Study- Half of All States Approaching a ‘Caregiving Emergency.’

Home care worker shortages and rising care costs in America have pushed nearly half of states to the brink of a “of an unpaid family caregiving emergency,” according to a new study by Columbia University Mailman School of Public Health. “America’s Unseen Workforce: The State of Family Caregiving” is the latest installment in a caregiver research series sponsored by Otsuka America Pharmaceutical, Inc. (Otsuka). Unlike most studies that concern the availability of paid professional caregivers, the new study focuses on unpaid family caregiving.

The good news: Ohio and Missouri are among the list of 20 states categorized as "Safe for Now;" the others are Alaska, Colorado, Connecticut, Delaware, Illinois, Indiana, Kansas, Maine, Massachusetts, Montana, New Jersey, New York, Pennsylvania, Rhode Island, South Dakota, Utah, Vermont, Washington, and Wyoming. The study warns, however, that active monitoring is necessary in these states to ensure that family caregivers remain in control; economic and demograghic pressures are stressing these family caregivers. More, even in states where critical shortages don't yet exist, and family caregivers are generally supported, caregiving is especially challenging in more rural communities.

The challenges are felt most acutely in Alabama, Arkansas, Florida, Georgia, Louisiana, Nevada, South Carolina and Tennessee. In these states, pervasive workforce shortages and large rural populations make it extremely hard for home-based care providers to deliver services, placing an outsized caregiving burden on seniors’ family and friends. Georgia, for example, has one of the largest home care aide shortages in the US and is designated as “critical” in the report.

Nationwide, unpaid caregivers contribute approximately $375 billion in labor each year, the report found. The report also highlighted the high and growing burden of dementia caregiving. Dementia is associated with approximately 40% of the total value of unpaid caregiving in the US, according to the report. This is equivalent to roughly $150 billion annually in unpaid dementia-related care costs.

Given these significant burdens — as well as the federal government’s focus on cost-cutting — the researchers called on state and local policymakers to implement solutions that benefit unpaid family caregivers. John McHugh, PhD, lead researcher for the report, said in a statement:

“At a local level, it is repeatedly the family caregiver who shoulders the immense pressures generated by healthcare shortages and rising dementia cases.Without strategic, state-level initiatives, the strain on our healthcare system and economy will only intensify. It is important for policymakers to recognize the value of family caregivers and consider the long-term savings that can be achieved by acting now.”

Debra Barrett, vice president, corporate affairs at Otsuka added:

“Although caregivers don’t have a choice but to continue their vital work, it is essential that policymakers understand the difficult choices being made by families across their state and assist in supporting the valuable contributions of unpaid caregivers. Progress is being made, but achieving comprehensive change requires strong support and collaboration from both federal and state governments. At Otsuka, our support of this study reflects our broader commitment to advocating for family caregivers everywhere. As we look ahead, we must commit to long-term solutions that uplift and sustain family caregivers, recognizing their critical impact across the country.”

The report findings underscore the need to advocate for more support and resources for unpaid family caregivers:

• In an era of reduced government spending, it’s crucial to establish a consistent and reliable standard of support for unpaid family caregivers at the state level.

• States must advocate for funding to support programs that provide financial assistance, training, and respite care for unpaid family caregivers to meet the growing demand and avoid putting more strain on their local healthcare systems.

• States with a higher rate of dementia care must urgently implement new solutions for unpaid family caregivers to bridge the workforce gap. 

• To get ahead of the rising demand for managing complex, chronic conditions like dementia — traditionally managed by healthcare professionals — training and certification programs for family caregivers are essential.

• States with higher rural populations must implement targeted strategies to support the unpaid caregiving workforce. 

• Where there is a shortage of healthcare workers, states can support family caregivers financially in recognition of their contribution to the healthcare system.Investing in the long-term care workforce at the federal level is crucial. This involves better training, higher wages, and finding long-term solutions for staffing challenges for both institutional and community-based care.

Just the fact that there is a focus on home health caregivers is important- these cargivers are vital in an aging in place plan. Tax, and regulatory reform could better incentivize and support family caregiving.

Otsuka is the lead, founding sponsor of Caregiving, a two-hour documentary for PBS portraying paid and unpaid caregivers navigating the challenges and joys of "this deeply meaningful work." Intertwining intimate personal stories with the untold history of caregiving, the documentary reveals the state and the stakes of care in America today. The project, created with executive producer Bradley Cooper, premieres June 24 on PBS and is available to stream on May 27 on PBS.org and the PBS App. It is the next feature film of the WETA award-winning Well Beings campaign, which addresses critical health needs in America. To learn more about Otsuka’s caregiver commitment visit: otsuka-us.com/caregiver.

Executive Order Expanding Apprenticeships Could Ease Staffing Shortages in Nursing Homes, Assisted Living Facilities

An executive order to consolidate federal workforce programs could address workforce shortages among senior living and other aging services providers by expanding apprenticeships, according to an article penned by Kimberly Bonvissuto, writing for McKnight's Senior Living. This comes at a critical time given that Biden era staffing mandates have been stuck down by a federal court.

Trump signed an executive order, “Preparing Americans for High-Paying, Skilled Trade Jobs of the Future,” on April 23 with the goal of expanding and improving job training for skilled trades. The order directs the Labor, Education and Commerce departments to streamline and consolidate federal workforce programs, with a focus on expanding registered apprenticeships to more than 1 million annually.

