Survey changes, value-based care and other regulatory updates are shaping how operators hire and build clinical teams. As regulatory priorities shift and staffing conditions stabilize, nursing home hiring is increasingly driven by specialized expertise and a clearer sense of accountability to a company’s core values.
And while federal policy actions, such as greater scrutiny of antipsychotic use, remain influential in hiring practices, a company’s approach to recruiting, interviewing and promoting employees is playing an ever more important role in building and retaining a stable, long-term workforce.
Monarch Healthcare Management’s approach tries to balance a range of internal and external factors, VP of Innovation and Bench Strength Dan Strittmater, told Skilled Nursing News.
For bolstering clinical teams, staff with more expertise in polypharmacy have been added, he said, referring to residents taking five or more medications daily – Minnesota-based Monarch seeks out this expertise, supported by technology used to monitor these areas.
It makes sense that polypharmacy is affecting hiring as well, considering CMS’ focus on balancing antipsychotic reduction with appropriate use, and the agency adding schizophrenia coding limitations to its risk-based survey eligibility test. MDS and compliance rules also require facilities to track antipsychotic drugs and “as-needed” medications, while state and federal surveyors now look for documented proof that nursing homes have tried non-medication treatments before using behavior-altering drugs.
Polypharmacy is handled by the medical director at New York-based Gurwin Healthcare System, CEO Stuart Almer said, and the operator has its own in-house pharmacy with hands-on clinical expertise. Almer has seen other operators bolster polypharmacy through vendor partnerships.
“Increased attention to psychotropic medications, supporting diagnoses and medical oversight requires stronger collaboration among nursing, prescribers, the medical director, consultant pharmacists and behavioral health professionals,” Stuart Lindeman, CEO of Florida-based Mission Health, told SNN. “Operators may not create a separate position for every need, but they will seek more specialized expertise and clearer accountability.”
Another specialized role on the rise involves quality assurance and improvement, Almer said, filled by a staff member with clinical training. Quality measures, quality care and survey readiness are all central to this role, he said.
Overall, surveys affect hiring decisions because they connect staff to resident acuity, competencies, turnover and outcomes, Lindeman said. That means nursing homes must hire the right combination of skills while continuing to validate competencies and ensure leaders understand what’s happening at the bedside.
Operators want staff with deep knowledge of infection prevention, behavioral health, wound care, medication management, the MDS, staff development and transitional care, Lindeman said.
Leadership still hired internally
Monarch also adheres to its mission of hiring and promoting from within.
Monarch’s leadership is filled internally 80% of the time, no matter if it’s clinical, administrative or another area, said Strittmater.
“We are heavily invested in developing our own and reach all the way down into high school and college collaborations,” said Strittmater. “There are two examples of high school students becoming interns and then administrators.”
Today’s nursing home leaders, including the medical director, need to be visible, hands-on and comfortable with data, Lindeman said. It can’t be a passive role; the medical director needs to actively implement care policies, coordinate medical care and address clinical concerns addressed through QAPI and survey activity.
The biggest hiring opportunity comes when operators stop talking only about jobs and start talking about careers, he said.
“We want a CNA to see a pathway to becoming a nurse, and a nurse to see a pathway to becoming a clinical or operational leader,” said Lindeman. “The future of skilled nursing depends not only on whom we hire, but on how well we welcome, develop and retain them.”
Monarch leaders ask questions prior to an interview and shares more information about a position so interviewees are more informed going in, and time isn’t wasted on either side on what won’t be a good fit. Weeding out individuals who may not get what a role entails has helped keep a more predictable hiring success rate, he said.
AI use in the interview process has helped too, Strittmater said.
“Only if the candidate is comfortable with that,” Strittmater added of AI interviews. “These strategies allow us to spend more ‘human time’ with candidates that need or want more time, or have more questions.”
At Mission Health, interviews are more intentional with behavioral-based interviewing and realistic job expectations baked into the process.
Generally, applications and interviews happen after hours or on weekends, and potential staff want to see immediate progression without worrying about setting up and waiting for an interview, Strittmater said.
“This allows our talent acquisition specialist to work asynchronously and again spend more human time with folks who may get most of the information from technology but want to spend a lot of time on a few topics,” said Strittmater. “Other candidates just want to breeze through, maybe they already know us.”
Gurwin’s hiring practices hinge on culture and the employee experience, Almer said, so much so that the operator changed its tagline from “Caring for Generations” to “Caring for YOU.”
“We have made a decision to emphasize a people first focus with our employees, providing hiring and referral bonuses for hard-to-fill roles and offering other perks including training programs and connections with educational institutions to help our employees and find new talent,” said Almer.
The link between relationships and quality care
Medical directors and similar roles require a large amount of time and energy poured into building relationships – this person needs to know and understand Monarch as an organization and have a good handle on the communities nearby.
“Long-term care is about long-term relationships,” Strittmater said of the evolving medical director role. “They want to be connected to the local community and hospital. We spend time and work with wonderful providers who are excited about serving our rural, suburban and urban communities.”
And while a nurse practitioner can’t fill the medical director role, their experience and perspective creates a valuable resource for the medical director and interdisciplinary team.
“The right NP can make any medical director more effective,” added Strittmater.
A medical director that is good at building and maintaining relationships internally and externally is critical to quality care Almer said, echoing Strittmater’s link between good medical directors and connections in the community, and with staff.
Gurwin has been lucky enough to have stable nursing home leadership and medical director positions with deep connections to the surrounding communities. More specialized roles are contracted out, but the training and experience ripples through the organization “like waves,” Strittmater added.
Monarch uses external resources for polypharmacy, wound care, mental health and other specialized services to help internal staff move up the learning curve. Staff oftentimes focus on such special areas to help Monarch maintain and improve care.
Strittmater noted that value-based care was another external force affecting hiring practices – the initiative has helped Monarch strategically plan out how to spend valuable resources.
“Value-based care shifts the focus from staffing positions to building capabilities,” added Lindeman. “Through our partnership with Theoria Medical and participation in an ACO, Mission Health strengthens timely clinical access, early identification of changes in condition, medication management and care coordination.” Theoria Medical provides technology-driven primary care and clinical management.
With value-based care taken into account, Mission Health increasingly values staff that can collaborate, use data and help prevent avoidable hospitalizations, all while keeping the resident and family experience at the center, said Lindeman.
Companies featured in this article:
Centers for Medicare & Medicaid Services, CMS, Gurwin Healthcare System, Mission Health, Monarch Healthcare Management
