Nate Schema

A third of skilled nursing providers report their workforce situation has worsened since late last year, with more than three-quarters still relying on high-cost agency staff or overtime to fill vacant shifts, according to a new survey released Tuesday by the American Health Care Association/National Center for Assisted Living.

AHCA published the survey in conjunction with its 2023 Congressional Briefing in Washington, DC, where members were making the case this week for legislation that could increase access to foreign-born workers and open new avenues to improve training and retention.

More than a quarter (26%) of providers said they were “very concerned” they will have to close their facility because of persistent workforce challenges.

Overall, 90% of providers are increasing wages and 85% are offering bonuses, according to responses gathered in May.

“We’re finally getting to the point where frontline care workers are earning a living wage, but the problem is that state legislators in every state have not kept up with those increases and inflation in the corresponding Medicaid rates,” said AHCA President and CEO Mark Parkinson.

Underfunding has led to tough choices for providers when it comes to hiring staff and keeping the doors open. AHCA leaders brought several operators together at a Tuesday press conference to illustrate the challenging dynamics as the sector moves out of the COVID shadow.

Closures and slow gains in the Midwest

Nate Schema, president and CEO of the Good Samaritan Society, the largest not-for-profit nursing home provider in the US, has about 2,000 job openings (down from 2,100 a year ago) across 22 states. That’s an average of 13 needed workers per building.

“I have served my entire career in senior care, and even 17 years ago as a brand new administrator in rural New Mexico, I’ve never experienced staffing challenges like we’re seeing today,” Schema (pictured) said. “While we face staffing challenges in nearly every community, finding qualified caregivers is even more difficult in rural areas.”

Ads for a permanent night shift nurse as a facility in rural Miller, SD, have gone unanswered by qualified candidates for three years. Higher wages and creative resourcing haven’t necessarily eased labor pressures quickly; a training program to entice new directors of nursing also has turned up no successful candidates since it launched last year, Schema told McKnight’s Long-Term Care News.

Such workforce shortages have already led Good Sam to shutter 13 facilities over the last two years, most of them in communities with fewer than 2,000 people.

“If CMS proceeds with an unfunded minimum staffing mandate, our nation’s seniors living in rural areas will pay the price,” Schema added. “An unfunded minimum staffing mandate will undo the progress we’ve made. We need CMS and our elected officials to invest in and strengthen programs to attract, retain and grow the long-term care workforce.”

Big losses in Colorado

Sarah Schumann, vice president of operations at Brookside Rehabilitation and Wellness and Brookside Inn in Castle Rock, CO, said that she has faced shortfalls of up to $16,500 per Medicaid patient annually during COVID. That major gap was softened only by federal pandemic aid, which has all-but dried up.

Colorado leaders cut Medicaid rates by 2% during the COVID crisis, though lawmakers proposed a 10% increase starting in 2024. 

“It has been difficult to keep up with the rising costs, while at the same time we are also struggling to recruit caregivers,” Schumann said. “In the last three years, I lost four nurse managers due to retirement and burnout. Collectively, these managers had more than 50 years of experience and knowledge with my organization.”

For three months in 2021 and 2022, one of Schumann’s buildings also went without a cook. Staff from other departments had to step in and prepare resident meals.

And where RNs are needed but can’t be found, Brookside has had to rely more heavily on fresh LPN graduates, who need more intense education and mentorship than their higher-level or more experienced peers.

Schumann advocated for improving the Medicaid reimbursement system and creating more national incentives for direct care staff that choose to work in long-term care, including student loan forgiveness and tax credits.

Self-competition, agency run up costs

Coleen Condon, owner of Suncrest Healthcare Communities in St. Albans, VT, runs two of the 38 nursing homes in her state. In 2021, faced with untenable agency staffing fees that had climbed to $1.5 million, she decided to close a residential care facility she ran.

Coleen Condon
Vermont nursing home owner Coleen Condon speaks at an AHCA press conference on Tuesday.

She has raised workforce wages to recruit and retain permanent staff, but with the state’s unemployment rate at 2.4%, Condon said is often competing against herself to hire.

Still, she’s making modest gains and is down to two full-time nurse positions and six CNA positions covered by agency. The costs continue to add up, but without that staff, she would have to restrict access further in St. Albans – the only city in all of  Franklin County.

She predicts reliance on agency staff will increase again under a federal staffing mandate. Having to rely more on agency was also the No. 2 concern about the mandate in AHCA’s broader survey, falling behind only “finding staff.”

“No facility should resort to expensive staffing agencies,” Condon said. “But so many of us are backed into a corner without being able to fill our staff on our own. Staff vacancies have forced me to limit admissions …. Limiting admission bleeds into other healthcare sectors.”