Senate Special Committee on Aging Issues Testimony From New York University Assistant Professor

WASHINGTON, May 11 -- The Senate Special Committee on Aging released the following testimony by Jasmine L. Travers, an assistant professor of nursing at the New York University, from a hearing dated April 16, 2024, entitled "The Long-Term Care Workforce: Addressing Shortages and Improving the Profession":

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Chairman Casey, Ranking Member Braun, and members of the Senate Special Committee on Aging, thank you for the invitation to testify. I am an Assistant Professor at New York University Rory Meyers College of Nursing, I currently co-chair the workforce committee of the Moving Forward Nursing Home Quality Coalition, which was created to move several recommendations from the National Academies of Sciences Engineering and Medicine Report, The National Imperative to Improve Nursing Home Quality forward, and am a member of the Gerontological Society of America.

In the United States, 84% of nursing homes report severe staffing shortages impacting patients' quality of care; this problem is similar in long-term care community settings.1 If patients don't have assistance getting up each day, they become frail. If they don't have help to eat, they experience malnutrition. And if they aren't changed, they remain in soiled clothing and develop pressure ulcers. As a nurse practitioner who spends a significant amount of time in long-term care settings, I witness these issues daily due to system failures that overlook the importance of having sufficient and trained staff to maintain the well-being and safety of older adults in long-term care compared to services used by the general public. For example, we know that if a domestic flight had a similar shortage of flight staff, the plane wouldn't take off. Long-term care should be no different.

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Who is the Direct Care Workforce?

The long-term care system relies on a workforce that is often unseen and unheard, known as direct care workers. These people enter the homes of your older parents, grandparents, friends, and neighbors. They are the aides and assistants who care for your relatives and friends in nursing and residential communities. They bathe your grandma, assist your aunt in toileting, and feed and dress your dad with dementia. Without these critical workers, who would care for your loved ones? Would it be you?

These 4.8 million personal care aides, home health aides, and nursing assistants constitute the largest segment of the long-term care workforce and provide the majority of direct care for more than 7 million older adults.2 They are predominantly female (87%), people of color (59%), and of immigrant status (27%).3 They represent a diverse but historically marginalized group in low-wage occupations, which contributes to the challenges of bringing direct care out of the margins of the long-term care system and recognizing its value.4,5 Without these critical workers, many older adults would struggle with the basic activities of daily living and maintaining a sense of independence and well-being.

Despite the critical role of the direct care workforce, it faces significant challenges in recruitment, retention, and morale that threaten its sustainability. Between 2021 and 2031, the long-term care sector will need to fill 9.3 million jobs,2 but the supply of direct care workers is shrinking relative to demand, especially in facilities serving a high proportion of Black older adults and in socioeconomically deprived neighborhoods.6,7 Turnover among direct care workers has been as high as 129% per year in nursing homes and 46% across long-term care settings.8,9 Direct care workers continually report that their job is physically taxing, emotionally draining, and stressful.

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What Are the Issues Affecting These Workers?

The issues affecting the recruitment, retention, and morale of this workforce are multidimensional and are compounded by an external environment that devalues this work. Put simply, it is the "job behind the job," or the underlying realities, that make direct care work unsustainable. These realities include the following:

* Low wages and limited benefits: The median wage for direct care workers is $15.43 per hour, falling well below a living wage and insufficient for covering basic daily needs, such as housing, utilities, groceries, and transportation.2 This forces direct care workers to work multiple jobs, live in poverty, and forgo common necessities. Years of experience barely increase wages; for example, those with 10 or more years working in the field earn just $2 per hour more than those with less than 1 year of experience.10 Benefits are often poor, inaccessible, and unavailable immediately. Forty-two percent of direct care workers do not participate in their employer-sponsored insurance plans because they cannot afford it.10 Similar entry-level roles in other settings offer higher pay, better benefits, and less demanding work environments, making long-term care jobs unattractive and leading direct care workers to ask, Why work here?

