As the skilled nursing sector awaits the proposed federal staffing mandate, leading industry operators renewed calls for funding the initiative, and said the Centers for Medicare & Medicaid Services (CMS) should carry it out in phases while also adjusting staffing ratios based on the acuity of the resident populations being served.
Speaking at Skilled Nursing News’ Staffing Summit Thursday, operators said that they are continuing grassroots efforts to recruit and retain their workforce with a special focus on turnover, and also keeping up communication with policymakers. All agreed that while workforce numbers had improved, they were still a long way off from normalizing.
Mike Landi, COO for iCare Health Network, along with Gurwin Healthcare System CEO Stuart Almer and Laurel Lingle, vice president of talent acquisition at Majestic Care, participated in the Summit.
“We take care of 1,400 residents in Connecticut alone, and close to half of them have a mental illness. So, higher on the behavioral acuity, lower on the [activities of daily living] acuity. We want that to be taken into consideration,” said Landi, referring to the upcoming federal minimum staffing mandate accounting for variation in acuity.
To accommodate for differences in acuity, some operators, including iCare are already in ongoing conversations with states that have placed staffing minimum ratio requirements on facilities to also put in place waivers, he said. On the federal level, Landi would like to see some sort of waiver or other accommodation which takes acuity into account.
Lingle said that the expenses to meet whatever requirement CMS puts out is another concern. New hires have to be attracted through better offers for benefits and ongoing education. Meanwhile, there is also the worry that if operators are unable to fulfill the obligations of the federal mandate, they will likely need to pay penalties they can’t afford.
CMS should be helping the industry figure out how to get more people involved in long-term care, Lingle said, and only then look at a staffing mandate “down the road.”
“It’s at the worst possible time,” added Almer. “There’s clearly a shortage for staff, and clearly there’s a funding need to support increased staffing … funding is clearly an issue and contributing to the problem.”
Staffing costs on a zero margin
Existing costs to attract talent are already draining nursing homes while reimbursement levels remain inadequate, executives said.
Gurwin saw a 10% increase in salary and benefit cost – no small feat on a zero margin – while doubling what it had done in terms of sign-on bonuses and referral bonuses, Almer said.
And, Gurwin is operating with more vacancies to ensure safe staffing levels – paying 10% more for nursing labor overall with fewer patients is a “recipe for disaster,” he said.
While state and federal increases in reimbursement have helped, it’s “not nearly enough to stop the freefall,” according to Almer. In New York alone, the shortfall in Medicaid per patient per day is $80, he said.
“There’s still some opportunities, but not for labor adjustment,” added Landi. “Over the years, we’ve had to evolve with struggling, stagnant reimbursement. Those pennies and nickels were already picked up.”
Gurwin has doubled its educational allotment as well, so nurses and other staff can go back to school. But, retention still remains a problem.
“All of this comes at a cost,” said Almer. “It’s working … we’re seeing good people, young people joining us but never enough, never fast enough. We got to watch retention too, but I think the changes are working.”
Still, it’s important to note that what happened during the worst of the pandemic was equivalent to the system eroding over a 10- to 15- year span, he said. Now, it’s a “call to arms,” Almer said, with the SNF business in crisis.
Wage enhancements have been tied to Medicaid increases in Connecticut, Landi said, with supervisor wages upwards of $100,000 annually, and registered nurse (RN) salaries are also at a premium.
Landi said that the top concern has “flipped” from recruiting to retention and turnover now, as the team adds positions and sees turnover statistics creep up.
And besides higher wages, operators are willing to offer up other incentives to improve retention and reduce turnover.
Majestic’s “all-inclusive package,” Lingle said, has a perfect attendance bonus, a cell phone, and discounted housing, among other things. The team continues to add to this benefits package as well as raising wages where needed, she said.
To that end, the team at Gurwin decided to remove the cap on vacation and holiday time, a “dramatic” move that was not easy to do, and of course had costs associated with the decision.
But, this move helped the operator cut turnover by two times, Almer said. Gurwin would only pay out this time if someone leaves – giving leadership even more of an incentive to retain workers, not to mention the change is huge for staff mental and physical health, he said.
But, operators are willing to offer these extra benefits because losing a worker is also expensive.
“That turnover cost is just as big as having a vacancy in the building,” said Lingle. “If we could find a way to keep those individuals happy, keep them in those roles and engaged, I think that is where the offset would come from. We’re still finding that recipe to make it work.”
Operators help themselves
In the meantime, operators have had to take more of a grassroots approach to recruiting and retention, with panelists mentioning applicant tracking software, and internal staffing pools.
Landi said the “must-have” software Apploi has allowed iCare to talk with thousands of candidates all at once, and remove communication barriers throughout the recruiting and hiring process. The Connecticut operator went from hiring 20 people a month to 100 people, especially once the software was opened to administrators and HR staff, rather than just recruiters.
“I literally did turn myself into a recruiter, contacting and talking about positions across all of our facilities. Now I have all these interested people I don’t know what to do with, all at once,” Landi said.
Landi’s advice is to really understand the obstacles to hiring and recruiting, and being open to finding creative solutions.
For iCare, this meant removing access issues for future employees. Calling an Uber for new hires to complete fingerprinting and safety checks, and making reference letters optional, were two ways iCare circumvented some of these barriers.
While it’s been said before that SNFs are competing with outside industries, Almer did say that competition with hospitals specifically has evolved. It was always a challenge to compete with acute care systems in terms of salaries and benefits, but he believes that gap has widened.
“As hospitals are more challenged, it just gets even harder for us to compete,” noted Almer. Hospitals are in a staffing crunch too and trying to get clinical staff in with similar tactics of sign-on bonuses.
More locally, Almer said a lot of staff have simply left the state, left the Northeast in favor of other regions.
“When you put those factors all together, it’s certainly a challenge to obtain a sufficient number of staff,” said Almer.
Concerns are starting to shift
Overall though, there seems to be a glimmer of hope among the panelists when asked about the trajectory of the staffing crisis. Landi hopes the industry won’t have a regulatory crisis on its hands in the coming years.
“That’s what the staffing mandate is. You can look at what’s happening with [civil monetary penalties] CMPs across the industry, fines. I think we know it’s post-pandemic, potentially, but, hopefully it’s just not more of a regulatory crisis.”
In terms of staffing levels and getting people into the workforce, filling positions, iCare has seen a lot of relief in the last six to nine months.
Lingle said she has seen some relief in the last few months, with states placing caps on price gouging of staffing agencies, among other changing regulations.
The numbers are proving that the staffing situation is getting better, added Almer, but it’s hard to predict anything especially given what the industry has been through in the last several years.
Companies featured in this article:
CMS, Gurwin Healthcare System, iCare Health Network, Majestic Care
