It’s never been easy finding workers willing to help others with their most personal bodily functions for not much more than they’d earn at a fast-food restaurant, but the pandemic pushed staffing at Colorado’s nursing homes from tight to a near-crisis.
The state’s nursing homes were hit harder than almost any other institution during the pandemic, with almost 28,000 infections and more than 1,900 deaths among residents and staff attributed to COVID-19 since April 2020.
More than 2,000 people working in Colorado nursing homes have left the industry since the start of the pandemic in March 2020, forcing some homes to stop accepting new residents and straining care for those already living in them.
The situation isn’t expected to improve much during the current lull in COVID-19 infections, and both owners and employees of nursing homes are skeptical of a new proposal by the Biden administration to boost staffing.
Megan Emmerich, who retired in November after 30 years working as an administrative nurse focused on quality improvement in a Fort Collins nursing home, said it’s going to be difficult to hire new staff. Hospitals are aggressively recruiting nurses and raising their wages, and the rates Medicaid pays to nursing homes make it impossible to compete, she said.
“I think long-term care is in a bind that many other health-care facilities aren’t,” Emmerich said.
President Joe Biden’s plan to build up staff would require the Centers for Medicare and Medicaid Services to propose minimum staffing levels for nursing homes within the next year. The federal government also would increase some penalties for repeat violations of quality rules and give states more money to conduct inspections.
“For too long, corporate owners and operators have not been held to account for poor nursing home performance,” the White House said in a fact sheet.
Nate Schema, CEO of the Good Samaritan Society, said that new staffing mandates would push more nursing homes out of business, especially if they came without additional money. Staffing shortages led the Good Samaritan Society to close its Greeley campus recently and halt new admissions at its Fort Collins location for much of the last two months, he said.
“It would be a death sentence for many of our nursing homes,” he said.
Schema said the Good Samaritan Society’s nursing homes in Colorado and 21 other states would like to hire more people, but right now they can’t find takers for about 2,500 jobs that are already open across the organization.
“Our staffing challenges have been nothing short of extraordinary,” he said. “It’s a struggle on a daily basis.”
Jayla Sanchez-Warren, director of the area agency on aging serving Denver and seven surrounding counties, said advocates have pushed for higher staffing ratios for three decades, but it’s generally gone nowhere because of opposition from the nursing home industry and concerns about how much more Medicaid might have to pay.
The issue has become more urgent over time, because people are living in their homes for longer, making the average nursing home resident older and sicker than they were when the debate started, she said.
Choosing a nursing home
If you’re trying to decide on a nursing home for a loved one, call your local long-term care ombudsman’s office for the most up-to-date information about staffing levels and conditions in facilities, said Jayla Sanchez-Warren, director of the area agency on aging serving the Denver region. Just because a hospital recommended a facility doesn’t mean it’s the best choice, because some have financial arrangements that guide their referrals, she said. It’s also a good idea to visit facilities in the evening or on a weekend, since staffing is often lower in off-hours, Sanchez-Warren said. If you think someone is being mistreated in a long-term care facility, contact the Colorado Long-Term Care Ombudsman’s Office. More information is available at tinyurl.com/longtermcareombudsman.
The current federal standard is that homes should have a nurse available for at least eight hours each day, and enough staff to provide two hours of care to each resident, Sanchez-Warren said. While that might sound like a lot of attention, some residents are dependent on staff for things even as basic as turning them in bed so they don’t develop wounds from lying in one position for too long, she said.
Staffing “is absolutely fundamental. It’s the most important thing in a nursing home,” she said.
People who don’t work in nursing homes don’t always understand the amount of work that goes into caring for residents, said a Front Range nurse who has worked in the industry for 30 years. She spoke on the condition of anonymity over fear of retaliation by her employer.
The situation has improved a bit since last year because nursing homes no longer have to worry about staffing separate units for COVID-positive residents, but it’s still not unusual to be responsible for 20 patients, the nurse said. Ideally, each nurse should have about half that many, because they need to oversee medication distribution, make sure those who have medical appointments get to them, clean and bandage any pressure sores and wounds residents have, help with hygiene care and talk to residents who are lonely, she said.
