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 The Great Workforce Shortage

Providers report all levels of workers are needed to fill vacancies throughout skilled nursing and assisted living communities.

 

Two sets of people are needed to have a functioning skilled nursing, assisted living, or related facility: residents and caregivers. The equation is simple enough. But, even at a time when occupancy levels are a major concern for many long term and post-acute care (LT/PAC) owners and operators, it is the scarcity of workers to care for the nation’s elders and people with disabilities that has shaken the profession and forced new ways of thinking on how to find and keep employees.

All Levels Affected

From nurses, to cooks, to activities staff, longtime administrators and human resources (HR) managers tell Provider that all levels of workers are needed to fill vacancies on a consistent basis, which is increasingly tough to do given the historically strong job market that has escalated wages and often makes working at a care facility less compelling.

Even though employment trends are cyclical, these experts insist the current drought of workers in LT/PAC is more like a virtual Dust Bowl, beyond anything seen previously. And, demand for workers should only grow in the coming decades, with the federal government estimating nearly 27 million people will need some kind of long term care by 2050, potentially magnifying the workforce shortage that exists today.

“It’s probably the toughest environment I have seen emerge. I have been in HR for 25 to 30 years and seen the ups and downs,” says David Lucia, PhD, vice president of human resources at Tealwood Senior Living. “But the demographics of the workforce and the changing nature of the work that has occurred over the last decade are causing some dramatic shifts.”

As a result, many leaders in the HR and workforce development fields are calling for providers to rethink how they recruit, train, and retain staff. This includes allowing more flexibility in worker scheduling, taking a more collaborative “coaching” approach to managing staff, boosting wages when able or offering more incentives, and relaxing facility rules.

But, sharing best practices and implementing new models of staff oversight is not a one-size-fits-all endeavor as the workforce crisis is uneven across the country and even drastically different from facility to facility.

The severity of the problem also often turns on the financial state of the individual property, geographic factors, and important side issues, like the availability of immigrant workers and competition from service sector establishments and hospitals.

Staff ‘Mom’ Helps One Provider

For Renee Naylor, vice president of intellectual/developmental disabilities services, Westcare Management, in Salem, Ore., the task of developing a stable and sustainable workforce is difficult given the wage constraints of being a 100 percent Medicaid-reimbursed operation.

“We are attacking it at a multitude of levels, and we have staff monitor turnover and measure staff satisfaction,” she says, speaking to Provider at the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) Convention & Expo in October.

One new “trick” Westcare has deployed, and to great effect, is the hiring of a staff concierge, a person dedicated solely to the needs of workers, which has resulted in a significant 30 percent decline in turnover since the woman Naylor calls “the staff mamma” came onboard.

“The concierge is the one involved if there is a behavior issue. If there is an issue with HR, this person helps assist them and walks them through all that stuff and makes sure they show up for orientation and trainings,” she says. “We have to find creative ways to give the jobs meaning and purpose to increase staff longevity.”

Westcare has also ditched some old ways of thinking about management and worker relationships, which has helped to bring more collaboration to the facility on how rules and procedures work, and to usher in more of a “coaching” atmosphere versus a punitive one.

“We believe everybody has meaning and purpose,” Naylor says. “Everybody is unique, important, and useful, and using that philosophy we discipline a lot less, using on-the-floor training or one-on-one counseling ... doing hands-on kinds of things between a supervisor and a staff that is not punitive.”

Strict discipline when practiced these days will likely leave an opening on staff and start the hiring-training-retention cycle over again. “All that does is upset people, and why would they stay when they can go to McDonald’s” and make the same or more money, she says.

Being in the LT/PAC profession is stressful enough, Naylor says, considering the mandates on documentation to meet regulatory requirements, for instance, which can lead a punitive workplace to generate more burnout and stress.

Other ways in which Westcare has adapted to bolster the chances of keeping good staff is to undertake a bottom-up management style, where monthly meetings are held to gain input from staff on company decisions. There is also a popular self-staffing model in place where each staff member has a buddy to pair off with to take responsibility for their work weeks.

“If someone needs a sick day or vacation, they have to go to their buddy first and trade internally ... they drive who takes the days off, with no permission needed as long as you are working it out with your buddy. They schedule themselves,” Naylor says.

