Healthcare Insights: The Crisis At Nursing Homes

Lest we forget….

COVID-19 deaths in Long Term Care Facilities (LTCFs) make up at least 23% of all COVID-19 deaths in the US. 

This statement of fact ought to be enough to take our collective breath away. Indeed, the COVID-19 pandemic brought some temporary public concern and interest to the long-standing plight of nursing home residents and the workforce who cares for them.   

However, here is the hard truth about the state of the nursing home sector of American healthcare: “The long-term care system is one of the greatest challenges in healthcare today and a challenge that became acutely visible during the pandemic,” said Dr. David Grande. “It is the largest gap in our patchwork American healthcare system involving more than 1.4 million individuals in over 15,500 nursing homes. Thirty years after the 1986 Institute of Medicine report identifying inadequate care and abuse in these facilities, we’re still failing to protect nursing home residents or provide them with high quality care.”

That 1986 report emphasized that nursing home residents not only suffered substandard care, but were actually subject to abuse and neglect.

Like the rest of the healthcare sector of our economy, I see shifting structural trends with regard to ownership and control.  In hospitals and health systems there is increased consolidation of previously community based or smaller systems into giant health systems, as well as more and more for-profit and venture capital control as well.

This trend has been escalating in the long-term care sector over the past 40 years. This article illustrates that 70% of the nation’s nursing homes operate for profit.

There was a time when most nursing homes were operated by government or by not-for-profit entities, often affiliated with religious or community-based organizations. Government and not-for-profit facilities tended to be high quality and good places to work. Zelma Carroll, a certified nursing assistant in Philadelphia told me that she has worked at the same nursing home for 25 years.  “When it was run by a not-for-profit, care was better, there was more staffing, and the workers were treated well.”  Zelma told me that she put two of her four children through college with education benefits offered by the not for profit ownership.

But since her facility was purchased by a for profit corporation, the care has gone downhill, the facility is chronically short staffed, and after 25 years Zelma is looking forward to leaving nursing home work to take up a new career in social work.

Here is a photo of Zelma during the early days of the pandemic:

Lest we forget…Zelma like thousands of her co-workers around the nation were not provided proper personal protective equipment, were not told how to care for themselves or residents, and according to Zelma were simply “left to fend for themselves.“(In the photo you will note that Zelma is wrapped in a trash bag, surgical mask and shield, all improvised due to lack of proper equipment.  She did not receive proper equipment until her Union, SEIU Healthcare Pennsylvania, procured Personal Protective Equipment (PPE) and literally delivered it to nursing homes directly).

Labor-Management relations in healthcare have enormous challenges. While all collective bargaining is impacted by external forces such as competition, rapidly evolving technology, workforce shortages, rising expectations, and financing, among others, it is difficult to fully appreciate the dysfunction of healthcare national spending of $4.5 trillion per year that produces the worst health outcomes in the industrialized world.  These facts are undisputed. 

The disconnect between unimaginable spending and poor outcomes is at the center of labor-management relations in the nursing home sector.  In our market-driven system, vast outlays of financing, most of which comes from Medicaid and not tied to health outcomes, creates confusion and finger-pointing at the worksite.  Labor-management tensions are ever-present as frontline caregivers work understaffed. Patients do not receive the care they deserve, and ownership complains there is never enough money to improve staffing, which is the key to better care. What is going on?

The tight margins have driven the industry, once dominated by not-for-profit organizations, to sell to for-profit, private equity, and venture capital corporations, which now dominate the nursing home industry.

• The impact on labor relations is that employers have become more and more powerful with decision-making made far away from the bedside.
• Workforce shortages are at all-time highs which increases staffing shortages, the central complaint of healthcare workers across the industry, especially in nursing homes where low pay and difficult working conditions create high turnover.

Mistrust and anger are common experiences in labor relations in nursing homes due to the long-standing environment I have described.

I spoke with Matt Yarnell, President of SEIU Healthcare Pennsylvania about the challenges the union faces in its representation of 7,000 nursing home workers in 117 facilities across the Commonwealth of Pennsylvania.  That is approximately 17% union density. Matt began his working life as an 18-year-old Certified Nursing Assistant (CNA) at a nursing home in State College, PA.  By age 19, he was a union delegate, and by 2002, joined the staff of the union he now leads as President since 2016.

Matt described the devastating impact of COVID on union members.  His perspectives of the experience track exactly with Zelma Carroll’s remarks earlier in this article.  He added that the emotional toll of seeing so much death of residents so quickly drove many staff to leave nursing work and healthcare generally. This is a phenomenon that is widely discussed across the country and contributes to the already severe work force shortages.

The workforce shortages, staffing challenges, high turnover, and relatively low wages ($17-25/hour for CNAs), makes for a very unstable labor market and a continuation of the long and painful story of residents receiving substandard care.  As a result, the collective bargaining environment is very challenging with a long history of conflict.

