A few years ago, Iowa legislators and policymakers surveyed the demographics of their long term care leaders. They found that more than 40 percent of nursing home administrators were at least 55 years old. Less than 5 percent were under 30 years.

 

“It’s a challenge to us,” Iowa Health Care Association Deputy Director Cindy Baddeloo says. “What we’ve been looking at is, how do we develop our young, future leaders?”

That’s a question on many a long term care advocate’s lips. The profession’s guard is graying, and experts are worried that, as baby boomer administrators retire, they’ll leave behind a gap in leadership—just at the moment when demand is sharpening.

“I think it’s going to influence a lot of long term care decisions in the future,” University of Pittsburgh Professor Nicholas Castle says. “Over the years, as the cohort gets older and older, you’re reaching a tipping point. The policy decision there is critical: Are we going to get any warm body, or increase quality, increase care, increase pay so that we have people who want to be there and will work hard?”

Castle is currently studying turnover among administrators and hopes to have a more complete picture of the problem soon, but, anecdotally, the long-term signs for long term care are not encouraging. According to the National Association of Boards of Examiners of Long Term Care Administrators (NAB), an average of 3,778 would-be administrators applied to take its federal exams each year between 1988 and 1997.
Since then, the average number of applications has dropped to 2,521 (see chart, left).

If that seems bad, don’t worry. It gets worse. Only about 40 percent of those who apply to take the administrator’s test are first-timers, which means that barely 1,000 new bodies are even taking a shot at administration every year.

“It’s been a concern that we have been focused on for the last half-dozen years, at least,” NAB’s Randy Lindner says. “It’s not a crisis yet. But the longer we wait, the more likely that this will become

a crisis.”

But the plain fact is the so-called “silver tsunami” is close to arriving, and long term care—nursing homes, home health, assisted living—is going to need every hand on deck.

This isn’t just a matter of giving baby boom administrators a soft landing for their retirements. The fact is, job stability isn’t just good for administrators: It’s also good for patients, Pittsburgh’s Castle says. He and his colleagues crunched the numbers and found that nursing homes with high turnovers also had huge safety problems: High-turnover homes had a lower safety score than even hospitals with similar turnover problems.

“I think in many facilities, the care is in crisis,” Castle says. “When you have six administrators in a year, how do you expect a facility to provide quality care? And the answer is, you probably can’t.”

“Pipeline,” you hear experts say. Long term care needs a pipeline of young(ish) professionals.

But how to build it? On the face of it, experts say, long term care administration is attractive: Salaries are high, there’s relatively quick advancement (“You can get a degree and be running your own home in two years,” Castle says), and there are plenty of jobs, with even more to come.

“It’s like being a school teacher in 1950,” says David Kyllo, executive director of the National Center for Assisted Living (NCAL). “I mean, there will always be jobs.”

So, why, in the worst economy since the Great Depression, isn’t there a line out the door?

Part of it is the demands of the job, experts say.

“For the most part, people work a job that’s 9 to 5. In long term care, it becomes your life,” says Florida Health Care Association President Scott Allen. “That’s just part and parcel of what we do. Holidays, weekends, nights, the whole nine yards.”

Then there are the huge risks in the job. A bad outcome, a bad law, a bad regulator, or even a bad jury and all that hard work can be turned to dust.

“You’re responsible for that building, 24/7,” Iowa Health Care Association’s Baddeloo says. “And whatever happens in that building could cost you your job and your livelihood.”

Indeed, despite the near-guarantee that there will be jobs in long term care for years to come, people are also living in an era of austerity and uncertainty, experts say. Governments are throwing nickels around like manhole covers even as they’re demanding more quality and better performance from operators.

“It’s extremely difficult to go to staff, when they work so hard for you, and say, ‘I can’t afford a pay increase this year,’” says Gregory Hamley, administrator at Wolcott Hall Nursing Center in Torrington, Conn. “I think that’s the hardest part of my job. Because you know how hard they work for you.”

Part of it, NAB’s Lindner and others say, is that, despite the rapid advancement, long term care is a tough profession to break into. Very few administrator-in-training positions are paid, which means that, “Someone gets a master’s degree and faces the prospect of going into an AIT program for six to 12 months and not getting paid,” Lindner says.

Florida’s Allen agrees. When he started his career at the age of 23, he was offered a paid internship. Those opportunities appear to have dried up, he says. Today, there are only two paid internships in Florida. One of the programs has about 300 applicants annually and picks—one.

“A lot of students would like to do this but can’t afford it,” Allen says. “It’s very hard to find a student who’s willing to work 40 hours a week—for lunch.”

(The flip side of that, though, is that when administrators see their protégés willing to work for cheap or for free, they know they’ve found a diamond in the rough, Allen says: “It really shows you how solid they’re going to be because they’re already dedicated at that point.”)

Additionally, even if someone is willing to go through an unpaid apprenticeship, there is a patchwork of state exams, which can make it difficult for would-be administrators to follow their careers across state lines, Lindner says.

But the biggest problem, undoubtedly, is the D-word.

