As Acuity Rises, Nursing Homes Gain Ability to Out-Compete Hospitals for Nurses

As acuity rises in the long-term and post-acute care settings, nursing homes and hospitals are in greater competition for nurses.

Nurses may have in the past preferred to work in the traditional hospital setting for the chance to apply their clinical skills in more sophisticated ways, and for higher salaries. But an increase of residents needing more critical care in nursing homes is beginning to attract nurses to the nursing home setting, and the career path for nurses has widened to include nursing homes right after graduation.

Aided by good outreach efforts from nursing home providers, nurses are welcoming an opportunity to engage their skills and work in a less hectic environment than the hospital, leaders in the sector say. That said, the move still remains hampered by lower salaries for nurses employed in skilled nursing facilities (SNFs).

Some operators, like Trilogy Health Services and Lutheran Life Communities, are using the shift to greater acuity at nursing homes to ramp up recruiting of highly skilled clinicians who would normally go straight to the acute care setting.

“We’re creating an environment that gives [nurses] the ability to use their skills, maybe in a smaller, less hectic environment,” said Leigh Ann Barney, president and CEO of Trilogy Health Services. “They have a lot of control as nurses in a skilled nursing environment, maybe more so than they do in a true acute setting.”

For nurses who still want that fast pace, the post-acute care setting has them covered too. The split between short-term stays and chronic care or long-term stay residents gives nurses their pick of either option, she said.

“They think of it more as a chronic care situation where someone is here long term. They don’t know how much the industry has shifted,” said Barney.

Marketing and talking to local nursing schools on that shift is paramount now as potential career paths continue to change.

Trilogy has its nurse leaders go out and speak to nursing students, and make sure schools understand just how many clinicals Trilogy facilities can host.

This outreach by nursing home operators has been at the forefront of changing the thinking about nursing homes as an employment destination for nurses after college. It’s a career route that has not been emphasized by nursing schools in the past, which has been a flaw, no doubt, educators say.

“There is limited discussion for new grads regarding a career in a nursing home – that is a fault of our academic system,” said Jasmine Travers, assistant professor of nursing at NYU Rory Meyers College of Nursing. “We’re not preparing undergraduates and nursing students for a career in a nursing home, nor are we promoting careers in nursing homes. Limited nursing students get experiences in nursing home settings.”

Instead, nursing schools are largely still promoting work in an acute care setting through the curriculum, she said.

Moreover, with a need at nursing homes for more trained staff given the rising acuity of patients, there is an opportunity for greater career satisfaction.

For Dina Lipowich, vice president of clinical operations at Lutheran Life Communities, close proximity to area hospitals means SNFs have no choice but to compete for the right nurses. “This is a must,” she said. And, graduates are becoming more aware of rising specialized services in the setting.

While clinicals in a skilled nursing facility isn’t exactly something new for nursing grads, the number of IVs administered, gastronomy tubes, and feeding tubes seen in the post-acute world has absolutely increased, said Lipowich.

Advantages of the nursing home environment

Acute care systems are recognizing the shift too. As collaborations between nursing homes and hospital systems – and their clinical staff – become more commonplace, there is a bigger need for more specialized nurses in the nursing home setting.

Cindy Wade, president of LincolnHealth, told Skilled Nursing News that the hospital system is considering cohorting certain types of patients into their skilled nursing facilities. One skilled unit could take care of IV therapy patients while another can focus on dialysis, she said.

“It’s almost like they’re mini hospitals in their own right,” said Wade. “We’re trying to think more creatively, how to support our nursing homes in order to be able to take on these patients, because they are more clinically complex.”

LincolnHealth is one of nine local hospital systems in Maine, run by not-for-profit integrated health system MaineHealth.

Nursing homes are attractive settings for nurse graduates because of the smaller scale and less hectic pace compared to hospitals.

Trilogy’s skilled units are “fairly small” with 50 to 55 beds, compared to the rest of the industry or a hospital, Barney said.

“You’re dealing with a smaller population that you can really use your skill set on,” she said. “You get to spend time with the resident.”

