Glacial Processes, Painfully High Costs Mar Immigration as ‘Silver Bullet’ for SNF Staffing

The process of hiring immigrant workers for the nursing home industry – from start to finish – looks like a grueling task for operators, but leaders in the industry say it’s the closest to a ‘silver bullet’ we have to meeting the staffing crisis.

Such a long-term investment is marred by glacial immigration processes, and skyrocketing costs to bring people over as staffing agencies get in the game. There’s competition from other countries too that have far shorter wait times for prospective nurses, and Covid caused a backup in applications.

Indiana-based Majestic Care through a partnership with PSR Global brought over five immigrant nurses for its Goshen facility, and has plans to look at other avenues for nurses from Mexico, Laurel Lingle, vice president of talent acquisitions, told Skilled Nursing News.

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That’s an investment of about $28,000 per nurse, Lingle said. The effort was already in the works by the previous owner when Majestic acquired the facility. Majestic operates 35 facilities across four states including Indiana.

Mick Vujanovic, CEO of Louisville, Ky.-based Clearview Healthcare Management, said he has invested about $15,000 per nurse working with Accelerated Consulting, including immigration fees and expedited fees. Clearview operates 35 facilities across Tennessee and Kentucky.

“For my 40 nurses that I’m attempting to bring over, that’s going to be about a $600,000 investment for our organization,” Vujanovic told Skilled Nursing News. “The concern has been the timeframe that it takes to process all of this. As it is right now, with the rules of immigration, everything just works so slowly.”

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Even so, Vujanovic calls it a “bargain.” Other agencies wanted to charge upwards of $30,000 per nurse, he said.

Coupled with demographic trends in the country, and the industry down 240,000 caregivers since the start of the pandemic according to the Bureau of Labor Statistics, Axis Consulting president Thomas MacDonald says we’re not likely to see any sort of rebound in the labor force on our own. We have to bring people in from overseas, he said.

“The demographic trends in this country are not favorable to see any kind of rebound in labor force participation, unless we do something about immigration,” noted MacDonald. “That’s the silver bullet to this problem. Our government needs to address this and we need to get more people here legally.”

Excruciatingly slow process

Vujanovic, along with other leaders in the skilled nursing space, have been lobbying federal agencies to expedite different aspects of the process, starting with the prevailing wage system.

He said it has taken six months to get the green light on a prevailing wage determination for immigrant nurses – more or less an agreement saying the wage the employer is offering is what the government says it should be paying in a given market.

“Now, from a process standpoint, it seems silly,” said Vujanovic. “We’re in desperate need of nurses, there is a Covid pandemic crisis of epic proportions, people are being hurt because we don’t have the staff. Can we either expedite to prevailing wage, or can we find a way through attestation? If we bring someone on board, we [could] attest that we’re going to pay them the Level 3 wage.”

To that end, Clearview wrote a letter to former Secretary of Labor Marty Walsh requesting expediting the licensing process, but the plea didn’t go anywhere, Vujanovic said. And, none of the original 40 nurses have made it over yet, 15 months after the process began.

Some states have been more accommodating though, he said. Kentucky is able to fasttrack the approval for immigrant nurses to work once they are here, and their license is active usually within 24 to 48 hours.

“If I have a nurse that actually lands here in Kentucky, this person could be working or actually going through extensive orientation [within that time frame],” said Vujanovic. “The license will be active within 24 to 48 hours because Kentucky understands how critical this shortage is for us.”

Mike Filippo, CFO for Transitional Care Management, said his team paid about $8,000 per registered nurse about 15 years ago, and even back then operators were lucky to get foreign nurses working after an 18-month immigration process.

“There’s so many things that can get [the process] delayed,” said Filippo. “The average is probably closer to 24 months now. There was a time that it was closer to 36 months.”

Filippo said Covid worsened an already excruciatingly slow process to get nurses in from overseas as well, with the timeframe jumping up from a year and a half to two years, to five years for some nurses.

Another major roadblock is the limited number of visas that allow nurses permanent residency status and permission to work known as “EB3 visas,” or employment-based visas, available every year. Currently, only 40,000 are available this year, according to a bulletin published by the U.S. Department of State and Bureau of Consular Affairs.

Of the immigrant registered nurses (RNs) hired by Transitional Care 15 years ago, 50 were recruited. Thirty of these recruits took up the operator on its offer, and of those 30, only half hit American soil. Competition has something to do with it, Filippo said, with cities like Dubai having less strict working requirements than the U.S.

“They can wait two years to come to the U.S., you know, or they can go to Dubai tomorrow. “The salaries in Dubai are not as much as they are in the U.S., but they are a lot more than they are normally in the foreign country that the nurses are coming from,” said Filippo.

Moreover, in recent years, the investment price tag for getting overseas nurses to the U.S. has skyrocketed, Filippo said, in part due to staffing agencies getting into the immigrant nurse recruiting business.

Somewhat risky long-term investment

The immigrant process is fraught with challenges right from the get go.

Visas rank in order of priority, with thirty-plus levels based on speciality, and the easiest way for foreign registered nurses to start working in a nursing home is through an EB3 visa.

