the healthcare industry in recent years. For nursing homes, which have struggled with staffing levels long before Covid-19 ravaged long-term care facilities, those departures have hit especially hard.

More than eight in 10 facilities reported moderate to high levels of worker shortages, and nearly all (96%) said they’ve had difficulty hiring new staff, according to a January American Health Care Association (AHCA) survey that polled 524 nursing homes. And 45% of nursing homes surveyed said their overall workforce situation has worsened in the last year.

With more states rolling out nursing home staffing rules and federal standards on the horizon, industry experts say changes—like mandated minimum ratios or flexible work options—are needed to bolster the long-term care workforce, especially if paired with adequate funding.

“Unless you create a culture in a nursing home that is inclusive of all the workers—respects one another—has people at the table, including the direct caregivers […] to be part of the care planning, and the family’s involved in it, you’re running a top-down, 1980s-style organization from a leadership point of view,” said Tara Cortes, executive director of the Hartford Institute for Geriatric Nursing and a clinical professor at New York University (NYU) Rory Meyers College of Nursing. “It doesn’t work in 2023.”

However, some industry groups, like the AHCA and the American Hospital Association, have cautioned that new staffing mandates could “exacerbate already growing access issues for patients in need of post-acute care.” Instead, they’ve called for policies that allow for more internationally-trained workers, support apprenticeship programs, and expand loan repayment programs, among other things.

Under review

In April 2022, the National Academies of Science, Engineering, and Medicine’s Committee on the Quality of Care in Nursing Homes released a report highlighting key goals (and related recommendations) to improve the long-term care industry.

Jasmine Travers, an assistant professor at the NYU Rory Meyers College of Nursing who sat on the committee, told Healthcare Brew that the report’s recommendations recognized that the issues cannot be addressed in a vacuum.

“There’s no one focus that says, ‘Do this, then you’ll change everything with the nursing home [industry],’” she said.

To improve the nursing home workforce, for example, the committee recommended that federal and state officials ensure competitive wages and benefits to recruit and retain staff, and that administrators enhance available expertise in facilities and empower certified nursing assistants (CNAs).

The panel also suggested that the federal Centers for Medicare and Medicaid Services (CMS) improve staffing standards at nursing homes, and urged the Department of Health and Human Services to research, identify, and test specific minimum and optimum ratios to guide new regulatory requirements. Nursing homes are federally required to have enough staff to safely care for residents, but there are currently no staffing level standards.

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CMS announced in August 2022 that it would reexamine the minimum levels and types of staffing needed to provide safe and quality care in nursing homes. The agency unveiled a proposed rule on skilled nursing facility payments in April, and new minimum standards are expected to be released later this year.

Several states already have their own minimum staffing requirements—and nearly a dozen have updated those standards in response to the pandemic.

New York, for example, implemented new regulations in 2021 that require nursing homes to provide 3.5 direct care hours to residents daily—1.1 hours of which must be performed by a registered professional nurse or licensed practical nurse—or face fines of up to $2,000 per day. But the pandemic public health emergency, as well as industry pushback and legal challenges, delayed the rules from taking effect for almost a year.

Still, Cortes said, “everyone in New York is struggling” to meet the new standards.

“We need mandates. I think to keep people honest, we need to have them,” Cortes said. “But you’re squeezing out the long-term care organizations so that they won’t be able to meet a margin to operate unless they get more money.”

Another approach

As state and federal officials eye regulatory and policy changes, others like Todd Walrath, founder and CEO of ShiftMed, a workforce management platform, argue that flexible scheduling options could help solve some of the nursing home industry’s staffing woes.

ShiftMed allows nurses, CNAs, and other workers (who it onboards, credentials, and hires) to search and sign up for open shifts available at around 2,000 partner nursing homes, health facilities, and home care settings—whether they want four hours or 40+ hours a week.

That gig worker-like option, Walrath said, presents a win-win for staff who want more control over their own schedules and administrators, whose facilities must now meet minimum requirements. And it can reduce dependence on costly travel nurses, as most of ShiftMed’s workers are local and often a relatively short commute away from a facility.

“Having an on-demand partner—some people use ‘gig’ and ‘on-demand’ interchangeably—is something that every single healthcare operator is going to have if they don’t have it already,” Walrath told Healthcare Brew. “It replaces the madness.”

Navigate the healthcare industry

Healthcare Brew covers pharmaceutical developments, health startups, the latest tech, and how it impacts hospitals and providers to keep administrators and providers informed.