Between adopting evolving technologies to enhance exchange of patient health records and adjusting to emerging standards for evaluating patient outcomes, long term and post-acute care (LT/PAC) providers have been busy the past several years putting policy and practice in place at the backend of their operations to meet health care reform initiatives.
But brewing over these same years has been another issue that forces providers to now address the other side of their health care operation—a growing shortage of caregivers.

CNAs Top the List

With demographic changes about to increase the demand for health care in LT/PAC settings over the next decade, the need is particularly great for the people who interact all day and every day with residents of skilled nursing and rehab centers and assisted living communities.

From helping them get out of bed and dressed in the morning, to making sure they take their medicine on time, to bringing them their meals, to ensuring they get to faith and fitness activities and even some fresh air, certified nurse assistants (CNAs) operate on the front lines of health care.

About 650,000 strong and making up more than a third of the staff, these caregivers are the largest group of employees working in U.S. skilled nursing centers, according to the Bureau of Labor Statistics. While their names don’t appear at the top entries of a staff organizational chart, a shortage of these integral caregivers can have a huge impact on the profession.

“We’re seeing home care agencies that are turning down new cases because they don’t have an employee they can assign to the case,” says Susan Misiorski, BSN, national director of coaching and consulting for Paraprofessional Healthcare Institute (PHI). “In some of the worst-case scenarios, we’re now seeing provider organizations that have temporarily closed entire units because they don’t have enough staff” to fill positions.

The Depth of the Problem

High employment is one reason LT/PAC centers across the country are having trouble finding people to fill frontline health care roles. After recovering from an economic recession marked by thousands of layoffs, it’s now a buyer’s market for job seekers, especially those with caregiving skills.

Patti Cullen“We are in competition wage-wise and benefit-wise with every other entry-level employer for starting-level positions. We’re also in competition with health insurance [companies], hospitals, and care coordinators for the registered nurse [RN] and licensed practical nurse [LPN] positions,” says Patti Cullen, president of Care Providers of Minnesota.

Like many health systems across the country, Cullen’s 900-member association, composed of centers that represent the continuum of older adult services, is experiencing a 50 percent vacancy rate. “Just for nursing homes in my membership, we have nearly 3,000 vacant positions,” Cullen says.

The situation is similar in Indiana, where there also is a shortage of caregivers, specifically CNAs, LPNs, and RNs.

“The more the better as of yesterday would be great,” says Zach Cattell, president of the Indiana Health Care Association. “Our members say that this is the worst they’ve ever seen it with respect to the available staff and workforce.”

The Problem Will Escalate

Compounding this challenge will be the loss of many seasoned caregivers as nurses currently on duty leave the profession over the next couple of decades.

“We’re trying to increase the number of caregivers we have to take care of a population that’s older and sicker, while also managing having fewer workers—people retiring—and then fewer people who are coming into our industry,” says Erin Hennessey, vice president of development for Health Dimensions Group, a Minneapolis-based firm that manages care communities and serves as a consultant to the profession.

Experts say staff shortages will become even greater over the next several decades as the U.S. Census Bureau projects an increase in the population of people 65 and older from 48 million now to 88 million in 2050.

For LT/PAC providers in Nebraska, these numbers, along with the state’s unique demographic trends, are driving their workforce development effort.

“There’s a tendency for people once they retire to leave Nebraska and move somewhere else, but the odd thing is they tend to come back when they’re older, maybe in their 80s when they have health care needs,” says Cindy Kadavy, a senior vice president at the Nebraska Health Care Association (NHCA).

“We know we have vacancies in long term care positions right now, and we know that the need is just going to increase in the future,” Kadavy says. “So we’re trying to implement as many workforce-related strategies as we can.”

Recruitment Efforts

To meet workforce needs, provider groups are deploying a number of strategies to recruit talent for jobs that will develop over the next several decades, as well as fill available positions now. One strategy that accomplishes both goals centers on creating partnerships with medical colleges, community colleges, and even high schools to introduce students to career opportunities in the field.

Lindsay Schwarts“I think that exposure early on is key to getting people really interested in long term care,” says Lindsay Schwartz, PhD, director of workforce and quality improvement programs for the National Center for Assisted Living (NCAL). “Of course we can always intervene when they are in college or trade school, but I think getting that passion started earlier is when you really get people interested in long term care and maybe change the trajectory of where they actually would go.”

That’s why Cullen in Minnesota and Kadavy in Nebraska have gotten involved with HOSA, an international association for students pursuing careers in health care.

