‘We Just Don’t Sell Long-Term Care’: A Top CNA Leader on How Operators Should Hire and Evolve Post-COVID

On the surface, Lori Porter earned a seat on a federal commission to improve nursing home care to serve as a voice for certified nursing assistants (CNAs).

As the CEO and co-founder of the National Association of Health Care Assistants (NAHCA), Porter — a former CNA herself — advocates for those vital frontline employees who provide so much of the direct care to seniors in nursing homes and other residential facilities.

Her perspective came through in the final report issued by Coronavirus Commission for Safety and Quality in Nursing Homes, which among many other suggestions called for increased professional and developmental resources for CNAs.


But Porter’s knowledge goes beyond the lived experience of a CNA. As a licensed nursing home administrator and former regional manager for a group of 10 nursing homes, she’s dealt firsthand with many of the bigger-picture problems that providers have faced for decades, from persistent budget shortfalls to aging physical plants to staff retention.

SNN called Porter earlier this month to discuss her work on the report, and learn what a veteran caregiver would prioritize when tackling the massive project of reforming the post-acute and long-term care landscape.

While her ideas range from increased government funding to radical transparency with families — as a regional manager, she opened up her facilities’ books to anyone who was curious — it all starts with treating CNAs as professionals worthy of investment, support, and respect.


“We need to educate Americans on what greatness there is to be developed,” Porter said. “I’m a high school dropout. Where else on Earth could I have gone and had this career? And I’ll give you about two days to answer that, and you’re not going to be able to come up with anything. There’s no place on Earth a person like me could go and have the career I’ve had, and my friends.”

From your perspective, what should operators, lawmakers, and investors take away from the commission report?

Obviously, wages have to be addressed, and the sticking point with that always comes [down to]: Who’s going to fund it? I don’t think any of this — our problems around staffing — providers themselves can fix without some assistance. If you and I own a 100-bed nursing home, we can only afford what 100 beds will bring in. You and I wouldn’t have been able to do hazard pay without some help. Let’s say our census dropped to 80. Now we’re really in trouble. How are we going to pay for five times the PPE? For pandemic reasons, we need to protect and we need to pay.

One thing I would want people to know is that we haven’t even begun to tap the resource for people who will become CNAs in this country — but not unless we make the CNA role a professional role.

What’s your vision for professionalizing CNAs? I know that was a major conclusion of the report, and it’s also something that Doctors Without Borders has talked about as a primary takeaway from COVID-19 in nursing homes — particularly by taking advantage of resources that already exist in many areas, such as schools of public health and nursing.

It is such an dissected industry, if we can still refer to it that way. These 15,400 and some-odd skilled nursing homes are all owned by different people. There’s some big chains, and there’s a few mom-and-pops left, and then there’s some small chains, but they’re all owned by different people. What we need is a one-size-fits-all, but you can’t get to one-size-fits-all independently. It’s left to each provider to figure out recruitment and retention, figure out pay, figure out what CNAs want.

What we’re going to do here at NAHCA and CNAs for Quality Care — if we can get enough support, because we can’t do it on our own — we’re developing something called NICE: National Institute for CNA Excellence, a one-stop virtual career center for CNAs that will do nationwide recruiting, nationwide preparation, vetting.

Inspire, lead, teach, prep. Then connect them with a state-approved CNA training program. Then we provide all of the continuing education they’re going to need throughout their career — a one-place stop to go beyond compliance.

NICE will have a pillar of developing a surge team, a voluntary corps of CNAs who are no longer working in the field necessarily, but would serve during a disaster — as well as a registry of CNA volunteers that could come from other buildings that are more staffed to assist in disaster areas.

I live in the Joplin, Mo. area and in 2011, we were nearly blown off the planet by a tornado. I could have had 200 CNAs land in Joplin, Mo. to take over the nursing homes, so the ones that got blown away could go see if their children were still alive.

