Solving the Long-Term Care Facility Crisis

No group has suffered more loss, health decline and death during the pandemic than residents and staff of long-term care facilities. COVID-19 has ravaged nursing homes, resulting in more than 195,000 deaths. The pressures of COVID have been compounded by staffing shortages, which meant prolonged isolation for residents, as well as sometimes neglectful, abusive conditions where many suffered severe weight loss, malnutrition, dehydration, bed sores, infections and preventable deaths not related to COVID.

Long-term care facilities are experiencing major staff shortages—shortages that pre-date but have only worsened in the pandemic. Historically, too many facility owners and operators have failed to devote the necessary resources to staffing, and as a society, we have not valued such staff enough to sufficiently compensate them with a living wage, adequate training or a supportive work environment.

Low staffing has a significant negative impact on the health and well-being of residents living in these facilities. In homes with too few staff, residents may not receive basic care, including being helped with eating, taken to the bathroom, given a shower, or repositioned regularly to avoid skin breakdown.

A 2001 study commissioned by the Centers for Medicare & Medicaid Services (CMS) recommended a daily minimum standard of 4.1 hours of direct care per resident, a threshold below which the quality of care would be compromised. Nursing homes with higher staffing levels, and higher numbers of registered nurses, had fewer COVID cases and deaths. The average staffing levels in nursing homes during the second quarter of 2021 was 3.75 hours per resident day, with at least one state average as low as 3.16 hours per resident day.

A recent study shows that turnover rates among nursing home staff are around 100%.

The current staffing crisis has placed tremendous strain on residents and staff. Due to the pressures of the pandemic, fear of getting themselves or their families sick, poor working conditions, high caseloads of 15, 20, 25 or more residents, many staff reached a breaking point and left their jobs.

An average of 30% of nursing homes currently report they are facing staffing shortages, and a recent study shows that turnover rates among staff are around 100%. Due to a federal waiver of regulation implemented at the start of the pandemic, nursing homes have been able to employ workers who have not completed certified nurse assistant (CNA) training and certification requirements. Additionally, facilities are using increased numbers of temporary or agency staff. These people don’t know the residents and are less likely to notice changes in their condition or to provide care in the preferred manner. The result is a destabilized workforce that puts both residents and staff at increased risk of harm.

With so many difficulties in retaining and attracting new staff, several states, like Minnesota, have turned to the National Guard for help. While the support of the National Guard has been a godsend in some areas, clearly this is a temporary fix. Bold, strong action is needed to support those working in this field, and to make this a vocation that attracts new workers.

Resources Needed to Improve Care and Working Conditions

Nationwide, resources must be dedicated toward increasing pay and providing benefits for workers. A 2020 LeadingAge report found that providing a living wage for direct care workers would not only benefit the workforce, but also benefit the individuals they care for, and the communities in which they live.

Any additional resources allocated for long-term care, however, must be used to support workers and provide better direct resident care; and there must be transparency and accountability for how the money is spent.

‘The absence of a federal minimum staffing standard has demonstrated that facilities will not staff to recommended levels without being required to do so.’

Improving working conditions includes having sufficient staff on-hand, which will require a minimum staffing standard. Currently no such federal standard exists, and state standards are largely inadequate. The absence of a federal minimum staffing standard has demonstrated that facilities will not staff to recommended levels without being required to do so. The federal government must set that requirement.

Instead of extending waivers that allow facilities to employ staff that are not sufficiently trained, let’s ensure that opportunities and supports exist to help staff get full training, such as providing financial assistance to complete the training and certification requirements, or offering expedited training courses, such as that developed to provide certification training to the Minnesota National Guard members.

Billions of dollars in COVID relief funds have been made available or allocated to states and the long-term care industry that can be (and in some cases are) used to enhance wages and support training. The recently stalled Build Back Better Act contains important provisions that will address these issues, including billions of dollars to hire and train long-term care workers.

Sadly, the solutions to improving staffing in long-term care facilities are not new ideas. But the failure to act on them has contributed to this current crisis. As we thank the National Guard members who are stepping up and filling in to help with caregiving, let us see meaningful action by our federal and state policymakers that results in long-term solutions.

Lori Smetanka is the Executive Director of the National Consumer Voice for Quality Long-Term Care in Washington, DC.