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Long term and post-acute care (LT/PAC) providers are resourceful. Amid a caregiver shortage that has much of the health care world looking for answers, they have tapped into the power of the foreign-born workforce, embraced diversity, and learned lessons along the way. With the right resources, any provider willing and able to recruit, employ, and help foreign-born workers succeed will find a set of challenges and opportunities that, if managed appropriately, will help boost quality-of-care efforts, providers say.

About one in four direct care workers is an immigrant, according to a 2017 research brief from the Paraprofessional Healthcare Institute (PHI), titled, “Immigrants and the Direct Care Workforce.” And the total number of immigrants in direct care continues to grow—from 520,000 in 2005 to 860,000 in 2015.

A large percentage of the immigrant direct care workforce emigrates from Mexico, the Philippines, and Jamaica, while others come from Caribbean, Central American, and, increasingly, African countries.

According to a 2014 report from PHI, nurse assistants comprise more than one-third of the nursing center workforce, at 37 percent. Their role in LT/PAC is broad, helping residents with daily tasks and to take part in social activities. They also perform a variety of clinical tasks performed under the supervision of licensed professionals.

About 20 percent of nurse assistants were born outside the United States. About 90 percent of all nurse assistants are U.S. citizens. Taking a deeper look, about 80 percent of nurse assistants in 2015 were citizens by birth, 12 percent were citizens by naturalization, and 8 percent were not U.S. citizens.

Jennifer Trapp is vice president of communications and organizational development at Consulate Healthcare, a national provider of senior health care services, specializing in post-acute care. The company has several centers across the country and a broad approach to working with foreign-born workers.

The language barrier is always the biggest challenge, says Trapp. “A lot of foreign-born professionals, when they first come to the U.S., are not speaking fluent English if any at all. And if they want to take an exam, the materials are usually not in languages other than English and Spanish,” she says. To remedy the issue, Consulate’s creative services department has created and printed items like employee manuals in multiple languages.

The same is true for the center’s marketing materials. “We have patient populations where English is not their first language,” she says. The company prints those in multiple languages as well.

Consulate has sponsored employees to help them get their U.S. citizenship, especially nurses, says Trapp. It also stepped up in a big way to help hurricane victims. “When Hurricane Irma struck, several of Consulate’s Florida-based care centers implemented programs to help provide jobs for those coming over from Puerto Rico,” she says. Consulate also looked for ways to help staff help their families. “We had clothing, food, and supply drives,” she says.

At press time, Consulate was in the process of putting together an internal, formalized international recruitment program built specifically for Consulate Care.

Chelsea Senior Living offers assisted living, independent living, memory care, behavioral health, and respite care in 18 communities throughout New York and New Jersey.

Roger Bernier, president and chief operating officer, points out that it’s especially hard to get staff in rural communities. “We’re competing with grocery stores,” he says. “There just aren’t enough people to go around. The greatest need by far is for direct caregivers.”

To recruit qualified workers, Bernier says, Chelsea does everything from buying classified ads to writing Craig’s list posts. Word of mouth is a big contributor. Chelsea also has hiring incentives for referrals, and staff who stay their first 90 days get a bonus.

It's not just foreign-born workers that providers are tapping into, but native, non-English speaking populations as well. Chelsea has reached out to Puerto Rico. At the urging of the company’s chief executive officer, Chelsea launched a mission to help individuals left jobless by Hurricane Maria. For those interested in joining the company and working, Chelsea offers a training program that includes transportation and housing.

The first challenge was communicating, says Bernier. Communication with Puerto Rico was poor with all the phone lines down; getting information was very difficult because the storm had knocked everything out. 

Chelsea advertised in local Puerto Rican newspapers. Any applicants need to have their drug and background tests completed while still on the island. Once they are accepted, enrollees make the trip, and training starts immediately. As soon as they arrive, they begin a three-day training for a home health aide license, and within six months, they earn certification as a certified nurse assistant.

Kim Sugranes is Chelsea’s first success story. After Hurricane Maria wiped out her cable and internet access in Caguas, Puerto Rico, she was no longer able to work as an online educator and translator. One day she opened the local newspaper and saw an ad from Chelsea. Her sister urged her to apply, and she did.