Nurses don’t qualify for higher priority-based visa categories, such as the EB1 or EB2, for instance, which would be viable visas accorded to say a rocket scientist coming over to the U.S. from another country. Your average RN wouldn’t qualify for those visas, Filippo said.

To get the process started, the employer in the U.S. usually needs to file complicated paperwork first, Filippo said. Most employers will hire an immigration attorney with contacts in the foreign country of interest, and maybe a recruiter too.

Once the recruiter and attorney bring resumes to the employer, it’s up to the employer to fill out more paperwork agreeing to hire applicants, share proof of need and that it can’t be fulfilled by an American employee, he said.

“I understand the process and why it’s there. But when there’s a national emergency, and there’s an obvious shortage, you would think maybe that part could be expedited or waived, or just an attestation page [would suffice] versus the whole investigation,” said Filippo. “From the time you fill out that form to the time a nurse actually gets involved is usually about six months.”

This is the part that could be cut down, Filippo said.

On the opposite side, the nurse is completing medical examinations, going through criminal background checks, verifying degrees and work experience. For an EB3 visa, a nurse must have at least two years of experience, so no nurses right out of school.

There’s also an English proficiency test for immigrant nurses, and nurses must also pass the National Council of State Boards of Nursing exam (NCLEX) in order to practice in the U.S. Several years ago, foreign nurses applying for their EB3 visa were allowed to take the NCLEX on native soil, speeding along the process somewhat, but that’s changed, Filippo added.

As for the process for Majestic’s handful of immigrant nurses, PSR did all of the front-end paperwork during the process, Lingle said, with Majestic getting involved to sign some affidavits, or providing its general counsel to take care of legalities.

“I think things were easy. They integrated into the buildings very, very well,” said Lingle. Majestic took more time with its immigrant nurses’ orientation, a commonality among operators pursuing this staffing path where nurses are given a two-week orientation to get settled, compared to three to five days for a domestic nurse, she said, and duties look identical among all nurses.

One disappointing development, she said, was seeing two nurses break their three-year contracts and leave their positions at the facility after nine months.

“Due diligence wise … we would want more of an agreement with the [recruiting] firm. It’s a hard three years if they leave. [There should be] some type of a prorated fee or there’s something discounted,” said Lingle.

And yet, Lingle said, it was still worth the experience to have these nurses on hand during the staffing crisis. Moreover, the cost to Majestic from the contract breach was paid by the nurses.

“There’s no guarantees,” said Lingle, but added, “Those five that we brought on, we acquired during an acquisition. We thought that was the most amazing thing ever. We absolutely wanted to move forward with [the immigration process]. We didn’t care what the cost was.”

Experiences of immigrant nurses in long-term care

Vujanovic said he was able to bring over two immigrant RNs through separate channels when a deal fell through between another operator and the immigration agency, and the nurses were already far along in the process and needed to be placed somewhere.

Of Clearview’s two RNs, one is in Memphis, and the other is in Louisville, he said, and both are from the Philippines.

“A lot of these folks leave their family behind, and then their family comes and joins them later,” said Vujanovic. With EB3 visas, families are allowed to come over too, but many wait to get settled in the community and with their role in the nursing home prior to introducing family to the mix.

Benjamin Mananggit, an RN who immigrated from the Philippines to work a three-year contract at Future Care of Chesapeake in Maryland, said that he had contracts in Dubai and Abu Dhabi prior to coming to America. Mananggit says he was lucky enough to already have family in Nevada when he started working on U.S. soil in 2016.

His wife, also a nurse, and daughter stayed with family members in Nevada until he was situated in Maryland.

“Some Filipino nurses had a difficult time and difficult experience. My transition was really smooth. Future Care, the nursing facility that hired me, made it really, really easy and made it very comfortable for me and my family,” said Mananggit.

While working for Future Care, Mananggit was able to pay off his house and car. When he finished his contract, he decided to stay on with Future Care for two more years before deciding to work at a nearby hospital instead.

Difficulties are often caused by middlemen, Mananggit said, especially if a staffing agency is the hiring entity rather than the nursing home operator.

“The skilled nursing facility pays that agency and the agency gets their cut, and unfortunately, pays these new nurses a little bit lower than what they’re supposed to get,” said Mananggit. “Some offer green card visas, some offer working visas and are tied up with multiple facilities, multiple hospitals here in the U.S.”

While Mananggit has switched over to an acute care setting, he’s still in contact with Future Care, and connects his old company with potential nurses overseas via social media. Each time, he receives a $500 referral bonus from the company.

“In general, I’m trying to encourage nurses, or some friends or some family, if they want to sit for an interview,” he said. One was recruited from Germany, surprisingly, a friend of a friend that had already completed her NCLEX.

Clearview helped their immigrant nurses find apartments and furnishings, and took them to the only Filipino grocery store in the community.

Orientation and facility placement is more hands-on too, with immigrant nurses meeting more management during their first few weeks in order to develop more of a connection.

“I can’t imagine the isolation these nurses feel … we at least want to pair people in the same situation from their home country, maybe someone they went to school with or someone from their community,” said Vujanovic. “Our focus is always to put multiple people in one center at a time just so they already have a built-in social circle and a support network.”

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