In the wake of a historic shortage of nurses and assistants, America’s nursing homes have been forced to get creative when it comes to hiring, scheduling and retaining workers.

Now many are pushing lawmakers and state regulators to respond to the ongoing workforce crisis with a similar openness, one that in some ways reimagines the sector’s professional landscape.

Emerging is a patchwork of new-to-skilled nursing positions that vary from state to state, with some designed to attract a fresh crop of entry-level workers, and others made to help providers target increasingly complex patient populations while also enticing workers.

Temporary nurse aides in 18 states will be allowed to continue to work under federal waivers through the end of the public health emergency. But some states already have developed a permanent state-level alternative in personal care attendants. Meanwhile, skilled nursing medication technicians are now allowed in some 38 states, and nursing homes are increasingly hiring behavioral health technicians, too.

While it’s unclear how such positions will fit into any federal minimum staffing requirements, individuals filling these jobs are already improving their employers’ ability to provide quality care and keep their doors open. That’s a factor state and federal rulemakers ought to consider moving forward, several providers said.

“Those types of things will be really helpful to the industry,” Ciena Healthcare Senior Vice President Amy La Fleur told McKnight’s Long-Term Care News. “When you dovetail it with some of the career paths and some of the workforce grants out there, it gives us a pretty robust set of offerings for people that are considering coming into long-term care.”

And the sector still badly needs more workers. In a February report, the American Health Care Association said a major obstacle in filling the 210,000 jobs vacated through December 2022 is a lack of interested or qualified candidates.

Florida developed its personal care attendant program as a temporary COVID-19 patch, but after initial success, the state legislature made it permanent in 2021. State skilled nursing facilities have placed thousands of frontline workers through the program. At least 3,000 have gone on to sit for the certified nursing assistant exam, with about three-quarters passing, according to the Florida Health Care Association.

Just as important as the numbers, says Senior Vice President of Quality Affairs Deborah Franklin, are the types of people who have applied for these very hands-on, critical jobs since they were first created under emergency conditions.

“All these people who’d never thought about healthcare, because they needed a job, they saw the ads for the PCA and answered it,” Franklin told McKnight’s. “They found out they loved healthcare. Now they’ve enrolled in nursing school. We’ve just kept hearing over and over again these great stories.”

Franklin considers it a “wonderful, unintended consequence” that by making the program permanent, lawmakers essentially created an apprenticeship that allows workers to sit through eight hours of classroom training and competency testing then get immediate, daily exposure to the skilled nursing setting without spending thousands on a private certification course.

“This removed those barriers for those who didn’t have the money or the means to get to CNA school,” she says, sharing the story of a CNA whose previous job was at a hog-butchering factory. She became an advocate to help the PCA position become permanent. Others have used the PCA program as a gateway to nursing home back office jobs, also increasingly hard to fill.

Med techs moving forward

Tackling a perceived inability to move up is a critical difference-maker for those who view CNA work as a dead-end job. Robert Vande Merwe, executive director of the Idaho Health Care Association, has spent 15 years trying to convince various state agencies to remove hurdles to offering medication technician positions in nursing homes.

At press time, a bill had been introduced allowing facilities to train CNAs to sit for a med tech exam, to be administered by a regional testing organization. It was expected to pass before the session adjourns this spring, Vande Merwe said.

He expects each of the state’s 80 nursing homes might hire only one tech, but that would have a ripple effect on existing RNs and LPNs, allowing them more hands-on time with patients, as well as on recruiters.

“This gives CNAs a true ladder. Sometimes, it’s really hard to see: What’s the next step? Be a shift manager? We’re trying to find other intermediate steps for them. I think this will help us find more CNAs too, to help them see their options,” he said.

Med techs have found solid footing in many nursing homes nationwide, and more states appear poised to approve them. Ciena operates in Indiana, Michigan and Ohio. So far, La Fleur said, Indiana is her only state partner that allows them, but Michigan legislation advanced far last year — only to die post-election.

“We were ready to wrap up getting our temp nurse aides tested and trained and then quickly move into medication assistant training, but now we’re on hold,” said La Fleur.

That was a defeat because operators need the help, but also because it means some CNAs might lose interest while they await entry into that specific opportunity. Med techs, tasked with passing non-dangerous meds that don’t need an assessment, get more pay along with more responsibility.

Certified med techs earned an average of $18.27 hourly, vs. $16.87 for CNAs, according to the 2022-23 Nursing Home Salary & Benefits Report published by the Hospital & Healthcare Compensation Service. 

The next frontier?

In addition, providers in several states are looking at how they can incorporate behavioral health techs, or mental health specialists, into facilities.

These techs can be CNAs with advanced training or hold a standalone certification, which many already use to work in similar hospital roles.

CNAs can earn additional certifications to assist with medication delivery or behavioral health needs.

In either case, they are prepared to help develop care plans for, and ensure that daily interactions align with, treatment for patients with psychiatric or psychological needs. They also are trained to de-escalate problematic behaviors and can identify patients for possible medication reductions.

Given a Centers for Medicare & Medicaid Services push to accommodate more skilled nursing patients with behavioral diagnoses and substance abuse disorders, hiring more behavioral health workers makes perfect sense to providers like Amina Dubuisson, DNP, vice president of clinical services at Ventura Services in Florida.

Dubuisson has recently hired two behavioral health techs at one of the chain’s 12 skilled nursing facilities. Her long-term goal is to have two to three in each building. She’s starting with those where she has the highest concentration of young, ambulatory patients with significant behavioral diagnoses such as bipolar disorder or major depression.

“We reviewed our buildings where there were more incidents with mental health, resident altercations, and you can see why it’s happened. At the same time, those facilities have a higher rate of return to hospital and also, they’re using psychotropics,” Dubuisson said. “And we know there is more in treating patients with mental disorders than just medications … so in an effort to try and do that, we’re going to hire these mental techs.”

Under Florida’s minimum staffing rule, revised last year, nursing homes can include services provided by behavioral techs in a flexible category calling for 0.6 hours daily of any hands-on care. 

In a short time, she has already seen the way additional help relieves staff. Just as PCAs give relief to overburdened CNAs and med techs reduce the burden on licensed nurses, behavioral health techs relieve aides and nurses from time spent on managing behaviors — and they give behavioral patients a dedicated resource to help manage their condition and liaison with families and other members of the care team.

She hopes to eventually advance existing CNAs into behavioral roles through in-house training.

“They’ve been in the building. They know the residents. They know the long-term care setting,” Dubuisson said. “And it will be another motivation on the career ladder for them, and I think as far as hiring, we’ll probably have a higher chance of retaining our own staff.”