10% Cost Increases on a Zero Margin: SNF Providers Rely on Efficiency, Flexibility Amid Labor Crisis  

“There are things that I know my colleagues here do that we would not have considered a year ago, two years ago, three years ago. We have to be flexible if we’re going to retain staff and bring them into our organizations.”

These are the words of Stuart Almer, president and CEO of Gurwin Healthcare System, which operates skilled nursing facilities as part of a full continuum of health services on Long Island.

Such radical flexibility is imperative in order to staff buildings while maintaining the bottom line in the current labor crisis facing the sector, he believes. And his perspective was shared by other nursing home leaders who recently spoke on a panel at Skilled Nursing News’ Virtual Staffing Summit.


Flexibility must go hand-in-hand with operational efficiency, according to Mike Landi, COO of iCare, which operates 11 facilities in Connecticut. iCare has invested in applicant tracking software, which helped the provider go from hiring 20 people a month to hiring 100 people. But tech alone is not sufficient, he said, and iCare has enacted changes across its hiring and onboarding process, including busting some myths about hiring requirements.

“It’s really peeling back the entire process,” he said.

And Majestic Care — which operates 36 care communities across Indiana, Ohio and Michigan — likewise has enacted broad changes, from raising wages to subsidizing housing, according to VP of Talent Acquisition Laurel Lingle.


But while operators are taking steps that might have seemed radical even a few years ago in an effort to meet the moment, all three executives also agreed that more sustainable reimbursement and public sector financial support is required.

“We’re seeing, certainly on the nursing side, a full 10% increase in our salary and benefit cost; 10% on a zero margin is pretty tough. So it’s clearly a great challenge,” said Almer.

Read on for further highlights of the panel discussion in the following transcript, which has been lightly edited for length and clarity.

Skilled Nursing News: Mike, you mentioned that you’ve “turned yourself into a recruiter.” Can you explain what you mean by that?

Landi: … We brought in some applicant tracking software, which we hadn’t used before. And I think it’s a must have. And now you’re able to talk to hundreds or thousands of candidates all at once. And we did see [applicant] numbers increase last summer, but we weren’t getting back to them. We weren’t getting back to them timely … and once I literally did turn myself into a recruiter, contacting and talking about positions across all of our facilities. It kind of created a mess, because now I’ve got all these interested people I don’t know what to do with all at once. But I realized what those obstacles were to get them through our process, our hiring process, our recruitment process.

SNN: Has iCare implemented any changes then in its hiring and onboarding processes?

Landi: We did. Some of them are a little subtle. We do centralized hiring, just because Connecticut’s small and we have 11 facilities that are drivable. But getting more orientations on the calendar. Connecticut has a fingerprint system, where you have to be fingerprinted as part of the background screening … what did we do, if they showed up at orientation not fingerprinted? We sent them away. Now, I’ve driven them, [or] we hire an Uber. There’s five or six people going to get fingerprinted that day and coming back to orientation.

It’s really peeling back the entire process. And what are those myths? There was a company myth that we had to have reference letters. Now, reference letters are good, but it’s another step for people to be taking, that they’re not taking, and being almost maybe fearful of all those requirements for the job. So,we don’t want to be in a position where we’re hiring anybody, but we want to be in a position where we’re making the process as easy as possible. And there’s just countless examples there.

So a big change for us was using applicant tracking software. We use a company called Deploy. They’re based out of the health care space, primarily. We interviewed a bunch. I’m sure there’s strengths or weaknesses to many of them. But we found that product to really be very easy to use. And we opened it up; instead of [just] the recruiter being able to use it, all of our administrators need DNSes [directors of nursing services] are using it, all of our HR staff … At the end of the day, we went from hiring 20 people a month to 100 people a month.

SNN: That’s a big jump. Any changes that Gurwin has made in hiring and onboarding?

Almer: I clearly agree we have to be smarter in how we approach things. And in order to do that, it’s also collecting data and continuing to monitor. At times, we’ve looked at our hiring rates, we’ve looked at our retention rates, and sometimes we’re surprised by what we see. So staying on top of that, and then adjusting as needed is important. Flexibility is key.

There are things that I know my colleagues here do that we would not have considered a year ago, two years ago, three years ago. We have to be flexible if we’re going to retain staff and bring them into our organizations. But there are a few things that we’ve done that I think are a little bit unique, and they’ve really worked with us.

One that’s not so unique but a bit grassroots-oriented is working with schools. We’ve always had great relationships with universities, with colleges. And now we’ve taken that to another level. In the past, if we ever had to approach a department and say, can you take students in rehab or in recreation, sometimes there would be a reluctance to doing that. It’s work. It’s involved. It takes a lot of time. Yet here, I’m thrilled our whole management team has strongly embraced it. Why? Because they realized that’s really the answer. We have to bring young people into our system, we have to do more training. This is the future. This is our labor force. And it’s tough, but it’s working.