Today, she is the newest staff member at The Chelsea at Toms River in New Jersey, where she works as a care aide.

For Sugranes, Chelsea’s program sparked a new career, but it also helped bring her back to a familiar setting that she treasured. She had worked in a nursing center setting earlier in life while traveling through London. “I loved those people,” she says. “I always told my sister, I was born to help people. The most important thing is that the team members are on the same wavelength.”

At press time, Chelsea had six people in the process of coming from Puerto Rico. Referring to the paperwork, Bernier says it is a long process. “We’re still trying to recruit more.”

In addition to the paperwork, language is a challenge. “Even though Puerto Rico is a U.S. territory, a lot of people do not speak English,” says Bernier. “We have someone in human resources who speaks Spanish to help with the screening, but we may need to find an ESL [English as a Second Language] program to help us.”

J. Scott Hale is president of Symmetry Healthcare Management, based in Arlington, Wash. The company provides consultation services to post-acute care providers and organizations that support them. A majority of Hale’s work has focused on operational issues for independently owned facilities, which include projects related to staffing recruitment and retention.

When it comes to recruiting foreign-born staff into LT/PAC, Hale says methods depend on the target population. Each group is different in how staff are recruited and how they are supported, he says. He cites his work in southern California, which has a large Latino population. In downtown Seattle, the immigrant population is largely African-born.

The issues one could run into with recruiting and employing foreign-born workers depend on the cultural make-up of that group, Hale says. With the Latino population, for example, it would be a language issue. In Mount Vernon, Wash., Hale worked with local workforce development groups to solicit ESL programs. The success of these programs depends largely on government support.

“If the government program existed or you could find resources locally from the government that would support [the ESL program] with grants, for example, it would move forward,” he says. “Part of the problem we have in all of the settings is [funding] limitations on all of those programs.”

If a provider is in a position where it wants to bring in more immigrant workers, the first thing it should do is meet the ones it already has. “Go and start talking to them,” says Hale. “Find out about them, what they are interested in, find out where their friends are. It may sound so simplistic, but if you build that interest, they will come.”

Peer-to-peer referrals are big, especially among African-born workers. When someone asks Hale how to recruit, he first tells them to make the center hospitable for the immigrant or non-native English-speaking individual to be there.

“If they feel comfortable there, frankly, they will find other people that want to come work there too,” he says. “It’s more than you can do if you just advertise in the newspaper. They are by nature very culturally ‘clique-ish’ with each other.”

In communities with heavy Latino influence, Hale would advertise the existence of the facility in the local Catholic newspapers, because there would be a high proportion of Catholics in the Latino community. “I would usually get a referral or two out of that.” He also says putting up flyers in ethnic stores is helpful, especially in Filipino or Latino communities.

Another issue that may arise when working with new staff is supporting them when they may not pass certification exams on the first try, Hale says. When a center partnered with the local workforce development agency to bring in three Latino individuals to complete their licensed practical nurse training, they did not initially pass their exams, and the center looked for ways to keep them working until they were able to take the exams again.

“The problem is, if you don’t [keep them on], they fall out of the system,” says Hale. And that is discouraging when the center and the workforce development agency both have made a financial investment in the workers.

The workers did eventually pass the exams, and one individual moved up the ladder to obtain another position within the company.

Also known as the “Tulip capitol” of the United States, Mount Vernon is largely a farmland area. “There are lots of immigrants, and I was very successful in recruiting foreign-born workers,” says Hale.

The contrast can be viewed 30 miles away. “On some of the local islands here, you can’t find any immigrants,” he says. The centers there struggle like crazy to get staff from the United States-born population. “My overall feeling is that it’s beneficial that you have the immigrant population in your community. It’s almost become a necessity out here.

“If facilities can tap into [the immigrant workforce], and they do a good job supporting them, the facility can meet its basic staffing needs,” says Hale.

“The ones that are remote, they are kind of left trying to recruit from the local American-born population, who are often not that inclined to be nurse assistants.”

