Strong leadership translates into a stable workforce, which is one reason why executives across the nursing home sector are recognizing the urgent need for support for Administrator-in-Training (AIT) programs. High turnover among leadership is causing massive ripple effects in just about every area of the sector.

But bolstering the administrator workforce has tremendous challenges. For starters, it takes more lead time to develop the pipeline for administrators in comparison to recruiting and retaining frontline staff, for whom workforce strategies can be changed pretty quickly.

And then, inconsistent licensure requirements, a lack of financial support from states while future administrators go through multiple years of training, and a lack of robust mentorship for AIT programs at large are major barriers to building up the administrator workforce, industry leaders said.

However, operators are hoping to address the problem head-on with higher salaries, administrator mentorship programs and decentralized training models. Given a projected shortage of nursing home administrators within the next decade, with retirements outpacing replacements, this focus on administrators is a key nursing home workforce initiative at play.

This is the second article in the SNN series on the state of the nursing home workforce.

‘Not an easy entrance’ to leadership

Companies like the PACS Group apply a decentralized model to their AIT program to create a balance between onerous federal and state requirements while also making the experience as individualistic and supportive as possible. As a result, their administrator turnover is less than 4%, compared to the national average of just under 50%, according to federal data.

Josh Jergensen, COO for PACS, told SNN that his organization’s program takes into account the challenges administrators face when they first step into the role.

“Being an administrator of a skilled nursing facility is a difficult job. There’s a lot of different hats that you have to wear, there’s a lot of things that you have to do. There’s a lot of problems you have to solve, fires you have to put out,” said Jergensen. “I don’t know if people fully expect the intensity of the position when they get into the industry. And then you couple that with at times lack of support or lack of pay.”

The intensity of the administrator role makes mentorship within the AIT program all the more important, said Leah Klusch, executive director of the Alliance Training Center, who advises nursing home operators across the country.

“That’s what the American College of Healthcare Administrators program is all about. We have a mentorship program, with some very successful administrators who mentor the AITs and spend a lot of time with them,” said Klusch. “The mentorship program, I think, is one of the most important parts of the AIT program, because then they have somebody that they can call and that really is going to take the time to either explain things or get them resources.”

Klusch completed a fellowship program with the American College of Healthcare Administrators, and the association awarded her with their Education award in 2011.

For Health Dimensions Group, the shrinking number of administrators at its facilities is a palpable issue, with some of its rural markets lacking a licensed administrator in town. Existing administrators are retiring and the road to becoming licensed can be difficult even for seasoned health care leaders, HDG executives told SNN.

“There aren’t a lot of people coming into the profession and we need more. Even if you are a seasoned hospital executive or clinical executive, you can’t just become a skilled nursing administrator overnight,” said Erin Shvetzoff Hennessey, CEO of HDG. “There are classes, there is a practicum. We don’t have a lot of people coming in. It’s not an easy entrance if you’re making a career change, and we have a lot of people retiring.”

Barriers to becoming licensed administrators

Right now, many operators are worried about the day-to-day challenges like filling the night shift. But five to 10 years down the road, there’s another high level staffing issue the industry will bump into, Hennessey said.

Stu Almer, president and CEO of Gurwin Healthcare System in New York, said there has been a significant shortage of administrators in the state, and it’s something local operators have been very vocal about given how onerous it is to actually get licensed in New York.

“We don’t allow people to really transfer over well or easily from the acute care side. We need more people with talent qualified during the most difficult times,” said Almer. “We need the best pool of people who are out there, and the requirements as they exist now for licensure are a disincentive for anyone to cross over to join us on this side, and we need it.”

Almer has served for the past year or so on the Governor’s Master Plan for Aging Task Force, reminding policymakers that requirements as they are is a huge barrier to recruiting good, qualified people.

“Yes we have qualified people, but not enough. That training requirement really just stands in the way, unfortunately,” he said.