Although the initiative is most directly aimed at the  administration’s goal to revive US manufacturing, LeadingAge Director of Workforce Policy Amanda Mead said in a written announcement that it could help alleviate critical workforce shortages in the aging services sector: 

“While the president’s executive order is widely seen as part of the administration’s push to revitalize US manufacturing, the initiative to expand apprenticeships could also benefit direct care workers — such as nursing assistants and home health aides — by offering enhanced training and alternative educational pathways beyond traditional four-year degrees.” 

Argentum is a national trade association representing senior living communities across the United States. It advocates for policies that benefit the senior living industry and its residents, serving companies that own, operate, and support professionally managed senior living communities. Argentum’s mission includes promoting quality care, operational excellence, and workforce development within the sector.

Back in 2020, Argentum  touted the success of the Healthcare Apprenticeship Expansion Program, which served more than 7,600 incumbent workers through a $6 million Closing the Skills Gap grant from the Department of Labor. The association also petitioned the Centers for Medicare & Medicaid Services (CMS) to include assisted living in an incentive program geared toward attracting registered nurses to skilled nursing facilities.

Since the 2020 grant, staffing challenges in the senior living industry have persisted and intensified, particularly due to the COVID-19 pandemic. In response, several efforts emerged to bolster the workforce:

• Workforce Development Initiatives: Argentum has continued to prioritize workforce development, launching initiatives such as partnerships with educational institutions in 2022. These programs aim to create career pathways, offering training and opportunities for individuals entering the senior living field.

• Legislative Actions: At both state and federal levels, there have been efforts to address staffing shortages in healthcare, including senior living. These include funding for training programs, loan forgiveness for healthcare workers, and incentives for employers to hire and retain staff. For instance, discussions around immigration reform in 2023 have explored allowing more foreign workers to fill caregiving roles, while some states have introduced minimum staffing requirements for nursing homes, potentially influencing senior living practices.

• Improved Compensation and Benefits: To attract and retain staff, many senior living providers have increased wages and enhanced benefits, recognizing the competitive labor market and the need to make these roles more appealing.

• Technological Innovations: The industry has also turned to technology to supplement staffing needs. Solutions like telehealth services and remote monitoring have been adopted to enhance care delivery and reduce the workload on existing staff.

In late 2023, a survey I conducted for an article (I never published) suggested that  38 states and the District of Columbia had established their own minimum staffing standards for nursing homes, but that figure was gleaned from internet searches; I could find no readily available source cataloguing the states and their staffing regulations.  I was surprised that the information wasn't more readily available since federal staffing mandates were then a hot topic.  

An Argentum spokesman told McKnight’s Senior Living:

“There are far too few caregivers to meet the needs of our rapidly aging population, and it will take an across-the-board approach to recruit and retain more than 20 million workers who will be needed across long-term care by 2040.” Three million of that 20 million will be needed in senior living alone, according to Argentum."

The American Seniors Housing Association (ASHA) told McKnight’s Senior Living that  the aging population demands a steady pipeline of workers to serve older adults living in senior living communities and other long-term care settings. ASHA Vice President of Government Relations Jeanne McGlynn Delgado appears optimistic:  

“Identifying and implementing federal training programs that can attract and grow this workforce, whether it be in retooling existing grant programs or expanding apprenticeships specifically for senior living workers, shows much promise,” ASHA ."

The American Health Care Association/National Center for Assisted Living told McKnight’s Senior Living that it continues to support making apprenticeship programs more available and accessible, including supporting the recently introduced American Apprenticeship Act to provide tuition assistance to fund apprenticeship programs:

“We’ve seen the value they can bring through our own apprenticeship partnership with Equus Solutions, who has supported some of our long-term care providers with the process. Apprenticeships are one of the many solutions we need to help recruit and retain more long-term caregivers, and we appreciate this effort to help address the nation’s growing caregiver shortage.”

Despite these efforts, staffing remains a critical and ongoing challenge in senior living. The effectiveness of these measures is under evaluation as needs increase, and the industry and governments continue to seek innovative and sustainable solutions to ensure high-quality care for residents. 

You can help.  Develop a plan to age in place.  To the extent possible, relegate institutional choices to "when and if it is absolutely necessary, and there is no available alternative."  You and your loved ones will likely experience better outcomes, and you will relieve an already burdened system.  

Federal Judge Blocks Biden-Era Nursing Home Staffing Rule – Implications for Care Quality and Families

On April 8, 2025, a federal judge in Texas struck down a Biden administration rule aimed at establishing minimum staffing requirements for nursing homes that receive Medicare and Medicaid funding. This ruling, issued by U.S. District Judge Matthew Kacsmaryk, has significant implications for the quality of care in nursing homes, the families who depend on these facilities, and the broader debate over healthcare regulations in the U.S. I'll explores the details of the rule, the lawsuit challenging it, the court’s rationale for blocking it, and the potential effects on nursing home residents and their families.

The Blocked Rule: Minimum Staffing Standards for Nursing Homes

The rule, announced by the U.S. Department of Health and Human Services (HHS) in April 2024, sought to address chronic staffing shortages in nursing homes by imposing the first-ever federal minimum staffing standards for long-term care facilities. Issued by the Centers for Medicare & Medicaid Services (CMS), the regulation required nursing homes to:

• Employ a registered professional nurse (RN) 24 hours per day, seven days a week, a significant increase from the existing federal requirement of eight hours per day.

• Maintain total nurse staffing, including nurse aides, at a minimum of 3.5 hours per resident per day (HPRD), ensuring a baseline level of care for residents.