Another issue that Hale has observed is that often immigrant workers take multiple jobs. “You would see individuals working in two nursing centers for 12 to 16 hours a day,” he says. A lot of these workers have family back home, and getting funds sufficient to send back home is important to them.”

And working multiple jobs is even more common in metro communities, where facilities are close to each other, Hale says. “You’d have a nurse or nurse assistant working a day shift at one building and the evening shift at the next building,” he says. They could be overlapping eight-hour shifts. And at times, they would ask if the facility would accommodate that, and “I generally did. Because if I didn’t, they’d find another facility that would,” says Hale. 

Hale says that experience has shown him that a lot of foreign-born workers actually understand and relate to English fairly well. The bigger issue is that they are just not comfortable talking and using it. This can lead to a misunderstanding. “I think that gives off at times an aura of them not being as concerned or compassionate as other employees might,” he says. “They’re not used to expressing their feelings in English.”

To tackle the issue, Symmetry Healthcare offers employees training on pleasing mannerisms and how to present oneself visually versus trying to talk through it. “That was a strategy that we did to help break barriers and get them better accepted by those residents that might have been inclined to think that they don’t care or they were not listening to them if they didn’t answer their questions sufficiently.”

If undealt with, the problem can have a ripple effect. “At times I’ve seen facilities with citations dealing with employees that are speaking foreign languages,” Hale says. “That’s always a challenge to deal with.”

To prevent and manage problems that may arise, Hale says, centers must be very active. In other words, if a center brings in non-English speakers and doesn’t manage their issues properly, they’re setting themselves up for the obvious complaints that are going to be made.

“It’s going to be a resident council issue or it’s going to be a family member, and it’s going to be a mandated call and the surveyor’s going to come out. But if the facility has inoculated itself well enough, then they’re going to get through it okay. If they haven’t, then they’re not.”

Forest Hills of the District of Columbia (D.C.) is a private, not-for-profit, full-service retirement community in Northwest D.C. Services at Forest Hill include assisted living, Forest Side Memory Care (located one mile away), short-term rehabilitation and skilled nursing, and long term care.

Upon entering Forest Hills and Forest Side, one immediately feels at ease. “That’s a comment we hear all the time here,” says Mary Savoy, executive director and administrator at Forest Hills.

Walking into the front door the visitor is greeted with a smile from the front desk attendant, and as one moves down the hall, there is a calm buzzing of activity that extends from the dining room, to the lounge, to the activity room. Throughout both buildings, the focus of the staff—all of it—is on the residents.

This is the setting of another success story. Claudia Campusano arrived at Forest Hills in 2005. Originally from El Salvador, she had just received her green card and wanted to get her citizenship. She started out as an activity aide during a time when the activity department also provided transportation for the

residents.

For a while, Campusano did both. She drove the van as well as participated in the center’s activities. When the transportation coordinator position opened up, it became hers.

It took her about 11 years to apply for her citizenship. It was some time in 2016 that she applied but she didn’t quite have enough money to pay the fee, so Forest Hills helped supplement the amount that she had.

But that wasn’t all Forest Hills helped with. To help her prepare for her test, Campusano and her supervisor developed questions from the test and made a trivia activity out of it. Campusano asked questions, and the residents answered. If they didn’t know the answer, she would give the correct response.

“It was good for the residents and fun,” says Savoy. “They knew what was going on. But it also challenged Claudia and helped her feel comfortable with giving the responses and confident that she could pass the test.”

And pass it she did. It was in the same year, 2016, she voted for the first time and that was the icing on the cake, says Savoy. Campusano’s story was featured in the local evening news. “Claudia is worth her weight in gold,” says Savoy. “Her heart is in what she does, and we are ever grateful we made the investment in her. It’s paid off 1000 percent.”

The majority of the staff at Forest Hills and Forset Side are foreign-born. While many of their staff are African-born, the center’s most recent Minimum Data Set coordinator was Chinese, a concierge staff member is from Columbia, and a large number of staff are from the Dominican Republic. “We’ve got a melting pot here,” says Savoy.

