Americans today are living longer than ever. Even with the advent of new diseases like COVID-19, exponential advances in medical science have continued to promote a steady decline in mortality rates. Yet with extended longevity comes the need for additional healthcare, and there are challenges facing LTC providers. As Staffing Industry Analysts noted, “The continued growth in demand for long-term care — including skilled nursing, assisted living and nursing homes — has exacerbated workforce shortages.” And that’s just one obstacle to overcome. By better understanding these hurdles, staffing firms can develop some creative solutions to improve the situation for LTC providers and the quality of care their residents receive.

The Long-Term Dilemma for Long-Term Care Providers

Nearly 70% of adults aged 65 years and older will rely on long-term care at some point. And long-term care (LTC) facilities will require skilled, qualified, motivated, and compassionate healthcare professionals well into the future. It’s a simple fact with a not-so-simple remedy.

“The skilled nursing and assisted living sectors lost more than 400,000 jobs during the first two years of the pandemic, not due to a drop in demand, but mainly due to a drop in supply of willing and available workers,” SIA explained in its “2023 Skilled Nursing and Assisted Living Overview” report. 

Why has supply plummeted at a time of soaring demand? Because healthcare professionals are exhausted, which is an issue we’ve discussed in previous posts. The average national turnover rate for nurses is typically 17% annually, with some regions reaching as high as 40%. The pandemic had a profoundly detrimental impact on those figures. We now confront the worst nursing staffing shortage in decades, with 60% of nurses and 20% of physicians preparing to exit their professions directly because of burn out.

Prior to the outbreak of the pandemic, LTC facilities were already dealing with annual turnover rates of 128%. Since 2020, we’ve witnessed an exodus of about 420,000 LTC employees from their jobs, many of them nursing assistants. As a result, close to 50% of the nation’s 140,000 nursing homes have been forced to limit patient and resident admissions.

Burn out and staffing shortages aren’t the only problems, though. Analysts and researchers have detailed other complications that are creating long-term problems for long-term care facilities. 

Lack of Gender Equality and Pay Parity

In our recent article on the ongoing lack of gender equality and pay parity, costing the economy some 15% of its GDP, while contributing to greater levels of attrition. If the current voluntary attrition rate for men is 9%, it’s nearly 11% for women. To put that into perspective, voluntary attrition figures for men and women in 2020 were virtually the same.

Across the entire LTC industry, the median hourly wage for men is $16.32, while women earn just $14.98 for the same work. The median wage for higher-paying roles, such as RNs, is estimated at $30.28 per hour for men, compared with $28.25 for women, according to the U.S. Bureau of Labor Statistics (BLS). 

“The long-term care workforce has a high percentage of women due partly to their history as primary caregivers, providing informal care to a child, spouse or parent,” SIA wrote in its report. But with more rigorous demands, less flexibility to focus on responsibilities at home, and lower average pay for commensurate work, we can expect more LTC nurses and assistants to seek opportunities elsewhere.

Immigration and Discrimination

According to the Economic Policy Institute, immigrant women account for 12.8% of the long-term care workforce compared to 7.2% of the overall workforce. SIA’s research indicates that they also face heightened levels of discrimination based on their identity. 

The skills shortages plaguing our industry—particularly in healthcare and nursing—are more easily solved through bolstering inclusion. In reality, immigration has been a constant source of economic vitality, innovation, diversity, production, and social benefit. Immigrants are taxpayers, caregivers, workers, job creators, and consumers.

In 2021, we cited Alexia Fernandez Campbell who broke down the real immigration issue in her 2019 article for Vox: “The hardest-to-find workers are no longer computer engineers. They are home health care aides, restaurant workers, and hotel staff. The shift is happening because more and more Americans are going to college and taking professional jobs, while working-class baby boomers are retiring en masse.” Historically, employers have leveraged immigrants to fill those positions. 

Behavioral Health

In analyzing data from a University of Chicago study of 255,000 senior housing residents, SIA determined that “4 out of 5 nursing home residents have a behavioral health diagnosis.” Those figures infer that staffing requests from LTC providers may start including roles based in behavioral health, including substance abuse registered nurses, psychiatrists, social workers, and others.