National recruiting would be ongoing, a digital campaign of 2020 and beyond that is a direct target to people who would be moved by the message of being part of a career.

People don’t know CNAs. They think all CNAs want to be a nurse. Only 6% of CNAs want to be nurses. They want to be compensated and respected for the profession of being a CNA. They don’t want to be nurses.

What are some of the biggest challenges you see in hiring and development of CNAs at nursing homes?

One of the hardest things in the 26 years of NAHCA’s existence is breaking down egos.

I grew up as an operator on the operations side — from CNA, to nursing, to regional manager, over 10 buildings. I feel fairly uniquely qualified to do things like the summit, do things with NAHCA. I teach CNAs a lot of things that I learned in my route to becoming an administrator that they need to know. People need to know the answer to their question: Why? Why are we doing it this way? Why?

Nursing homes are in such bad shape because of this — it’s difficult to find data on administrator and DON turnover, but the last I saw years ago was 43%. Everyone will agree that when a nursing home administrator or DON when changes, it sets a facility back six months. It’s just like a do-over. You’ve got to get used to the new gal, got to get used to the new guy.

It creates a phenomenal wave of mistrust, because I just got to where I understood what you wanted, Alex — and now there’s a new guy. Got to start all over with figuring out the way he wants it then, and that’s not the way it should be looked at.

The constant turnover of leadership leads to mistrust, anger, fear, a lack of transparency — all of the things that put the residents and the staff on high alert. And if you’re always on high alert, not being able to believe, not being able to trust, not having somebody to inspire you, then you’re angry, you’re frustrated — and you can’t be your best.

We have tied every single issue, for the most part, back to CNAs in long-term care. You ask the residents, what do they want? They want more CNAs. You ask a family member: Who’s the most important person to you at the nursing home? They’re going to say the CNA. They’re not going to say the administrator. They’re not going to say the DON. They’re not even going to say the charge nurse, all these people that are “above” CNAs. The resident and the family are the only people, the only two people, that consider CNAs as experts.

As a CNA, we’re told: “Don’t talk to the families. Don’t be telling the families things.” Well, what do we think when we’re told that? What does the CNA think? Oh, we’re supposed to lie to the families?

How would you market the jobs in a way that a nursing home HR team may not?

I would market it in a way that is slanted as a professional making a difference. It’s not a job. No CNA does this as a job. There are much, much, much easier jobs. You’ve got to first know what keeps somebody there 20 years, and then you have to wrap it up in a nice package and sell it.

The other thing NICE will do, our career center will have employer partners, and we will place CNAs. But I am no more doing the turn-and-burn thing. I won’t recruit for people that aren’t going to take care of their great recruits and placements. If they’re going to go to a place where their voices don’t matter, and they can’t work as a professional, we won’t be recommending those employers.

It’s the riskiest business I know anybody to be in. If you and I owned [a nursing home], we’re going to be in hell. That’s all there is to it: hell. And so we can either [raid] it, or we can sink every dime we’re making back into it. They’re just designed that way.

I was at a hospital less than 24 hours, and I didn’t even get my nighttime heart medicine. My bill is $13,800 for less than 24 hours. No one even came into my room until 8:30 the next morning when my cardiologist walked in. That’d be a $150,000 fine in a nursing home! And none of the ER docs were wearing masks.

So my portion of that less than 24 hours is $600. The average nursing home [gets] what, 200 bucks a day? How in the world can you deliver person-centered care on $200 a day, when my portion of less than a day was $600? Imagine the kind of quality and person-centered care we could provide our elders if we got $600 a day.

I am tired of seeing nursing homes suffer. They can’t do the right thing. Nobody got into this business to be penniless. How about looking at the faith-based homes who have all these wages frozen for the last three or five years? I have a friend of mine that runs a faith-based, big CCRC, and he hasn’t been able to give a raise in years. Yet he makes fortunes every single month. He’s never had a month of not [recording] a high profit. And he tells me it’s faith-based — I said faith in what, the God almighty dollar?