The Biden administration framed the rule as a critical step to improve care quality for the 1.2 million residents in Medicare- and Medicaid-certified facilities, citing systemic issues exposed during the COVID-19 pandemic, such as understaffing leading to neglect and poor health outcomes. CMS argued that higher staffing levels would enhance resident safety, reduce infections, and improve overall care, aligning with the Federal Nursing Home Reform Act’s (FNHRA) goal of protecting residents’ “health, safety, and dignity”.

The Lawsuit: Basis for Challenging the Rule

The lawsuit by the American Health Care Association (AHCA), a major nursing home industry group, and Texas Attorney General Ken Paxton, among others, in May 2024 argued that the rule was unlawful on several grounds:

Exceeding Statutory Authority: The plaintiffs contended that HHS and CMS lacked the authority to impose such stringent staffing mandates. Federal law, specifically the Social Security Act, explicitly requires nursing homes to have an RN on-site for eight consecutive hours per day and to provide “sufficient” staff to meet residents’ nursing needs. The plaintiffs argued that the new rule’s 24/7 RN requirement and 3.5 HPRD standard went beyond what Congress had authorized, effectively rewriting the law.

Financial and Operational Burdens: The nursing home industry highlighted the practical challenges of compliance, citing workforce shortages and financial strain. The AHCA claimed that the mandate would force many facilities to close, displacing vulnerable seniors, as the industry already struggles to hire and retain staff amid a national shortage of healthcare workers. At least one operator, LaVie Care Centers, blamed the staffing rule for its bankruptcy filing.

Arbitrary and Capricious Rulemaking: The plaintiffs argued that CMS failed to adequately justify the rule’s immediate implementation and did not tailor the staffing requirements to the diverse needs of nursing home populations, as required by federal law. They claimed the 3.5 HPRD formula was a “one-size-fits-all” approach that ignored facility-specific factors.

The Court’s Ruling: Legal Basis for Blocking the Rule

Judge Matthew Kacsmaryk, granted summary judgment to the plaintiffs on April 7, 2025, vacating key provisions of the CMS rule. His decision rested on the following legal bases:

Lack of Congressional Authority: Kacsmaryk ruled that HHS and CMS exceeded their statutory authority under the Social Security Act. He noted that Congress had explicitly set the RN staffing requirement at eight hours per day, and the 24/7 RN mandate went beyond this limit. Similarly, the 3.5 HPRD standard was deemed inconsistent with the law’s requirement for “sufficient” staffing tailored to residents’ needs, as it imposed a rigid national formula.

Failure to Tailor Requirements: The court found that CMS did not meet statutory requirements to customize staffing levels based on the specific needs of each facility’s resident population. Kacsmaryk criticized the 3.5 HPRD formula as an unlawful “one-size-fits-all” approach, arguing that it did not account for variations in resident acuity or facility resources.

Procedural Deficiencies: The judge held that CMS failed to adequately explain the need for immediate implementation of the rule, a requirement under the Administrative Procedure Act. This procedural lapse further supported the decision to block the mandate.

The ruling was celebrated by the AHCA and industry groups as a victory for nursing homes, with AHCA President Clif Porter stating that the “unrealistic staffing mandate threatened to close nursing homes and displace vulnerable seniors.” Critics, including elder abuse attorney Ed Dudensing, argued that the decision “undermines the very safeguards designed to protect our elders’ dignity and well-being.”

Impact on Quality of Care: RN Staffing and Health Outcomes

Vacating the staffing rule raises significant concerns about the quality of care in nursing homes, particularly given the establishment view of well-documented correlation between RN staffing levels and resident health outcomes.  In a later article I will address critically recent challenges to this establishment view.  Regardless,  studies have consistently shown that higher RN and LPN staffing is associated with generally better physical and psychological outcomes for residents, while understaffing contributes to neglect, infections, and increased mortality.

Physical Health Outcomes: 

• A 2021 study published in Health Affairs found that nursing homes with higher RN staffing levels (at least 0.75 hours per resident per day) had significantly lower rates of hospitalizations, pressure ulcers, and infections compared to facilities with lower RN staffing. The study estimated that increasing RN staffing to this level could prevent 136,000 hospitalizations annually.

• During the COVID-19 pandemic, a 2022 CMS report highlighted that nursing homes with RN staffing below 0.4 HPRD had a 30% higher mortality rate from the virus, as understaffed facilities struggled with infection control and timely care. See, CMS, “Nursing Home Staffing and COVID-19 Outcomes” (2022).

• The blocked rule’s requirement of 3.5 HPRD, including RN presence 24/7, aimed to address these issues by ensuring consistent oversight and care. Without this mandate, facilities may continue to operate with insufficient RN staffing, potentially leading to increased physical health risks for residents, such as falls, medication errors, and untreated infections.

Psychological Health Outcomes:

• A 2019 study in The Gerontologist found that higher RN staffing was associated with lower rates of depression and anxiety among nursing home residents. RNs, with their advanced training, are better equipped to recognize and address psychological distress, provide emotional support, and coordinate mental health interventions.

• Understaffed facilities often rely on chemical restraints (e.g., psychotropic medications) to manage resident behavior, a practice that led to litigation in the Talevski case, where the Supreme Court affirmed residents’ rights under the FNHRA to be free from unnecessary restraints. The blocked staffing rule could have reduced such practices by ensuring RNs were available to implement non-pharmacological interventions, improving residents’ psychological well-being.

