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Our Take

The state of the post-acute workforce

15 Minute Read

Workforce challenges are among the most difficult threatening health care providers today. Nursing turnover, vacancies, and premium labor use are at their highest peaks in 15 years. Meanwhile, the frontline workforce continues to struggle with the personal and systemic impacts of the pandemic.

But this pain is not felt evenly across health care employers. Many post-acute providers, particularly SNFs, are facing staffing shortages so severe as to be existentially threatening. And perhaps more troubling: these shortages are driven not only by the trauma of the pandemic, but by the many structural workforce challenges present before March of 2020.

This report will explore those long-standing challenges and how they intersected with the pandemic. It will also detail where post-acute leaders have the best opportunity to address them—and chart a course to workforce stability and growth.

 

The conventional wisdom

Staffing is one of the most significant challenges facing post-acute providers— specifically, a shortage of nursing staff including RNs, LPNs, CNAs, and other aide roles. But while most care settings have seen some rebound in employment since the early days of the Covid-19 pandemic, SNFs, and to a lesser degree home health agencies, lag the rest of the industry.

Provider leaders and industry experts typically cite three causes behind the unique severity of post-acute shortages, all triggered by the pandemic.

1. Many clinicians endured intense emotional and physical burdens during the pandemic, and those burdens were particularly hard on people working in long-term care facilities. Despite leaders’ best efforts, environmental factors inherent to long-term care—specifically a patient population particularly vulnerable to infection and negative outcomes from the virus, and a lack of necessary infection control supports (such as negative pressure spaces, private rooms, and sufficient PPE)—made it arguably the most difficult setting in which to work during the pandemic. Yet while nursing home employees suffered the highest proportion of health care worker infections and deaths, the stigma surrounding these outbreaks excluded staff from receiving the widespread (and deserved) public recognition that many hospital staff received as “health care heroes.”

2. Post-acute sites primarily employ the nursing roles with the largest exodus from the workforce, including nursing assistants/aides. While RN turnover is creating widespread shortages across the care continuum, only 1% of RNs left the workforce from April 2020 to June 2021. In contrast, 10% of CNAs left the workforce during that same time. So, in addition to experiencing the rising turnover seen throughout the industry, providers (especially SNFs) are also competing for a smaller number of CNAs. While the drivers of this exodus are not fully understood, part of the explanation lies with broader labor market changes. Nursing assistants and aides have had significant incentive to leave health care entirely for better pay and hours offered by industries that were also suffering severe staffing shortages, including manufacturing, hospitality, retail, and order fulfillment.

3. Acute care RN turnover rose to 18% in 2021, the highest recorded rate in Advisory Board’s 15 years of collecting benchmarks. This turnover impacted post-acute organizations in two ways. First, hospital leaders are increasingly turning to other sources of talent to fill their nursing ranks—including LPNs, who have historically been employed largely by SNFs. Second, sky-high starting bonuses at hospitals and lucrative travel opportunities draw RNs from both SNFs and home health.

Today, shortages in post-acute care pose a nearly existential threat to financial stability—especially for nursing home and assisted living facilities. In September 2021, 58% of surveyed nursing home leaders reported limiting new admissions due to workforce shortages. And 35% of those leaders were “very concerned” their facility would close if those challenges persisted. While shortages are comparatively less dire for home health agencies, nearly 80% of home care leaders cite staffing shortages as the primary driver of declining client growth rates.

SNF staffing shortages will likely be exacerbated by minimum staffing requirements proposed in February 2022 amid a bundle of federal nursing home reforms. While CMS won’t issue their proposed rule until February 2023, the mandate will likely increase the number of nursing staff the average SNF needs to employ—compounding a projected increase in demand for LPNs and CNAs.

 

Our take

There is no question that the pandemic disproportionally impacted post-acute providers and clinicians. Covid-19’s effect on older adults and the staff who care for them, especially in residential facilities, left emotional and financial scars that will linger for years to come.

Yet while the severity of staffing shortages is new, staffing instability is not. A study of SNF staffing in 2017-18 estimated average turnover rates for RNs and CNAs at well over 130%. Home health turnover clocked in at 64.3% in 2019, far above the 2019 U.S. national turnover rate of 22%. Even if post-acute employers were able to return to pre-pandemic staffing levels, they would likely still not have enough workers to position for growth.

If I didn’t have staffing problems, I wouldn’t
have any problems.

-Matt Bourque, Administrator, Chateau Senior Living
January 2020

In short, the pandemic didn’t introduce new staffing challenges. It exacerbated pernicious challenges within the workforce that have left post-acute employers at a disadvantage in an increasingly competitive labor market. And it is essential post-acute employers focus their efforts on these legacy pain points if they are to make any progress on today’s staffing shortages.

 

Three challenges to post-acute workforce stability

The rest of this report explores how the following structural challenges evolved during the pandemic. We will also detail the approach workforce leaders should take stabilize their workforce, with the goal of addressing both the historical pain points and those introduced or exacerbated by Covid-19.

  • Challenge

    Stagnant wage growth

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  • Challenge

    Burnout

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  • Challenge

    Limited career growth and development

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Parting thoughts

Providers have never been more committed to attracting and retaining the talent they need—none more so than post-acute care organizations. Yet with limited resources and heightened competition for talent, leaders aren’t sure what else can be done. One avenue to achieve both objectives is to build an intentionally differentiated employer value proposition that sets the organization apart from competitors, both within and outside the health care industry.

The key to a successful employer value proposition is outperforming on a small set of compelling values while simply doing “well enough” on the others. But the problem post-acute leaders face won’t be indecision around which values to choose. Many leaders are already aware of their organizations’ natural workforce strengths (e.g., connection to mission, interprofessional career pathing, flexible hours, and independent practice, among others) and weaknesses (primarily compensation).

The challenge will be highlighting these values in a way that meaningfully inflects retention. Merely communicating them to existing staff or candidates won’t be sufficient. Leaders must find intentionally reinforce them within the work environment. By doing this, they can both can both stabilize the current exodus of staff and create long-term solutions to staffing instability.

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