* A blind eye to inequities: Workers of color receive lower wages, face higher poverty rates, are more likely to work in under-resourced settings, and experience greater strain and burnout than their White counterparts.3,11 Black and Hispanic workers spend more time on work-related activities and have less time for leisure, including longer work commutes and less time exercising, which may affect their health and subsequently the care provided to older adults. Foreign-born workers, essential to direct care work, encounter immigration barriers that limit their participation in the workforce.12 - Chronic undervaluation and a demanding work environment: Direct care workers' working conditions are egregious. The hierarchical nature of long-term care settings positions them as inferior to other workers and excludes them from important conversations and meetings, perpetuating an environment of disrespect, devaluation, and mistreatment.13 They often face disrespect from peers, supervisors, and families as well as verbal and physical abuse from patients, such as racial slurs, threats, spitting, and biting.14,15,16 A direct care worker noted, "If a cashier was punched, they would without a doubt be arrested, but you can punch, spit on, kick, or bite a health-care worker with no punishment." Furthermore, chronic understaffing leads to heavy workloads, with direct care workers in the nursing home setting often responsible for 16 or more residents17 with complex care needs. Accountability systems and processes for responding to reports and complaints made by direct care workers are either absent or problematic.

* Insufficient training, preparation, and growth opportunities: Training for direct care workers often lacks the depth needed to manage complex resident needs and navigate challenging patient and family interactions. It is inadequate in terms of duration and didactic and practical experiences and is often inaccessible due to direct and indirect costs to the providers and the direct care workers themselves. For example, a direct care worker stated, "I was gonna get my CNA license before I moved out of state, but why pay around $1,500 to get certified when I can get into Burger King without an interview and make more money?" Few opportunities exist for career advancement within the direct care worker role or to transition to other health-care professions, which exacerbates hopelessness and low morale.

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Consequences of a Strained Workforce

The problems facing direct care workers have a direct impact on both the quality of their lives and the quality of care they provide to older adults. Understaffing is linked to patient falls, emergency department visits, and inappropriate medication use.7,18 High turnover rates result in a workforce that is less experienced and less familiar with patients' needs. These issues limit the availability of care for people who need it: 83% of community providers turned away new referrals in 2022, and 54% of nursing home providers reported having to limit new admissions due to insufficient staff.1,19 Consequently, many people in need of care are forced to move to institutional settings because community care providers are unavailable.

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Solutions for a Stronger Direct Care Workforce

Addressing these challenges requires a multi-pronged approach involving federal and state governments, managed care organizations, aging organizations, payors, providers, advocates, care recipients, and direct care workers. Organizations such as the Moving Forward Nursing Home Quality Coalition bring together a variety of experts to conduct outreach activities and explore how to address these issues.

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Invest Financially

* Competitive wages and benefits: Direct care workers deserve compensation that reflects their critical role and the difficulty of their work. Implementing minimum wage floors, wage pass-through requirements, incentive payment programs, or adjustments to local, county, or state minimum wage laws, inclusive of direct care workers, should be considered. Competitive comprehensive benefits packages should include health insurance, childcare, transportation, flexible scheduling, paid leave, rural pay differentials, and sick pay. Notably, union membership for direct care workers has led to better pay and benefits.20 Moreover, strategies are needed to prevent a "benefits cliff," whereby workers lose access to public benefits as earnings increase.21

* Staffing spending minimums: States should mandate that a certain percentage of Medicaid payments be allocated to staffing, similar to that implemented in New York.22 For example, during the pandemic, 60%-75% of Paycheck Protection Program funds required for nursing home staffing effectively increased direct care workers' hours.23 A rule proposed by Centers for Medicare and Medicaid Services (CMS) in 2023 aims to require that at least 80% of all Medicaid payments for specific home- and community-based services (i.e., homemaker services, home health aide services, and personal care services) be spent on compensation for direct care workers.24 This rule must be finalized. Moreover, designating long-term care employers of direct care workers as eligible for health professional shortage area benefits could provide access to funds for loan repayments, sign-on bonuses, and increased wages for direct care workers.