Generally, residents understand when they have to wait for assistance, but it’s frustrating for staff, and family members sometimes yell at the caregivers for delays that aren’t under their control, the nurse said. She’s skeptical anything will change in the near future, and said federal officials have said they’d study the problem of low staffing multiple times, with no noticeable results.
“This has been going on forever,” she said.
While staffing is important, the federal government would do better to put resources toward educating providers about how to improve quality, rather than conducting inspections and leveling fines, said Doug Farmer, president and CEO of the Colorado Health Care Association, a nursing home trade group.
The administration’s “accusatory” tone was disappointing, since most owners are doing their best for residents, he said.
“Certainly, staffing is worth taking a look at, but in our current environment, I don’t know where those staff would come from,” he said. “The money would be better used to put people out in the field to teach providers what it is they want done.”
Pandemic worsened staffing shortage
In March 2020, employment in Colorado residential care homes peaked at about 44,000, according to data from the U.S. Bureau of Labor Statistics. As of December, the last month with data, about 41,700 people were working in long-term care facilities in the state. That’s a roughly 5% drop, and unlike most health care settings, their employee numbers haven’t begun to rebound.
During the worst point of the omicron surge, in January, Colorado sent about 260 members of the National Guard to help with residents’ direct care in understaffed facilities. The state had taken a similar step in December 2020, when so many workers were out sick that some homes couldn’t care for all of their residents without help.
Keeping workers is also an issue. Of the 183 Colorado nursing homes with data on Medicare’s Care Compare website, 123 saw at least half of their staff turn over in the last year.
It’s not solely a Colorado problem. Nationwide, just over half of nursing home workers turned over in the last year, though some likely stayed in the industry. The American Health Care Association reported half of nursing homes nationwide were limiting admissions because of staffing challenges as of early January.
Leah McMahon, the state’s long-term care ombudsman, said some difficulty hiring and keeping enough staff isn’t a new problem. Still, states never had to send the National Guard in to help with elder care before COVID-19, she said.
“Since the pandemic, I think what we’re looking at is really unprecedented,” she said.
The ombudsman’s office doesn’t track the reasons why residents call looking for help, but the regional ombudsmen have reported hearing concerns about failures in basic care that often come with low staffing, like residents being left alone or becoming dehydrated, McMahon said. Falling while unattended or going too long without food or water could send residents’ conditions spiraling, possibly causing permanent harm, she said.
Inspectors attributed failures in care to low staffing in 32 Colorado nursing homes in 2021 and 22 facilities in 2020. Both figures are likely undercounts, since inspectors don’t always record the reasons behind problems they cited, and a report only happens if they happen to find something during a routine visit, or if someone files a complaint.
The most common ways that care fell short were that residents didn’t get their showers consistently or reported long waits to have their call lights answered. In multiple cases, residents said they had to sit in wet or soiled underclothes because no one was available to help them to the bathroom.
It wasn’t clear from state inspection records whether low staffing contributed to COVID-19’s impact on Colorado’s nursing homes.
A 2020 study of nursing homes in Connecticut where registered nurses had more time with each patient recorded fewer COVID-19 cases and lower death rates, but that could reflect other differences among facilities. And while bringing in additional workers to fill the gaps means more people can care for the residents, it also increased their exposure to the virus, particularly when those staffers had worked in other facilities with outbreaks.
Farmer, the head of the Colorado nursing home trade group, said the industry got hit hard from the beginning of the pandemic, when staff had to stay home to care for children, or quit because they feared bringing the virus home. Some of those people have left the industry permanently, while others joined staffing agencies, where they command much higher rates, he said.
Typically, about 80% of beds in Colorado nursing homes are full, Farmer said. In the first months of the pandemic, occupancy dropped to about 65%, as hospitals stopped elective surgeries that might have resulted in temporary admissions and some families kept their relatives at home longer.
Now, occupancy has risen to about 70%, and homes don’t have enough staff to open more beds, he said.
The situation has exacerbated problems through the health care system. If nursing homes don’t have beds for patients who need physical therapy before returning home, those patients remain stuck in hospitals, which are themselves short-staffed. Home health care agencies have reported a similar staffing problem, making it harder to discharge patients who need support to live on their own.
