Twenty years ago, experts predicted that seniors would face a shortage of caregivers and clinicians as the Baby Boomer generation aged into retirement. They explained that caregiving “is intimate and labor-intensive and can be especially difficult when done for an aging parent.” It is challenging to attract workers who are willing to perform “unglamorous” work that “pays very poorly.”
The prediction proved to be accurate. A national shortage of caregivers is affecting older adults who want to age at home but can’t find the in-home care they need. The adult children of aging parents often sacrifice to provide unpaid caregiving services as they wait for the shortage to ease.
That shortage may have been inevitable, given that 10,000 baby boomers turn 65 every day. Millennials and members of Gen Z tend not to have many children (if any), leading to a decline in the population of workers who are available to meet the care needs of older adults. Fairly or unfairly, Americans have tended to rely on immigrants to fill low wage positions. The politics surrounding immigration add uncertainty to the labor market’s future.
Nursing Shortage
Unfortunately, the caregiver shortage also affects hospitals, nursing homes, rehabilitation centers, assisted-living facilities, and other institutions that rely on skilled caregivers to assist patients. While home health aides may or may not require a state certification, institutional caregivers typically include Certified Nursing Assistants (CNA), Licensed Practical Nurses (LPN), and Registered Nurses (RN).
Nurses, like other caregivers, are in short supply. A labor shortage in the nursing profession might deprive hospital patients and nursing home residents of access to quality care.
A nationwide analysis found that the supply of RNs decreased by more than 100,000 from 2020 to 2021 — a decrease the analysts attributed to younger workers leaving the nursing workforce. Arizona, a state with a large population of retirees, expects a shortage of nearly 30,000 registered nurses by 2025.
Nursing Homes
Nursing homes need adequate staff to deliver safe and effective care to patients. Nursing homes struggled to retain staff during the pandemic. Labor statistics highlight the problem in an industry that “lost nearly 229,000 caregivers (or more than 14 percent of its workforce) since February 2020, the worst job loss among all health care sectors.” A recent inspector general’s report described the nursing home staffing shortage as a “monumental” problem.
Nursing homes continue to struggle to fill vacant positions. They have faced the nursing shortage in different ways. Some have offered higher wages or incentives to entice employment. Some have limited their new admissions even if they have rooms available — a responsible strategy but one that, in the long run, might limit access to necessary healthcare. Unfortunately, some nursing homes have provided services with insufficient staff members. Their hope that patient care will not suffer is not always justified.
New CMS Standards
Nearly all nursing homes depend on Medicaid to fund the stays of long-term patients and on Medicare to pay for certain short-term stays. To receive payments from the Centers on Medicare & Medicaid Services (CMS), nursing homes must comply with federal standards. Those standards are intended to assure that nursing homes provide safe and high-quality care.
Recognizing that some nursing homes will be tempted to operate with inadequate staff members and that some nursing homes report higher staff levels to CMS than they actually achieve, CMS has adopted new requirements that nursing homes must meet to maintain their certification for CMS payments.
CMS uses the term “hours per resident day (HPRD)” to represent the total number of hours that all nursing staff work in a day divided by the number of residents on that day. Its new staffing standard requires nursing homes to maintain “total nurse staffing” in a ratio of one nursing staff member for each 3.48 HPRD. That staffing level must include at least 0.55 HPRD of direct RN care and 2.45 HPRD of direct nurse aide care. The remaining hours can be met with any combination of direct care nurses, including LPNs and licensed vocational nurses (LVN).
The new rules require nursing homes to have an RN working onsite 24 hours a day, seven days a week. While the RN may perform supervisory or administrative duties, the RN must be available to provide direct resident care.
There may be unforeseeable emergencies that prevent a nursing home from meeting the staffing requirement. The rules provide for “regulatory flexibility” under those circumstances.
The rules also strengthen reporting requirements by requiring greater evidence of staffing levels than a number typed into a form. That reform may add greater value to the CMS Nursing Home Compare tool.