With a staff that is predominately foreign-born, Savoy says that a big advantage for Forest Hills and Forest Side is that staff see the value in the work they’re doing. Her gut feeling of why that is, she says, has to do with culture.

“A lot of folks in other countries honor their elderly, and they want to serve them,” she says. “We can probably make a correlation without a lot of research that a sense of service is part of this benefit that we enjoy here.”

And it isn’t just nursing staff. “Housekeeping, dining, therapy, and maintenance personnel are also assiduous and interested in pleasing and doing a good job,” says Savoy. So it’s really all across the board. The benefit is the commitment and the dedication that the folks bring to the job, she says.

While speaking with Savoy about the foreign-born staff there, a consistent theme emerges: Everything that staff do ties back again and again to commitment and dedication. It’s a theme that transcends differences.

“Our resident population is very different from our staff population, which makes it even more challenging for the workers to meet their needs,” says Savoy. “But that’s where the commitment and dedication come in.” Staff pull out all the stops as best they can. She cites communication challenges as another example, which the staff work hard to overcome.

But on the other hand, diversity in staff languages has helped, especially with those residents who speak the same language.

“We have some particular Spanish-speaking residents who are more comfortable communicating in their own language,” Savoy says. Having staff who speak their language not only helps them feel more comfortable, but it’s a way to make a connection. “The benefits work not only from employee to resident but vice versa, from resident to employee,” she says. 

Savoy says that a big part of the centers’ culture has always been inclusivity. New staff come into an environment that embraces diversity, and so it works from day one. As staff members are oriented to customer service, it happens by any means necessary, says Savoy.

“We are committed to meeting our residents’ needs,” she says. “So that transcends birthplace and ethnicity and whatever else might be a barrier for us. We work hard to make sure that all of our staff share the commitment and know that that is the expectation. That feeds the dedication and the whole culture of caring, because that’s who we are,” she says.

The top three things for recruitment are peer recruitment, peer recruitment, peer recruitment. Start with one or two workers that you already have, says Hale.

“Get the word out, and you can give referral bonuses. Make sure you have a good policy on how you’re going to deal with nepotism. The reality is you’re very likely going to have husbands and wives and other

family members join.”

If the center has the population, if it opens up and gets the word out, it works, say providers. But this comes with a word of caution.

“When hiring foreign-born workers, do so with eyes wide open,” says Hale. “Realize that you’re probably going to have allegations that you haven’t had before. And be ready to deal with that and don’t assume that they are guilty because they’re different. It’s just the nature of them being different.”

It doesn’t help to get mad at the people making allegations either because that’s not going to help you, he says. The provider’s goal is to settle it down and protect everybody. “Go into it with your eyes open that way and if you do, you’ll be fine,” he says. “Remember, you have to support the foreign-born workers once they’re in your facility.”

To make this all work, say providers, management has to accept that there will be differences. And management has to decide how they want to overcome those differences, says Savoy. To embrace a diverse workforce, providers also have to accept different approaches.

“That means that we have to encourage our employees to accept our differences,” she says. “It becomes a reciprocal agreement between the employer and the staff. That we will accept each other’s differences, and that the care and services that we provide to our residents is paramount.”

Differences may also come in the form of personal space. “Realize that you can integrate these cultures to some extent but don’t force them to integrate to everything that native-born Americans do,” says Hale. Throughout his career, Hale would generally see that may African-born workers were having lunch by themselves. They would be in their own corner in the employee lounge and that’s okay.

“Everybody doesn’t have to be the same to make this thing work out,” says Hale. “Everyone has to embrace the fact that when they’re in their space, they get to be them. When it’s not okay is when they’re out there at the nurses’ station speaking in Tagalog because it’s easier to do so, especially when residents or families are around.”

At the end of the day, employing a foreign-born workforce benefits in multiple ways. “I’d rather work in a community that has the opportunity to get the immigrants than one that doesn’t,” says Hale. “For those centers that don’t have that opportunity, it’s incredibly tough.”

“If we know that anyone is applying for citizenship, we certainly will give them all the support we can,” says Savoy. “We just never think about it as foreign-born versus not foreign-born. We’ve just got a great bunch of folks who work here.”