Addressing Cracks in Long-Term Care

By Ronit Rose

Ronit Rose is a freelance writer, based in Chicago. She has a special interest in health, healthcare and preventive medicine.

With staff shortages and residents’ social isolation, what needs to change in our nation’s nursing homes?

Undeniably, the pandemic has exposed vulnerabilities in our nation’s long-term care facilities, including skilled nursing facilities and other communal residential facilities for older adults. 

Deaths in senior housing due to Covid-19, along with the impact of social isolation, dominated the news throughout the first year of the pandemic. Now, unaddressed staffing issues are spiraling, leaving more skilled nursing facilities woefully understaffed.

Of course, problems in long-term care communities are not new, but the pandemic has magnified many concerns. It is clearer now more than ever that our long-term care system needs to change to better protect residents, experts say. 

In Illinois, some 100,000 residents live in 1,200 long-term care facilities statewide. Many senior living residences and assisted living communities proved to be safe places for older adults during the pandemic, providing activities and engagement. But many nursing homes, also called skilled nursing facilities — with frail residents who need more nursing care — have been worse off. 

Nationally, skilled nursing facilities have experienced much higher Covid-19 mortality rates than assisted and independent living communities, according to a report from the research organization NORC at the University of Chicago. While 67% of independent living, 64% of assisted living, and 61% of memory care communities in the U.S. had no Covid-19 deaths in 2020, only 39% of skilled nursing facilities experienced no Covid-19 mortalities.

In the multitude of issues facing the industry, two stand out: staffing and family visits. 

Staffing shortfalls

Staffing has long been a problem for skilled nursing facilities, even before Covid-19. And in the pandemic’s wake, employee challenges — including high turnover, few opportunities for advancement, and overstretched workers — have only intensified, impacting all areas of long-term care facilities.

“You can’t offer the type of care that nursing home residents need without staff, a stable staff — not a transient staff — an appropriately paid staff, and appropriately supplied staff,” says Chicago lawyer Steve Levin, who often represents patients and families in lawsuits against nursing homes.

Now, a nationwide labor shortage is compounding the staffing problem. Many low-wage workers are taking jobs that are less physically and emotionally demanding than healthcare positions, furthering the shortage of care workers.

In 2020, there were just over 56,000 care workers in nursing homes in Illinois, down 2% from the year before. From all indications, the downward trend continues. In September, the American Health Care Association reported that 99% of nursing homes say they are having difficulty finding enough staff and 78% of them fear that staffing challenges might force them to close their doors.

Many times, workers don’t even last three months in a job. “[There is a] constant turnover of staff. Our research shows that, pre-pandemic, departures in the direct-care workforce typically happened in the first 90 days,” says Natasha Bryant, senior director of workforce research and development at the LeadingAge LTSS Center at UMass Boston, which conducts research about the aging population to inform policy changes.

Chronically low wages hurt direct-care workers, who often don’t earn enough money to support themselves and their families. With a median annual income of $20,200, 44% of direct-care workers live in low-income households, according to PHI, a direct-care advocacy group.

Part of the issue with low wages comes down to how skilled nursing facilities receive payment for their services. Medicaid pays for low-income patients; Medicare may cover care in a skilled-nursing facility for up to 100 days; and a small portion of residents pay out of pocket.

In Illinois, with its chronic budget shortfalls, Medicaid payments are not adequate to keep the system afloat. When Medicaid payments lag, skilled nursing facilities have less money to spend on staff wages.

“It’s a matter of changing the way you do things to a way that becomes more rewarding for the worker.”

Because wages are low — often too low to live on and support a family — certified nursing assistants and other staff frequently work multiple jobs to make ends meet. 

Besides the personal toll, this practice almost certainly exacerbated the pandemic in long-term care communities. Working more than one job, staff went in and out of risky situations, possibly bringing the Covid-19 virus into more than one building, putting residents and fellow staff members at risk.

Another hazard: Staff members who are too thinly stretched don’t get to know residents whom they care for. 

“It’s best to always care for the same people all the time,” says Lee Moriarty, Illinois deputy state long-term care ombudsman. “That doesn’t necessarily happen in every building. They rotate, and staff isn’t as invested or as connected and might be more liable to leave.” 

