Breaking Down Nursing Home Staffing By Geography

With wage inflation and crushing labor market shortages, skilled nursing operators face steep competition relative to other industries — especially those in regions where labor availability is limited and employer demand is high.

The industry as a whole still remains 220,200 jobs below pre-pandemic levels, and 312,600 jobs below its peak in September 2011, according to data from the Bureau of Labor Statistics (BLS).

The greatest shortages of health care staff continue to be among essential workers such as nursing staff and aides, according to a report from the National Investment Center For Seniors Housing and Care (NIC), but even that can vary regionally.

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Staffing shortages in the Midwest are seemingly more dire, according to NIC’s data. About 37% of skilled nursing properties in the Midwest reported nursing staff shortages, and nearly 40% reported aide shortages back in January, the highest levels recorded since the onset of the pandemic across all U.S. regions.

NIC Senior Data Analyst Omar Zahraoui looked at staffing from three different perspectives: region, occupancy, and population size.

“Labor availability differs from one state to another, from one market to another, and obviously from one region to another,” NIC Senior Data Analyst Omar Zahraoui said. “Yet in regions like the Midwest, where labor demand is tighter, this creates a cyclical relationship between labor and occupancy.”

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Breaking down regional disparities

Even when looking at data from mid-September, when staffing shortages have slightly eased for some providers, about 30% of skilled nursing properties in the Midwest still reported nursing and aide shortages — nearly twice that of the South, Northeast and Western regions.

For Wisconsin Health Care Association CEO Rick Abrams, staffing has always been a struggle in the Midwest and it doesn’t appear to be getting better in the short-term.

The association’s staffing survey, completed this year, shows an average vacancy rate of 28% — compared to 12% when the association started collecting results in 2016. The average CNA vacancy rate is about 28.4%, Abrams said.

Although those percentages represent a limited snapshot of the issue, the problem persists. Abrams said he is working with operators to focus on solutions, including raising the base pay for CNAs and housekeepers.

“So that we can begin to compete, not only with hospitals and other components of the healthcare continuum, but also retail and fast food. So, that’s been really helpful, but you know, that is a bandaid, in my opinion. What we need to do is to broaden the base, we need to broaden the funnel of a lot of candidates who want to work in long-term care,” he said.

Abrams also pointed to the Wisconsin Department of Health Services’ new program for certified direct care professionals. Abrams said the goal of the program is to train 10,000 new workers in the direct care profession, 3,000 of which will be CNAs.

The program provides a reimbursement mechanism for the facilities who train CNAs and a retention bonus to new nurse aides who pass their exams and remain employed with their training employer for at least six months. Abrams said what separates the program from previous iterations is the employment first model.

“The candidate is hired by the nursing facility first, then they go through the training and hopefully pass the certification exam,” he said. “What happened in the past was that, since the funding was a lot less, it was not an employer and Employment First program. So the candidate would go through the training and a community college or the facility and pass the test, but then we would lose track of the employee, so that we don’t know whether the employee went to work in the facility.”

In Minnesota, geography has played a significant role in the success of recruitment for skilled nursing facilities, according to Care Providers of Minnesota CEO Patti Cullen.

Having facilities that are accessible by bus from high schools where operators are training workers helps, and not just for student workers. Bemidji, a city in northern Minnesota, has a high population of East African immigrants who work in the healthcare industry. Since many of them do not have drivers licenses, transportation and housing are integral.

“So if the transportation system isn’t good enough and they don’t have apartments nearby to live in, that’s not going to work for them. Similarly, driving an hour in the winter in Minnesota is pretty tough. So in some of our rural communities, where there’s no childcare in the rural community or the spouse works in the neighboring community where there’s a manufacturing plant, they really think twice about taking the drive into the rural nursing home,” Cullen told SNN.

The Mayo Clinical Health System, which has a huge presence in the southeast part of Minnesota, provides housing and their own bus line to facility locations which presents stiff competition for nursing home operators.

“Our members in that part of the state really do struggle,” she said.

Zahraoui told Skilled Nursing News that the findings from the NIC analysis also showed that the higher the occupancy, the lower the share of SNFs reporting staffing shortages.

“In some instances, if labor isn’t available, then a new patient cannot be admitted, especially in the skilled nursing sector,” Zahraoui said. “And if a patient cannot be admitted, occupancy cannot be improved.”

NIC Senior Principal Bill Kauffman said the industry overall is going to have to continue to adapt to competition from both other health care settings and indirect competitors like hospitality and retail.

“Before it was more direct competition with other health care settings — skilled nursing competing with assisted living or memory care and competing with hospitals and adjacent healthcare industries,” Kauffman said. “Now, it’s more of an indirect competition. So although the labor pool got larger, it’s more challenging now because some of the workers can work in other industries and it’s really hard to bring them back.”

The grass isn’t always greener

Heading further west, only 5% of relatively larger skilled nursing properties that are more than 100 units, with an occupancy rate of 90% or more, reported CNA and nursing shortages.

But that doesn’t mean the grass is always greener on the other side.

Colorado Health Care Association CEO Doug Farmer was surprised to see the NIC data reflect that Western states fared relatively well with staffing concerns.

“I don’t see that we’re having less trouble being short of staff than most of the rest of the nation. I feel like we’re kind of right in the middle of a bubble on that,” Farmer said.

A lot of staff who left the profession when the pandemic first began due to safety concerns or childcare needs did return – but not as full-time employees, he said.

“As they started to come back, when school started reopening, they started to have options again, a lot of them started to go back to work or staffing agencies,” he said. That was for a couple of reasons. One, they could choose what days they work and what facility they worked in.And the staffing agencies were able to charge whatever they felt they wanted to charge for those services.”

While an operator might pay a CNA $18 to $19 an hour, that same person could be contracted through a staffing agency for a slightly higher hourly rate and sold back to the nursing home for $75 an hour.

“If you ask me as a regulator, ‘Do you have enough staff?’ My answer is yes. But if you ask me as a business person, the answer is no, I don’t have nearly enough,” he said.