States Must Take ‘Multi-Factorial’ Approach to Fixing SNF Workforce Shortage

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Meeting the direct care workforce shortage is a “multi-factorial” issue, industry leaders say. Naturally, the solution must also be multifaceted.

A guide with “action areas” for government entities and operators to focus on amid the historic workforce shortage was published last week by the Milbank Memorial fund, along with other academic and nonprofit organizations.

While acknowledging every state is faced with unique challenges to recruiting and retaining staff, the guide breaks down actions government entities and operators can take into four categories: wages and benefits; professionalization of the role; social value elevation of the direct care worker; and improving data collection and analytics surrounding workforce interventions.

“We’ve been concerned about not having sufficient platforms for the people who do this work, to exert an influence over the policymaking process and even identification of the challenge,” sKate McEvoy, program officer for the Milbank Memorial Fund, said during a Friday webinar.

The New York-based Milbank Memorial Fund is a private grantmaking organization focused on improving population health.

Pulling different “levers” at the state level is the best means of elevating the people who do this work, McEvoy said during the webinar Those levers include supporting their economic security and increasing social value of their roles, while also reducing turnover and improving quality of care.

Courtney Roman, senior program officer at the Center for Health Care Strategies, led a discussion on the four core action areas included in the guide. She also shared good examples of states that have implemented aspects of these actions via legislation.

The New Jersey-based Center for Health Care Strategies serves as a nonprofit policy design and implementation partner to state and federal entities.

“It’s specifically designed for state leaders who are committed to strengthening the direct care workforce and looking for ways to broaden existing efforts or even just get started,” Roman said of the guide. “It’s meant to help states understand the complexity of the issues regarding the current direct care workforce shortage and the role they can play in strengthening and improving this absolutely critical workforce.”

The Center for Health Care Strategies, IMPART Alliance and Michigan State University contributed to the guide. Each had representatives at Friday’s webinar.

California was brought up a couple of times by Roman; the state has implemented a wage bump for bilingual direct care workers and those who complete equity training. Although it appears to be for adult day center workers specifically, Roman said the state also offers a monthly $400 stipend that can be applied to health insurance, car insurance or other personal needs.

New Jersey was listed as another example of incentivizing via wages and benefits. The state’s minimum-wage requirement for CNAs, supported by additional Medicaid funding, is $3 higher than the statewide minimum wage.

“A second strategy is through collective bargaining,” Roman said of potential wages and benefits action. “Not all states are going to be able to go this route, but some have successfully partnered with organized labor to establish bargaining rights for direct care workers.”

Connecticut, for one, established collective bargaining for personal care assistants through an executive order. Later implemented via an enabling statute, the collective bargaining agreement led to higher wages, paid sick time and dedicated training funds, added Roman.

Professionalizing the direct care workforce has been an ask of advocates and stakeholders for many years, Roman said, through competency standards, and training and skill building credentials.

“Arizona has enacted uniform training requirements that ensure a baseline level of skill and credentials for all personal care aides, and that includes family caregivers, across all Medicaid long-term care programs,” Roman noted.

The guide’s third action area – elevating the social value of direct care workers – “could not be more important,” Roman said, as multiple industries including skilled nursing face a worsening workforce shortage.

She added that a “concerted, cultural shift” in how such workers are viewed internally and by the public takes time, but there are concrete steps to help shift perception.

State leaders and stakeholders need to be talking about the direct care workforce differently at every opportunity, including high school career fairs, apprenticeships, or via public awareness campaigns.

Drawing from lived experiences and worker stories can have a powerful influence over public opinion and policy, she added.

Colorado has used a significant portion of its American Rescue Act funds to invest in public awareness campaigns highlighting direct care workers. Indiana gave workers a seat at the table quite literally, with 17 sitting in an advisory board created by the state family and Social Services Administration.

The fourth action item focuses on improving data monitoring and evaluation, Roman said. Without real-time data, states are blind to really understanding demographics of the direct care workforce in individual communities.

The Texas Health & Human Services Commision in 2018 began measuring direct care workers turnover, retention and compensation to better inform Medicaid policymaking and workforce planning, according to Roman.

Another evaluation conducted by the NYS Office for Aging, with the help of Cornell University and the City University of New York, examines the economic impact of increasing wages among DCWs, and in turn a reduced reliance on public assistance programs.

“There isn’t one perfect answer, but you’ll find the guide offers concrete examples throughout of states that are making changes,” said Roman. “Our aim was to offer states an opportunity to see that these important shifts can happen.”

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