Impact on Families of Nursing Home Residents

Families who depend on nursing homes to keep their loved ones safe and well face significant challenges as a result of this ruling. To family members, the decision removes a federal safeguard that could have ensured consistent care, leaving families with heightened uncertainty and potential risks:

Increased Risk of Neglect and Abuse: 

• Understaffing is a leading cause of neglect and abuse in nursing homes, as overworked staff may lack the time to provide adequate care. The NHRA requires personalized care plans and regular reviews, but without sufficient RNs, these plans may not be implemented effectively. Families may worry about their loved ones experiencing preventable issues like pressure ulcers, dehydration, or untreated infections due to inadequate staffing.

• For example, in the Talevski case, a family discovered that their father was chemically restrained with psychotropic medications due to understaffing at a county-owned facility, leading to his deterioration. Families will likely worry that such incidents may become more common without mandated staffing improvements.

Emotional and Financial Strain:

• Families often choose nursing homes expecting professional care that they cannot provide themselves, particularly for loved ones with complex needs like dementia. The ruling may force families to spend more time monitoring their loved ones’ care or hiring private caregivers to fill gaps, increasing emotional and financial burdens.

• If facilities close due to financial pressures, as the AHCA warned, families may face the trauma of relocating their loved ones, potentially to facilities farther away or with even lower staffing levels.

Aging in Place Planning

One positive effect of the court's decision, and the controversy surrounding it, is that more potential residents and families of potential residents will take seriously the need to age in place, and implement comprehensive aging in place planning. If you would like to know more, subscribe to this blog.  You will be receive periodic notifications of online aging in place planning workshops. If you can't or don't want to wait, there is a recorded, somewhat dated, workshop available here: https://bit.ly/Aging-in-Place-Workshop.  You can watch this presentation in the comfort of your home, and share it with your successor trustees and health care agents. 

Aging in Place Planning is a comprehensive estate, financial, and health care plan orienting your decision-making and resources to make aging in place more attainable, likely, and enforceable by your trusted advisors and fiduciaries, all to the goal of avoiding non-hospital institutional care entirely.  It incorporates reducing the risks of guardianship, and protecting assets from a court-appointed guardian.  

Aging in Place Planning can be incorporated into any existing estate plan.  It can be can be used in conjunction with irrevocable trust planning to shield assets from nursing home spend down, or as an alternative to such planning if it is deemed unnecessary or unacceptable.  

Advocacy Challenges

The NHRA provides for ombudsmen to investigate and address nursing home issues, but without federal staffing mandates, families may need to rely more heavily on these advocates to ensure care quality. Ombudsmen, too, are often overstretched, and their ability to enforce improvements may be compromised by increased demand resulting from the consequences of inadequate staffing.  Of course, like any funded resource, the ombudsmen program is limited without robust federal backing.

Broader Implications and Critical Analysis

The ruling reflects a broader tension between regulatory oversight and industry autonomy in healthcare. While the AHCA and nursing homes argue that the mandate was unworkable amid workforce shortages, critics assert that it was a necessary step to protect vulnerable residents. The decision also highlights the political divide on healthcare policy: Congressional Republicans and the Trump administration, including CMS Administrator Mehmet Oz, have signaled opposition to the rule, while Democrats sought to preserve it.

The establishment narrative—both from CMS and the industry—has obvious gaps. CMS’s rule, while well-intentioned, did not adequately address the root causes of staffing shortages, such as low wages, poor working conditions, vaccine mandates, and a lack of training programs, which continue to drive nurses away from the industry. Mandatory staffing may, actually miss the point entirely, since it is the nature of the resident population that dictates needs; some populations require less from an RN, and more from either LPNs or aids. Finally, staffing is not likely a panacea for the inherent risks of institutional care, many of which lead to rehospitalizations, the real target of federal effort. 

On the other hand, the AHCA’s claim that the mandate would lead to widespread closures may be overstated, as some facilities might have adapted by leveraging technologies like telehealth, and future demand may slow as a result of greater reliance on hospital-at-home, the former as specifically suggested by Oz.

Regardless, from a resident and family perspective, the ruling is a setback. The public will likely perceive that without federal enforcement, care quality may remain inconsistent, particularly in underfunded facilities, leaving families to bear the burden of advocacy and oversight.

A focus on either providing more alternatives to institutional care or encouraging and financing aging in place where possible might provide greater and more satisfying solutions. Reconsideration and reorientation of long-term care in the U.S. is long overdue.

Conclusion

The federal judge’s decision to block the Biden-era nursing home staffing rule on April 7, 2025, removes a critical safeguard intended to improve care quality for nursing home residents. The rule aimed to address systemic understaffing by mandating 24/7 RN coverage and a minimum of 3.5 HPRD, but the court ruled that CMS exceeded its authority, citing inconsistencies with congressional legislation and procedural deficiencies. The ruling is likely to perpetuate understaffing, increasing risks of neglect, infections, and psychological distress for residents, as evidenced by studies showing the benefits of higher RN staffing.

For families, the decision heightens concerns about safety and well-being, potentially requiring greater involvement and resources to ensure adequate care. While the nursing home industry celebrates the ruling, the long-term impact on vulnerable residents underscores the need for alternative solutions, such as state-level mandates or incentives to address workforce shortages, to uphold the FNHRA’s promise of dignity and care for nursing home residents.