I’m tired of hearing “non-profits and faith-based, they’re better.” They’re still not good enough. They may be better, but they’re not good enough. I want this country to pay for all people.

The providers seem to be pretty fond of their new Medicare wings. They’re the Taj Mahals of every building. Then you cross through to the Medicaid section, and then you look like you’ve gone into some kind of mental institution, third-world country.

But in the Medicare unit, you’ve got private rooms and flat-screen TVs. So is that the sweet spot? That’s probably about $500, $600 a day. If that’s where they like to operate, then let’s move the dial to that, and then let’s enforce some of these regulations. You can’t enforce what you’re not willing to pay for. That’s why there’s no staffing requirements; nobody’s gonna pay for it.

That’s such a big looming problem, I think — the Medicare/Medicaid divide. There isn’t really any willingness to invest in new infrastructure for long-term Medicaid residents. All you see, in terms of new development, are those beautiful Medicare properties. They serve a purpose, of course, but it’s not the only need in the sector.

But they don’t really elevate pay. You’re not seeing a significant difference in what they pay a CNA versus the old, beat-up nursing home. That’s the other thing: Nursing homes are trying to sell a Taj Mahal. That’s to make you feel better if you have to put Grandma there. By the time Grandma goes to skilled, she doesn’t know where her medicine comes from.

It’s all about marketing. Well, what you need to market in this business is care — nothing else but care should be marketed. Not the baby grand piano. Care. That’s all people really care about.

When I was a regional [manager], all my buildings were old Medicaid buildings — and this was in the ’90s, and they were already 50 years old. So they were old, old buildings, and they’re still up today, all but one of them. So they’re even older.

[Other developers] were building up … all the swanky, baby-grand-piano facilities, and I wasn’t worried about it at all. I lost some staff, but I didn’t lose any residents because I sell care, and I sell the truth. I started a family council. My families were in on hiring with me. I shared the monthly financials with them every month. The president of the company called me up and said, “Did I hear you’re showing the families?” I said, “Yeah, I’m showing the families that signed up for my budget and finance committee; yeah, they’re seeing the financials every month.”

He goes: “Why on Earth are you doing that?” And I said, “Why not? They don’t care. As long as we do what we say we’re going to do, they understand businesses are supposed to make money.” And what I’ve learned is they all sit there every month shaking their heads going, “Why would anybody buy one of these things?”

They don’t complain anymore, because they know what I’m up against. My hiring committee of families, we review the applications; they know what I’m up against. That’s why all the families are now coming in to feed other people’s families at mealtime, because I made them part of the team. And those who didn’t want to sign up for one of my committees, they shut up and went away, because people will complain until you give them something to do. Then they either want to be part of the solution, or they go away.

We built a hell of an empire at that building. They didn’t care if we made $18,000 one month, because they knew we lost $7,000 in the next. Sometimes we made $80,000. They don’t care, as long as you’re taking care of their [loved ones] the way you say you’re going to. But no one wants to come out and be open.

There is no way to operate a nursing home anymore. There’s no profit to take. So you’re taking something that doesn’t really exist, and it would take every cent a nursing home chain brings in, or a [standalone] nursing home. You and I wouldn’t be able to survive.

How sad is that? Think about when all the mom-and-pops are gone. [Let’s say] you and I owned a building here in Joplin, Mo., a city of about 50,000, and we’re out at the local restaurant having lunch while you’re down to tour and see about your investment — I’m kind of the face because I live down here.

The reason we’re going to have such a better home than everybody? Because we’re sitting there at the Red Onion having lunch, and you and I can’t afford to have somebody walk across the restaurant and go: “You killed my grandma.”

A mom-and-pop has to be good because they can’t afford to disappoint their community. This industry has run every one of them out of business. They’re going out at a high rate. There’s no way to stand it alone. And where will quality go?

This interview has been condensed and edited for clarity.