According to the BLS, the employment of mental and behavioral health clinicians in general is projected to grow 22% from now through 2031, much faster than the average for all occupations.

Pay and Scheduling Flexibility

The shortage of nurses isn’t coming from an actual deficit of skilled nurses — it’s coming from a lack of skilled nurses who are willing to work under their current conditions. Retention and recruiting now demand efforts far beyond sign-on bonuses and racing to fill seats. Flexible schedules, pay innovations, and manageable workloads are the top priorities for nurses.

• Nearly 80% of nurses who choose to travel or work per-diem are doing so not because of the increased pay rates but because they desire more flexibility in their work-life balance, in opposition to the rigid scheduling that accompanies full-time roles. 
• “While nursing facilities have faced a number of financial challenges, including inadequate government reimbursement levels, they have still needed to increase pay rates for staff in 2021,” SIA said. “Wage growth more than doubled in 2021 for RNs, LPNs, and Aides.”

Outsourcing Aversion

Acclimating the culture of LTC facilities is also much different than floating from the ICU floor to the PCU floor of a hospital. As the name implies, residents of LTC facilities are there long term. They need to see familiar faces, and staff that are on the floor every day will be more confident in what patients and co-workers need.

LTC providers often say the use of staffing agencies has an impact on staff morale, quality, and resident satisfaction. The perception is that temporary staff don’t know the policies, procedures, or the residents. And the assignment-based duration of their roles contributes to that mindset..

How Staffing Agencies Can Help LTC Providers in Meaningful Ways

The SIA report does an excellent job of illustrating the existing challenges and current state of affairs for LTC facilities. Unfortunately, it never really goes into detail about how the staffing industry can help overcome the challenges, mostly concluding that staffing agencies have opportunities to partner with “health system clients to fight this battle.” Let’s try to brainstorm some solutions that could bring real value to LTC providers and erase the stigma associated with outside staffing.

Negotiating Competitive Pay

Before the escalated rates that came in response to the COVID-19 crisis, the average hourly earnings for CNAs were between $12 and $14. Even then, those wages fell short of keeping pace with the rest of the market. A starting job at a retailer like Target is in the neighborhood of $15 an hour. The average salary for an associate-level position at In-N-Out Burger in California is $17.43 per hour, which is 28% above the national average. If LTC administrators want to return to those pre-pandemic rates, what’s stopping a burned-out CNA from deciding to ring up home appliances or flip burgers in roles where they’d face less stress and earn more money?

Across all industries, decades-high inflation has contributed to a drive for wage increases. But it’s a more pronounced issue in healthcare, where nursing supply and demand gaps have widened. On February 15, union-aligned lawmakers in California introduced legislation that would mandate a $25 minimum wage for healthcare workers and support staffers, which will likely affect hospitals, nursing homes, and dialysis centers. 

But even without government intervention, retention strategies today must include commensurate increases in wages, hazard pay, and safer nurse-to-patient ratios. Here are some tips from a recent article we penned on the topic.

• Staffing partners should provide clients or MSPs with market rate research that demonstrates the average rate increases to benchmark acceptable thresholds. They should be willing to use this data to negotiate and gain buy-in from client decision makers to increase rate caps in order to attract and retain the staff they sorely need.
• Staffing firms should embrace transparency and offer a breakdown of the cost elements that go into the bill rate: pay rate + statutory costs (e.g., FICA, FUTA, SUTA) + SG&A costs + benefits + profit percentage.
• Showcase the soft benefits that staffing suppliers offer their talent. Anyone involved in travel nursing will tell you that workers expect support and advocacy for their complex roles, including licensing assistance, logistics help, per diem structures, and more. And help clients understand how these necessary actions can increase overhead costs for firms who are providing exceptional and skilled staff.
• Look past budgets or heightened executive compensation to gauge where the market is. Nurses and allied staff are primary caregivers for patients, and their level of care reflects the reputation of LTC providers. Reputation also determines the relative value of a healthcare facility.

