Rhode Island nursing homes are struggling. Staffing shortages, employee burnout, and serious financial challenges have been problems since before the pandemic – but all have gotten significantly worse in recent years, leading to an uptick in things like neglect and preventable deaths. Morning Edition Host Luis Hernandez spoke about the issues with Elizabeth White, Assistant Professor of Health Services, Policy, and Practice at the Brown University School of Public Health and an expert in long-term care.
Transcript:
This interview has been edited for length and clarity.
Luis Hernandez: So since 2020, Rhode Island nursing homes have lost 20% of their workforce. In addition, six nursing homes have closed because of massive staffing shortages. And then in December, Governor McKee declared a state of emergency in relation to nursing homes. How did we get to this point?
Elizabeth White: I think it’s important to recognize that Rhode Island is a microcosm of what’s happening in long-term care across the entire country. The nursing home workforce has long suffered from challenges with staffing, high burnout, high turnover, and then we basically threw a pandemic on top of that that just created much more stress both on the actual work that people have to do on a daily basis and the complexity of the care that you have to provide. We also have seen COVID disproportionately affect the populations who live and work in nursing homes. And then it also, on top of that, added a lot of additional financial challenges to owners. You know, lots and lots of additional costs for personal protective equipment, for sick pay, for having to revamp HVAC systems, you know, lots of additional costs that just kind of exacerbated this problem.
Hernandez: We know that nursing home workers are paid a lot less than people with the same qualifications who work in hospitals and other healthcare settings. Why is that and how do we fix it?
White: Yeah, so that’s the million-dollar question. What happens in nursing homes is, we have this financial system where there’s a small subset of patients that are coming into the nursing home for post-acute care, so care following a hospitalization, and that’s covered under Medicare, but that’s only covered for a short period of time, and that’s a higher daily rate, but then most of the care is being paid for by Medicaid than a smaller proportion are people who are paying out of pocket. But nursing home care is very expensive, so there are a lot of people that can’t pay. So Medicaid is kind of the safety net for long-term care. So because of that, we have a financial system for nursing homes where basically nursing homes have to cross-subsidize their Medicaid patients based on their Medicare population. So a hospital can pay much higher wages than a nursing home can. In this conversation, we also need to make sure that there’s financial transparency for nursing homes, that the dollars that they do receive are going towards wages and that there are appropriate regulations in place to make sure that funds are spent appropriately.
Hernandez: You have the issue of pay, but you’re also talking about a job where you are surrounded by people nearing the end of their lives. And we already know from studies that this has an impact on the mental health of a worker. I’m wondering, are these the only challenges right now to recruiting people into this workforce, or is there something else?
White: You know, the strains of the job can really wear you down over time and contributes to burnout. You know, that kind of gets into a perpetual cycle where when you have high burnout that contributes to turnover. Turnover contributes to staffing shortages. Staffing shortages further contributes to burnout, and you just end up in this kind of perpetual cycle. So as important when we’re investing in this workforce is to invest in leadership in these nursing homes, having stable administrators, having stable directors of nursing and medical directors who are providing leadership that can ensure that people have safe working environments, making sure that the organizational culture and facilities values the work of people who are providing the care on a daily basis, that there are career advancement opportunities. So being a [Certified Nursing Assistant] in a nursing home can’t just be a dead-end job. It has to be valued. And people have to have an opportunity to progress. It’s a very kind of fragmented piecemeal system right now.
Hernandez: I’d imagine, too, that if you have staffing shortages, this is problematic for the patients. A lot of problems can come up. What are some of the issues?
White: So there’s a 30-year body of evidence from nursing homes that show consistently that higher staffing is associated with better quality care, and that things like reduced use of antipsychotic medications, other psychotropic medications, reduced falls, reduced incidence of pressure ulcers, higher patient and family satisfaction. So there’s a very robust body of evidence that shows that better staffing is associated with better quality care. … You know, I’ve been fortunate. I’ve worked with some wonderful CNAs and when you have a CNA who’s been working with a patient for months or years and they really understand all the nuances of that person’s care. And I can’t tell you the number of times as a nurse practitioner that a CNA coming to me saying, “Hey, Betsy, you need to come take a look at Mr. So-and-so because they just don’t look like themselves this morning. You know, normally they have a full breakfast. This morning they just wanted to have a little bit of fruit. That’s not like them. Come take a look at them.” And the number of times that kind of interaction leads to realizing that there’s a really significant issue going on and being able to intervene is so important. So having consistency of staff and having staff that stay in their jobs because they feel valued and because they’re receiving appropriate wages and benefits is really important.
Hernandez: So, considering what Rhode Island is going through, and as you said, this is a national problem right now, is the nursing home industry sustainable?
White: We’re already seeing some nursing homes going out of business. I think another thing that we’ll probably start to see – we’re seeing it a little bit already – is you might see some nursing homes that decide to transition and just become assisted living communities. Assisted living communities are regulated much differently. They’re not subject to the same federal oversight that nursing homes are subject to. So they also don’t have the same kind of staffing requirements. Only about half of the living communities in the country have licensed nurses on campus. You know, we’re already seeing a lot of movement within the long-term care sector and I think we’re going to continue to see a lot of changes in the years to come.
Hernandez: Do you get a sense that lawmakers right now are doing enough on this issue? Do they have the political will to attack this issue?
White: You know, the main difference with state government and federal government is states have to balance their budget every year. Medicaid dollars going to long-term care is a huge chunk out of state budgets. So they really need the coordinated efforts with the federal government, through grant funding and other mechanisms to improve reimbursement rates in the state. I would say, just to re-echo this, when we’re talking about investing in long-term care, the first, second, and third priorities have to be investing in this workforce. We don’t have long-term care without people. Long-term care is not something that can be provided through AI or through tech solutions or through telehealth or whatnot. It’s hands-on intensive care. And it’s so important that we value this workforce working in this sector.
Hernandez: Elizabeth, I really appreciate the insight. Thank you so much.
White: Great. Thanks for having me.