Stretched to the Limit

In long-term-care facilities, who has time to see suppliers when there’s so much work to do?

July 2022 – The Journal of Healthcare Contracting

By Mark Thill

It’s no wonder that many people call the current staffing situation in long-term care a crisis. Nursing homes lost 220,000 jobs – 40% – from March 2020 to October 2021, according to the Bureau of Labor Statistics. Compare that to hospitals, which experienced a 1.6% loss during the same period, and home health, which experienced a 1.2% loss.

“I’ve been in this industry for nearly a decade and this is by far the biggest issue facing long-term-care,” says Guy Cunningham, vice president of sales for Clock Medical Supply. “Facilities that never used agency for staff are having to do so while being forced to pay higher wages for directly hired employees. Additionally, staffing agencies are now having difficulty finding willing participants, which is adding further stress on our market.”

Longstanding issue

More than 1.4 million people live in over 15,500 Medicare- and Medicaid-certified nursing homes across the nation. For years, those nursing homes have been underfunded and understaffed, often delivering inadequate care to their vulnerable residents, according to healthcare policy experts in a recent issue of Annals of the American Academy of Political and Social Science. “The spread of the virus across the country introduced a new emergency to a long-term care sector that had already been in a state of crisis for multiple decades.”

In the past two years, more than 200,000 residents and staff in nursing homes died from COVID-19 – nearly a quarter of all COVID-19 deaths in the United States, according to the White House. “The pandemic has highlighted the tragic impact of substandard conditions at nursing homes, which are home to many of our most at-risk community members.”

Staff shortages weren’t the only factor contributing to those deaths, of course. The highly transmissible nature of SARS-CoV-2, the nature of congregate care settings, and the high-risk status of people who reside in nursing homes all played a role.

And there is some positive news. According to January 2022 data from the Centers for Disease Control and Prevention, the share of COVID-19 deaths in long-term-care facilities has decreased since the start of the pandemic (though nursing homes did experience disproportionately high case and death rates during the recent Omicron surge). Several factors are responsible, including high rates of vaccination among residents, rising vaccination rates among staff, an increased emphasis on infection control procedures, and declining nursing home occupancy.

A watchful eye

The Biden-Harris Administration has every intention of maintaining the trend. In January, the Centers for Medicare & Medicaid Services began posting nursing home staff turnover rates (as well as weekend staff levels) on the Care Compare website, and the agency will be including this information in the star rating system starting in July 2022. “This information helps consumers better understand each nursing home facility’s staffing environment and also helps providers improve the quality of care and services they deliver to residents,” according to the agency.

In February, the White House ordered steps be taken to ensure that:

  • Every nursing home has a sufficient number of staff who are adequately trained to provide high-quality care.
  • Poorly performing nursing homes are held accountable for improper and unsafe care.
  • The public has better information about nursing home conditions
    so that they can find the best available options.

The adequacy of a nursing home’s staff is the measure most closely linked to the quality of care residents receive, according to the White House, citing one study, published in the Journal of the American Geriatrics Society in June 2020. That study found that in one state – Connecticut – nursing facilities that increased registered nurse staffing by just 20 minutes per resident day encountered 22% fewer confirmed cases of COVID-19 and 26% fewer COVID-19 deaths. CMS intends to propose minimum standards for staffing adequacy and will conduct research to determine the level and type of staffing needed to ensure safe and quality care. Proposed rules will be issued by February 2023.

The White House has also instructed nursing homes to reduce resident room crowding. Most nursing home residents prefer to have private rooms to protect their privacy and dignity, but shared rooms with one or more other residents remain the default option. According to the Administration, multi-occupancy rooms increase residents’ risk of contracting infectious diseases, including COVID-19. CMS will explore ways to accelerate phasing out rooms with three or more residents and to promote single-occupancy rooms.

A willing staff

Some long-term-care facilities have been forced to close for lack of a willing staff, says Cunningham. “The reason is simple: From a monetary standpoint, inflation coupled with a lack of increased reimbursement are crippling the industry. Census was significantly reduced during the pandemic and many [certified nursing assistants] who had previously staffed those buildings left. Some [didn’t] want the vaccine and as a result, left the industry. Now, many facilities can’t accept residents because they don’t have the required licensed nursing and CNA staff to meet government standards.”

Facilities in urban areas, where willing staff are more prevalent, are managing better than others, he says. “However, they are paying up to $7 more per hour for staff than they have historically. This is a result of both supply and demand as well as inflationary pressures. Several of our customers have closed entire wings of their facilities to reduce fixed and ancillary costs as well as staffing relief.”

Staffing shortages among customers affect medical suppliers, says Cunningham. “Directors of nursing, administrators, and non-direct-care staff are being forced to work the floors and do the jobs that others once did, and they don’t have time for personal meetings with suppliers/vendors. My staff used to spend most of their pre-pandemic days in buildings, meeting with long-term-care staff, trying to understand their issues and pressure points while formulating solutions to help. This has been cut by 70%. [But] this is getting better as the pandemic normalizes to some degree.”

Reps can help their customers in a few ways, for example, by assisting them make supply choices that can affect outcomes in a positive way and help with cost-in-use, he says. But such help can only go so far. “It is never my immediate instinct to look to the government for answers to private sector problems, but in this case, they have caused the problem. The only way to fix this, in my opinion, is to increase reimbursement, which will give facilities the ability to pay a competitive wage to those willing to take care of our seniors.”

Nurse practitioners

Some believe that recruiting more nurse practitioners will help long-term-care facilities address staffing shortages. In the Journal of Post-Acute and Long-Term Care Medicine in February 2022, three researchers made the case that the pandemic “revealed the consequences of years of inattention to the many challenges facing nursing homes, including lack of access to primary care providers – physicians or NPs [nurse practitioners] – both of whom bring a complementary skill set to the LTC sector.”

Studies have found that long-term-care facilities with nurse practitioners have lower rates of depression, urinary incontinence, pressure ulcers, and residents with aggressive behaviors, they said. More residents experience improvements in meeting personal goals, and family members express more satisfaction with medical services. “By being onsite, NPs can identify changes in residents’ status, treat acute medical problems prior to progression to more complex, life-threatening situations, prevent adverse outcomes, and reduce resident suffering.”

Better days ahead?

COVID-19 has presented serious challenges for long-term-care providers, says Dennis Loflin, director, NH Med Services, an extended care distributor in Denton, North Carolina. But he believes the industry is slowly recovering, to the benefit of their communities, residents and staff.

“A nursing home is a living, breathing organism. It is a big part of the larger community and is home to a lot of people. In a sense, COVID took the life out of that for a while, because it isolated staff and residents from the outside community. But we’re slowly recovering. Families are back to visiting on a regular basis, and whether they realize it or not, they are providing care, even if it’s not direct patient care. Their presence gives residents something to look forward to and helps staff feel less isolated in what they do.

“If you go back five or 10 years and extract COVID from the equation, you’d find the culture in these communities has been getting better and better. We’ve all worked hard to make them seem more like home instead of institutions. And they are becoming much better places to work too.”

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