Leverage Workforce Technologies and Automation

LTC facilities may not realize how staffing data could benefit them during strategic planning initiatives. This is a core area where partnership and collaboration could make a significant difference. Advanced analytics collected through vendor management systems (VMS) and human resource information systems (HRIS) contain metrics and data that can help clients forecast supply and demand for nurses, determine optimal rates, and predict client occupancy requests. Nursing homes can increase their census, contain costs through targeted workforce planning, and anticipate potential spikes in demand for staff increases or lulls, further helping maintain strong staffing levels while reducing overhead expenditures.

Diverse Talent Pools and Immigrant Inclusion

Diversity, equity, inclusion, and belonging (DEIB) efforts are hallmarks of the staffing industry. Not only do staffing firms have resources, hiring strategies, networks, and even automated tools to track and bolster diverse employee pools, many have payrolling, compliance, and education equivalency protocols in place to work with immigrant talent. LTC clients need to understand that staffing firms today do much more than fill seats. We also need to rebrand ourselves as workforce solutions partners, not temporary fixes. The ability to more efficiently hire, qualify, and support immigrant healthcare professionals falls squarely in the lap of outsourced staffing providers. This is another aspect that should be clarified to LTC facilities. 

Building diverse pipelines also means focusing proactively on upcoming demands, not reacting to immediate needs with transactional approaches. So, for example, concentrating on developing talent pools for behavioral health clinicians will help LTC facilities address potential gaps before they widen into troublesome chasms. 

Better Scheduling Flexibility and Float Pools

Floating in LTC facilities is not as straightforward as in hospitals. Scheduling flexibility and integration with residents and staff are key. Here are some ways staffing agencies could help. 

• Work with nurses and CNAs to determine their ideal schedules, including shifts, shift hours, holidays, and the dates and times they want to be on call. As staffing providers build out their float pools, they should use this information to create strategic staffing plans that ensure coverage for all client needs while satisfying the expectations and preferences of the nurses in the pool.
• Determine the type of pay best suited to the nurse and his or her assignment. You can offer traditional payrolling structures like full-time or part-time, which guarantee rates and hours each week, or per diem.
• Staffing agencies should be proactive by gathering information upfront from their nurses and incorporate that data into staffing plans. This way, the best-matched nurse is always dispatched to a commensurate assignment without disruptions or surprises.
• When floating between facilities, nurses will encounter new protocols or procedures. Confronting an unpredictable situation will complicate performance and satisfaction. Savvy staffing providers should take the initiative to learn as much as they can about the facility’s demands, resident expectations, processes, procedures, operating environment, culture, and other relevant details. By incorporating these elements into an adaptive onboarding experience, nurses will be better prepared to hit the ground running. If possible, collaborate with clients to leverage the onboarding process as an acclimation and acculturation exercise, allowing new nurses to interact with residents, shadow staff, and have meaningful interactions that foster familiarity.
• If redeployment is not an option, use nurses or CNAs whose contracts are expiring as mentors for staff who will be coming onto assignment. This level of culture and knowledge transfer can be incorporated into formal onboarding processes as a way to expedite integration with the LTC facility for better outcomes at the start. Perhaps offer a bonus or payment schedule to mentors as incentive for leading these enhanced onboarding experiences. 
• Beyond that, staffing agencies can step up their games by hosting events, forums, mentoring sessions, informal gatherings, and knowledge sharing groups within the community of nurses on their staffs. Not only can this strategy heighten the sense of community and culture among the talent employed by the staffing agency, the diversity of perspectives can become a powerful tool for strengthening the acumen and development of nurses in the float pool.

Long-Term Providers Need Long-Term Partners

At our core, we believe in the same mission as our LTC clients — prolonging lives and ensuring the nation’s health. That’s why everyone on our team is invested in the relationships we forge throughout the healthcare industry and in teaming with clinicians as trusted partners, not headhunters. It’s more than a mission, it’s our passion. LTC facilities will continue to need skilled, qualified, motivated, and compassionate healthcare professionals well into the future. It’s an issue we think about often and a solution we’ve been focusing on for years. Let’s talk to see how we can collaborate to enhance the continuum of care you deliver each day.

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