Emmerich, the Fort Collins nurse, said her employer had it easier than some, because students interested in medical careers would sometimes work as certified nursing assistants to get some hands-on experience. CNAs provide much of residents’ personal care, such as helping them with baths.
Staffing got tighter during the pandemic because so many CNAs had school-aged children, and the remaining staff couldn’t work enough overtime to fill the shifts, Emmerich said. They managed by having nurses and administrators fill in for CNAs, but residents did have to wait longer for care, she said.
While CNAs and nurses handle direct care, shortages of other staff have also caused problems, Emmerich said. For example, if there aren’t enough people working in the dining room, the direct-care staff have to take time out of their shifts to bring residents their meals, she said.
“If they couldn’t make other arrangements, they just couldn’t work,” Emmerich said. “There just were not enough people to fill available slots.”
Pay is low, but can it go higher?
There’s broad agreement that pay for caregivers in nursing homes is low. The dispute is whether nursing homes can offer more with the resources they have.
The roughly 300 Good Samaritan campuses spent about $62 million last year on temporary staffing to fill gaps, which is more than twice as much as they would have paid if they’d been able to hire enough permanent workers, Schema said. The labor cost of caring for each resident jumped from an average of $170 to $245 per day, he said, and the Medicaid rate would need to be at least $30 higher each day to completely cover a resident’s needs.
“In many ways, the math doesn’t work,” he said. “If we don’t see more support… I’m concerned we’re going to see more skilled nursing facilities closing.”
Medicaid is the largest payer in most nursing homes. Medicare, which pays a higher rate, only covers short-term stays, such as when a person needs rehabilitation after a long hospital stay. Residents covering their care out-of-pocket typically pay higher rates until they largely exhaust their resources, and then Medicaid takes over.
Medicaid pays an average of about $242 per resident per day, though it varies based on how much care residents need, Farmer said. That rate has to cover their room, meals, medications and day-to-day care, as well as a portion of the facility’s maintenance, housekeeping and administrative costs, he said.
A report commissioned by the American Health Care Association estimated that expenses exceeded revenues by almost 6% at the median nursing home last year — meaning half were further in the red, and half either lost less or made money. A separate report by the Medicare Payment Advisory Commission, a nonpartisan group that advises Congress, found revenues had exceeded expenses by about 3% over the last year, mostly because of supplemental funding due to the public health emergency. It’s not clear why they reached such different conclusions.
The trade group’s report estimated hourly wages rose by about 8% in 2021, with larger increases for certified nursing assistants, who are some of the lowest-paid employees. Job listings in the Denver area in early March showed rates were still relatively low, though, ranging from about $17 to $30 per hour.
Target recently raised its hourly rate to $24, for a job that’s far less physically and emotionally taxing, said Sanchez-Warren, with the metro area agency on aging. Plus, certified nurse assistants have to complete a state-recognized training program, which can take up to 10 weeks.
“Would you rather sell clothing or wipe people’s bottoms?” Sanchez-Warren said. “You have to pay more to get the kind of people you need.”
Schema said the Good Samaritan homes are trying to come up with ways to attract workers when raising pay isn’t feasible. They’re examining the benefits package and looking at ways to make scheduling more flexible for people who don’t want to work the same shifts every week, which is how they’ve usually done things, he said.
One of the biggest things that would help is if the state and federal governments remove barriers for people who want to move up the career ladder, Farmer said. That could mean offering financial assistance and child care to people taking classes, or increasing the number of available slots in nursing schools, he said.
A partnership between the Centers for Medicare and Medicaid Services and the U.S. Department of Labor would attempt to recruit more people for direct-care jobs in nursing homes, but an overview released by the Biden administration was light on details.
“We’re in the middle of a true staffing crisis right now,” Farmer said
Nursing homes are facing headwinds, given that people can find less-stressful jobs that pay more, and some have left the field either because they didn’t want to get COVID-19 or didn’t want to get vaccinated, Sanchez-Warren said. Still, some chains have managed to pay out dividends to shareholders, suggesting that in some cases it would be possible to raise wages and attract workers, she said.
“I think (Medicaid and Medicare) are going to have to pay more, but I think they need to do a deep dive… and make sure that money goes to care,” she said.