One of the barriers to administrator path includes needless education – by nursing homes themselves.

A hospital CEO could say they want to run a skilled nursing facility, but operators typically require administrators to take extra classes to get acclimated to the sector. Useful as that practice is, the issue of excessive classes for seasoned executives can stand as a barrier to entry and should be part of the staffing conversation too, Hennessey noted.

Administrator safety net

Recognizing this, the PACS AIT program ensures trainees are well supported and have resources and thought partners they can reach out to when challenging situations arise. A system of support for every type of question: clinical, regulatory, or financial in nature, he said.

PACS administrators make anywhere between $300,000 and $400,000 in annual compensation, added Jergensen, while the national average is closer to $150,000 to $200,000 per year.

PACS has a rotating bench of administrators in training, usually anywhere from 30 to 35 across its footprint. That translates to about two AITs per region in the company and an all-time 77% retention rate.

Through March, PACS hired 219 and 169 of those AITs are still retained, said Jergensen.

“We believe this is the future,” said Jergensen. “This is the way we improve the talent in our space at the administrator position. We believe firmly, as an organization, that this is going to happen through infusing talent into the AIT program, getting them trained and allowing them to take on responsibilities of being an administrator in a facility.”

When talking about improving the nursing home sector overall, hiring great people and improving the quality of administrators through the AIT program is a major path forward, he said.

Decentralized approach

PACS has been very committed to their AIT program, Jergensen said. Key components of their program involve putting AITs with preceptors that they think will take a vested interest in that trainee. AITs are given greater autonomy and encouraged to act as CEOs of their individual facilities, while the compensation matches the level of leadership.

Most importantly, preceptors must be administrators that are experienced and successful from a clinical and financial perspective, he said. It’s a careful balancing act to make the program individualized while also adhering to state and federal requirements.

“It’s a little more individually based,” Jergensen said of the PACS program. “Every state has different requirements to go through. It’s important that each individual preceptor in each state understands the requirements, can build a program that is suited to the needs and the requirements of the particular state.”

There’s federal aspects to the program but it’s mostly state-driven, Jergensen said. That’s allowed PACS to be successful with the program since decentralizing the program fits in with the company’s wider business strategy. And, local needs and requirements of the state are met using the decentralized model.

Administrator training gets even more complicated for multi-state operators and if there’s a consolidation of ownership, Klusch said, with some states allowing administrators to move from state to state and be given reciprocity.

“Having an administrator’s license in Ohio and Pennsylvania, or Ohio and West Virginia in this area is very common, because a lot of the ownership groups have facilities in multiple states. If they want to move from one building to another, you know, that there’s also that issue,” she said.

More training uniformity, less stringent requirements needed

But it would be helpful to have a more uniform AIT program process, he said. Financial aid from the state would be helpful too, Almer said. In New York, AITs must find a facility who will take them on and train them, and then they aren’t getting paid anywhere from six months to a year while in the program.

At the very least, the state should approve a length of duration for AIT programs in New York, Almer said, while Hennessey supports some sort of bridge for seasoned executives in other health care settings to get licensed without having to go through the same process as someone fresh out of college.

“I understand the scrutiny, because we’re asking these people ultimately to hang their license and be responsible for a facility that has anywhere between 50 and 300 patients in it, and that’s a big responsibility to take on. But I do believe at times, the requirements are so different and sometimes so stringent in some states that it makes it difficult to attract new talent to the space,” said Jergensen.

Stringent requirements that vary from state to state is a barrier to entry for people who may be interested in the nursing home sector, but eventually go to other areas of health care where the barriers aren’ quite as high, he said.

Better pay will help recruit AITs, which is historically pretty low. And the longer the AIT program lasts before an individual can get licensed and see a bump in pay, the more challenging it gets to commit to the program.

A new grad coming out of college, for one, might find it difficult to commit themselves to a career if it’s going to take multiple years to get licensed, Jergensen said.