Nursing home staffing is an ongoing issue, but things are slowly calming down. As Skilled Nursing News continues to monitor changes in staffing issues—especially in light of federal staffing mandates—our focus has become even more vigilant. So we wanted to step back and offer our readers a four-part series on the current state of the industry’s workforce and some critical questions moving forward.
As the nursing home industry heads into the final quarter of the year, some operators are reporting that they have resolved the staffing issues that have wreaked havoc in recent years, though this varies by chain size and region.
“There are always going to be issues that you have to resolve. You lose someone and then you have to fill a new position. But I think things have really calmed down,” Laurel Lingle, vice president of talent acquisition at Majestic Care, told SNN.
However, the operators are not yet ready to take a breather.
“We’re seeing a turn for the better, but we’re not out of the woods yet, even though we know the rule is coming,” Lingle said, adding that operators are constantly reassessing their staffing needs and asking themselves, “What does it look like in the next six months to a year or two, and how do we get there?”
In April 2024, the Centers for Medicare & Medicaid Services (CMS) issued a staffing rule that drew widespread criticism from providers. The rule requires a minimum of 3.48 hours per resident per day (HPRD) total staffing, with special allocations for registered nurses (RNs) and nursing assistants, and a 24/7 RN requirement. This rule has been called an “extinction event” by some industry leaders due to its potential impact on operations, including increasing closures and worsening the access crisis.
And while the industry lagged behind the rest of healthcare in improving staffing levels following the Covid-19 pandemic, providers now appear to be catching up by adopting unique strategies as well as better pay and benefits, resulting in lower turnover rates and reduced use of temporary staffing agencies.
While these trends may be encouraging, it is important to remember that the Department of Health and Human Services (HHS) estimates that 75% of nursing homes nationwide will need to hire additional staff to meet the order’s requirements.
In fact, SNN has published many articles over the past year about the impact of staffing issues ranging from closures, downsizing, hospital shortages, overworked and burned-out employees, to difficulties recruiting and retaining employees. And rural and smaller nursing home chains still face an uphill battle to fill positions, especially nurse positions.
This is the first article in the series.
Recruitment efforts
At Diversicare Healthcare Services, recruitment and retention strategies that have been in place for several years are preparing for the upcoming recruiting exercise, CEO Steve Nee told SNN.
For Diversicare – and other mid- to large-sized operators SNN spoke with – a reduction in agency usage is an important indicator of progress in their efforts to stabilize and strengthen the staffing situation.
“We’ve been 100% agency-free in all of our buildings for over a year (and) we’re in the process of adding staff to get through this (staffing mandate),” Nee said. “We’re all about recruiting, attracting top talent and then also closing that back door and keeping them here. We’ve deployed a significant amount of resources and invested in our employees. And not just in the form of pay adjustments.”
Based in Brentwood, Tennessee, Diversicare operates more than 46 long-term care centers with approximately 4,500 beds. The facilities are located primarily in rural areas and provide a range of health care services, including skilled nursing and other specialized ancillary services.
Corporate culture is a central part of the company’s human resources efforts, he said.
“One of the focuses is getting the talent into the company, and secondly, retaining and ensuring that engagement. There’s a focus on things like leadership development, career advancement, additional certifications, the things that are important to those people. But we really have to tailor those things on a case-by-case basis,” Nee said.
One of the staffing initiatives that has helped Majestic is the promise of the stability of a full-time position while maintaining flexibility in work hours. It is Majestic’s in-house staffing agency, launched in 2021, a year after COVID reached its peak.
“(Our internal agency) has helped us tremendously in making sure (the employees) are trained the way we want them to be trained. They are trained on our EMR. They are trained on our guidelines and our policies. So instead of an agency employee coming in and not knowing who Majestic is, these individuals are wearing our name tags and knowing what our mission, vision and values are,” Lingle said.
These workers have all the benefits, paid vacations and everything a construction worker would have, only they make more money, she said. And the reason for the higher pay is the travel between plants.
“They get a building for their home base and a travel area. And they have flexibility in terms of shift work,” Lingle said.