And, nurses in post-acute care may gain more autonomy – sometimes fast tracked to a leadership position – compared to the hospital setting, Barney said. They still need to put care plans together in conjunction with a physician, she added, but there’s more room for critical thinking, more problem solving in the post-acute care setting.

“We have a ton of success stories of people that have come to us at the start of their career and really expanded what they can do,” said Barney. “That may be another area where we have an advantage … there are a lot more management opportunities in skilled nursing facilities versus a large hospital.”

Lipowich echoed Barney’s comments, noting that post-acute care clinicians have to rely on their “nursing instincts” rather than technology shortcuts. That means applying nursing knowledge to monitoring a resident’s behavior, or whether their eating habits have changed.

“Those assessment skills are even more important, in my opinion,” siad Lipowich. “If I were to speak to a roomful of new grads, and my job was to recruit them, I would focus on building these critical thinking skills without necessarily those high tech gadgets that you find in the ICUs or emergency departments.”

While Travers agrees that nurses find more autonomy in the nursing home setting, this positive for the industry is not being communicated in nursing schools.

And while some grads may be attracted to autonomy or leadership roles, nursing homes still don’t have as much shift flexibility as hospitals, she said.

“People are looking for more flexible scheduling. Having more of that flexible schedule is probably more challenging in a nursing home, because it’s fewer staff to be able to cover needs,” said Travers.

Existing nursing home clinicians can attend skills fairs and other learning opportunities, with pay increasing as they secure, say, a phlebotomy or IV certification, or a wound care certification. There’s also education for Trilogy clinicians for infection control via National Institutes of Health (NIH) certification and training on stroke protocols.

Caregivers are freeing up time for nurses too, gaining certifications to pass out medications to residents, she said. The more certified nursing assistants can do, the more that allows the registered nurses (RNs) and licensed practical nurses (LPNs) to provide more hands-on care.

Keeping up with hospital salaries

Despite a less hectic and more meaningful employment experience in a nursing home, nurses might prefer to work in the hospital settings due to salary considerations.

According to the Bureau of Labor Statistics (BLS), the mean yearly salary for a hospital RN is $81,680, while a skilled nursing facility RN makes about $72,090.

However, it’s a different story when it comes to salaries for corporate or management positions in long-term care.

A regional nurse makes on average $120,915 in long-term care, according to the 2022-2023 Multi-Facility Corporate Compensation Report issued by the Hospital & Healthcare Compensation Service (HHCS). Meanwhile, a regional MDS coordinator makes about $119,192 in long-term care, according to national salary ranges compiled by HHCS.

And if nursing homes want to attract talent, they have to be willing to offer better salaries to their nurses who are equipped to deal with more acute residents. And in the long run, this strategy will pay off.

Trilogy wants to do everything possible to keep patient care in the nursing home. Serving higher acuity patients is one of the best ways SNF operators can stay competitive, Barney said, with higher reimbursement rates through the Patient-Driven Payment Model (PDPM). Higher Medicaid rates help too, but many states have chronically underfunded facilities for so long that in many cases it hasn’t kept up with acuity nurses face today.

Ultimately, Barney tells her nurses she wants to get to a point where it would be offensive for SNFs to send residents to the hospital.

“I think what we’ve shown is that we can do this. We have the capability to take care of [higher acuity patients], and in a lower cost setting,” said Barney. “The reimbursement in these cases is higher, which was the intention, but that allows us to pay more to our staff. So we can be more competitive with the hospitals.”

Barney points to a couple reasons surrounding higher acuity among skilled nursing patients – one being reimbursement changes around the PDPM to drive more clinically complex patients into the setting.

Another huge driver has been the three-day stay waiver, she said, which allows the Medicare patient to move from the hospital to post-acute care sooner – a policy that is staying for Medicare Advantage patients, but not for traditional Medicare. The waiver is set to expire with the public health emergency in May.

“It’s still less expensive than being in an acute care setting. There are savings in the health care continuum, to have people come to us sooner, and then under that reimbursement model, we can pay more and get higher quality skill sets in the workforce,” said Barney.