“We’ve found a correlation between death anxiety and unwillingness to work with older adults,” says Elaine Eshbaugh, an associate professor of gerontology at the University of Northern Iowa. “Younger people tend to not want to be confronted with their own aging and their own mortality.”

“It’s a tough sell to 18- to 24-year-olds,” Eshbaugh says. “They tend to subscribe to a lot of myths. They tend to see the jobs as depressing.”

Amy Pellerin is the administrator of Westfield Care & Rehabilitation in Meriden, Conn. She, too, is a second-career professional who came to long term care after a degree in early childhood development. And she remembers, crisply, the first time one of her residents died.

“I had to witness her signing her own DNR,” Pellerin says, referring to a “do-not-resuscitate” order. “And she was the same age I am now. She was 42 years old and basically drank herself into oblivion. It scared the heck out of me. Watching how she alienated everybody and had no family or friends to hold her hand—my staff became her family. I went downstairs and did my living will with the social worker.”

But the experience didn’t scare Pellerin off, and she’s been in the profession for more than 14 years. Moreover, she’s mentored more than a dozen would-be administrators—almost all of whom stayed in the business.

“It’s not for the weak of heart, that’s for sure,” Pellerin says of the job. Still, “it’s the most rewarding job I could have asked for.”

The people Provider talked to all agreed that long term care has to work on its image problem. Eshbaugh has found that the most effective pitch is merely to show the numbers.

“One way is just showing graphs and statistics—look at all these aging people: That’s where the jobs and opportunities are,” she says.

But Lindsay Schwartz, NCAL’s director of workforce and quality improvement program, says it goes beyond mere public relations or dollar-based recruiting. Long term care ought to confront the cultural bias of death head-on.

“A good death,” she says, “is just as important as a good birth.”

In the meantime, though, Eshbaugh and her Northern Iowa colleagues may have furnished a clue to bringing in the next generation of administrators. In the same study that found that death anxiety was a predictor that a student would avoid long term care, Eshbaugh and her colleagues also found that younger people are more open to a career in long term care if they have prior experience with the elderly. She herself practically grew up in nursing homes.

If she’s right and her research bears out across the field, it may help to explain why so many new administrators are second-career professionals: They’re often social workers or nurses with experience in the field who see an opportunity to improve their careers. It also may offer opportunities to recruit the next generation from those kids of nursing home employees.

It’s not just the recruiting that is a problem, though, it’s the retention. New administrators tend to leave the profession quickly and don’t come back, experts say.

“Once they’ve been in a facility for more than two years, they tend to stay for a long, long time,” Baddaloo says. “It’s the under-two years that leave.”

One of the keys to building that pipeline, then, may be a recommitment to mentoring, experts say.

“When you have the resources where you can just put your finger on a phone button and get direct, immediate help on anything, it’s just invaluable,” says Hamley of Wolcott Hall in Connecticut.

“My feeling about management is, if you have good people, you can just provide them with the knowledge base and they’ll make intelligent decisions on their own.”

Hamley has been in the business for 26 years. He came to it through a first career as a nurse-anesthetist in his native Connecticut. He thought that was too narrow a field so he obtained a business degree.

His father-in-law happened to own five nursing homes. “He said, well, if you want to try it out… and I said, sure I’ll give it a swing,” Hamley recalls.

If Hamley emphasizes mentoring young administrators, it’s because he still winces when he recalls his own first day on the job.

“My orientation was with the outgoing administrator,” Hamley says. “I expected an all-day orientation. And he showed me his file cabinet, gave me the key, and left. And I was oriented.”

Florida’s Allen agrees that mentoring is key. He has spent the better part of the decade working with local colleges to build long term care curricula. At the end of November, he was scheduled to sit down with 15 students for mock interviews. But he’s also finding that it’s difficult to find mentors for these protégés.

And, from his own experience, Allen says he thinks that the same pressures that scare young professionals away from the industry could be preventing veterans from helping young professionals into the industry.

“I was scared to death to go out there and teach folks,” he says. “Really, it was just fear. I didn’t want to screw up anybody’s life with bad advice.”

Rebecca Veniscofsky has just finished her second year as an administrator at Apple Rehab in Watertown, Conn. She spent eight years as a social worker, then as an admissions/marketing official, before pursuing her gerontology degree and becoming an administrator. She’s proud of the work she does, but she doesn’t really talk to her outside-the-industry friends about her job.

“It’s easy to explain, ‘I try to take care of patients every day,’” Veniscofsky says. “But to talk to them about budgets and labor hours and reimbursement, that’s not something I involve them in.”

She agrees that mentoring is important, but she also says that the profession has to be honest about what it demands from its administrators. And she doesn’t mind the idea that some of the faint hearts won’t pursue the job.

“If a 19-year-old came to me and said, ‘My mom worked in a nursing home, and I think I know what it takes to be an administrator,’ I would say, ‘You should work a little bit before diving in,’” Veniscofsky says.

“Because it’s not easy. It’s very hard.”

She adds: “You’ve got to make sure you like people, you’ve got to make sure you like the elderly. It’s a job that requires you to be available, 24/7. You’re rolling up your sleeves to have a good outcome.

“So does a 19-year-old know what that means? I would say, no. I needed to work in it for eight years before I decided to go into it.”