Direct-care worker shortage expected to disrupt staffing in post-acute care

Loretto Health & Rehabilitation in Syracuse, N.Y., was struggling with a nearly 65% turnover among certified nursing assistants, home health aides and licensed practical nurses, many of whom faced difficult challenges with transportation, child care and other issues.

That’s a chronic and growing problem for nursing homes, home-care agencies and hospital systems, which rely on these staffers to provide the bulk of hands-on, nonclinical care for patients. Good post-acute and home care are key factors in achieving quality outcomes in value-based care, but research shows that high turnover hurts quality.

And turnover is expensive, with estimates that it costs at least $2,500 to replace a direct care worker.

Over the last three years, Loretto, a comprehensive post-acute provider with 2,600 employees, has launched a bevy of programs to enlarge the pool of potential caregivers, including recruiting intensively from Syracuse’s large refugee population.

A major goal is to help new hires better manage their financial and life issues and stay on the job. Improving pay and benefits also is considered crucial, though Loretto has a union workforce with competitive pay and perks.

“We need to expand that workforce, and we need to be very innovative in how we approach talent development,” said Loretto CEO Kim Townsend. With baby boomers aging into retirement, “I’m concerned whether we’ll have enough workers to do what needs to be done.”

A severe shortage of high-quality caregivers could crimp the ability of hospitals, physicians and health plans to move patients out of higher-cost inpatient settings into post-acute and home- and community-based care. That would hobble value-based care delivery.

Other long-term care providers also are urgently developing ambitious new strategies for recruiting and retaining these workers, who provide personal care such as bathing, dressing, eating, toileting, housecleaning and administering medications. Nearly 20 million adults in the U.S. need assistance with daily tasks due to physical, cognitive, developmental or behavioral conditions.

Of the 4.5 million direct care workers in 2018, nearly 90% were women, almost 60% were people of color, and about 1 in 4 was an immigrant, according to a new report from PHI, a long-term care research group, based on data from the U.S. Bureau of Labor Statistics and the Census Bureau.

The inability to hire and keep direct care workers has even forced some nursing home and home-care operators to downsize or turn away patients. In Wisconsin, a new survey of not-for-profit nursing home operators found that lack of staffing has reduced bed capacity by 14 percentage points, to 77%, with the vacancy rate for staffing at nearly 20%.

The shortage of direct care workers is expected to get worse over the next decade as boomers age and the under-65 workforce shrinks as a percentage of the population. It’s estimated there will be 8.2 million job openings in nursing homes, home care and residential care through 2028, according to PHI. Meanwhile, first-year turnover can exceed 80%.

That doesn’t bode well for hospitals and health systems that are relying on post-acute care providers to help in reducing and preventing readmissions.

“We know workforce vacancies have caused providers to limit admissions both in nursing homes and assisted living because they don’t have enough people to provide the care,” said Jim Williams, who recently retired as director of member enrichment for LeadingAge Wisconsin, which represents not-for-profit aging services providers.

The crunch will be even more dire if the U.S. continues policies to reduce immigration, providers and independent experts warn.

“Any policy restricting the entry of immigrants is going to harm long-term care and will lead to further shortages and higher costs for those seeking care,” said David Grabowski, a health policy professor at Harvard Medical School, who recently visited a nursing home where the majority of caregivers were Haitian immigrants.

There’s a broad consensus that raising wages from the median hourly wage of $12.27, or $20,200 annually, to at least $15 an hour is necessary to recruit and retain workers. A number of states and cities have moved to do that, under pressure from labor unions. Fifteen percent of direct care workers have incomes below the federal poverty level, while 44% earn under 200% of poverty, according to PHI.

Experts say it would also help to offer them health insurance and other benefits. More than 2 in 5 workers are enrolled in Medicaid or other public assistance programs, based on PHI data.

“It’s a struggle paying rent, utilities and car insurance,” said Thomasine Wilson, a veteran home-care aide in Richmond, Va., who makes $10.50 an hour with no health insurance. She’s working with the Service Employees International Union lobbying Virginia lawmakers to raise the state’s $7.25 minimum wage. “They’re paying us early 1970s wages and it’s 2020.”

Improving pay and benefits is particularly necessary in the current tight labor market where unskilled workers can earn as much or more in less demanding fast food or retail jobs. But the pressure for higher wages is putting a squeeze on long-term care providers, who rely heavily on Medicaid payments that may not be adequate to cover higher pay.

But a push for boosting Medicaid rates to cover higher pay could lead to fewer services being offered.

“Medicaid is always challenged by providers and other stakeholders to increase reimbursements everywhere,” said Matt Salo, executive director of the National Association of Medicaid Directors. “So the call for a (higher) minimum wage in long-term care is at odds with calls for increased funding for dental care, primary care, hospitals, etc.”

Better compensation isn’t the only issue. Improving supervision, training and career opportunities, and the social status of direct care work are also essential.

“We haven’t valued this workforce,” said Robyn Stone, senior vice president of research at LeadingAge, which represents not-for-profit providers of aging services. “They aren’t just taking people to the toilet. They are doing more sophisticated work such as observing changes in condition. Better wages can help, but the work environment is the most important ingredient.”

