In the 2022 National Academies of Sciences, Engineering, and Medicine report, the National Imperative to Improve Nursing Home Quality, nine recommendations were created to address the severe staffing challenges that have plagued our country’s nursing homes for decades. 

The Moving Forward Nursing Home Quality Coalition Workforce Committee is responsible for  putting two of those recommendations into action: 

  1. Ensuring competitive wages and benefits for certified nursing assistants (CNAs) and
  2. Advancing the role of and empowering the CNA

Action plans to address these recommendations — which were published in July — were developed by academic researchers, nursing home leadership, staff, residents, long-term care advocates, and policy experts who comprise the workforce committee. 

Marissa Bergh

As members of the workforce committee, we provide a summary of what those action plans entail and where help is needed from states, nursing home leaders, policymakers and providers. This is particularly critical in light of the recent unveiling of the federal minimum staffing standards and the need to attract and retain more individuals to nursing home roles.

Action Plan 1: Increasing wages and benefits

Currently, the median pay for CNAs is $35,240 annually and $16.94 hourly. While this pay may work for someone just coming out of high school, it is not a liveable wage for the majority of CNAs, who have a median age of 36 years old and have multiple obligations, such as paying for housing, transportation, food, childcare and utilities among many other things. As a result, 38% of CNAs are living in or near poverty, 34% rely on public assistance, and 29% live in unaffordable housing.

Increased wages would lead to a better supported CNA workforce and an improved ability to recruit and retain workers, who otherwise could obtain increased wages in similar entry-level positions (e.g., $3-4 more per hour and greater) with less stress and burden.

To this end, the Moving Forward Coalition Workforce Committee seeks to improve CNA wages through Medicaid Incentive Payment Programs. These programs (e.g., quality incentive payment and value-based payment programs) are payment models that involve certain process, structure and outcome goals tied to an accompanying payment enhancement if those goals are met. 

States are able to develop such programs within their Medicaid payment structures to encourage improved CNAs’ wages, benefits and other workforce issues by incorporating relevant workforce metrics, yet few states have considered such metrics within their incentive programs to date. A 2022 scan found that only 12 of the 24 states with a nursing home Medicaid value-based payment program in place included a workforce metric, and only two of those states included a wage metric. 

Through exploring the value of incorporating these metrics into Medicaid Incentive Payment Programs, the Committee will develop a “how-to guide” for states with various program options on how they can incentivize workforce improvements (such as increased wages and benefits) through these nursing home programs. The Committee will also recommend the Centers for Medicare & Medicaid Services (CMS) consider including this guidance for states through a CMS memo, bulletin, or other communication and/or as part of the incentive payment program applications submitted to the CMS. 

Kim Hadson

Where help is needed: The coalition is asking for one or two states with existing nursing home payment incentive programs to include a metric designed to incentivize nursing home workforce improvements, potentially including increased CNA wages, benefits or other adjustments. Experts in wage related policy are needed as well as nursing homes that have participated in payment incentive payment programs that include workforce goals. 

Additionally, CMS support is needed in providing guidance to states to include CNA compensation metrics or other workforce metrics (e.g., staffing turnover) in their proposed nursing home Medicaid Incentive Payment Programs. Lastly, it would be beneficial for the committee to receive guidance from state and local workforce commissions on living and competitive wage indices.

Action Plan 2: Advancing the Role of the CNA

While making a living and competitive wage is important to CNAs, equally and arguably more important is that CNAs feel valued, respected and empowered by receiving sufficient education, training and advancement opportunities. CNAs care for an increasingly complex resident population, which has not kept pace with the education and training that they receive. They want to be able to do more but not necessarily leave the CNA role. 

Thus, CNA career lattices have been popular among CNAs, as they allow the CNA to advance in the CNA role while earning additional pay at each lattice and “earning and learning.” Such lattices have included the Health Support Specialist Program in Minnesota, the WIN A STEP UP Program in North Carolina, and the CNA Upskilling Pilot in California. These programs have resulted in improved retention among CNAs and better care for residents. However, CNA career lattice programs are currently not transferrable from nursing home to nursing home and there is no nationally recognized program.

To this end, the workforce committee plans on creating a standardized CNA career pathway model under the Registered Apprenticeship Framework and developing a robust evaluation plan to generate evidence for replicability and sustainability of this career pathway model on a national level. The pathway model will incorporate state-specific guidance for incremental wage increases with each pathway stage. 

Natalie Baysinger

Where help is needed: The coalition will be piloting a CNA pathway model in one or two states. Potential employers along with educational and apprenticeship partners are needed to create and implement this pathway and engage nursing homes and their CNAs. Additional needs include information on lessons learned from existing and past CNA career pathway programs, including barriers and opportunities.

The Committee will work over the next 12 months to put these plans into action. The success of the action plans is predicated on engaging with nursing home stakeholders in the areas where help is needed. With broad support, the CNA role can be transformed into an adequately paid career of experts in caregiving. 

More information about the action plans and co-chairs of this committee can be found here

Jasmine L. Travers, Ph.D., MHS, RN, is an assistant professor at NYU Rory Meyers College of Nursing and affiliated faculty of the Hartford Institute for Geriatric Nursing.

Marissa Bergh, BSN, RN, is a graduate student at NYU Rory Meyers College of Nursing and policy intern for the Moving Forward Coalition Workforce Committee.

Kim Hadson, BSN, RN is a graduate student at NYU Rory Meyers College of Nursing and policy intern for the Moving Forward Coalition Workforce Committee.

Natalie Baysinger is an undergraduate student at University of Delaware Biden School of Public Policy & Administration and policy intern for the Moving Forward Coalition Workforce Committee.

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