Enlarging the Labor Pool

On the other side of the country, Roger Bernier, president and chief operating officer for Chelsea Senior Living in New Jersey, has facilitated the entry of Puerto Rican-based labor into the U.S. mainland as a way to augment his locally based workforce.

Roger BernierThe idea to look to Puerto Rico as a possible source of workers originated following the aftermath of Hurricane Maria, which struck the U.S. territory in September 2017. That tragedy resulted not only in thousands of deaths, but in the loss of livelihoods and homes for many of the island’s citizens, opening a potential source of workers for businesses on the mainland.

So, given the opportunity to help storm victims out, and to fulfill a need for labor, Chelsea has found success in flying qualified and well-vetted Puerto Rican workers to New Jersey, offering them temporary housing while they establish themselves on facility staff. This program has resulted in Chelsea gaining six employees when they first started the initiative six months ago, with a new round of recruiting underway.

Chelsea just recently started placing ads again in Puerto Rico, trying to recruit folks, and “Already we have three coming over,” Bernier says.

Puerto Rico’s Status Offers Ease of Entry

Since the island is part of the United States, there is not nearly as much of an issue with the process of getting Puerto Ricans to the mainland as there would be if they were immigrants, and Chelsea does a lot of the groundwork while the potential new employees are still at home.

“One of the things we try to do is we tapped into resources over there to get drug testing and some of the background checks done in Puerto Rico,” he says. “So, we have done the pre-employment screening already, which is helpful.”

For interviewing, part of Chelsea’s HR team is bilingual and speaks Spanish, so that has been beneficial, too. “We have some systems in place to move it along, but yes they are U.S. citizens so it is easy once you get them here,” Bernier says.

There is also a thriving and large community of Puerto Ricans in New Jersey, particularly in the Newark area, which also helps assimilate the new hires since it is not uncommon to see compatriots in the area.

“We have also put things in place to give them housing for six months to get them on their feet and such. One of the successes has been that they have also brought over other family members. So, that has helped us to increase our workforce as well,” he says.

The whole point of the effort is to increase the labor pool, and if that means offering English as a Second Language classes and job training and certification, then providers who can should look into the options for bringing people from other locales to their facilities, Bernier says.
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Retail Woes May Free Up Workers

Other factors may also help ease the labor crunch in coming months, Bernier says, pointing to the continued slide in retail store employment, which could bring some new applicants to the doors of nursing and assisted living communities.

“I see when looking at this with a macro-type lens that the recession in the retail space, which has resulted in a lot of retail in malls closing down and fewer retail jobs, as being a potential help overall to the health care industry,” Bernier says.

But, even though many outside of the LT/PAC sector assume the hard part of finding and keeping workers is wages and benefits, there is more to it than that.

“For us, clearly we have to be competitive as far as wages and benefits. But, we have found that people leave jobs because of people,” Bernier says. “The

No. 1 thing is employees want to have really good managers who are engaged and engage employees. They want to feel like they are a part of something. They want to be included, not excluded.”

And, he says, workers want career ladders. “They want to have a chance to grow within an organization. And, we have created a lot of ladders for folks to better themselves and continue to grow with us,” Bernier says.

Chelsea has excellent retention of workers, and very low turnover when it comes to full-time staff, less than 30 percent. “Where we don’t do as well is with our part-time workforce because if there is a full-time job somewhere else they will take it,” he says.

Expert Seeks to Build Professionalism

As providers around the country try new methods in their search for workers, workforce development experts and HR managers are also digging deeper into what has turned into a science of how to attract good staff and cultivate their careers in LT/PAC.

Bianca FrognerOne such leader is Bianca Frogner, PhD, associate professor, Department of Family Medicine, and director, Center for Health Workforce Studies, at the School of Medicine, University of Washington. She focuses her work on the “allied professions” in health care, or, in other words, the lower-skilled jobs that do not involve being a nurse or doctor.

Working under a grant from the Health Resources and Services Administration, Frogner and her colleagues attempt to bring light to all the different players in health care and what important roles they play, especially now when people are concerned about staffing shortages.

“We talk about roles and occupations and offer context on how health care has been one of the largest job contributors to the economy. Many of the fastest-growing jobs are in these fairly low-education requirement jobs,” Frogner says.