Senior Care Staffing Shortage Crisis- Nightmare Scenario Warns One-Half of Facilities Could Close

The shortage of staff in long-term facilities and home care agencies has gone from a problem to a crisis, according to Howard Gleckman,  a fellow at the Urban Institute.  Consider the following:

• Three rural nursing homes in Maine close because they cannot hire enough staff to maintain care for patients and residents.
• One of the oldest nursing facilities in Summit County, Ohio closed, citing an array of post pandemic financial difficulties, including cost of maintaining adequate staff. 
• A senior living facility in Camden County, Georgia was forced to close due to staffing shortage.  
• A nursing home in Oklahoma shuts its doors due to staff shortages.
• A nursing home in Kansas closes due to staff shortages.
• A new industry survey reports that only 1 percent of nursing homes and 4 percent of assisted living facilities (ALFs) say they are fully staffed, while 89 percent of nursing homes and 82 percent of ALFs report moderate or severe shortages.
• Fifty-eight percent of nursing homes and 28 percent of ALFs say they are limiting admissions because they do not have enough staff to care for residents.
• As many as one-half of all nursing homes and assisted living facilities in the nation could close within the next year, if the current staffing crisis is not alleviated, according to Washington Health Care Association CEO Robin Dale.

Gleckman notes that staffing shortages don't impact just nursing homes and assisted living facilities, but impact the entire spectrum of senior care.  For example, the operator of a Maryland home health agency claims it is turning away families looking for assistance because it does not have sufficient aides; “We cannot provide the care our clients deserve with the staff we have,” she told Gleckman.  

Fundamentally, though, as resources are spread thin across the entire health care industry, opportunities for cover and redundancy are disappearing.  Whether those opportunities are within or outside of a formal system, seniors are forced to rely upon less in the hopes that care quality will remain high. The reality is that a system can provide generally high quality care only when it's component parts work to support each other; hospitals support care institutions, care institutions rely upon a full complement of staff within a facility, and upon other outside institutions, to supplement and support care and accept patients best placed in the care of others.  

Many long-term care workers are leaving the health care profession entirely. Widespread shortages of low-wage workers in the hospitality industry give aides the opportunity to work for as much money—or even more—at jobs that are far less physically and emotionally demanding.

Gleckman also warns that these labor shortages appear to be growing at the same time the long-term care industry is confronting another equally important trend: consolidation. Not only are facilities closing, but operators are selling out. Small facilities being acquired by mid-sized chains and large chains are selling out to bigger ones, often owned by private equity firms.

How will these owners, often obsessively focused on the short-term bottom line, confront these labor shortages? It is hard to know, but the answer will be critically important to workers as well as to residents and their families.

Medicare Advantage Plans and Staffing Shortages Slowing Hospitals Discharges to Nursing Homes

Skilled nursing admissions are being slowed by both staffing shortages and Medicare Advantage restrictions.  According to a recent article in Mcknight's Long-term Care News, the delays  are threatening log jams in "hospitals desperate to discharge patients to post-acute care and free up needed beds."  The problem is especially pronounced in states with high COVID-19 case rates. 

Hospital executives and healthcare leaders have complained that the prior authorizations needed to send no-longer acute patients on to post-acute care have always come slowly in states like Florida, Louisiana and Oregon. But the problem is limiting access to care for would-be hospital admits during the ongoing delta surge.

Many Medicare Advantage plans have suspended their restrictions during this stage of the pandemic, but their replacement requirements and expiration dates vary. Humana’s waiver for Louisiana lasts until Sept. 17, while Florida Blue’s is open-ended. 

Some want uniformity directed by state or federal regulation.  “The challenge when it is not being directed by a state or federal agency is you have significant variation from one plan to the next as to how they are providing the flexibility, which creates more confusion at a time when we need to minimize as much confusion as possible,” Mary Mayhew, CEO of the Florida Hospital Association, told Modern Healthcare.

In places where waivers exist, they can be highly effective. AdventHealth in Altamonte Springs, FL, estimated waivers issued by some Medicare Advantage plans cut transitions into post-acute care down to about 24 hours.

“If the waiver goes away, we are concerned hospitals could return to seeing delayed transfers contribute to challenging capacity constraints,” said Lisa Musgrave, vice president of home care administration and post-acute services.

The American Hospital Association has been working with the Centers for Medicare & Medicaid Services (CMS) and Medicare Advantage organizations to “encourage adoption of these waivers.”  For its part, CMS issued a memo that “strongly encouraged” plans to relax prior authorizations “to facilitate the movement of patients from general acute-care hospitals to post-acute care and other clinically-appropriate settings, including skilled nursing facilities.”

Whether skilled nursing facilities could accept patients more quickly if prior authorizations are lifted remains to be seen. Kristen Knapp, spokeswoman for the Florida Health Care Association, said the larger issue “is all about staffing.”

A survey of FHCA members in early August found half had had to reduce admissions in the previous month due to worker shortages.

“The workforce crisis is real, and while we want to be good community partners during the surge, nursing centers right now are doing everything they can to maintain and recruit more staff to support the patients they are currently caring for,” Knapp told McKnight’s Long-Term Care News.

Home Health Care Staff Shortages Threaten Health- Frustrates Aging in Place

This Blog has reported the threat staffing shortages pose to the long-term institutional care industry, its residents, and its patients.  Staffing shortages in the home health care industry present similar threats, both to the industry and to actual and prospective customers.  

There is a legal maxim that "Justice Delayed is Justice Denied."  In the long-term care and the health care industry there is no simple maxim that  warns that "freedom delayed is freedom denied," but there should be.  A shortage of home health care workers means that some seniors may be unable to safely return to their homes, and may, instead, be forced into institutional care alternatives otherwise avoidable.  This may seem an anomalous result, but it is real.  Seniors are transferred to institutions that are woefully understaffed every day.  