“We believe that it’s important to start early in the pipeline.” Cullen says. “We give them an opportunity to visit our sites where we talk about the different careers as they are thinking about what they want to do.”
With a membership of about 500 students participating in 34 local chapters at schools throughout the state, Kadavy discovered a wealth of future health care talent within the Nebraska HOSA association, and signed NHCA up as a sponsor.

“When I started looking into it, the groups that sponsor those chapters in exhibits at their trade shows and are contributors tend to be the hospitals,” she says. “We saw that as a real opportunity to try to get long term care into that association so they have a better understanding of what it would be like to work in long term care as a nurse assistant as part of a career ladder to becoming an LPN or RN.”

New Worker Sources

As part of the strategy to fill vacant posts right now, organizations in some states are recognizing the potential talent their immigrant populations might bring to the profession. Minnesota, for example, is among the top states for refugee resettlement.

“Maybe they were a physician or a nurse where they came from, and now that they are in the United States they are looking for health care opportunities,” says Hennessey, whose firm, Health Dimensions Group, manages care communities in Minnesota, along with several other Midwestern states.

“We have some medical career advancement programs for immigrants and legal refugees here, and [we are] looking at cultural adaptations as well as English as a second language programs,” Cullen says.
She’s also asking her membership to consider restructuring positions to attract job seekers who don’t want to work a full-time schedule.

“We are encouraging people to consider part-time positions that are flexible around people’s work schedules and life schedules,” Cullen says. “For example, we may hire more older workers now who want to work part-time.”

Cullen says hiring retirees might require adjustments to role descriptions.

“If you have an older workforce that works part time, you may want to schedule the younger folks to deal with the transfers and the lifts and the older workforce to do other tasks,” she says.

Beefing up Training

Retaining those caregivers set to soon retire also is what developers of Iowa’s training program for CNAs have in mind as they introduce specialized training. Prepare to Care, a six-module online course the Iowa Department of Public Health administers, recently launched an additional course that offers caregivers certification in oral health. Graduates will be able to apply the training across different health settings.

“The specialties, I’m particularly excited about,” says Di Findley, president of Iowa CareGivers, an advocacy group for nurse assistants. “We received a grant from Delta Dental of Iowa Foundation, and so the first specialty that was developed was an area of oral health called Mouth Care Matters. If someone could just specialize in doing mouth care, that is a program that could help keep older workers in the field longer ​by taking some of the physicality out of the work.”

Prepare to Care is developing other specialties for training in dementia, autism, mental health, and positive behavioral support.

Offering Wider Options

In addition to holding on to caregivers set on leaving the profession, provider organizations in some states are welcoming people working in other fields.

The Indiana Health Care Association in January launched a recruitment website aimed at reaching people who are unfamiliar with the field. It features text and video content that helps visitors learn about LT/PAC and get details on specific roles at care centers.

“The website tries first to explain four main areas of what we think long term care means and give some definition and background in very digestible paragraphs,” Cattell says. The career ladder information in it gets to the workforce issue of trying to make individuals understand that nursing centers offer more than clinical jobs. “There’s an administration. There’s a hotel operation. There’s a dietary component. There’s a therapy component,” he says.

Erin HennesseyPeople entering care communities after working in other fields might also bring ideas that spark innovation, Hennessey says. “Maybe they come from the hospitality industry or the food services industry, and they bring best practices and new ideas into our industry.”

Kadavy says provider organizations should see what funding their state labor departments have for workforce innovation and development and make sure LT/PAC is represented to introduce new recruits to the profession.

“Those funds come to a state to help with workforce. In Nebraska, they’re using it to create career pathways. Initially they were just looking at manufacturing and IT [information technology], but they have expanded it to the health care arena as well,” she says.

To get these newcomers trained and ready to hire, NHCA operates its own accredited post-secondary college with branches onsite at some centers. It hosts classes at its headquarters, and its foundation offers scholarships to students who commit to working at least one year in LT/PAC.

“Almost every day we are having students come to our building to go through that training, then go on to be nurse aides or medication aides,” Kadavy says. “There’s an opportunity for long term care facilities to sponsor lunch for students who are taking that training and let them know if they’re looking for employees.”

Retention Barriers

Even as springing for lunch might facilitate a conversation between a recruiter and prospective employee, it may not be enough to get the new caregiver to accept an offer and then remain at the care center through his or her first anniversary.

