Outlook 2024

(First in a series on providers’ attitudes and concerns about operating conditions in 2024.)

After rebounding from the pandemic’s darkest days, many skilled nursing administrators and nurse leaders are again feeling less-than-excited about the sector’s future heading into 2024.

Nearly half (46%) of those participating in the McKnight’s Long-Term Care News 2024 Outlook Survey said they felt “less optimistic” about prospects for the industry in 2024, with another 27% still guarded and reporting a “neutral” outlook and another 27% feeling “more optimistic.” Among administrators, 53% say they are feeling less optimistic.

All of those numbers have slipped since the 2023 Outlook Survey, which had found more leaders looking forward to the year following an easing of COVID’s clinical complications.

But 2024 could be a year in which nursing homes face industry-changing regulation, primarily in the form of a first-ever staffing mandate that is expected to significantly impact at least 75% of US nursing homes. That appears to be weighing heavily on providers’ minds. 

Staffing and the possible mandate were the top two 2024 concerns noted by respondents, with 82% worried about simply having enough workers and 57% worried about the impact of the mandate itself.

“We’re just trying to come out of this pandemic and you throw one more thing onto this massive pile we’re trying to carry on our backs,” Bob Lane, president and CEO of the American College of Health Care Administrators, told McKnight’s Long-Term Care News Thursday.

“There doesn’t seem to be a correlation really between what the government is wanting to do versus what reality would dictate,” he said of the mandate proposed in September. “You’re asking us to do all of this and yet at the same time, by your own leaked information, the efficacy of being able to meet this mandate is slim to none.”

This year’s survey drew about 350 responses from skilled nursing owners, administrators, nurse leaders and other key voices. It was administered online from Dec. 1 through Dec. 28.

The 2024 survey drew a large share (44%) of responses from leaders at rural facilities, and most respondents identified the buildings where they worked as either a single nursing home (37%) or part of a small, regional chain (38%).

That could have sunk the numbers when it comes to optimism, said Amy Stewart, chief nursing officer of the American Association of Post-Acute Care Nursing, or AAPACN.

“These folks are very concerned about finding and retaining staff. These are also facilities that struggle to find RNs,” Stewart said, noting that the looming staffing mandate and Medicaid funding that typically lags in rural states could combine to suppress any kind of upbeat outlook coming out of COVID. And the struggle ahead may be perceived as especially burdensome on existing directors of nursing and other leaders in small buildings, Stewart added.

“Single facility entities have fewer corporate resources to help them so more falls on the nurse leaders,” she told McKnight’s. “For example, a nurse leader in a single entity may have to develop and implement policies where in a larger corporation, these are developed at a corporate level.”

Burdens building

Regulatory compliance will be a major concern for providers in 2024, when the Centers for Medicare & Medicaid Services could finalize its staffing rule and continue to pursue other tenets of the Biden administration’s get-tough-on-nursing-homes stance. Fresh or coming changes include more transparency measures, updates to the value-based purchasing and quality reporting program and expected additions to emergency preparedness requirements.

Still, set against other major shifts in the sector, tighter compliance and regulatory issues only placed third among providers’ top concerns for the year ahead, with 36% of respondents choosing that option. Medicaid reimbursement was the No. 4 concern, chosen by 35% of respondents.

While Lane concedes Medicaid pay is an age-old complaint, it feels different this year as inflation and new state and federal requirements threaten major cost increases. Some 40% of administrators picked Medicaid as a top-four concern, with 35% citing inflation effects.

“I think most states have tried …  to give providers somewhat of a softer landing [as pandemic subsidies ended],” Lane said. “But still yet, at the end of the day, even those states where they’ve got reasonable reimbursement as opposed to their costs …, we know that it’s like pulling teeth trying to get rate increases out of legislators. And our costs are going to continue to go up. I mean all of those wage increases that out of necessity we had to incorporate, you can’t take those back.”

And nurses aren’t immune from the pressure that comes with rising costs either.

“There are states that have very low Medicaid rates and the cost to care for some patients exceeds that rate. Expensive medications and treatments are part of the nursing budget. If a nurse leader can’t meet the budget because of high-cost patients, this can be quite a conundrum,” Stewart said. “This adds to the burden of the role of the DNS. As nurses, we know we must get the medications and treatments needed but if this continues on, month after month, it puts the viability of the facility at risk.”

Job satisfaction drops

With continued staffing issues, questions about census and their employers’ long-term survival on the table, it’s no surprise that optimism is hard to come by.

In addition to asking respondents whether they were more optimistic, less optimistic or neutral about 2024, McKnight’s also asked why they chose a given response.

Among those choosing “less optimistic,” staffing and the mandate were recurring themes. A sample of comments includes:

  • “With the minimal staffing requirements and a very small pool of qualified individuals, the prospects look bleak.”
  • “Regulatory changes to nursing staff ratios and Covid guidelines for LTC are impossible.”
  • “Too many unknowns. I’m sure there’ll be a lot of complaining and we’ll figure out how to make a nickel after spending many hours [on it] but it’s getting to be exhausting.”

Meanwhile, workers dealing with all of these stressors are reporting lower job satisfaction than heading into 2023.

Overall, 2024 respondents rated satisfaction at 6.7 on a scale of 1 to 10, 10 being the highest. That’s down from 7.3 across respondent type in the 2023 Outlook Survey.

This year, nurses reported the lowest satisfaction rating at 6.4, with administrators coming in at 6.6. They also rated “having enough staff” as their No. 1 concern for 2024, with 84% choosing the option.

“Being pulled in many directions means that you can’t do your job as well as you’d like. This increases the stress of the role which leads to lower satisfaction,” Stewart said. “Also, the demands of the job as a nurse leader have increased in the last few years. … For example, just making sure you have enough staff can take a lot of time for nurse leaders today.”

“They are juggling this with all the other things that come up: managing resident changes in condition; falls; resident and family concerns; monitoring quality and outcomes; and ensuring they have the resources to care for the resident population they serve,” Stewart added. “This on top of managing the clinical operations can be very overwhelming.”

Up next in the McKnight’s 2024 Outlook Survey series: How providers are reacting to the proposed staffing mandate and how they predict they’ll cope.