Resolving staffing challenges

Experts offer many potential solutions — from increased training to more immigration — to resolve the multilayered staffing problem. 

“It’s a matter of changing the way you do things to a way that becomes more rewarding for the worker,” Moriarty says.

Paying a living wage would be a start. Education and training are also a vital part of the solution.

“Having a strong team of dedicated workers is important. It’s important for companies to show them how much they care about them and how much they’re appreciated,” says Efrat Dallal, chief marketing officer at Chicago’s Selfhelp Home, a continuing care retirement community. 

Partnerships with community colleges to train young people right out of school are vital. So are programs that train certified nursing assistants on theory as well as practical skills. 

“Staff retention is very important,” says Angela Jalloh, director of nursing at The Admiral at the Lake and adjunct professor of nursing at Oakton Community College. “That’s why we support education so much. When people understand what they are doing and why they are doing it, it makes sense to them to keep doing it.” 

In addition, more immigration is essential for a robust workforce. Immigration to the U.S. has fallen off dramatically in the past few years, with a 43% drop in 2020 over the previous year, according to the Cato Institute. This means fewer immigrants are available to staff home care and nursing roles. 

“Immigrants are certainly a significant and growing part of the direct-care workforce. It’s about one-quarter made up of people born in other countries,” Bryant says. 

Hiring and retaining these workers will be a challenge if some aspects of the job — including wages, benefits, and lifestyle — do not change. “These are complex jobs that should be recognized in terms of pay,” she adds.

Visitation rights gone wrong

When the pandemic shut down society, family members were shut out of long-term care communities, with no in-person visits allowed. When visits resumed, they were at first limited to window visits or outside visits, often with a restricted number of guests. 

The restrictions adversely affected many residents. Some felt abandoned and experienced cognitive and physical decline as a result.

Visiting loved ones in long-term care facilities is not merely a social issue. Family members provide stimulation, comfort, exercise, and contact with the outside world, as well as a form of oversight, making sure their loved ones are properly fed and looked after.

“When families are excluded from the [nursing] home, and [nursing homes] are dealing with infection, and they’re understaffed, we’re dealing with a plethora of cases now where the care is further breaking down in other care areas such as pressure ulcers, malnutrition, and dehydration,” Levin says. 

Ensuring contact

Even in a pandemic situation, family visits need to continue in some form, as safely as possible. People are taking steps now to ensure those visits in the future. In fact, Governor J.B. Pritzker recently signed a law mandating that long-term care facilities implement policies to provide virtual visits in the future. 

Another way to ensure contact in future emergencies is to green-light one essential caregiver for each resident. Even in times of infection, a resident could be guaranteed one approved visitor, helping to abate isolation.

In December 2020, at a crucial point in the pandemic when many older adults were experiencing extreme isolation, the Illinois Department of Public Health issued guidelines that encouraged long-term care communities to safely admit one essential caregiver for isolated residents. 

“Essential caregivers are not general visitors,” the guidelines say. “These individuals meet an essential need for the resident by assisting with activities of daily living or positively influencing the behavior of the resident.” 

However, the guidelines are not mandatory, and some senior communities were not even aware of them. Still, some are moving forward to ensure more caregiver access in the future. “It sounds like a very ethical idea as long as you can figure out a way to make it safe,” Dallal says. 

On the national level, an essential caregiver bill before Congress seeks to guarantee that residents could select up to two essential caregivers who would have access for up to eight hours per day during any public health emergency.

Despite the challenges, long-term care communities can provide a dignified, happy, and stimulating environment for older adults. The communal setting provides social opportunities and engaging activities. 

“It’s important to find safe ways to ensure people are not alone and provide comfort,” Dallal says.

Kelly D. Richards, the Illinois long-term care ombudsman, agrees. “[Nursing homes] definitely have a role to support our seniors,” she says.

But as we all know — and as the pandemic drove home — long-term care communities are only as good as the caregivers within them. We must value their work and compensate them fairly to ensure a safe, hospitable environment for workers, essential visitors, and residents.