Dr. El

Before the pandemic, residents were admitted for rehabilitation following elective surgery or a health crisis. The rehab residents either returned home or joined the group of long-term residents who had previously arrived in a similar fashion. 

Now, as the threat of COVID-19 recedes from long-term care, we are left with empty beds from a reduction in elective surgeries and from having lost many long-term residents to the coronavirus. 

This is combined with an increased familial aversion to nursing homes, capitated healthcare models that favor less costly home-based rehab services and a push towards enhanced community supports for elders, such as the Program of All-Inclusive Care for the Elderly (PACE). While these changes might benefit seniors, they’re not so good for those running nursing homes.

It might be tempting to address the budgetary challenges of empty beds by reducing the number of staff on the units. The logic is that there are fewer residents, so fewer workers are needed.

This reasoning might hold true if the mix of residents was the same as it was prior to the pandemic. From my observation and those of other psychologists I’ve spoken to around the country, the types of residents currently being admitted to facilities are different than the pre-pandemic cohort.

Without the influx of post-elective surgery residents, the people who now fill nursing home beds mostly fall into four general categories: 

  1. Residents with higher medical acuity. 
  2. Residents without enough social support and/or personal wherewithal for home-based rehab even with enhanced professional home care services.
  3. Residents with dementia whose behaviors are too difficult for families to manage at home.
  4. Residents with concurrent serious mental illness such as schizophrenia and bipolar disorder.

While the people in the second category generally don’t require excess assistance from staff, consider the impact on staffing of the other three types of residents.

Medically fragile residents necessitate a much greater degree of nursing attention to prevent a decline in condition. A stable team will be able to detect a change in appearance or functioning that a team with inconsistent, sparse members will not. Additionally, high acuity residents are more likely to need to return to the hospital, entailing a substantial amount of urgent paperwork that takes nursing attention away from other residents. When they leave, a bed will be empty, to be filled by someone new who will require a substantial amount of urgent paperwork by the whole team.

People with behaviors associated with dementia require constant monitoring by the aides on the unit. Anyone who has observed a CNA struggle to prevent confused residents from rising from their wheelchairs on legs they’ve forgotten no longer work while simultaneously attempting to supervise a dayroom full of anxious new residents with their own needs will recognize that additional staffing is required when more confused residents are admitted.

Residents with serious mental illness, who are often younger than average, can be far more demanding than the typical nursing home resident and are sometimes frightening and occasionally abusive. A medically trained team generally has few resources to address their intensive mental health needs, and a system that relies on fee-for-service individual psychology treatment doesn’t prioritize the creation of the effective therapeutic milieu necessary for behavior management. 

Short-staffing has the potential for graver consequences with this new cohort of residents – medical emergencies not attended to in a timely fashion, increased falls in residents with dementia, mental health crises, etc. 

Rather than relying on staffing levels that are theoretically sufficient but inadequate in reality, LTC leaders should consider the actual staffing requirements of their current and anticipated case mix. 

Take into account the level of burnout of employees, as that can affect their ability to adapt to a more challenging population. Those workers who hung on throughout the pandemic hoping for a return to normalcy may find that this new normal is too much to handle without leadership recognition, support, training and sufficient staffing.

Be aware that most staff members won’t tell leaders that they’re drowning. Walk through the units unexpectedly to pick up the vibe. Read between the lines of the comments during supervisors’ meetings. Ask and listen.

Staffing to need, while more expensive in the short term, has the potential to save money in the long term by reducing costs associated with turnover, liability claims and poor community reputation.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition andGold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements and/or content writing, visit her at EleanorFeldmanBarbera.com.