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Provide Robust Training and Development Opportunities

* Enhanced training programs: Providers, states, and the federal government must invest in comprehensive and accessible training that equips direct care workers with the skills to manage complex resident needs and challenging interactions. This includes sufficient hours of training, relevant topics, and experiential training. To address cost barriers, providers and community colleges can collaborate to offer free or subsidized training programs. Payors can also consider how to financially support providers that offer additional training to their workers. For example, managed care organizations can consider ways to alleviate the additional burden, time, and cost for workers to participate in training programs, such as providing training stipends or financial assistance (e.g., transportation, childcare).25

* Opportunities for career advancement: Clear pathways for career advancement within the direct care worker role and into other healthcare professions are essential. This fosters a sense of growth and motivates direct care workers to stay in the field and do their jobs well. As an example of a program that may help, the Department of Health and Human Services is in the process of awarding 43 Geriatrics Workforce Enhancement Program grants to develop a registered apprenticeship to support the advancement of direct care professionals. It would be ideal if additional funding was available to award a grant for every state. State programs can continue to incorporate and expand advanced training and career advancement through scholarships, stipends, and demonstration projects.

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Foster a Positive Work Environment through Culture Change

* A respectful and supportive work environment: Direct care workers report that a pervasive lack of respect is more detrimental than low pay. Long-term care settings must foster a culture of respect and appreciation for direct care workers and focus on improving the worker experience through systematic cultural change. This includes holding leaders accountable for creating positive work environments that are free of abuse and disrespect. As one direct care worker shared, "I feel like if management were required to work alongside nurses and CNAs in hospitals, rehab, and long-term care for one day a week, so many things would change." State and federal governments can incentivize and recognize providers who invest in culture change. The use of technological solutions to ease staffing burdens and support direct care workers also needs to be supported. Furthermore, the use of volunteers could alleviate some of the burden on direct care workers (e.g., feeding). Finally, long-term care environments must promote learning, satisfaction, and a desire to work in these settings.

* Empowering direct care workers: Payors, as well as state and federal governments, must incentivize providers to better integrate direct care workers into care teams and to center their voices.26,27 It is imperative that the input of direct care workers are sought in all of these efforts and they are supported to lead change wherever possible. If solutions are designed to support the workforce without including them in the planning, these efforts will be set up for failure.

* Improving staffing levels: The federal government must ensure that the best version of the proposed minimum staffing standards is enacted immediately to improve the quality of care for those currently in nursing homes.28

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Focus on Both Recruitment and Retention

* A desirable workplace: To address the issues of recruitment and retention of direct care workers, there must be a focus on making long-term care settings desirable places to work. There is a need to emphasize open communication, implement open-door policies, and establish staff councils. It is also important to enhance workers' quality of life, such as by providing flexible schedules and free food and beverages. Creating a desirable workplace requires significant investment, but the benefits will far outweigh the costs. These efforts must begin with developing better relationships with long-term care staff and gaining a full understanding of their needs and goals. In the long run, long-term care settings need a clear mission, leadership that is strong but collaborative and transparent, and improvements in compensation, culture, work-life balance, opportunities for advancement, and clear communication. Only when long-term care settings are attractive places to work will the stigma surrounding long-term care work begin to change.

* Equity at the forefront: Because direct care workers often come from historically marginalized groups, support for them should consider and seek to address the social determinants of health and other systemic social and equity challenges that prevent them from entering or remaining in this field.25 Providers must actively challenge and respond to bias, harassment, and discrimination that occur within an organization and create appropriate processes and procedures to support workers (e.g., training for leaders, robust reporting systems). Moreover, because immigration policy affects the long-term care workforce, reforming immigration policies to support direct care workers is necessary to increase their supply.

* Direct recruitment and retention: Direct recruitment and retention efforts are needed, such as recognition programs, sign-on bonuses, retention specialists, and investigations of high turnover situations. CMS intends to propose payment changes based on staffing adequacy and retention. Moreover, CMS has begun to measure and publish staff turnover and weekend staffing levels--metrics that are closely related to the quality of care provided in a nursing home and could further hold nursing homes accountable for retention efforts. The use of value-based purchasing contracts to recognize and reward providers who seek to improve retention would also be beneficial while taking into account unintended consequences, such as disparities in which providers have access to these incentives.11Finally, a nationwide campaign, such as the National Nursing Career Pathways Campaign proposed by CMS and the Health Resources and Services Administration, is needed to recruit, retain, and transition workers into nursing home careers.

