Moving Forward Coalition Members Discuss Nursing Home Staffing Issues, Action Plans

As the comment period for the federal government’s staffing proposal winds down, advocates for both nursing homes and residents alike are looking at ways to reach a middle ground.

Among these advocates for measured change are members of the Moving Forward Coalition – an organization formed in April 2022 following the National Academies of Sciences, Engineering and Medicine (NASEM) report aimed to improve nursing home quality. The organization completed its first year of formation in the summer by issuing a set of action plans that develop, test and promote ways to improve how the country finances, delivers and regulates care in nursing homes.

Its leaders stress the importance of a holistic approach to maintaining the nursing home sector’s wellbeing and resolving problems ranging from staffing, surveyor shortage, and even unappealing post-acute care spaces, among other issues, by putting the resident voice as well as that of certified nurse aides (CNAs) and other clinicians at the center of the coalition’s recommended solutions.


Some of its members recently sat down with Skilled Nursing News to discuss its resident council action plans, ways to streamline the survey process so that they target nursing homes that need them the most, and share ideas to finance and enable the conversion of outdated nursing home infrastructure into the preferred small home model.

Coalition members also delved into surveyor training around person-centered care and big questions surrounding the minimum staffing proposal.

Some members weighed in on the minimum staffing proposal as well, saying operator cries for help should send a “strong signal” to the Centers for Medicare & Medicaid Services (CMS) to work together with the industry for solutions, rather than spewing out punitive measures.


To be clear, the Moving Forward Nursing Home Quality Coalition does not take a public position on the CMS notice of proposed rule making on nursing home staffing, even though individual Coalition members may take a position.

Coalition members who spoke to SNN included Alice Bonner, Coalition chair; Mary Ousley, chief strategy officer for PruittHealth; Martin Allen, reimbursement policy with the American Health Care Association; Doug Pace, senior director of long term and community-based care with the Alzheimer’s Association; Anna Fisher, Hillcrest Health Services education, quality and regulatory expert; and, April Diaz, VP of clinical services for Marquis Companies participated in the discussion.

“If lots of people are saying, ‘we simply cannot find workers, we would hire them if we could’ – that is a signal. That is not noise, that is a signal, and it’s a strong signal. We have got to fix that,” Bonner told SNN.

And the Coalition’s recommendation for alleviating the staffing crisis is to involve all the disparate areas of the sector.

“We want to bring together all the organizations, all the programs, all the apprenticeships, and then together figure out what would help a state like Montana or an inner city in New York City or Newark, what would help any of those places to be able to find staff,” Bonner said.

This interview has been edited for length and clarity.

How does the Coalition fit in with the skilled nursing industry?

Pace: We’re talking about the goals, preferences and priorities of residents who live in nursing homes and how we can elevate their voice, no matter if that’s through the providers, the surveyors – anyone that comes in contact with a nursing home to help us understand more how we can listen to the voice of the residents in everything we do.

Bonner: And act on it. That’s why we have so much engagement from the long-term care ombudsman program, because their job is to bring that voice forward. That’s a lot of the work for the resident council. If the residents are saying this, what is the nursing home’s response? What are they doing in response? What can they do? We know that not every nursing home can do every single thing that every resident asks, but there’s a lot that we can do. Helping nursing homes to understand what they can do is a lot of the focus of that work.

How have the action plans been progressing since July of last year?

Bonner: The work has been continuing since then in terms of where we can test these action plans. Where can we implement state partnerships, partnerships with organizations. Mary, Martin, and April are all running nursing homes, or helping the nursing homes to operate. These are not researchers up in an academic institution … a lot of our committee members have been selected because they’re out there doing this every day.

Fisher: With the resident council, we solicited the feedback from the residents, and from the other stakeholders, and they completed the template. Now that we’ve received all this feedback we’re in the data gathering and the analyzing stage of it and then we’re going to update the guide with this feedback and get ready for round two.

