Nursing homes are under increasing pressure to transform their businesses and care models to cater to patients with higher acuity, shorter stays, and tighter budgets.

The challenge isn’t just recruitment of staff with the right skill set, but also building an infrastructure that supports ongoing staff development. And this, in turn, calls for greater investment in training and education – not just in salaries, but in creating in-house competencies that elevate care quality.

“Skilled nursing has been the new hospital for a long time already. I’ve been saying it to my staff for over 10 years,” Joseph Kiernan, chief strategy officer and senior vice president of network development for Ocean Healthcare, told Skilled Nursing News.

With the COVID-19 pandemic leaving no doubt about the trend, organizations began modifying their practices and overhauling their workforce programs.

“Along with retention and recruitment, we have to make sure you’ve got the resources in place to be able to give the staff the training that they need, as opposed to setting themselves up for failure, which ultimately just sets us up for failure as well,” he said.

These challenges have only intensified with the growing influence of Accountable Care Organizations (ACOs) and shared savings programs, which demand greater efficiency from providers, he said. To meet these demands, facilities need highly trained, top-tier staff – and yet they’re also in direct competition with acute care hospitals for the same talent pool, while still depending on them for patient referrals.

“[Hospital partnership is] a double edged sword, where we need those high quality and highly trained staff members to be able to handle what is being asked of us these days,” Kiernan said. 

That’s why workforce development has become more of a core focus for organizations like Ocean Healthcare, which owns 12 skilled nursing facilities, all located in New Jersey, with over 2,100 beds as well as other assets in long-term care.

“But you really have to be set up and ready to go to give [workers] that training to create those competencies in house, and raise that profile of your staff – and that takes money, not only in salaries, but it takes a significant education investment for your staff,” he said 

And, organizations based in rural states require this mindset shift even more.

In rural states like Minnesota, where Monarch has 45 nursing homes throughout the state along with 17 assisted living facilities, with locations in urban and rural communities, workforce shortages remain quite pronounced. This makes the need for investment in education and retention ever more urgent, which Monarch has engaged in with help from the state.

“You have less people in these rural areas, so it’s about how do we invest in them and make it the best and and then establishing pipeline partners,” Strittmater said, adding, “Some communities are very good about partnering with the high schools, partnering with local colleges. And with others, it’s a little more of a struggle.”

And so operators have to be more proactive and self-starting in their recruiting efforts, he said.

Competition with hospitals

In rural parts of Minnesota, staffing skilled nursing facilities has been difficult – not just due to rising patient acuity, but also because of fierce competition with nearby hospitals. While urban areas may have a larger talent pool, small towns often face stark realities: fewer candidates and hospitals that set the tone for wages and expectations.

To stay competitive, some operators are taking creative approaches.

For Monarch, Strittmater explained how about half of their facilities are unionized, which adds complexity to wage structures, but their organization has worked to raise pay where possible and establish an internal float pool of 300 staff statewide. This not only helps manage staffing shortages but also offsets the high costs of overtime and external agency use. The organization has also set strict rate caps when working with agencies to keep spending under control.

Still, the key to long-term staffing success in rural regions lies in building workforce pipelines. Instead of simply competing for graduates, many facilities are working to partner with high schools and local colleges to cultivate future employees early.

“It’s really about creating careers, not just offering jobs,” Strittmater said, adding that investing in the existing local workforce is essential when options are limited.

Monarch is investing in long-term training and career advancement programs that build loyalty and promote from within, Strittmater said. As an example, he noted the career trajectory of a current director of nursing (DON) at Monarch who began as a home health aide, completed certified nursing assistant (CNA) training, and steadily advanced through the ranks – a career path that was made possible by targeted investment in staff development and a pandemic-era waiver, which nursing home advocates have requested to extend or make permanent.

In Minnesota, half of the funding for the nursing workforce supports CNA training, while the other half helps staff advance into licensed nursing roles.

It’s important for nursing homes to distinguish themselves from hospitals, Strittmater said, and can do so by better explaining their role in communities to recruits. In contrast to the often transactional nature of hospital care, nursing homes emphasize connection and community, which makes employee retention and development even more essential but also doable.

“Long-term care is about long-term relationships – with both residents and employees,” he said. “The hospital [setting] and ambulatory care is just more transactional – going to see a person once.”

Recruiting early, recruiting right

Skilled nursing facilities are recognizing that success starts with recruiting the right kind of employee – someone who truly wants to work in long-term care – and when they are just beginning their careers. 

Unlike hospital settings, skilled nursing is both clinically demanding and deeply personal, requiring staff to embrace the dual role of providing high-acuity care in what is essentially the resident’s home, said Kiernan.

“It’s like you’re in someone’s home [but] you’re dealing with IVs and drips and all of the acuity that we have to manage … that’s a different employee. It’s not a med-surg employee. It’s not an ICU or a ward nurse,” he said, reflecting on his own experience starting out in an emergency room and working in that setting for a decade, calling the difference “night and day.”

And so, rather than competing with hospitals, many operators are better off leaning into their unique strengths and seeking candidates who align with that mission. By exposing potential hires – especially those unfamiliar with long-term care – to the specialty services and complexity of nursing homes, operators hope to challenge outdated perceptions and attract talent that sees value in the work.

“Instead of fighting against it and competing with our acute-care partners, we should partner with them and just realize that that’s their space, and we’ve got ours. And let’s find the right people who want to actually be in our space,” Kiernan advised.

And focusing recruiting efforts on workers at the high-school level could improve the longevity of workers, with the state and high-school or college collaborating with nursing homes.

“How do they know if they’re going to like long-term relationships in nursing homes? Well, let’s start them early,” said Strittmater.

Monarch has multiple ongoing relationships with local high schools, which provide course credits for working in nursing homes.

“I started when I was 16, working in laundry and housekeeping in a nursing home. And when they see they can build those relationships,” that’s really how organizations can get candidates to come on board and stay, he said.