* Community and external resources: Long-term care settings should use community partners to assist with recruitment. For example, school boards and high school career counselors are instrumental in assisting with outreach and increasing awareness of direct care opportunities through mediums such as job fairs and technical experiences. The Direct Care Workforce Strategies Center, funded by the Administration for Community Living, provides training and technical assistance to build capacity and promote systems change in the recruitment, training, and retention of direct care workers, but intensive support is limited to six states. Expansion of this center to provide nationwide support is needed to ensure access to these critical resources.

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Plan for Evaluation and Dissemination

* Workplace satisfaction surveys and demographics: It is necessary for states, providers, and/or the federal government to regularly collect data on workplace satisfaction, demographics, and workforce capacity to better understand staffing challenges and evaluate the effects of interventions. This will help identify areas for improvement and track the effectiveness of implemented solutions across groups. Furthermore, CMS should develop a standard set of measures to reflect workforce capacity.25

* Sharing best practices: Some providers have begun to implement improvement strategies and are seeing positive outcomes, but this information is not being widely disseminated. There is a need to identify and share successful strategies to facilitate positive change across the long-term care industry. The Direct Care Workforce Strategies webinar series disseminates some best practices, such as recruitment. Congress should require HHS to study best practices across systems and states and identify opportunities for standard requirements that balance accountability and burden on providers while improving the quality of care and staff experience. Collaborative efforts to measure and communicate impacts to policymakers can help ensure that reporting burdens are minimized. Moreover, states can identify how they compare on specific staffing metrics to other states, with measures collected through the AARP Long-Term Services and Supports State Scorecard.29 States performing well in staffing efforts might share more about their successes.

Finally, other workers, such as registered nurses, licensed practical nurses, and therapists (e.g., physical, speech, recreational) who have a direct effect on the quality of care of older adults and face similar challenges described in this testimony (e.g., wages, shortages, stigma, training), should not be left out of the conversation specific to addressing shortages and improving the profession.7,28 Conclusion

To improve access to and quality of long-term care, we must ensure that all direct care workers receive a living wage, a safe, respectful work environment, opportunities for advancement, adequate training, and accessible benefits to maintain their health and well-being. Only when we recognize that these workers are critically important, hardworking professionals, can we begin to improve equity and health outcomes for staff and patients alike.

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Footnotes:

1. AHCA. State of the Nursing Home Sector. 2023;

2. PHI. Direct Care Workers in the United States: Key Facts. 2023;

3. Scales K, Altman A, Campbell S. It's Time To Care: A Detailed Profile of America's Direct Care Workforce. PHI: Quality Care Through Quality Jobs. 2020;

4. PHI Quality Care Through Quality Jobs. U.S. Nursing Assistants Employed in Nursing Homes: Key Facts. Accessed November 14, 2022. https://www.phinational.org/wp-content/uploads/legacy/phi-nursing-assistants-key-facts.pdf

5. Scales K. It Is Time To Resolve The Direct Care Workforce Crisis in Long-Term Care. The Gerontologist. 2021;61(4):497-504.

6. Falvey JR, Hade EM, Friedman S, et al. Severe Neighborhood Deprivation and Nursing Home Staffing in the United States. Journal of the American Geriatrics Society. 2023;71(3):711-719.

7. Travers JL, Castle N, Weaver SH, et al. Environmental and Structural Factors Driving Poor Quality Of Care: An Examination Of Nursing Homes Serving Black Residents. Journal of the American Geriatrics Society. 2023;71(10):3040-3048.

8. Gandhi A, Yu H, Grabowski DC. High Nursing Staff Turnover in Nursing Homes Offers Important Quality Information: Study Examines High Turnover of Nursing Staff at US Nursing Homes. Health Affairs. 2021;40(3):384-391.

9. National Core Indicators. National Core Indicators Intellectual and Developmental Disabilities 2020 Staff Stability Survey Report. 2022;

10. Squillace MR, Remsburg RE, Harris-Kojetin LD, Bercovitz A, Rosenoff E, Han B. The National Nursing Assistant Survey: Improving The Evidence Base for Policy Initiatives to Strengthen the Certified Nursing Assistant Workforce. Gerontologist. Apr 2009;49(2):185-97. Doi:10.1093/Geront/Gnp024 11. Shippee TP, Fabius CD, Fashaw-Walters S, Et Al. Evidence For Action: Addressing Systemic Racism Across Long-Term Services and Supports. Journal Of The American Medical Directors Association. 2022;23(2):214-219.