The Majestic Staffing program includes 146 employees who are called upon to fill positions as needed, similar to a temporary employment agency.
Further evidence that operators are reducing agency use – and cutting associated costs – comes from recent earnings calls and financial reports from major publicly traded companies in the sector, such as Sabra Health Care REIT (Nasdaq: SBRA) and Omega Healthcare Investors (NYSE: OHI).
Not only does temping incur higher costs, but it can also result in inconsistent care and lower patient satisfaction. As recent reports have found, these agencies often provide their staff with less knowledge of the specific needs and protocols of individual facilities, which can negatively impact the quality of care.
Majestic’s in-house agency has really helped avoid the use of external contract workers and reduce labor costs from $5 million per month during the pandemic to about $200,000 currently.
Other organizations are implementing a centralized recruitment system and leaders in the field believe this is critical to effective recruitment.
“We have centralized recruitment initiatives where regional recruiters help on the ground or we use centralized platforms to find and recruit staff,” Mark Hancock, executive vice chairman of the PACS Group, told SNN earlier this year.
Customer retention efforts
Retention efforts are also being supported by increased investment in training and professional development. Facilities are recognising that providing opportunities for advancement can help reduce turnover and build a more engaged workforce. In addition, some operators are partnering with educational institutions to attract new talent, helping to meet the sector’s long-term staffing needs.
In addition to these efforts, many operators from PACS Group, Inc. (NYSE: PACS) to Health Dimensions Group (HDG) have programs in place to strengthen facility leadership, commonly known as Administrators-in-Training (AIT) programs. Leaders at these organizations told SNN that the strong leaders provide training and stability to front-line staff.
Meanwhile, both Majestic and PACS have benefited from career ladder programs.
“We also have continuing education programs that offer the opportunity for tuition reimbursement or continuing education programs. This allows nurses to improve their skills, stay current, continue their education and advance in their careers,” Hancock said.
PACS stated that its AIT program aims to combat turnover in these positions, particularly because turnover at the executive level has a massive impact on virtually every area of the company.
Companies like PACS Group also use a decentralized model for their AIT program to balance the burdensome federal and state requirements while making the experience as personalized as possible.
Building the nursing workforce remains critical for the nursing home sector as the industry faces the federal minimum staffing requirement. Some operators, such as Schmidt Wallace Healthcare, have found a way to train thousands of certified nursing assistants while remaining a small regional provider, while others work closely with academic institutions in the region.
Subsequent articles in this series will discuss AIT programs in more detail, efforts to expand frontline staffing, and provide updates and progress on the Dwyer Workforce Development model. The goal of this model is to expand the workforce pool for nursing assistants and advance their careers by addressing the real-world challenges they face that often contribute to their leaving the nursing home workplace.
Fires are still raging in some nursing homes
Nursing home operators in rural areas continue to face an acute shortage of staff.
According to Kimberly Green, COO of Diakonos Group, an Oklahoma-based and operated long-term care provider, the staffing shortage in rural nursing homes is severe and persistent.
Diakonos closed a facility in the Oklahoma city of Medford in 2021, and after converting it into a skilled nursing facility with a focus on geriatrics and psychiatric care, it still struggled to recruit enough staff, she told NPR.
Green’s efforts to resolve the staffing crisis included international recruiting, where she offered to fund the relocation of 50 registered nurses and their families to the United States. However, only 10 nurses accepted the offer. The recruiting agency eventually withdrew, citing uncompetitive salaries and the lack of attractiveness of rural Oklahoma as the main reasons for its failure.
The shortage contributes to the fact that nursing training has no connection to long-term care and that hospitals offer more attractive salaries and benefits.
A new AHCA report paints a grim picture of worsening access to health care, reporting that between February 2020 and July 2024, 774 facilities closed their doors and over 28,000 residents were displaced. Now, more than 66% of facilities are concerned they will have to close their facility if their staffing problems continue, the report says.
Given these sobering statistics, it is especially important to learn about the situation of nursing home staff and find innovative approaches to improve it.