There is no compromise possible, however, for a family seeking return of their mother or father to a home when they cannot demonstrate adequate and sufficient support services.  The systemic choice is clear; it is unacceptable for a senior to be at risk in their own home, but acceptable if that risk is institutional.  The Trump Administration learned, for example, that there were nursing homes opened and operating, without a nurse.  Medicare did not, and to this day, does not prohibit the transfer of a patient from a hospital to a poorly staffed nursing home or assisted living facility!     

Aging in Place Planning is specifically designed to reduce the risk of unnecessary and avoidable institutional care.  Unfortunately, many seniors may need home health care workers for short periods of time following acute needs or hospitalizations in order to rehabilitate safely at home.  "Freedom," may be denied these seniors if there is no choice but institutional care.   

Kaiser Health News, published a story about the on-going shortage, entitled, "Desperate for Home Care, Seniors Often Wait Months With Workers in Short Supply."  Using Maine as an example, the article explains:

"The Maine home-based care program, which helps....more than 800 in the state, has a waitlist 925 people long; those applicants sometimes lack help for months or years, according to officials in Maine, which has the country’s oldest population. This leaves many people at an increased risk of falls or not getting medical care and other dangers.  The problem is simple: Here and in much of the rest of the country there are too few workers. Yet, the solution is anything but easy."

Katie Smith Sloan , CEO of Leading Age, which represents nonprofit aging services providers, told Kaiser that the workforce shortage is a nationwide dilemma:

 “Millions of older adults are unable to access the affordable care and services that they so desperately need,” she said at a recent press event. State and federal reimbursement rates to elder care agencies are inadequate to cover the cost of quality care and services or to pay a living wage to caregivers."

This shortage was not unexpected.  Kaiser reported that "[f]or at least 20 years, national experts have warned about the dire consequences of a shortage of nursing assistants and home aides as tens of millions of baby boomers hit their senior years." President Biden even included funding for home and community-based care in the infrastructure bill ("human infrastructure").

And here we are. 

Picture Credit: Photo 19608638 / Help Wanted © Martinmark | Dreamstime.com

Staff Shortages Worsen in Long-term Care Industry

Among the many reasons supporting the decision to age in place is a worsening staff shortage in the long-term care industry.  A survey published by the American Health Care Association revealed 94% of long-term care facilities are struggling to hire staff. 

The U.S. faces a certified nurse aide shortage of about 200,000, with the situation made even more dire by a surging number of unvaccinated aides being forced to quarantine as cases of variant COVID-19 cases threaten to surge.  Regional variations make this shortage more or less extreme for the industry and residents.

There are many reasons that contribute to cause these shortages, but among the most surprising is the effect of workplace violence. Violence in all healthcare settings plays a role in the nursing shortage, with the "ever-present threat of emotional or physical abuse adding to an already stressful environment." 

Staff shortages, of course, negatively affect health outcomes. Nursing shortages lead to errors, higher morbidity, and higher mortality rates. 

Lori Porter, founder and CEO of the National Association of Health Care Assistants, is sounding the alarm.  "Bemoaning the twin crises (shortages and vaccinations) won’t resolve them. But neither will throwing just money at potential employees," Porter said, according to McKnights Long-term Care News, adding that "Medicaid pressures continue to make routine higher pay and better benefits elusive for many."

“Pay is one of the scariest things,” she said. “I’ve seen facilities giving up to $20 and hour … I’m not certain how you make that happen in today’s world.”

Porter suggested providers need to look at their individual recruitment efforts to address oversights and messaging, but she also suggested a federal recruitment campaign could be part of the solution.

“People want to be part of a team,” Porter said. “We want to blame the millennials because they don’t want to work. But I would hire millennials all day long because they don’t want to make a job. They want to make a difference.”

Some sociologists and economists have taken to calling the current labor challenge "The Great Resignation." Porter noted that it’s important to consider the cultural shift spurred by COVID-19 and seize on the industry’s intangible benefits to shift momentum.

“Pay and benefits (are) things we’re very weak on as a profession,” she said. “But the second thing we have to sell are emotional benefits, and we’re very high on emotional benefits if care centers and employers will learn how to articulate it in a way that resonates with ‘I want to be part of something that makes a difference.’”

Millennials are, though, among the most unlikely to want a COVID-19 vaccine, another issue that continues to plague providers. Porter told LeadingAge members that vaccine coverage among her membership remains her top concern. She has worked to counter hesitancy with information from AMDA, rather than the Centers for Disease Control and Prevention or the Centers for Medicare & Medicaid Services, and appealing with direct messages about the responsibility to residents.

But Porter said many of the workers her organization represents are still reluctant, at least until the vaccines receive full FDA approval.

“Many of their arguments are becoming weakened. More vaccines have been taken and no one has grown a third arm yet,” said Porter, who noted the rate of unvaccinated people in her area of Missouri recently led two major hospitals there to reopen their COVID units. “Now is the time to push harder than ever.”

SNF COVID Crisis Over? SNF COVID Deaths Fell 66% in Wake of Vaccine Clinics as Overall U.S. Fatalities Rose 61%

After a year of remarkable tragedy in nursing homes, a new analysis of federal COVID-19 data shows a significant drop in resident deaths in the weeks after vaccine clinics began, a trend made even more striking given the simultaneous spike in U.S. coronavirus deaths over the same period. The detailed analysis, courtesy of the Kaiser Family Foundation (KFF), paints a much-needed portrait of the COVID-19 pandemic as it has impacted, and continues to impact long-term term care facilities (LTCFs).  According to KFF, the final months of 2020 were the deadliest months of the pandemic for many LTCFs across the country, with over 26,000 COVID-19 deaths in LTCFs reported between Thanksgiving weekend and December 31, 2020. 