12. Muench U, Spetz J, Jura M, Harrington C. Racial Disparities in Financial Security, Work and Leisure Activities, and Quality Of Life Among the Direct Care Workforce. The Gerontologist. 2021;61(6):838-850.

13. Travers JL, Teitelman AM, Jenkins KA, Castle NG. Exploring Social-Based Discrimination Among Nursing Home Certified Nursing Assistants. Nursing Inquiry. 2020;27(1):E12315.

14. Xiao C, Winstead V, Townsend C, Jablonski RA. Certified Nursing Assistants' Perceived Workplace Violence in Long-Term Care Facilities: A Qualitative Analysis. Workplace Health Saf. Aug 2021;69(8):366-374. doi:10.1177/2165079920986159

15. Walton AL, Rogers B. Workplace Hazards Faced by Nursing Assistants in the United States: A Focused Literature Review. Int J Environ Res Public Health. May 19 2017;14(5)doi:10.3390/ijerph14050544

16. Lachs MS, Rosen T, Teresi JA, et al. Verbal and Physical Aggression Directed at Nursing Home Staff by Residents. J Gen Intern Med. May 2013;28(5):660-7. Doi:10.1007/S11606-012-2284-1

17. Jobs. PQCTQ. U.S. Nursing Assistants Employed in Nursing Homes: Key Facts. Accessed November 18, 2022. https://www.phinational.org/wp-content/uploads/2019/08/US-Nursing-Assistants-2019-PHI.pdf

18. Travers JL, Hade, E.M., Friedman, S., Raval, A., Hadson, K., Falvey, J.R.,. Staffing and Antipsychotic Medication Use in Nursing Homes and Neighborhood Deprivation. JAMA Network Open. 2024;7(4)

19. ANCOR. The State of America's Direct Support Workforce Crisis 2022. 2022;

20. Christman A, Connolly C. Surveying the Home Care Workforce: Their Challenges & the Positive Impact of Unionization. National Employment Law Project Data Brief. 2017;

21. Fund TC. Addressing the Shortage of Direct Care Workers: Insights from Seven States. 2024;

22. AARP. AARP New York Applauds Implementation of Nursing Home Staffing and Spending Requirements, Urges Additional Improvements. Accessed April 11, 2024. https://states.aarp.org/new-york/aarp-new-york-applauds-implementation-of-nursing-home-staffing-and-spending-requirements-urges-additional-improvements

23. Travers JL, McGarry BE, Friedman S, et al. Association of Receipt of Paycheck Protection Program Loans With Staffing Patterns Among US Nursing Homes. JAMA network open. 2023;6(7):e2326122-e2326122.

24. Centers for Medicare and Medicaid Services. Ensuring Access to Medicaid Services (CMS 2442-P) Notice of Proposed Rulemaking. 2023;

25. National MLTSS Health Plan Association. Strengthening the Direct Care Workforce: A Framework for Leveraging the Role of MLTSS MCOs to Address the Workforce Crisis. 2023;

26. Travers JL, Caceres BA, Vlahov D, et al. Federal Requirements for Nursing Homes to include Certified Nursing Assistants in Resident Care Planning and Interdisciplinary Teams: A Policy Analysis. Nursing Outlook. 2021;69(4):617-625.

27. Raval A. 16 Strategies For Integrating CNAs Into Care Planning and IDT Meetings. Https://Www.Mcknights.Com/Blogs/Guest-Columns/16-Strategies-For-Integrating-Cnas-Into-Care-Planning-And-Idt-Meetings/

28. Travers JL. Proposed Federal Nursing Home Staffing Standards Will Be Too Little, Too Late. https://www.usnews.com/opinion/articles/2023-12-21/proposed-federal-nursing-home-staffing-standards-will-be-too-little-too-late

29. Reinhard S, Harrell R, Amero C. Innovation and Opportunity: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers. AARP Public Policy Institute Washington, DC; 2023.

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Original text here: https://www.aging.senate.gov/imo/media/doc/78acd1e5-9076-9816-cdd0-f46fe9bc4454/Testimony_Travers%2004.16.241.pdf