For True Nursing Home Reforms, Operators and Experts Agree: ‘Invest in CNAs’

The COVID-19 pandemic exposed structural issues from top to bottom in the infrastructure of long-term care in the U.S., from infection control to staffing levels to SNFs’ role in the health care system.

But one solution would address, if not eliminate, a multitude of those problems, according to a range of operators, consultants, and frontline caregivers: prioritizing the role of certified nursing assistants (CNAs) in nursing homes.

The National Association of Health Care Assistants (NAHCA) CNA Virtual March on Washington, held Wednesday, focused on several goals designed to elevate the CNA role in nursing homes — including establishing the position as a career title, rather than an entry-level position that serves as a springboard to the nursing profession.


That has to include better pay, virtually every speaker agreed.

One of the goals for NAHACA is to advocate for a wage increase for CNAs from the current $13 per hour nationally to $16 per hour, “with a pathway to $22 per hour with self-investment,” Lori Porter, a co-founder and CEO of NAHCA, emphasized.

That goes hand-in-hand with the goal of increasing respect for CNAs, according to Branden Fillbrook, a member of NAHCA’s board of directors and a CNA himself.


“In the future, we need incentives for people to become CNAs, and not only to become CNAs as a passing job to their career as a nurse,” he said. “That is fantastic, but what we really need is incentives for people to become a CNA as a career path. That will only happen through wages and benefits.”

In addition, CNAs need to see a chance to grow in the scope of their practice, Sherry Perry, a self-described “career CNA of 34 years” and board chair of NAHCA’s board of directors, said.

“I can personally tell you from experience that I am treated more professionally, respected more, and treated as part of the whole health care team in my home health job than I ever had [been] in my 34 years in long-term care,” Perry said. “It’s time for a change.”

Nursing home operators for years have pointed to staffing as one of their biggest challenges, and a study using payroll-based journal (PBJ) data from nursing homes for 2017 and 2018 found that the median turnover rate at U.S. nursing homes was 94%.

For CNAs, the average turnover was 129.1%, according to that study — which used PBJ data from more than 15,000 facilities across the U.S.

Advocates and industry leaders alike have pointed to staff as critical to the quality of care provided in a nursing home, with Katie Smith Sloan of LeadingAge calling direct care workers “the heart of aging services.”

But CNAs had multiple stories during the virtual event of being disrespected by their supervisors in the nursing home setting, or not receiving the support they needed. And for all of the speakers, it was critical that this attitude change to improve the numerous structural issues in nursing homes exposed by COVID-19.

“Invest in the CNA profession, and you will see a change in long-term care,” Perry argued.

Fillbrook pointed out the hard reality of the numbers that many CNAs face at their current wages. Citing numbers from the Bureau of Labor Statistics in 2018, he pointed out that a CNA could expect to make between $10.24 and $19.02 per hour, with significant variations by location; some CNAs in some parts of the country will make about $19,000 annually.

While the average wage of a CNA was listed as $12.07 per hour in 2014 by the BLS — or $25,105.60 annually — the average cost of living in the U.S. as of 2019 was $13,000 per person, he noted. A CNA who is a single parent with two children would fall short of the average cost of living by $15,714 annually, at least with those 2014 statistics, he said.

“Now imagine what it would cost for you to live and raise your children and having $15,000 shy of that,” Fillbrook said. “That’s completely unacceptable. If we are to meet this country’s elders’ needs, we need to be able to meet our own needs.”

This problem is not confined to a few nursing homes, as David Grabowski of Harvard Medical School pointed out at the event.

“Most staff in nursing homes are not paid sufficiently,” he said. “Most CNAs are paid at or near minimum wage. They lack benefits like paid sick leave and health insurance. This is a workforce that’s largely female, lots of persons of color and immigrants, and this workforce is not valued. It’s not paid [adequately] in the majority of U.S. nursing homes right now.”

There is considerable disagreement on how to help improve the situation for CNAs, Mark Parkinson, the president and CEO of the American Health Care Association, said during the event. But he was emphatic on the fact that “the CNA profession has not been recognized at both the pay level and the benefits level that it needs to be to support what folks deserve and create a long-term career path.”

While he holds to the view that Medicaid — the primary provider of nursing home care in the U.S. — does not fund operators enough for operators to fix the problem on their own, he asserted that whether the problem lies with operators making too much money or the government, the problem must be fixed.

“It shouldn’t be the job of the CNAs to come up with a fix, but I think you can explain the problem,” he said. “And then we can present our case up on the Hill on how it ought to be fixed.”

AHCA and LeadingAge recently issued a series of proposals to address the various structural issues that have emerged in long-term care over the course of the pandemic, with a focus on increasing registered nurse staffing and developing a strategy for recruiting and retaining workers to the long-term care field.

Sloan, the president and CEO of LeadingAge, emphasized in both her presentation and in a Q&A with Skilled Nursing News earlier this year that paying the direct care workforce a living wage was critical to improving quality of care and worker retention, among other benefits.

That requires significant government funding, she said, but providers will have to step up as well.

“We also need providers’ commitment to fostering healthy workplace cultures that promote career advancement,” Sloan said during the event.

Scott Pilgrim, CEO of the Diakonos Group in Oklahoma, echoed this point in his comments.

“We are proud to support your efforts for increased funding,” he said. “And we really want you to earn more and have better benefits.”

Diakonos, which operates SNFs and assisted living facilities, ended up paying its COVID-19 unit staff at 180% of their base rate, while every employee generally received an extra *20% hero pay. And in the operator’s experience, the nurse aide presence was critical to caring for COVID-19 patients in the skilled nursing setting, especially in the early months of COVID-19.

“It turns out that all of the nurse aide care makes all the difference in the world,” Pilgrim said.

But Grabowski cautioned that any fix around government funding for CNA wages needs to come with greater transparency on how SNFs are using their funds, as he and other experts argued in the journal Health Affairs earlier this year.

“You can’t pay more when you don’t know where that money’s going, and so we need increased accountability,” Grabowski said during the virtual event on Wednesday. “More staff, more money, higher Medicaid rates, and finally, greater accountability. We want to follow be able to follow the money and make certain [it’s] getting into the pockets of CNAs and not elsewhere in these businesses.”

*An earlier version of this article listed the extra pay for all Diakonos employees as 2%, rather than 20%. SNN regrets the error.

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