A headshot of David Grabowski

Better federal policies to increase the number of immigrants working in nursing homes could help providers get over the hump in meeting expected new staffing requirements, new research shows. 

But investigators also cautioned against allowing an influx of immigrants to unintentionally harm the odds of hiring nurses with more education and higher skills. They warned against facilities potentially substituting “low-skilled certified nursing assistants (CNAs) for higher-skilled registered nurses (RNs) and licensed practical nurses (LPNs).” 

More nursing employees in the long-term care sector nonetheless would ultimately prove positive, they added, echoing recent calls from Senators and nursing home advocacy groups to embrace commonsense reforms.

“Increases in the immigration population result in improved nursing home direct care staffing levels, particularly among full-time staff, with little impact on industry wages or the skill mix of direct care staff,” wrote study authors authors David Grabowski of Harvard University, Brian McGarry of the University of Rochester, and Jonathan Gruber of MIT. 

“The nursing home industry has suffered from chronic understaffing,” they added. “We … find strong and consistent evidence that increased immigration leads to improved patient care, particularly for those who are in the nursing homes for short stays (typically rehabilitation). Collectively, these results suggest that immigrants increase the quality of care of older adults residing in nursing homes.”

Immigrant groups already make up a “disproportionate share” of workers at nursing homes, about 1 in 5 at the direct care level. But a backlog of processing immigrants’ work permits, however, is adding to the sector’s nationwide labor shortage, they added.

Direct care staff account for approximately two-thirds of a facility’s budget. Roughly half of that pays salaries for RNs, LPNs, and CNAs, according to the researchers.

The average facility features a ratio of 2.7 CNA hours worked to 1 LPN hour. The ratio vs. RN hours is 4.0 to 1.0 hours. The paper notes that immigrants make up approximately 19% of CNAs, 16% of LPNs, and 20% of RNs in nursing homes. 

With a federal staffing mandate forecast soon for the sector, increasing the immigrant workforce could help meet that requirement. Observers expect it to carry a minimum of approximately 4.0 hours of nursing care per resident day. 

The authors noted that after a 2018 state law increased the minimum staffing ratios for facilities, more than half of all nursing homes in California applied for a waiver because they were unable to hire enough CNAs. The researchers estimated that the median staffing level nationwide in 2019 was 3.7 hours per resident day and that just 29% of facilities met that.The paper was published by the National Bureau of Economic Research and can be downloaded here.