The other thing we’ve done is, we had a turnover in our Chief Human Resources Officer position. And we created a unique job description, and the title is Chief People Officer. And we’re proud of that. And we promote that. That’s important to us, because it’s really about the people, it’s about all of us.

We also created a position called Resident Care Associates. These are staff … who are providing very, very important assistance to residents on the floors. It might be bringing them water, answering phone calls for them, delivering their mail, whatever it might be. But by doing that, it makes the job easier for nurses. And that’s the key. If we can make the nurse’s job easier. We were challenged to find enough nurses and of course enough CNAs. Now, we took it a step further, and we now have a formal approved training program … we train, we pay them while they’re RCAs, and now they become CNAs, and they grow with the organization. So the pathway is clearly working.

I think these are the types of initiatives we all need to do, but not forget that being visible, doing the small things for staff day in and day out, getting their feedback and implementing things that they recommend are key. So it’s really a combination of smarter and more flexible, and yet going back to grassroots.

SNN: Laurel, what are some of the changes that Majestic made in onboarding processes?

Lingle: I’ve done a lot of different things … Like Mike, one of the states that we work in has a fingerprint [requirement]. We have decided everybody can come to the building at one time, and we take them to get the fingerprints.

We’ve moved a lot of our physicals … in house. The physicals get done prior to orientation. Some folks weren’t going to get the physical or we had to send them away. Once you’ve sent them away, and you don’t have them in a seat, they’re not coming back. And I think we’ve moved to a place of everyone is getting through the process quickly.

We’ve also created a slideshow with videos, so our message is consistent across every building. We have found that if someone was out, especially during the pandemic, if someone was out ill … it held up hiring. No longer will that be the case. Anyone in the building can hit play, and that same message is created and given to every care team member across the board. That has really made a difference in our facilities. When someone was out sick, it was like no one’s here to do the orientation … The buildings couldn’t sustain with continuing that. So, those are just a few of the things that have really made an impact for us.

SNN: Stu, I wonder if we can talk about pay and benefits a bit. Has Gurwin raised its hourly wages or enhanced its benefits packages recently, and is it helping to attract


Almer: We’re always looking to stay competitive. Certainly within the nonprofit sector, we have no choice, right? We need to stay competitive. So we’ve made adjustments where needed. We continue to do that. I’m happy to address benefits as well. But here’s the challenge that we have. We have fewer beds available, because we often have safe staffing. And yet we’re seeing, certainly on the nursing side, a full 10% increase in our salary and benefit cost; 10% on a zero margin is pretty tough. So it’s clearly a great challenge.

And in terms of benefits, you know, we have doubled what we’ve done in terms of sign-on bonuses and referral bonuses. And many of us have done this. Even our educational allotment for folks who want to take classes, go back to school, we’ve doubled our educational allotment. All of this comes at a cost.

It’s working. When I sign paperwork every day, the bonuses, the bonuses … It’s working, and we’re seeing good people, young people joining us. Never enough, never fast enough. We’ve got to watch retention. But I think the changes, they are working, it’s just, again, advocacy needed for financial relief and support, so we can all remain competitive.

SNN: Mike, I’d like to ask you the same question, anything you’d add related to iCare’s approach to wages and benefits?

Landi: I think a lot of providers are doing things they maybe have never done before, never thought they would do before. Looking at the benefits structure, there’s opportunities to improve it, too. We’ve done that in terms of retirement and certainly wages. Connecticut’s had wage enhancement since the only Medicaid increases we’ve seen have been tied to wage enhancement. So, for instance, RN supervisors. To be competitive, we’ve had to pay them over $100,000. A lot of them earn $120 for nursing supervision. There’s an RN requirement in Connecticut. RNs are at a premium.

… Eleven of our 12 facilities are union. So, we don’t have the flexibility, but we’ve had more adjustments in between contracts, and we’re catching the staffing crisis mid-way in a four year contract; usually, we’re seeing two-year contracts. So I don’t usually look forward to negotiations. I’m kind of looking forward to 2025, which is the next contract cycle, because that’s usually when we’re pushing through bigger increases, and the state is getting behind [us with] Medicaid dollars as well. So it’s tough being a union provider, when it comes to that flexibility, but for our non-union staff, as the other panelists are saying, that’s the reality. A good part of my day is matching offers and coming up with different strategies.

SNN: And Laurel, anything you’d like to add?

Lingle: We’ve looked at raising wages where needed. We also went fully into an all inclusive package, which we call the Majestic Difference. That allowed for a $5 perfect attendance bonus, every community member that’s full time to have a cell phone, discounted housing.

So we really looked at what can change the care team members’ lives in whole versus just that hourly wage. And we continue to enhance that. We’re always looking at something new to add to that package.

Companies featured in this article:

, ,