Bonner: We were talking about focusing on one state – New Jersey as an example – because we have a lot of interest there. If that goes forward, then there would be maybe a handful of nursing homes in New Jersey, where Anna and the team would bring the revised guide to them and encourage them to test it out and give them a few months to run a few resident councils.

How does the Coalition bring different people from the industry together through the action plans?

Pace: As an example, the Coalition is partnering with the Michigan Department of Licensing and Regulatory Affairs (LARA) next April on a person-centered care training initiative for surveyors that will also include providers, quality improvement organizations (QIOs) and Long-Term Care Ombudsman. We are collaborating with several other states to tailor programs that best fit their needs and that will ultimately improve resident-directed care and quality of life.

In terms of the federal staffing proposal, what has the Coalition been doing since CMS made its announcement on Sept.1?

Bonner: We’ve been saying to people, this is important, this is an opportunity to read the rule, and get as much background as you need, and then to send your comments to CMS. We’ve really been encouraging all of our organizations to send their comments. Our job is to raise awareness of staffing challenges in nursing homes, raise awareness of the opportunities and really put a positive view of [the proposal] in terms of, let’s figure out what we can do to solve this.

Nursing homes tell us it’s really hard to find staff and there’s not adequate funding – it’s not that those things aren’t true. We are here to do the background research.

How will these plans become actionable?

Bonner: We are talking a lot about staffing, but we’re doing it primarily in the context of our action plans. One of our action plans is about Medicaid incentive payment programs that a lot of states have, but not all the states have. The other one is about CNA career advancement pathways. We are working with specific states to try to get at least one of them on board with a pilot.

Pace: It’s not just about finding the people. It’s keeping the people, the retention piece, and giving people the tools and resources to do their jobs themselves.

Fisher: That’s the importance of the CNA pathways program. We recognize the work they’re doing, we recognize the challenges. And yet, we still believe in them, not only in their personal growth but their professional growth too. That’s where you see the CNA programs thrive, and the partnerships as a result.

Is the CNA voice an important part of your staffing-centered action plans?

Pace: What’s been exciting for me with this group is making sure we’ve had the voice of the CNAs and the residents on all of our workgroups. It sets us straight on what we need to be doing – it’s been phenomenal to have their voice.

Thoughts on potential litigation tied to the federal minimum staffing proposal?

Allen: [AHCA is] keeping its options open as the comment period ends and we wait for a final rule, which might not be immediate. There’s no requirement that [CMS] issue it in any certain timeframe. While the comment period for the industry and all interested parties is 60 days, CMS has great leeway in terms of how they take that feedback and what they do with it.

Bonner: CMS has to respond somehow to every single comment and that could take a year. The Moving Forward Coalition is not set up with any sort of regulatory authority and we don’t have a legal team. That’s not part of our mission. Our mission is really to educate, to advocate, to raise awareness. It is vital to have adequate, appropriately trained staff in every nursing home in this country. We will work to get that done. We do have a whole workforce committee that’s co-chaired by Jasmine Travers, associate professor at NYU, and Kesia Scales, who’s senior VP at PHI.

Any other comments on the minimum staffing proposal?

Ousley: Let’s look at what the underlying issues are and how we can solve them – and then do it together, not in a punitive fashion. Let’s keep the important individuals, our residents and our patients in the center of that thought process.

Pace: A lot of us have been doing this for a long time. If you go back and look at [the Omnibus Budget Reconciliation Act, or Nursing Home Reform Act of 1987] OBRA 87, a lot of these things we’re talking about were emphasized in that OBRA 87 report and we’re still trying to fulfill it. To me, the exciting thing was to have the [National Academies of Sciences, Engineering, and Medicine] NASEM report come out. It’s really that big landmark report, and then the John A. Hartford Foundation funding the Coalition to really say, how do we continue the conversation and see what we still need to do from OBRA 87 but reframe it in the NASEM report. It gives the Coalition an opportunity to take each one of those seven recommendations and then do something actionable with it.

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