Loyola University Chicago School of Law, JD 2022
The COVID-19 pandemic has impacted residents and staff of nursing homes and long-term care facilities more than any other demographic, accounting for nearly 40 percent of the total mortality rate from the virus in the United States. According to Centers for Medicare & Medicaid Services (“CMS”), at least 132,000 residents and employees have died from complications of the COVID-19 across 31,000 facilities, although some estimates place the death count closer to 200,000. One factor aggravating the number of deaths in nursing homes is the extraordinarily high rate of staff turnover each year.
So what is the staff turnover rate in nursing homes?
A recent study published in the health policy journal, Health Affairs, surveyed 15,645 nursing homes across the country and found the average annual staff turnover rate in federally certified nursing facilities was 128 percent, although a considerable number of facilities had a rate that exceeded 300 percent. The authors of the study analyzed 492 million work shifts for 4.4 million registered nurses and licensed practical nurses to provide an updated landscape in nursing homes during the pandemic. Not only is this study the most recent of its kind, but it is also the most comprehensive study that proves a much higher turnover than previously theorized. By utilizing the Medicare’s Nursing Home Compare tool, the study illuminated that nursing homes with a one-star quality rating had the highest median turnover rate surpassing 135 percent, while nursing homes with a five-star quality rating had the lowest turnover rate at 76.7 percent.
The pandemic has undoubtedly exacerbated employee decisions to stay on staff throughout the pandemic or transition out of nursing facilities and into other health care facilities. These newly calculated turnover rates translate into the reality that nearly all staff that were providing direct care to individuals in 2018 would no longer be working for the same institution in any given city, state, or region.
Industry experts have long called for CMS to publish all federally qualified nursing facility staff turnover rates on an individual level in an effort to spotlight facilities with exceptional turnover, as well as put individuals on notice about their specific facility. This adjustment would allow consumers to make more informed decisions about where their loved ones would receive the best care, a top priority for many during the current public health emergency.
But how has staff turnover negatively impacted residents during the pandemic?
High staff turnover rates are often indicative of other issues plaguing nursing homes, such as low wages or inadequate staffing resulting in long shifts of providing direct care to patients. A lack of staff retention during a prolonged state of emergency creates numerous barriers for nursing homes to uniformly train staff and implement strong infection controls. Absence consistent infection management protocols, an instantaneous and rampant spread of the virus among residents in any given facility can occur – regardless of its star quality rating.
Likewise, monthly staff replacements can impact the vaccination rate at nursing homes during the pandemic. For example, if a nurse receives a vaccination from the nursing home at the beginning of the year but leaves within a span of a couple months to a higher paying job at a hospital or clinic, the nursing home is left to replace that nurse and vaccinate the new hire. The costs associated with a new hire are difficult to calculate and are dependent on individual facility resources. The undeniable truth is new hires are expensive and burdensome until they are able to fully participate in the existing nursing home system as an independent caregiver.
Are there any feasible solutions to slow the staff turnover rates?
Although industry leaders have called for CMS to implement data reporting requirements for staff turnover and other related retention metrics to be published online, others have indicated this strategy does not address the issue at its core. Instead, many experts suggest that the problem is actually low Medicaid reimbursement rates which make it hard to pay staff competitive wages in nursing homes. One of the largest expenses for any type of health care facility has historically been the cost of staffing. If providers are allotted the proper resources for frontline workers, they would be more likely to stay on staff throughout the duration of the pandemic and there would be less expense on hiring, training, or vaccinating new workers.
There is dwindling health care workforce that specializes in providing care to aging Americans, yet the population of those over the age of 65 is slated to increase exponentially within the next decade. Reimbursement rates will need to reflect the demand on the health care workforce in order to attract and retain the talent needed to care for people in nursing homes and other long-term care facilities.
Although there are no clear answers to solve the staffing crisis in nursing homes across the United States, it is clear change is needed. Whether the solution is more reporting requirements with a reward system tied to higher quality ratings or more federal and state dollars allocated specifically toward services provided to Medicare and Medicaid beneficiaries – law and policymakers must act quickly. Nursing homes are heavily regulated health care entities and compliance officers within those institutions must be up to date on any changes to payments or policies from numerous agencies.