Emphasize Growth Potential

A possible key to changing how these low-skilled jobs get filled is to make workers aware that there is a career track for them in health care, and nursing and assisted living care in particular.

“Some of the fastest-growing jobs are most often found in the long term care setting [inside and outside of facilities], and that is where there is a great need as people are aging,” Frogner says.

Her group is looking across the states to figure out what type of incentive programs are being put in place that address health workers.

“There are quite a few different retention and recruitment techniques that are being used, like loan repayment, tuition reimbursement, and things like helping people find housing,” she says. “We [the industry and states] are actually not very systematic about providing those kinds of incentive programs for allied health professionals, and that is why we are trying to get a better sense of that landscape.”

Frogner agrees with the notion that while improved compensation would help attract and keep workers, it is not the be-all, end-all answer. “Higher wages should help, but it goes beyond that. What people are motivated about in health care jobs is very altruistic in nature. These are hard jobs, and [staff] are looking to be appreciated, to be respected,” she says.

Part of the acknowledgment should include the realization that many workers travel great distances to get to their jobs, so a provider may do well to think about transportation issues. Many workers are also not insured and are looking for health insurance, especially in the home health field.

“A good number of them are on food stamps. Many of our health care workers are, particularly in lower-skilled jobs, so what they need is support in their everyday lives that might make their work easier and getting to work easier,” Frogner says.

California Advocates Push Nurse Training

State-level efforts on solving the workforce conundrum are also taking place. An example is in California, where advocates for LT/PAC providers have worked to secure legislative and administrative assistance to promote jobs and training opportunities for the sector, according to the California Association of Health Facilities (CAHF), a state affiliate of AHCA/NCAL.

Claire EnrightA recent win came when CAHF’s education arm, the Quality Care Health Foundation (QCHF), secured a $2.4 million workforce grant from the state to establish in-house training programs to certify 1,000 candidates as certified nurse assistants (CNAs) over the next two years, says QCHF Executive Director Claire Enright, RN.

“The goal is to get 1,000 CNAs in the next two years in three phases,” she says. “The first 500 will be trained through in-house or community programs.” The second phase will increase the number of in-house training programs. To do that the association is working to get the number of facilities doing in-house CNA training increased, since there is a dearth of such efforts taking place currently, and the last phase will train the remaining 500 CNAs, Enright says.

Beyond the legislative and regulatory push to make it easier to train nurses, she says her group’s other priorities include helping facilities learn ways to enhance their own workforce culture by increasing opportunities for people they already employ.

“So, hiring people just off the street if you can find them is not always the most beneficial way to develop a culture of workforce in a facility,” Enright says.

“Instead, if you have people in housekeeping and laundry who you know are already engaged and passionate in long term care, these people are who you want to get into your CNA program and develop a career ladder so that they want to stay with you and are not tempted to go down the street to another facility,” she says. “You want to help them be a nurse, or social services expert, or billing specialist.”

The broader purpose of these initiatives is to enhance the view of the long term care profession, be it in the skilled setting, assisted living, or any other area where care is given to the population of elders and people with disabilities.

“People who end up in our profession are passionate about it, but a lot of people don’t think of it as an option because it is not the cool thing to do. And people like to think if they do health care, they will do [emergency room] nursing or pediatrics,” Enright says. “We somehow have to shift this perception and invest in the professionalism of long term care.”
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Compensation Relatively Static

The push for LT/PAC to be considered more than a marginal job stop is also the focus of PHI, a workforce training and consulting organization built on issues pertaining to the direct-care workforce inside facilities and in the home.

Robert EspinozaIn an overview of what the landscape looks like now for workers, Robert Espinoza, vice president of policy for PHI, says the general compensation level and job characteristics for direct-care workers in many ways have not changed much, at least in the past 10 years.

“Wages are about $10 to $11 an hour, and adjusted for inflation, that is pretty much the same for the last decade,” he says.

For people who have been in the sector for a long time, the difficulty of finding and keeping workers has always been considered a tough sell. “Part of the challenge in a historical sense—and with direct care in particular—is that the jobs have not always been rightfully valued as a real profession,” Espinoza says.