Chronic understaffing in the field leads to CNAs taking on more cases or work shifts than they can handle. Additionally, with nurse assistants three times more likely to experience work-related injuries, staff might routinely be needed to cover shifts for team members who call in sick. It’s not uncommon to hear stories of caregivers who have worked several weeks without a day off. This contributes to the high turnover rate across the profession, providers say.

“It becomes a vicious cycle,” Misiorski says. “You bring a new employee into an environment where you have vacancies and staffing shortages, and that new employee is not able to manage the workload and the stress that comes along with those staffing shortages. So, people quit because of it.”

Leadership Training Vital

As part of its Quality Initiative, the American Health Care Association/NCAL has challenged its membership to develop strategies to either reduce their turnover rates among nursing staff by 15 percent or hold them at or below 40 percent by March 2018. One way centers can accomplish this goal is through leadership development.

“People don’t really leave companies. They leave their bosses. So, good leadership is important. It’s really key to being able to keep and retain good staff,” Schwartz says. “Sometimes we promote people who are really good at their jobs but then we don’t give them that leadership training,” she says.

Lori PorterBut leadership training shouldn’t be offered only to staff members at the top levels of the organization or those who have been promoted, says Lori Porter, co-founder and chief executive officer of the National Association of Health Care Assistants (NAHCA). The Joplin, Missouri-based association works with 700 care centers to help reduce turnover.

NAHCA offers “executive coaching” for frontline caregivers aimed at educating, motivating, and inspiring CNAs as well as helping them become peer leaders and mentors at their centers.

“We do onsite coaching calls to continue their development, help with any challenges they’re facing, and supply them with the tools to keep morale up in their facility,” Porter says, adding that the program saved one of its member centers more than $100,000 in turnover costs.

In addition to helping CNAs develop the skills to navigate the workday, offering leadership training to team members builds a sense of loyalty, Cullen says. “If you continue to invest in their career development, you’re more likely to retain those individuals,” she says.

Staff Recognition a Prime Motivator

In addition to skill development, the key to retaining employees is recognizing the staff members for their efforts and accomplishments, says Porter, who prior to co-founding NAHCA in 1995 worked her way up in the profession from dishwasher to nursing center administrator.

“When I became an administrator, I thought, ‘Oh, my CNAs—they’re gonna love me and they won’t quit,’” Porter says. “I was buying pizza; I was buying little gifts. I learned my first year the difference between appreciation and recognition.”

That’s why the “key to quality” award program is one of the highlights of the association’s annual conference. “It’s like the academy awards of CNAs,” Porter says. “It will bring you to your knees to see CNAs giving their acceptance speeches for an award they didn’t even know they had been nominated for, let alone won.”

As a key component to turning around a group of underperforming long term care centers it purchased in 2012, HMG Healthcare President and Chief Executive Officer Derek Prince and his partners developed and implemented initiatives aimed at showing recognition and appreciation to their staff, and their strategy seems to be paying off.

In the five years since, HMG has doubled its operation to 24 skilled nursing, independent living, and assisted living communities in Texas and Kansas while at the same time reducing employee turnover from 200 percent to 75 percent. Prince says it’s important for employers to start seeing their team members as assets. “As I was climbing the ranks [from CNA to administrator] it just made sense that consistent staff that know our patients over the long haul deliver better care, and so you get better results,” he says.

HMG is very deliberate in its efforts to recognize and show appreciation to team members toward meeting the goal of reducing turnover.  

Prince plans employee retention programs he thinks employees will enjoy. “As I roll that out … I sit down with our direct care staff, our dietary staff, our regional staff, and basically ask them for feedback—what do they like about working for HMG, what do they not like, what would they like to see,” Prince says.

As a result, HMG took out all of the vending machines in the employee break rooms and replaced them with soda fountains and fresh fruit for the staff, for example.

Prince personally oversees Star of the Month, a retention program held at each center that recognizes a staff member with an award at a reception. 

In addition, HMG has an employee-of-the-year event. In past years, the company recognized that employee with an all-expenses paid vacation, but recently HMG has taken that program into overdrive. For the past couple of years, the stand-out employee has been surprised with the keys to a brand new car.

“For a life-changing event, we felt that buying a new car would be something that would help our employees longer than a few days in Las Vegas or on a cruise ship,” Prince says.

A Provider of Choice

As an operator of 30 care communities throughout the Midwest, Health Dimensions Group also is deploying strategies to recognize and engage its nursing staff to reduce turnover.