The end of 2020 saw the approval of the first coronavirus vaccines and the launch of vaccine administrations in LTCFs through the Pharmacy Partnership for Long-Term Care on December 21st, 2020 (Pfizer-BioNTech) and December 28th, 2020 (Moderna). As of February 22, 2021, about 4.5 million residents and staff have received one or more dose through the Partnership; over 2 million residents and staff have received both doses. In addition, some states and some LTCFs have vaccinated residents or staff outside the Partnership. Vaccinations have increased outside of LTCFs as well, though at a significantly lower rate. 

Weekly deaths in nursing homes fell 66% between the last week of December, when the federal government’s long-term care vaccination partnership with CVS and Walgreens ground into gear, and the first week of February, according to the Foundation.  That decline nonetheless represents more than 2,000 fatalities, but it came as nationwide deaths, excluding nursing homes, spiked 61% to nearly 20,000 during the week ended February 7, prompting the Foundation to ponder whether the end of the crisis in LTCFs has finally come into view.

KFF stopped short of definitively concluding that the vaccine clinics were the direct cause of the drop, noting that not every facility started the inoculation process on the same day, but the general association is obvious.

“According to the CDC, there has been strong evidence that the vaccines prevent severe illness and death, and the sharp divergence in deaths inside and outside of LTCFs is consistent with that evidence,” KFF observed. “In addition, given the emerging research around the vaccines’ ability to prevent transmission of the virus, there is reason to believe that the vaccine may be playing a part in reducing virus transmission within nursing homes, contributing to the more rapid decline in new cases in nursing facility residents than in the overall population.”

Total case numbers in nursing homes dropped 83% in the post-clinic period, far outpacing the 45% dip among the general, non-LTC population. “While cases have dropped both within and outside nursing facilities, new nursing facility resident cases peaked earlier (week ending December 20, 2020) as compared to in the general non-nursing facility resident population (week ending January 10, 2021) and declined at a faster rate in nursing facilities than outside nursing facilities,” KFF noted.

The most recent data marks a swift turnaround from record-high death counts seen in LTCFs at the beginning of 2021.  One in every 51 residents of LTCFs died during the four weeks bookending New Year’s Day, for a grim total of nearly 20,000, according to an AARP analysis.

“While the record high death rate in the four weeks ending Jan. 17 represents only a slight increase from the previous month, when 1 in every 53 residents died from COVID-19, it is more than a quadrupling of the resident death rate at the end of the summer,” AARP noted.

The gains also came amid continued concerns about relatively low uptake of vaccines among nursing home staff. Only 37.5% of workers accepted vaccinations during the first month of clinics, according to the Centers for Disease Control & Prevention (CDC), as compared to 77.8% of residents.  Meanwhile the debate regarding mandating vaccines roils. 

Sources:

"Nursing Home COVID Deaths Fell 66% in Wake of Vaccine Clinics — Even as Overall U.S. Fatalities Rose 61%," Skilled Nursing News, February 25, 2021.

Is the End of the Long-Term Care Crisis Within Sight? New COVID-19 Cases and Deaths in Long-Term Care Facilities Are Dropping, KFF, February 24, 2021.  

AARP Nursing Home COVID-19 Dashboard

The COVID-19 pandemic has swept the nation, killing more than 160,000 residents and staff of nursing homes and other long-term care facilities. The AARP Public Policy Institute, in collaboration with the Scripps Gerontology Center at Miami University in Ohio, created the AARP Nursing Home COVID-19 Dashboard to provide four-week snapshots of the virus’ infiltration into nursing homes and impact on nursing home residents and staff, with the goal of identifying specific areas of concern at the national and state levels in a timely manner. The dashboard looks at five categories of impact and will be updated every month to track trends over time. 

In addition, the dashboard site provides a link to state and national fact sheets with 33 additional data points providing more information about each dashboard category.  

This February 2021 dashboard release (with data for the four weeks ending January 17, 2021) shows how the COVID-19 situation in nursing homes has changed dramatically since the summer when data became available:

Among the most concerning data is that relating to staffing shortages.  Staffing shortages continue to be an ongoing problem throughout the pandemic, with 29% of nursing homes reporting a shortage of nurses or aides in the last 4 weeks.  Going back to June 2020, in every four-week period, more than one quarter of nursing homes have reported a shortage of direct care staff.  

The rates of COVID-19 deaths and cases in nursing homes remain staggeringly high as we enter the new year.  The resident death rate reached a new high, increasing from 1.88 per 100 residents in the previous four-week period to 1.95 per 100 residents in the four weeks ending January 17. 

New resident cases declined slightly from 10.8 to 9.2 per 100 residents, and new staff cases also declined from 9.3 to 8.3 per 100 residents.  These most recent case rates are still more than 3 times as high as the rates in late summer and early fall when AARP launched the dashboard, and only slightly lower than the record high numbers the previous month.

Counting both residents and staff, there were nearly 20,000 COVID-19 deaths and more than 170,000 new confirmed COVID-19 cases in nursing homes in the four weeks ending January 17.

There is considerable variation across states in both the magnitude of COVID-19 impacts, and the trajectory of those impacts.