The experience of COVID may have been a turning point in this long experience of conflict in the industry:  the union showed great resilience and militancy during the pandemic, and at the same time, lobbied hard for additional funding from the state government for direct patient care. They   achieved a first-time successful effort to win required minimum staff-patient ratios. Much of that work included new dialogue and some collaboration with the nursing home industry.

During the worst times of the pandemic the union ran wildcat actions demanding hazard pay and PPE for their members.  Around Labor Day, 2022, the union struck many facilities at the same time and won 20-60% wage increases over three-year collective bargaining agreements.  That success brought average nursing home pay to $20/hour which was a substantial improvement over a long-standing wage range of between $13.50-20.00/hr. 

The union held “crisis calls” during the worst days of the pandemic. The union held regular calls with then-Attorney General (now Governor) Josh Shapiro, members of Congress and the state legislature to be sure that the crisis in nursing homes was a top issue for policy makers.

Concurrently with labor militancy and activism, the union lobbied the state government in four budget cycles from 2020-2023 and increased nursing home funding by nearly $1 billion. The large infusion of funding was accompanied by a requirement that 70% of the funding had to be used for bedside care (staffing).  

The most significant advance came in 2023 when the Pennsylvania State Department of Health (DOH) passed staffing ratios which required that on the day shift, one CNA would have a limit of 12 patients, on the afternoon shift 15 patients, and on the night shift, 20 patients.  In 2024, the ratios decreased further to 10 patients on the day shift, 12 patients on the afternoon shift, and 15 patients on the night shift.

The attainment of the staffing ratios had been a goal of the union for many years.  The experience of the COVID pandemic finally created the conditions for passage of the staffing ratios over the objections of the industry who opposed them.  The industry complained that the penalties for not providing staffing were unfair given long-standing workforce shortages and high turnover.

To learn more about the impact of the ratios on working conditions and care quality, I had additional conversations with Zelma Carroll, as well with Tina Siegel, an LPN and union member who has worked in the same facility for 40 years.

I also spoke with Patty Ludwikowski, union Vice President and Director of the union’s nursing home sector.

Zelma expressed a sense of disappointment even though she spent many years lobbying in Harrisburg at the State Capitol for better staffing.  She also attended the White House Rose Garden ceremony in April, 2024 at which President Biden expressed renewed support for nursing home workers while signing a new national standard for higher hours per patient day (the new national standards have not yet gone into effect). 

Zelma complained that there is a lack of enforcement of the ratios by state government, and that while there are days when staffing is better than in the past, there are too many days when she and her co-workers care for far too many residents than what the law provides.  Zelma adds that while her employer tries to hire more staff, too many come with little or no experience.

Tina Siegel has seen many changes in ownership in her 40-year tenure at the same facility in Western Pennsylvania.  Tina was appointed to the State Board of Nursing and serves as only one of three nurses on the Board who are frontline caregivers. Most of the Board is made up of nursing educators.

Tina does her best to bring attention to the lack of enforcement of the ratios that Zelma spoke of.  She reports that the DOH listened to complaints of operators of nursing homes who complained of being penalized for not-meeting the ratios due to last-minute absences by CNAs.   The State gave the operators some relief in this area, and Tina now sees less enforcement and higher numbers of patients to care for.

However, Tina expressed more optimism than Zelma.  She shared that the union has developed a tracking sheet which keeps records of the staff-patient ratio for every shift.  When union members use the tracking sheets and send them to the state inspectors she has seen response and enforcement.  As a result, she has seen better staffing at her facility.

Matt Yarnell, the  local union President,  shared that as he watches nursing home membership in the local year over year, he has seen a stabilization in membership which he attributes to a trend of less turnover.  “Between higher wages, and improved staffing, for the first time, we are seeing that staff are staying longer than in the past, a sign that turnover may be abating to some degree.”

Nonetheless, turnover of staff in Pennsylvania nursing homes remains above 50% per year.

Patty Ludwikowski, the union’s Vice President for the nursing home sector also says that enforcement of the staffing ratios has deteriorated in 2024 from the first implementation period of 2023.

She recognizes that turnover is still a major problem. Even with the wage increases and the better staffing ratios, she reports what has always been the case:  nursing home work is very very hard work and as such it is very difficult to maintain a stable workforce.

Patty has the opportunity due to her position of engaging with the whole range of nursing home operators in the state, and is encouraged that some are seeking to build more collaborative relationships with the union to achieve better funding, and directing more funding to frontline care.  She is most encouraged by planning underway for what she calls “regional recruitment and education hubs” around the state to attract more people into the industry.

SEIU Healthcare Pennsylvania Chief of Staff, Zach Zobrist shared with me that:

The Statewide Workforce Board has passed a resolution to create a Nursing Assistant Workforce Hub. There is a bill circulating in the State House (due to union advocacy) to support the Hub. PHCA which is a for profit nursing home association has committed to supporting this direction as part of a labor-management 2024-2025 strategic alliance. 