“We are really working toward creating an environment where we are an employer of choice, where people feel valued, they feel a sense of purpose, they feel that they have fair and competitive wages and benefits, and they feel that they can make a difference and that there are career opportunities in their organization,” says Hennessey. “We do that through the day-to-day activities of thanking people and coaching them and rewarding great behavior, but also through more formal exercises like ‘stay’ interviews with employees who may be looking for another position about why and what can we do to make this a better place to work.”

The Political Challenge

But the challenge of retaining workers and reducing turnover can’t be solved by efforts of the LT/PAC profession alone, providers say.

“Early on I just thought we’re just going to do support groups and programs and nurture people, but you come to realize really quickly that there is no way you can work on these types of issues and be apolitical,” says Findley, who founded the Iowa CareGivers in 1992 as a support group for CNAs.

“[We need] a willingness on the part of legislators and policymakers to say yeah, we’re going to start investing in systems change that will bring stability to the workforce rather than continuing to pay for this revolving door and this high turnover and in some cases poor quality—and as a result of that, poor quality of care,” she says.

Iowa CareGivers in collaboration with fellow advocates helped develop language for a bill aimed at helping the state prepare a strategy for its LT/PAC workforce. One bill provision would create a database of all CNAs in the state as well as a plan to analyze data collected on turnover rates.

“It would give us some badly needed infrastructure to manage that information so that we can better plan as a state on how we are going to support and build this workforce for the future to ensure that we do have stability,” Findley says.

Although the bill received support on both sides of the aisle, it didn’t make it out of a subcommittee. Workforce development funds that supporters said could pay for the bill’s provisions were diverted to make up shortfalls in the state budget.

Even as action on the proposals in the bill is unlikely until next year’s legislative session, Findley says Iowa’s caregiver community should start a conversation on how to increase wages for nursing jobs.

Financial Reality

“When we talk about what we can do to enhance their compensation, there are only two answers—one is increasing the minimum wage, and one is provider reimbursement,” Findley says. “We need to ask the question: What are the possibilities? What might work?”

“There are great rate variances between payers like Medicaid and other payers like Medicare and private insurance,” Hennessey says. “For providers to survive, it has to be a mix of these payers because in many states, surviving on Medicaid—it doesn’t work.”

Di Findley“It’s important for policymakers to understand the kind of care that we give and the expense of the care we give not only to break even every day, but to have enough net income to invest in our communities and to invest in our employees.”

Without much room in their budgets to increase salaries, the strategy for provider organizations in Nebraska has been to support policy that helps caregivers retain the public benefits while they work.
Forty-two percent of Nebraska’s direct care workers rely on public assistance, according to PHI. That means that to retain benefits for themselves and/or their children, they can’t work more than a certain number of hours or earn above a certain threshold.

“One of the things we’ve heard from members is, ‘I have a great employee and she can only work so many hours a week,’ or ‘She can’t make over a certain amount or she’ll lose her benefits,’” Kadavy says.

There has been some success in Nebraska with extending childcare subsidies for a longer period of time. Nebraska also established a policy that allows people with disabilities who receive Social Security to earn and save money.

In addition to policies that improve compensation and benefits, Indiana’s Cattell says resolving the workforce shortage also involves working with education leaders to train health professionals to replace retiring nurses.

“Hopefully, we will get going on more concerted efforts to figure out a way to have more volume in nursing programs. CNAs don’t necessarily have to go through an academic university, community college, or otherwise to get that certification,” Cattell says. “But the progression of that CNA into an LPN or into an associate’s or a bachelor’s degree of nursing is very much constrained, it appears, by a lack of faculty and bandwidth within our higher education institutions to educate nurses.”

Taking Action

PHI’s policy team is also working several angles to influence public policy on frontline caregivers, including an exploration of the relationship between family members and CNAs.

The policy analysts at PHI aren’t the only experts who think family caregivers and professional nurse assistants need more attention from policymakers. “They don’t have a huge presence when it comes to policy and some of the decision making that has such a huge impact on them directly,” Findley says. The reason that things are so fragmented when it comes to the system is because people have not had a voice in some of the decisions that are being made, she says.

Caregiver voices may begin to be heard this September when under the theme, “passion in action,” Porter will bring her membership of CNAs to the nation’s capital for NAHCA’s annual conference.

NAHCA hopes to have members meet with lawmakers with the goal of participating in the conversation and helping develop solutions to the workforce shortage.

“We may be very lean, but if we can get 200 or 300 there this year, I’ll be happy,” Porter says.
Cassie M. Chew covers health care business and policy issues as a contributing editor for Provider.