- Before pandemic, 82% of facilities did not meet recommended staffing levels
- Pay levels are low and competition from hospitals is steep
- Industry says inadequate government funding impacts recruitment and retention
Correction & clarification: An earlier version of this story misstated the number of COVID-19 deaths in nursing homes during a surge of cases lasting from late 2020 to early 2021. There were 71,000.
Nursing home staffs shrunk in the weeks and months after severe COVID-19 outbreaks, according to a new study, and federal data shows most facilities lost more than half their nurses and aides in the past year.
The study found facilities have struggled to refill openings, particularly among certified nursing assistants, who provide most bedside care – findings that both complicate and underscore the need for President Joe Biden’s push to establish nationwide staffing-level requirements.
“Will they come back? Or is this going to be a permanent shock to the caregiving workforce?” asked Karen Shen, the health economist who led the study.
Increased nurse staffing is linked to better health outcomes for nursing-home residents, with registered nurses playing a particularly important role in managing the spread of infectious diseases. That reality gained broader significance during the COVID-19 pandemic, which increased public awareness of nursing-home shortfalls.
The pandemic also brought attention to the challenges faced by nursing-home workers, who historically have been paid less than their counterparts in hospitals or government-run health programs.
Shen says the study highlights not only the urgency to ensure nursing homes have adequate staffing during outbreaks, but also how facilities struggle to recover in the weeks and months that follow.
“We were thinking more on the side of how many staff are absent because they’re quarantining at the peak of the outbreak, but when we did the analysis, we found departures are an equally big, if not bigger, deal,” said Shen, an assistant professor of Health Policy and Management at Johns Hopkins University.
“Once a facility has a big outbreak, they see an increase in departures that’s higher relative to facilities that aren’t experiencing that sort of outbreak,” she said. “They’re seeing more people leaving their workforce permanently.”
Recommended minimum staff levels are rarely met
America’s roughly 15,000 skilled-nursing facilities serve a growing elderly population with higher medical needs than previous generations, as well as people of all ages with disabilities or who are rehabilitating after surgeries.
Even before the pandemic, at least 82% of facilities did not meet total nurse-staffing minimums recommended by the federal government to avoid care delays and harm to residents, according to a USA TODAY analysis of federal data from 2019.
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The homes are funded almost entirely by reimbursements through Medicaid, which pays for about two-thirds of long-term stays in nursing homes, or Medicare, the primary payment source for short-term stays by the elderly and people with disabilities. Those two health programs pay about $90 billion annually to nursing homes.
How much of that public money is spent on direct care is not well understood. The ownership structures of nursing homes have changed dramatically in the last 30 years from primarily small, local operations to nationwide chains with complex ownership structures.
Today, it’s common for services to be divided among multiple companies, sometimes including involvement from private-equity firms or real-estate investment trusts. The tangle of business interests means an individual facility might appear to be losing money in annual reports to the federal Centers for Medicare & Medicaid Services even as its business partners and corporate owners report profits to shareholders.
“The industry is essentially a subcontractor for public dollars,” said Matt Yarnell, president of SEIU Healthcare Pennsylvania and chairman of an international nursing home workers council. “Governments need to hold the industry accountable and require better outcomes.”
Pennsylvania state leaders have proposed setting a higher bar for staffing levels at nursing homes – one that still falls short of federal recommendations – and have budgeted another $600 million annually for state Medicaid to help facilities pay for it.
The American Health Care Association, the largest lobbying organization for nursing homes, blamed low staffing on “Medicaid underfunding” that made it difficult for facilities across the country to “compete for and retain qualified, dedicated caregivers.”
“Policymakers have continued to ignore the repeated pleas for help from our profession, and this inaction has put the sector in a very fragile condition,” said Holly Harmon, a senior vice president with the group, in an email to USA TODAY.
In a July news release, the organization cited an analysis by a financial consulting firm, which found that the expected staffing minimums would create 187,000 new jobs for nurses and nursing aides, but cost facilities nationwide an estimated $10 billion a year. The industry report cautioned that facilities might cut back their nursing-home resident population by 18% to meet staffing standards if they are unable to expand their workforce.
“An enforcement approach will not solve this long term care labor crisis,” Harmon said in that statement.
In addition to increasing reimbursement rates for care, the organization has called for federal leaders to expand programs that support their staff: student loan forgiveness, tax credits, affordable housing and child-care assistance.