Compared to the previous four weeks ending December 20, the resident death rate per 100 residents increased in 24 states (including Washington DC), and declined in 27 states.

Compared to the four weeks ending December 20, the rates of new resident cases and new staff cases each declined in two-thirds of states (34 states) and increased in the remaining third (17 states, including Washington DC). 

In every state, nursing homes continue to indicate a shortage of PPE (defined as not having a one-week supply of N95 masks, surgical masks, gowns, gloves, and eye protection during the last four weeks). Nationally, about 14% of nursing homes had a PPE shortage during the four weeks ending January 17, 2021.  This is a significant improvement from 18% in the previous monthly Dashboard and 28% in the summer.  Still, this means that about 1 in 7 nursing homes do not have a one-week supply of PPE during a time when deaths and are close to record highs. There is considerable variation in PPE supply among states: the proportion of nursing homes without a one-week supply of PPE ranged from less than 2% to as high as 42%.

The New Year Finds Nursing Homes Opposing New Minimum Staffing Requirements and Training Requirements for Dementia Care Workers

Nursing home providers are opposing proposed national legislation that would require skilled nursing facilities to meet minimum staffing requirements, and in New Hampshire  are looking to amend a newly effective state law that sets minimum training requirements for facility staff members who care for people with dementia, including Alzheimer’s. The industry is, instead, calling on lawmakers to find solutions to address what they characterize as a "workforce crisis" throughout the industry.

Sen. Richard Blumenthal (D-CT)  recently introduced The Quality Care for Nursing Home Residents Act (S.2943), which would revise minimum staffing requirements for skilled nursing facilities that participate in the Medicare and Medicaid programs.  The legislation has been referred to the Committee on Finance.  Rep. Jan Schakowsky (D-IL) also introduced the proposal (H.R. 5216) in the House. That legislation has since been referred to the House Ways and Means and Energy and Commerce committees.

Mark Parkinson, president and CEO of the American Health Care Association, said in a statement, that the legislation, without additional funding, would make it “impossible for facilities to implement new mandates” without risking additional closures.

“The skilled nursing profession has serious concerns about the practical implementation of the proposals in this bill. Today, our profession suffers from a critical workforce shortage and setting minimum staffing levels will not solve that issue. We need solutions like loan forgiveness that will help attract more workers to the long term care profession.”

He said that while the organization appreciates the interest in quality of care, more discussions are needed about “real solutions like the proposals that will allow reinstatement of CNA training programs. “These types of bipartisan solutions can help make meaningful progress and ensure access to care for seniors and individuals with disabilities across the country,” he said.

LeadingAge CEO and President Katie Smith Sloan said, though the proposed bill is “laudable,” it doesn’t address the true issue facing providers:

“There are simply more jobs open than can be filled across the U.S. In the words of one of our members: ‘We don’t even have people to interview, much less hire. Last year [2017], we had 9,000 RN, LPN, and CNA jobs in our state and only 2,500 applicants.” 

Smith Sloan added that the bill does not address the reason for the staffing shortages, which include demographics (America’s aging population) and money. She also urged lawmakers to support the Nursing Home Workforce Quality Act (H.R. 4468), which she said would “provide an opportunity to build a crucial talent pipeline.  According to Smith Sloan:

“Without mechanisms that address two significant issues, the availability of people to provide the care as well as the growing challenges of financing (Medicaid, which is the primary public source of funding for the majority of nursing homes, is inadequately funded, so providers are not reimbursed for the costs of care), this effort has small chances of achieving its desired end” 

The proposed legislation was commended by the National Consumer Voice for Quality Long-Term Care.

Meanwhile, providers in New Hampshire are looking to amend a newly effective state law that sets minimum training requirements for facility staff members who care for people with dementia, including Alzheimer’s. The law, which went into effect January 1st, was part of the state budget passed by the state lawmakers in September. The minimum training requirements apply to staff members working in residential homes or community-based programs with people who have forms of dementia, according to an Associated Press report. Direct-care workforce staff members, including staff at nursing homes and assisted living facilities, must also complete the training requirements, the Union Leader reported.

“We are committed to culturally competent dementia care. We are already providing it. We will comply with any legal mandate, but do want it to be practicable,” Brendan Williams, president and CEO of the New Hampshire Health Care Association, told McKnight’s. 

Williams said the organization wants the law to be more “practicable and prospective” for providers. One change providers are pushing for would allow for the use of a variety of training resources for staff members and not just rely on the Alzheimer’s Association curricula, as the current law requires. 

He argued that “no additional funding accompanied this new mandate for its Medicaid share-of-cost.”

“So we are wary of new unfunded mandates that may make it harder to recruit and retain staff.  An early state implementation draft would apply the new law even to volunteers,” Williams said. 

Williams added that the law is redundant, noting that federal regulations already require facilities and staff members to undergo training and provide “proper dementia care” to residents. 

He also noted that New Hampshire state law requires licensed nursing assistants to undertake 100 hours of training, which includes training in emotional support for how to respond to residents with dementia or cognitive impairments. 

“Hopefully, we can get to a result here that works for everybody,” Williams said. 

The foregoing demonstrates that the year 2020 is likely to be a year in which nursing home providers, legislators, regulators, and senior advocacy groups jockey for position in an effort to reform nursing home care to improve quality and accountability.  

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The foregoing article draw from several articles, the most important being a pair of articles published in McKnight's Long-term Care News: 

• New bills call for nursing home minimum staffing requirements;
• Providers want to change new state law that sets minimum training requirements for dementia care staff.