When reviewing the state of the workforce in LT/PAC, Espinoza says this pattern goes all the way back to the 1930s when there were some pretty serious biases being played out in the political discourse about caregiving not being a real job. “There was the thought that these jobs were something women were somehow more innately able to do and they did not require much skill or training, and you see these same issues playing out now,” he says.

History Offers Important Lessons

Susan Misiorski, vice president of workforce innovations, says before joining PHI she was in the LT/PAC caregiving field for decades. As a director of nursing responsible for staffing and hiring in the late 1980s, her facility had a 50 percent vacancy rate for both nurses and CNAs when she stepped into the job.

Susan Misiorski“One of the challenges I faced was trying to staff up. And, one of the differences between then and now was that with a really concerted, well-thought-out effort we were able to fill those vacancies within six months,” she says.

That same set of interventions today probably would not result in filling 100 percent of those vacancies, simply because the number of people between the ages of 20 and 64 who facilities typically hire is declining, the labor market is tighter, and other service sectors have increased their wages at a higher rate than LT/PAC has, Misiorski says.

“Businesses like McDonald’s, Target, Costco, and Walmart have all increased their wages to similar or better pay than direct care workers, and those other service sectors are not reliant on Medicaid reimbursement to help set their salary rates. It is a little bit complicated in that way,” she says.

Change the Perception?

As part of its work to change perceptions about working in LT/PAC, PHI has undertaken a public education campaign based on identifying the various policy and programmatic solutions to combat staffing shortfalls in home care.

Espinoza says the effort is seeking to explore scores of ideas on the subject with the goal of getting 60 such possible solutions identified. “We have identified 49 ideas thus far, and are also looking at what is happening in the states to better recruit and retain workers,” he says.

One specific effort PHI has conducted started in 2015 with the Massachusetts Senior Care Association, an AHCA/NCAL affiliate. The Quality Jobs for Quality Care campaign focused specifically on improving recruitment and retention for nursing facilities struggling in both areas.

“The association also worked on legislation where they were able to get $30 million to nursing homes to improve the wages of frontline workers,” Misiorski says. “They were able to fund supervisory training for members because supervisors have a significant impact on a person’s intent to stay. And, oftentimes, supervisors in long term care are nurses who got promoted because they have great clinical skills but were never given supervisory training.”

The project wrapped up in 2017 with positive results, and PHI and the Massachusetts advocates are seeking funding for phase two to keep the effort moving forward. “This is an example of a multi-stakeholder effort that went after improving wages, and because of data and public education they were able to successfully get wages improved,” she says.

A more recent program involves PHI partnering with AHCA/NCAL to help members of the association attract and retain qualified caregivers, with the two organizations providing coaching, supervisory training, and consulting to help providers deliver quality care.

Peer Mentoring Must Start Early

In a general sense, Misiorski says providers must get active with their retention strategies as early as possible. One method that has found success is to implement a peer-mentoring program that pairs a mentor with a new employee for the first 90 days of a new hire’s tenure for the benefit of both employees.

“It is an opportunity for advancement for incumbent workers so that they can receive extra training, build their skills, and take on additional responsibility and of course make additional money for having a formal role in onboarding and orienting a new direct-care worker when they start their role,” she says.

Organizations that PHI has worked with on peer mentoring have seen improvement in their retention of new employees in the first 90 days of between 30 percent and 92 percent.

“That is significant because most of the turnover that we see is actually within the first 90 days,” Misiorski says. “New workers come in, and they enter into a challenging situation and are not well supported and just don’t stay.”

Coaching Style a Hit

Another program she calls a tremendous success for retention, particularly after the peer mentoring period is over, is something PHI calls the Coaching Approach to Supervision. The program provides supervisory training to build the skills of the nurses CNAs report to.

“It is a method of supervision that is relationship-centered,” Misiorski says. “The supervisor is able to work with each of their employees to really build their critical thinking and problem-solving skills. It is much less punitive than with traditional supervision where supervisors tend to talk to the employee primarily when they have ‘done something wrong’ and ‘write you up.’”

The approach has produced a 30 percent increase in retention on average with organizations that have implemented coaching supervision, she says.

In the end, the work is the work, and finding people in a job market tilted heavily toward the prospective worker is not making it easy on providers. However, with change and evolving ways of conducting recruitment and embracing the idea of cultivating careers over simply filling jobs, the experts say there is hope for the future.

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