With nursing home operators having a couple months to process the minimum staffing proposal, many are taking a hard look at what would need to change to meet the proposal in its current form, and what revisions would make the most sense.
Leaders with Trilogy Health Services, Avamere Living and Ignite Medical Resorts caution that the mandate would worsen wage pressure that is already becoming hard to sustain. Meanwhile, suggestions for improving the proposal include an outcomes-based process rather than static ratios, and ensuring the Centers for Medicare & Medicaid Services (CMS) creates a pathway toward building the workforce needed to meet the mandate.
Expected demand for caregivers over the next decade is “somewhere between immovable and impossible,” said ConnectRN CEO Ted Jeanloz, adding that funding for nursing schools will be critical. Jeanloz spoke as part of an Oct. 23 Skilled Nursing News webinar on the mandate and the state of play for nursing home staffing. ConnectRN is an online community of more than 100,000 nurses looking to get connected with positions in SNFs, hospitals and home health.
Including other practitioners outside of registered nurses (RNs) and certified nursing assistants (CNAs) in the proposal can also help drive quality, said Carl Tabor, president of Oregon-based Avamere, which operates 33 facilities between Oregon and Washington.
The obvious addition is licensed practical nurses (LPNs), White said, along with therapists and other ancillary staff. Practitioners included in the proposal should be dictated by the types of services rendered, Trilogy COO Todd Mehaffey said. Louisville-based Trilogy operates 132 properties across five states.
“For us, we have a pretty dynamic set of campuses from independent living to skilled nursing with in-house dialysis units. Our in-house dialysis unit campus needs RNs 24 hours a day, seven days a week. We have a very strong clinical model there,” said Mehaffey. “We also have campuses that have memory care, and are more daily rhythms, bedside caregivers and are life enrichment-driven.”
Whatever the outcome of the mandate fight, the LPN labor market is going to be interesting to watch in the coming years, Jeanloz said, especially as the role has “floated up” to be closer in training to RNs rather than CNAs and being back in hospitals for the first time in a generation; the acute care space hasn’t really been hiring LPNs in previous years, at least until hospital started feeling the workforce shortage themselves.
There may be downward pressure on wage rates for the role, and it will be harder to convince CNAs to start on the path toward an LPN if the market faces wage compression for this position, he said.
RN requirement is the hardest ask
Overreaching, arbitrary, hollow and a little bit union-driven were adjectives assigned to the minimum staffing proposal – and while panelists agreed it’s a positive to require appropriate and robust staffing, the way CMS about crafting this proposal was not very well thought out.
The 24/7 RN requirement and 0.55 hours per patient day as part of the 3.0 total hours in particular is short-sighted, panelists said. Registered nurses are the one position that operators can’t really “self-generate,” Mehaffey said; building up that workforce demands a long-term fix.
Tabor said the 0.55 for RNs is still a hang-up for Avamere, even with its facilities in Washington and Oregon already meeting state-specific minimum staffing standards. If a state has 60,000 licensed RNs, typically 75% are actually practicing, and then on top of that only about 4% would be working in the long-term care space, he observed.
The availability of educators and nursing school resources is another consideration, Tabor said. Mehaffey agreed that there aren’t enough spots in schools because of a lack of educators, while facilities can grow CNAs and set them on the path to become an LPN in-house.
“Although it’s a three year phase-in in the state of Oregon, the Oregon Center for Nursing and the Oregon State Board of Nursing is anticipating anywhere from [a] 4.3 to 5.7 year recovery time … there’s not going to be enough nurses if recovery takes five years or more in the state of Oregon,” said Tabor.
Mehaffey said about 84% of Trilogy’s campuses hit the metric – right now.
“That’s today. Three years from now, if we think it’s pressurized today for retention and recruitment, holding on to what we’ve got is only going to get stiffer between now and when the mandate actually takes effect. It’s going to be paramount,” said Mehaffey.
As more operators focus on creating competitive wages for needed roles to meet the staffing minimum, that means there won’t be many dollars left for investing in other areas, he added. Inflation costs are eating away at overall revenue too.
“Florida is a prime example. Five years ago, the average percentage of labor as a percentage of revenue was running around 30%. Today, that number in Florida is 50% to 53%,” noted Mehaffey.
Existing staffing incentives will need to be reevaluated, Ignite Medical Resorts Chief Culture Officer Jim White said, given the expected labor costs driven by the minimum staffing proposal. Additional $5 or $6 to a base rate if a caregiver hits certain goals will need to be “amped up,” he said, along with potential extra paid time off, raises and gift cards that are part of Ignite’s employee incentive program.
Illinois-based Ignite operates 19 facilities across six states.
Concessions and incentives
CMS may be keeping the addition of LPNs in its back pocket, Mehaffey said, with a potential to increase the required hours per resident day if they are included. The agency is seeking comment on the alternative total nurse staffing standard of 3.48, among other options, which would still be made up of 0.55 RN HPRD, 2.45 CNA HPRD, while the leftover 0.48 is not assigned to any particular role.
He hopes to see LPNs added in some way to the 0.55 RN aspect of the staffing minimum requirement.
“I don’t see any mechanism where our profession survives without LPNs,” added Mehaffey. Tabor said it will be “impossible to function” without LPNs on the roster.
If CMS sticks with only requiring RNs and CNAs, Tabor said the demand for RNs in particular will put pressure on wages, when salaries are already escalating. Avamere has increased wages for its nurses by 46% over the last four years; Tabor expects the minimum staffing proposal to continue to drive that up, if finalized.
Tabor said Avamere properties have 1.2 to 1.3 total licensed nurse hours, but that’s dependent on LPNs.
Panelists agreed that retention and employee engagement will be paramount as operators prepare for the finalized minimum staffing rule. With that in mind, Ignite will continue to focus on a robust orientation process – a huge aspect of retention.
“A lot of the people that turn over, they don’t get the orientation that they need on the floor to feel comfortable in the building. They leave because they feel that they were thrown to the wolves,” said White.
Tabor said Avamere is looking at more engagement with RN programs and working closely with labor unions to help fund CNA to LPN pathways.
Trilogy continues to build out its tuition reimbursement and apprenticeship programs, which have been key for the company in the last three to five years. Leaders keep an eye out for potential CNAs that may have come to Trilogy as a housekeeper, while trainers have oftentimes come from its own workforce.
“There’s just not enough school programs where we can get the amount of staff that we need. And then we’re competing with everybody, even just on this call, quite frankly, for that same employee coming out of a class. When we do [classes] in-house, they’re a little bit more captive for us,” said Mehaffey.
In the years leading up to mandate implementation, Jeanloz said ConnectRN will be a platform for caregivers to upskill, especially those that are back in school.
“I think we’re going to see a lot of that as the mandate rolls out and RNs become more and more in demand,” said Jeanloz.