Some excerpts from the draft proposal for the Hub:

• It was developed by the unions’ Training and Education Fund (501c3) and SEIU Healthcare PA
• Purpose: Pennsylvania needs to train and credential nearly 10,000 CNAs across the entire state over the next few years to help meet staffing for quality care and to follow safe staffing regulations. PA has lost a large percentage of Certified Nursing Assistants, the core of the nursing home workforce, during the Covid-19 pandemic. The volume of incoming CNAs getting credentialed according to state data is around 20% lower in 2022 than it was in 2018, and there have been on-going challenges with recruitment and access to training and testing.
• Solution: To address the Nursing Assistant (NA) and LPN workforce challenge in PA nursing, Pennsylvania should invest in regional ‘Nursing Assistant Workforce Hubs’ to bring a new level not yet tried for scale and coordination under one regional or statewide entity to four phases: 1) Recruitment 2) Training 3) Job placements and social support and 4) Retention.
• The expectation is that the Hub entity has a long-term commitment to NA training and will be a “one-stop shop” with experience in recruitment, training, job placement and support, and retention initiatives. The Hubs will both supplement and coordinate with existing entities.

The recent experience of SEIU Healthcare Pennsylvania in the COVID era is a very interesting and an important one for observers of labor-management relations.  While on the one hand, there is a deep history of antagonism and conflict between the union and the industry driven by workforce shortage and turnover, the parties may finally find  new ways to move forward with some spirit of cooperation.  It is a testament to leadership on all sides, labor, industry, and government to try to find lasting solutions to the workforce crisis as exemplified by the proposed training Hubs.

I wish them success.

The question is, can the parties find lasting ways of solving the many challenges they face?

The stories shared by a Union President, Vice President, Chief of staff as well as frontline leaders, portray realities far from the headlines:  we live in a nation in which healthcare accounts for nearly 20% of the national GNP yet as I have reported in this column so many times, access to quality care is very difficult, and even with improved insurance coverage our health outcomes remain poor; and for our long term care  population dire and abusive.

Few are more forgotten or further from our daily lives than nursing home residents and their dedicated caregivers.  Stories of militancy and cooperation in this sector of our society are also difficult to appreciate and understand.  Through this brief story of those who experience these dynamics every day it is my hope that we recognize for those who live and work in this world each day that they really have no choice but to lead in a framework of pride and incredibly hard work to improve the lot of those who go to work each day.

Finally, it seems to me that labor, industry, and government ought to meet on a more formal basis, to create a permanent joint effort to substantially and sustainably improve the lives of nursing home residents by fundamentally changing the labor market, and the nature of the work that direct care workers perform.

We know from the work of scholars like Paul Osterman of MIT that, “Pressuring Medicaid and Medicare to improve reimbursement rates and direct that a portion of the increase go to employees has had some limited success in some states. However, it is unlikely to succeed if it is not accompanied by efforts to increase the productivity of health care aides”. (Creating Good Jobs, MIT Press, Cambridge, MA and London, England, 2019, pp. 130-131).  Osterman goes on to define what that increased productivity means in practice: “Fundamentally improving the nature of the jobs for healthcare aides requires us to rethink their roles and find ways to make them more productive and a more central part of the healthcare teams. We need new models of care where CNA’s work in self-directed teams and have considerably expanded roles.”

“Labor, government, and industry will need to collaborate more closely to create: “high performance work systems, broader training, employee involvement, and smarter operational and production strategies.  Proponents of this view commonly cite examples of firms in low-wage industries that have been successful while adopting high-road employment practices.” (Osterman)

We should remind ourselves that “the number of people over age 65 in the U.S. who will need assistance is expected to double in the next 25 years,” (Who Will Care for Us, Paul Osterman, Russell Sage Foundation, New York, 2017, p. 3).

The progress described in this article which highlights both heightened regulation and spending for improved staffing in nursing homes is positive.  Yet, given the market-driven nature of the industry, the continuing high workforce turnover, the increase in demand, and the on-going tensions between labor and management, it is a great time for leadership from all three sectors to collaborate for more sustainable solutions.  I hope that will be the larger and more successful impact of the COVID pandemic on the future of nursing home care.

John August is the Scheinman Institute’s Director of Healthcare and Partner Programs. His expertise in healthcare and labor relations spans 40 years. John previously served as the Executive Director of the Coalition of Kaiser Permanente Unions from April 2006 until July 2013. With revenues of 88 billion dollars and over 300,000 employees, Kaiser is one of the largest healthcare plans in the US. While serving as Executive Director of the Coalition, John was the co-chair of the Labor-Management Partnership at Kaiser Permanente, the largest, most complex, and most successful labor-management partnership in U.S. history. He also led the Coalition as chief negotiator in three successful rounds of National Bargaining in 2008, 2010, and 2012 on behalf of 100,000 members of the Coalition.