Nursing homes’ lethal health-staffing problem: Churn rates as high as 300%

churninnhomes-300x300Churn may be a wonderful word when discussing fresh milk, heavy cream, and butter. But it can be a nightmare term for the too-common, rapid, and lethal turnover that occurs in health staff at nursing homes and other long-term care facilities.

Personnel turnover left the aged, injured, and ailing residents at care centers, with an average annual health staff churn-rate of 128% and some facilities hitting as high as 300%, even more vulnerable during the coronavirus pandemic, a new study reported.

David Grabowski, a professor of health care policy at Harvard Medical School and one of the study’s authors, told the New York Times of the information he and his colleagues gathered:

“It was really staggering.”

As the newspaper reported of the research:

“Inadequate staffing — and low pay — has long plagued nursing homes and quality-of-care for the more than one million residents who live in these facilities. But the pandemic has exposed these issues even more sharply, with investigations under way into some states’ oversight of the facilities as Covid cases spiraled unchecked and deaths skyrocketed. The high turnover rate likely made it harder for nursing homes to put in place strong infection controls during the pandemic, and led to rampant spread of the coronavirus, said Ashvin Gandhi, the lead author and a health economist and assistant professor at the University of California Los Angeles Anderson School of Management.”

Who is to blame? As is seemingly always the case in health care, the owners and operators of facilities deny fault, cry “poor us,” and blame others, notably the federal government. They say taxpayers should fork over more money to them, so they can make higher profits — and, maybe, just possibly they would share the bounty with the over worked, under trained, and mostly well-intentioned people who toil in their facilities.

Who wants to work in a bad place?

Maybe. But maybe not, as the staffing study underscores.

It found that turnover ran higher at for-profit facilities owned by chains — a growing presence in the industry — and those serving Medicaid beneficiaries, the New York Times reported. The study also found, in a terrible data point, that the most-able health staff at the facilities — registered nurses with the highest skills and credentials — had the greatest churn. They could walk, and they did.

What prompted facilities to lose their people? As the newspaper reported [and see chart above, courtesy Health Affairs]:

“Facilities that had low-star ratings on Medicare’s website comparing nursing homes had the highest median turnover, and nursing homes with high ratings had the lowest turnover.”

As people showed with their feet, who wants to work in bad place? That’s what health workers told the New York Times:

“Melissa Unger, the executive director at SEIU 503, an Oregon division of the Service Employees International Union, said nurses struggle to work at facilities with too few staff members to adequately care for the residents. ‘You don’t feel great about the job you’re doing,’ Ms. Unger said, noting that many staff members are women and people of color. ‘You’re doing all of that for crappy benefits and low pay.’ Summer Trosko, a union member working at an Oregon nursing home, said she was used to colleagues leaving from burnout because of inadequate staffing and a lack of money. ‘They get tired and just can’t take it anymore and quit,’ she said. Many are replaced by people who have just graduated from high school with little training, she said.”

Harms rise when churn rises to levels at fast-food joints

Indeed. This is zero dig at the hard-working people who labor in fast-food. But just for perspective on nursing homes losing the vital personnel who can mean not only life-and-death but also quality daily care of residents, the newly reported staff turnover in folks dealing with the vulnerable is matched — in fast food. As CNBC reported:

“If you think it sounds like a mathematical impossibility for a company to lose more than 100% of its workers every year, you’ve never worked in the fast-food industry. At fast-food restaurants, losing 100% of employees — and then losing still more of the employees hired to replace those workers — is a common, and worsening, labor problem. The case of Panera Bread shows just how deep the employee turnover issue is for restaurant companies. Panera loses close to 100% of workers every year, and by fast-food industry standards that’s considered good.”

It was disastrous for nursing homes and other long-term care facilities during the pandemic. As the New York Times reported:

“At least 172,000 deaths from the virus had been reported among either residents or employees of nursing homes and other long-term care facilities by late February … The nursing home death toll alone has accounted for more than one-third of all Covid deaths in the United States, although death and case rates have begun to decline steeply as more than 70% of residents have received vaccinations.”

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them and their loved ones by abuse and neglect in nursing homes and other long-term care facilities. It is heartening news that the coronavirus’ reign of sickness and death in long-term care facilities may be subsiding. But this is not the time to take a victory lap, nor to revel in false self-congratulations. The vulnerable in the facilities, many so elderly, sick, and injured that their lives already were limited, can never recover lost time with loved ones. They need as much attention and care as can be lavished on them, in a post-pandemic period.

It also will be vital that we determine how we can reform the long-term care that has cost so many grandmothers, grandfathers, aunts, uncles, moms, dads, and friends their lives — in the pandemic and due to an operating model that clearly is dysfunctional.

The facilities’ owners and operators are not racing to deal with their challenges. As facilities reopen, and more information flows about what happened in them, disclosures are forcing residents and their loved ones to make tough decisions, for example, whether to seek justice with lawsuits in the civil system. And it seems growing numbers of plaintiffs are pursuing this option.

Going small, not big

Congress, as well as the chief federal regulator of nursing homes and other long-term care facilities (the Centers for Medicare and Medicaid Services), should not only halt the previous administration’s failed campaigns to lessen oversight of this industry. They should, for the sake of graying nation, launch a broad and deep inquiry into how to improve long-term care.

With staffing, the New York Times quoted Grabowski and others with these ideas:

“In addition to making the turnover rates available to the public, the authors point to a number of steps lawmakers could take to improve retention. Medicare could incorporate turnover into its star-rating system, and Medicare and Medicaid could reward nursing homes with higher rates if they had lower turnover. ‘If we’re going to change nursing homes, we have to start with the staff,’ Dr. Grabowski said.”

That sounds right. So, too, do findings by other researchers about long-term care. They say that the pandemic has emphasized the importance in this area of going not big but small. We need to rethink, as occurred in public housing, whether it makes sense to entomb human beings in giant towers — in the name of cost-saving and efficiency rather than safe, quality, and humane living. Do we really need big eyesores like the old East Capitol Dwellings, or the Cabrini-Green (in Chicago), or Jordan Downs (in Los Angeles) projects? Do we have their analogs in long-term care now, and why not different models like the small-residence Green Houses? As the authors reported:

“The unique properties of nursing homes as we know them —places where large numbers of fragile older people live in close quarters and often share bedrooms, bathrooms, and dining areas — have made them easy prey for a virus that thrives on close contact and shared air. Making matters worse, the people entrusted to care for seniors are undertrained and poorly paid, earning in 2020 an average $14.14 an hour. As a result, many staff work multiple jobs, often in other senior facilities. The results have been devastating … Yet one unique type of nursing home appears to have done a far better job of protecting residents: the 300 or so Green House homes, loosely affiliated but independently owned, that operate in 32 states and serve some 3,200 elders. In just-released research, a team at the University of North Carolina’s (UNC’s) Program on Aging, Disability, and Long-Term Care has found that residents of Green Houses are far less likely to be infected and to die than residents of traditional nursing homes …

“Long before Covid-19 cast a spotlight on nursing homes, researchers who study aging viewed Green Houses as a uniquely human form of housing and care for vulnerable elders that provide better quality of life while reducing hospital admissions, Medicare spending, and staff turnover. They were the standouts in an industry where unaccountable owners, underpaid workers, and miserly government reimbursement practices have incentivized some nursing home owners to cut corners and operate large facilities.”

The study is heartening reading. We have much work to do to get long-term care in much better place than it is now.


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