The day Virginia closed its schools in March of 2020, Tom Orsini knew he’d have a problem.
“It was devastating,” said Orsini, president and CEO of Lake Taylor Transitional Care Hospital in Norfolk. “Because our staff, they’re the caregivers at home.” Over the next several months, more and more employees struggled to make shifts at the nursing home as classes stayed virtual amid the COVID-19 pandemic.
Industry-wide, thousands more workers got sick and thousands quit, citing burnout and the stress of the job, according to surveying by the Virginia Health Care Association-Virginia Association of Assisted Living. Since February 2020, the state’s long-term care industry has lost more than 9,500 workers, raising concerns about its recovery and the quality of care that residents are receiving.
“I think the concern is also access for people who need nursing-level care,” said Amy Hewett, the association’s vice president of strategy and communications. “If there aren’t the direct caregivers there, then facilities have to make those difficult choices to reduce admissions. And then we get into a situation where somebody might not be able to find a place to go.”
The problem hasn’t been confined to any one area of the state. To get a sense of the pandemic’s effect on overall workforce, VHCA pulled the most recent data from the Bureau of Labor Statistics, which showed industry staffing had reached its lowest level since 2012. The losses “wipe over a decade of growth in employment by these providers,” the association said in a statement, dropping from nearly 79,000 in February of 2020 to about 69,300 in September.
They’re also creating new stressors for an industry that bore some of the worst impacts of COVID-19. According to a survey the association released last month, 81 percent of long-term care facilities reported their workforce situation was worse this year than in 2020, when deaths and hospitalizations among residents and employees peaked. Nearly 30 percent described their current staffing as a “crisis,” and 37 percent reported limiting their census because they didn’t have enough workers.
Joani Latimer, who advocates for residents as Virginia’s long-term care ombudsman, said there’s widespread agreement that staffing in nursing homes is worse than it’s ever been. The losses are creating serious safety concerns for residents, even as new coronavirus infections continue to decline.
“Right now, we’re certainly seeing that there are frighteningly low levels of staff in some facilities,” she said. For the vast majority of them, certified nursing assistants and other direct-care employees are in the shortest supply. Since those workers spend the most hands-on time with residents, losses have a substantial impact on care.
Over the course of the pandemic, Latimer said her office has received a growing number of complaints over residents losing weight in facilities. An apparent lack of basic hygiene has been another big concern.
“That can be so tied to staff just not having enough time to help someone with eating and observe whether they’re eating or not,” she said. “Or not being able to assist someone right away when they need to go to the toilet.”
Even at well-resourced facilities, open positions can have an immediate effect on patients. Dr. Jim Wright, medical director for Our Lady of Hope and Westminster Canterbury in Richmond, said the two nonprofit nursing homes haven’t faced the same difficulties as many others across the state. But even with comparatively minor staffing shortages, the number of patient falls increased almost immediately.
“Obviously you can trace that to fewer aides and nurses being available to monitor patients,” he said. Both he and Orsini also pointed out that more administrative staff are having to step into direct care roles, limiting their ability to focus on facility-wide improvement projects such as reducing the use of antibiotics and other medications.
The pandemic’s ongoing impact on nursing homes has made staffing a particular policy focus for Virginia legislators. For years, the General Assembly has turned down legislation that would set minimum staffing requirements for long-term care facilities. The policy is staunchly opposed by industry groups like VHCA, but costs have been another significant barrier, with lawmakers arguing it would require the state to spend more on boosting Medicaid reimbursements.
Many, though, say the pandemic has heightened their sense of urgency. More than a quarter of Virginia’s nursing home residents died from COVID-19, and facilities with lower staffing levels had a higher incidence of infections. Wright said short-staffed facilities are also more likely to be for-profit nursing homes that rely on Medicaid to reimburse the majority of patients. And in Virginia, there’s wide consensus that Medicaid reimbursement rates fail to cover the true cost of care.
“You have to live within your budgetary means, so low reimbursement on the Medicaid side dictates how much flexibility you really have for things like pay increases and bonuses,” said Steve Ford, VHCA’s senior vice president for policy and reimbursement. According to Latimer, the majority of direct care employees don’t receive health care or other benefits, and Wright said many facilities — especially for-profits that are expected to direct some revenue back to shareholders — just can’t compete with the pay increases offered in other industries.
“A lot of employees are choosing whether to work in a nursing facility that might have a COVID outbreak or a Walmart where they’re answering questions about where the TVs are,” he said. “So it’s kind of a no-brainer why we have trouble attracting staff.”
Legislators on the state’s Joint Commission on Healthcare are currently considering major policy reforms, including increased payments and a value-based purchasing program that would offer higher reimbursements to facilities with higher quality measures — potentially including staffing. And there’s growing bipartisan agreement that an increase in funding should be tied to minimum staffing standards.
How to structure those standards, though, is a debate that likely won’t be fully hashed out until the upcoming General Assembly session this winter. A report by commission staff suggested either a baseline requirement across all facilities or a more complicated acuity-based standard, which would base minimum staffing expectations on the needs of patients living in a facility.
A baseline standard could mean that some patients with more severe conditions still aren’t receiving the intensive level of care they really need. But an acuity-based standard would be far more cumbersome, commission staff said, and require facilities to frequently re-calculate staffing needs based on a fluctuating population. Some providers and advocates are worried a more complicated standard could prevent mandates from passing at all.
“I’m a little concerned it could be a stalling tactic,” Wright said. “And because of the complexity, there could be a request to delay implementation. But I just don’t think we have time to wait. If we don’t get minimum staffing levels implemented now — really, shame on us. We have no excuse.”
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