The timing and feasibility of the federal staffing mandate continue to haunt nursing home operators and communities, particularly those in rural areas, where providers across the health care continuum are competing to find clinical staff.
Take for example, the case of a nursing home owned by Diversicare Healthcare Services in Yorktown, Texas, which is one of three nursing homes in the county. The county, with its 21,000 residents, had just 99 registered nurses, a number barely sufficient for existing clinical care facilities, let alone for the additional staffing requirements mandated by new regulations, Steve Nee, CEO of Diversicare, noted in a recent conversation with Skilled Nursing News.
“There are simply not enough people to be able to meet the needs of the mandate,” Nee said.
Tennessee-based Diversicare operates more than 46 long-term care centers with about 4,500 beds, and has been working tirelessly to navigate a maze of challenges.
Meanwhile, Owen Hammond, president and CEO of Cascadia Healthcare, shared similar frustrations that have pushed operators to be more assertive with their lobbying efforts as they seek to change ill-conceived policies, especially on the state level, he said.
Idaho-based Cascadia operates 58 facilities across five western states.
Hammond and Nee spoke at Skilled Nursing News’ RETHINK conference in Chicago last week on how operators are managing the existing staffing challenges and anticipated ones stemming from the Centers for Medicare & Medicaid Services’ (CMS) minimum staffing mandate. The mandate is currently being challenged by various operators as well as lobbying groups for the sector.
And regardless of the outcome of that court battle, operators are in the midst of plans to fix staffing challenges, the leaders said.
“What we’re seeing in a lot of our facilities is that we’re not able to take all of the patients from the hospitals, simply because we just don’t have the staff to take them,” Hammond said.
For Cascadia, the turnover rate for its nursing staff is higher at 86% compared to the overall employee turnover rate of 76%, he said.
No easy solutions
The situation with staffing has left providers faced with deploying three strategies to increase workforce numbers, Nee said. None guarantee results nor are they worry free.
“You can grow your own [workforce], which is exceptionally difficult for operators to do on the nursing front – maybe a bit easier on the CNA front – by running CNA classes, med-tech classes, etc. You can poach from your competition, which is of no help to anybody, and is really just taking from one to pay for the other, right? And the third is being able to bring them in [from abroad],” Nee said.
To address the worker shortage – efforts that began prior to the Covid-19 pandemic for Diversicare – the organization partnered with employee-placement agencies to recruit foreign-trained nurses, primarily from the Philippines.
Fulfilling positions with immigrant nurses came with its own set of hurdles, however, including visa restrictions and delays as well as the complexities of integrating international staff into the rural workforce.
That said, even though it has been an ongoing process and still in its infancy at Diversicare, the strategy to get immigrant nurses has provided some relief and will play a vital role in alleviating some of the staffing pressures, Nee said.
“We’ve had some great success with that, but it comes with its own challenges. We’ve all heard of retrogression (with visas) happening recently. Also, the number of visas that are being approved for these type nurses are limited, but we are pushing through and making a significant investment,” Nee said.
Nee said the move for immigrant nurses also stemmed from a need to fill those “chronically” open positions for evening, night shift, or more difficult-to-fill weekend shifts, mostly for licensed nurses. It hasn’
The overall staffing ‘war’ versus the fight against the mandate
The industry has become a battlefield of sorts, with operators fighting both against the mandate and for the survival of their facilities. The regulatory burden is immense, and while the lawsuit against the mandate is gaining traction, the industry’s challenges are far from over.
“I don’t think that anything in our industry is wait-and-see. We need to plan for it,” said Hammond.
On the state level, efforts are being made to mitigate the impact. In Idaho, where Hammond’s organization is a major operator, there has been active engagement with the governor and local legislators.
Both leaders from Diversicare and Cascadia also said that they have been actively involved in lobbying against the staffing mandate, with Diversicare submitting hundreds of letters during the comment period as the organizations work closely with lawmakers at both state and federal levels.
“I think it’s just a continued effort by all of us in all the different states. We’re in five states, and we try to be as active as we can,” Hammond said. “But [the lobbying] is amongst everything else that’s going on in our industry.”
Even if the mandate is overturned, the staffing issue remains, Hammond said. And, the Cascadia team is keenly aware that the new staffing requirements would exacerbate their existing problems, so they are continuing to work to fill positions, even as the lobbying continues.
“Whether [the staffing mandate] happens the way that it’s proposed, or if it’ll be changed or modified, we don’t know, but we definitely have not only the issues with the mandate, but we still have a staffing issue, and so we still need to figure out how to overcome and get more staff into our facilities,” Hammond said.
The rising need for skilled nursing care – and an accompanying crisis of access – is projected by shifting demographics. By 2050, the population aged 65 and above will be 50% larger, and a substantial portion will require long-term care, Nee noted.
Tackling staffing
The challenges are not just regulatory but also deeply structural, and the executives recognize this. Many facilities are still facing difficulties in retaining staff, with high turnover rates.
“There are definitely a lot of headwinds in our direction,” said Hammond. “If we look at where we need to be at for the staffing mandate as it pertains to nursing hours … if you’re talking about the full 3.48 HPRD, around 20% of our [buildings] wouldn’t qualify for that. We would need to increase mostly in the rural areas [but] some urban areas are really tough to get there as well.”
And while increasing the clinical workforce through immigrant nurses has been helpful, overall retention of employees past the first 90 days has been a challenge, Nee said. And for that reason, the company has focused on improving onboarding processes and making sure new hires feel supported from day one.
“And what we’ve noticed is that 78% of our turnover occurs within the first year of employment, and of that 78% about 44% of that happens within the first 90 days. So for us, specifically, we’ve had a laser focus on orientation and onboarding,” Nee said.
This approach is reflected in Diversicare’s recent efforts to eliminate agency staffing. “We have been agency free for 100% of our buildings over the last year – that’s kind of an anomaly in this business,” Nee said.
Diversicare’s turnover rate for direct care staff is 56% on an annualized basis, he said.
“[Turnover] been ticking down year over year, and we are on pace to hopefully get that below 50% as we move into 2025,” Nee said.
For Diversicare too, ways to address staffing are important beyond the fate of the staffing mandate because the need and threat to access is so great.
“We’re probably going to get [the staffing mandate] overturned. The lawsuit is going to be very successful. But, think of that as winning the battle, when really we need to be focusing on winning the war,” Nee said.
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