Getting medical professionals to recognize personal caregivers as valuable members of the clinical team is key. “You can see the difference in patients when they have caregivers who are very engaged,” said Dr. Jennifer Reckrey, an associate professor of geriatric medicine at the Icahn School of Medicine at Mount Sinai in New York City who visits elderly and disabled patients at home. “I’ve been surprised by how often physicians and nurses consider them an interchangeable pair of hands rather than someone providing nuanced care. That respect piece is the first step.”

Long-term care providers increasingly understand they have to do much more to expand the pool of high-quality direct care workers to serve the burgeoning population of elderly and disabled Americans who need post-acute and long-term services and support.

Federal and state policymakers, as well as charitable foundations, also are starting to step up. Congressional Democrats last fall introduced the Direct Care Opportunity Act to invest in recruiting, retaining and supporting workers who provide daily living assistance to millions.

States like California, Minnesota, Pennsylvania and Wisconsin have convened policy work groups to develop strategies to respond to the looming workforce crisis. They have focused on boosting compensation, improving training, expanding the scope of practice, and developing career advancement opportunities. Wisconsin made $2.3 million available last year to train about 3,000 certified nursing assistants, though that program has expired.

But long-term care providers aren’t waiting for the government. Loretto has launched a car-buying and credit program, a free diaper bank, a free clinic, a fund to help in financial emergencies and a prenatal-care program.

In addition, it offers peer mentors to help the employees, mostly women of color who come from low-income backgrounds, acclimate to their new roles. A life coach is assigned to those who are particularly struggling, to connect them with resources such as counseling for domestic abuse.

Loretto also subsidizes employees who want to go to school to qualify for a better-paying job such as licensed practical nurse, which pays 50% more than a CNA. Townsend said her organization over three years has hired more than 450 employees under the program, with an 80% retention rate, which she considers a notable success.

Other providers, including hospital systems, are following similar playbooks. The leaders of Providence, which operates skilled-nursing facilities, assisted-living programs and home care in seven states, have focused intensely on retaining direct care workers by improving their on-the-job experience.

Large hospital systems are better able to offer higher pay, benefits, training and career advancement than smaller, independent long-term care providers, and generally have somewhat lower turnover.

Tim Cash, Providence’s chief human resources officer for the home and community care division, said his organization is facing a labor crunch partly because many younger people apply for direct care jobs without having a clear, well-informed commitment to that line of work.

As part of its stepped-up hiring and retention effort, Providence is recruiting direct care workers from colleges and high schools, and paying for their training as CNAs. Later, when they have more experience, Providence covers costs for higher-level training for those who want to become licensed professionals like registered nurses.

Providence’s HR staffers make sure they frankly explain to the recruits the nature of the job and check in with the new hires at 30 and 90 days. Supervisors are trained to work closely with the direct care workers to improve their performance and help them with personal issues.

Another lure is that Providence pays close to $15 an hour in some markets, and more than that in other areas.

Cash said his system’s efforts have improved first-year retention for direct care workers by 11.7 percentage points in the last two years, with an overall retention rate of 81% for those workers. “Staffing is the hardest challenge,” he said. “Every one of these things has to be maintained and recycled every year.”

Ascension Southeast Michigan, Cleveland Clinic and Catholic Health in Buffalo, N.Y., have launched comprehensive programs to increase retention of CNAs and home health workers through a $15 million, three-year grant from the Ralph C. Wilson Jr. Foundation.

Starting last June, they assigned workforce coaches to give these direct care workers individual support with challenges both on the job and in their personal lives.

Ascension has aimed the program at 174 in-hospital nurse’s aides in its seven hospitals, though it may expand that to caregivers in its long-term care facilities. The coach will work with each caregiver for a year on personal and professional conduct, communication skills, financial literacy, conflict and stress management, and issues like transportation and child care.

The workers initially came together for a four-day curriculum, followed by six group sessions throughout the year.

Before the program, first-year turnover for nurse’s aides was more than 30%. Since the program’s start, that’s fallen to 7.4%, said Maureen Chadwick, chief nursing officer for Ascension’s Michigan market. Beyond that, 20 of the aides have enrolled in nursing school.

“It gives me chills,” she said. “We are making a difference in folks’ lives. And seeing turnover plummet is powerful. Retention is what will drive improved outcomes and patient experience.”

While there’s a lot of work ahead to improve compensation, support and working conditions to expand the long-term care workforce, there’s no substitute for finding the right people. And it’s not a job that can be automated.

“We can teach technical skills,” Loretto’s Townsend said. “But we always focus on people who have the desire to be compassionate and meet the needs of others.”

Jess Marten, a CNA at Morrow Home Community, a nursing home and assisting-living provider in Sparta, Wis., said taking care of the residents, many of whom have dementia, is a hard, stressful job. The 37-year-old mother of two teenagers, who earns about $15 an hour after a decade of experience, says caregivers should be paid more for this work.

“To have the residents hug me halfway through the bath, all wet, and say thank you so much, you are very good at that, it’s rewarding,” she said. “You laugh and joke and cry and sing with them. Some days they break your heart.

“People just call you a butt-wiper, but there’s so much they don’t know. I’m definitely much more than that.”