The industry organization surveyed 759 of its members in May – which is about 5% of nursing homes nationwide – and found that most had taken several steps to improve recruitment and retention. They said they had strengthened workplace culture, promoted staff, paid for training, offered bonuses and increased wages. They reported that the biggest challenge with hiring were a lack of interested candidates and an inability to offer competitive wages.
Pay, undoubtedly, will be a factor in whether nursing homes are successful in expanding their workforce. Competition from other health services will remain steep.
From 2019 to 2021, average wages increased 4% for registered nurses at hospitals and 9% at nursing homes – which still did not close the pay gap between the two, according to the U.S. Bureau of Labor Statistics. Annual wages have been particularly slow to rise for nursing aides. While average hospital pay for aides increased 15%, to $36,000 a year, those working in skilled nursing facilities only saw pay increase 4%, to $30,000.
Richard Mollot, who leads the nation’s largest advocacy group for nursing-home residents, sympathizes with the workforce challenges faced by operators amid a global pandemic and a time of economic instability. For him, the bottom line is that most facilities have failed to provide adequate staffing levels under decades-old rules. He hopes that new, tighter regulations would finally make a difference.
“President Biden’s plans are the most ambitious and potentially the most valuable we’ve seen in 35 years,” said Mollot, director of the Long Term Care Community Coalition.
Workload of nursing-home jobs increased in the pandemic
USA TODAY’s analysis and academic research found that nursing homes, on average, maintained the same staffing levels during the pandemic as in the years before. However, that was largely because residents died or admissions were halted as workers left their jobs.
The nurses who remained often had a larger workload, with sicker patients and ramped up infection controls. When adequate supplies were available, changing gowns, gloves and masks between each room ate up precious time. With the homes closed to visitors, nurses – particularly aides – also found themselves responsible for routine care previously provided by some family members, such as feeding, clipping nails and socializing.
Amid the pandemic, they also witnessed more death among their patients and their coworkers.
“End-of-life care is part of our job, but the massive loss of life can’t be unseen and folks weren’t ready for that,” Yarnell said.
The union leader, who once worked as a CNA, related stories shared by colleagues amid efforts to raise staffing standards in Pennsylvania. He said one fellow nursing assistant had told him she was responsible for putting pillowcases over the heads of dead residents, but also had been told not to wear a mask so she wouldn’t scare those still living.
Death rates during the pandemic:This nursing home stood out
When USA TODAY investigated the chain that reported the highest COVID-19 death rates among residents during the worst pandemic surge – Trilogy Health Services – it found even lower-than-typical staffing levels.
Trilogy disputed the findings, saying it had misreported some deaths in its weekly reports to federal officials.
As COVID-19 cases spiked in the final months of 2020 and the first weeks of 2021, more than 71,000 nursing home residents died of the disease. During outbreaks, studies found deaths from other causes increased, too, which they say likely related to poorer care amid unprecedented demands on nurses. That same trend was found in the recent Johns Hopkins study of staffing levels during outbreaks.
Often, nursing homes relied on nurses to work extra shifts or hired contractors to fill in staffing gaps when regulars became ill, Shen said. Departures increased in the weeks after an outbreak, but most facilities refilled registered nurse and licensed nurse positions within a month.
Yet four months after the start of a severe outbreak, the analysis found facilities still reported fewer hours of care from nursing aides.
Those aides, disproportionately women and people of color, spend the most time caring for residents and make up the bulk of nursing-home budgets. During the pandemic, nursing assistants might have had the most exposure risk because they spent more time with more people, leading an uncertain number, but likely hundreds, to die of COVID-19.
Nursing homes could face more challenges hiring nursing aides in coming months as exceptions to federal rules made during the pandemic are phased out, including one that allowed facilities to hire people without certifications to do aide work.
One academic study completed for CMS in 2001 recommends one CNA should care for no more than eight residents, a standard that many nursing homes do not meet. The strain became worse during the pandemic, when Yarnell said daytime CNAs cared for more than 20 people and nighttime workers sometimes had twice that many.
“Resident-care loads that are not humanly possible,” he said. “Not fair to the residents and not fair to staff.”
The increased demands and personal health risks burned out many workers, Yarnell said. Others were devastated seeing residents die en masse without the comfort of loved ones at their side. Some decided to find new work with less stress or better pay. “We’ve got to make these better jobs,” Yarnell said. “Pay attention to the health of the workforce. I don’t think people are paying attention.”
Jayme Fraser is a data reporter on the USA TODAY investigations team. Contact Jayme at [email protected], @jaymekfraser on Twitter and Facebook, or on Signal and WhatsApp at (541) 362-1393.