Nobody is happy with the nation's nursing homes. Too many patients are receiving substandard care. Workers, particularly nurse's aides who provide the majority of direct care, suffer from low wages, lack of benefits, understaffing, inadequate training, and limited career opportunities. Families are often appalled at how their loved ones are treated. Owners and managers struggle with government reimbursements that do not allow higher pay or better treatment. Clearly, the $96.2-billion-a-year nursing home industry is failing its residents and workers.
Government is deeply implicated, since the majority of nursing home bills are paid by Medicaid or Medicare. Yet the Bush administration's tax-and-budget program precludes a national strategy to upgrade nursing homes and professionalize the caregivers who work in them. States vary widely in their strategies. Massachusetts and California have made recent gains in upgrading care quality and professionalizing care. In Florida, with its large population of seniors, there is the beginning of a coalition of patients, families, and workers on behalf of better care, but Governor Jeb Bush's administration is more obstacle than ally.
Nursing homes and other long-term-care facilities are unique among low-wage labor markets in that government, in effect, sets wages and career paths by setting reimbursement rates. Government also regulates the conditions of care and subsidizes training programs for nursing assistants and other paraprofessionals. Unlike other low-wage sectors, a broad-based, middle-class constituency for better wages and benefits potentially exists in the form of family members of nursing home residents. So there is a potential solution that benefits all the stakeholders: higher reimbursements coupled with tighter regulation and deliberate professionalization of the direct-care workforce. Though bits and pieces of this strategy are emerging in a few states, it is being blocked nationally by warped budgetary priorities and a failure of political imagination.
This problem will only grow. Hospitals are increasingly discharging patients before they can care for themselves at home. The over-65 population will double between 2000 and 2030, while the traditional paraprofessional caregiver population, women aged 25 to 54, will decline by 7 percent. The demand for nursing care is increasing dramatically, but the current labor market is providing better options than the low-paying, stressful job of nurse's aide and creating a huge labor shortage.
Nurse's aides, who provide 80 percent to 90 percent of the direct care in most nursing homes, earn an average wage of $7.93 per hour, usually without benefits. On an average eight-hour shift, a nurse's aide is expected to assist as many as 20 residents with bathing, dressing, eating, exercising, and eliminating. It is impossible to complete all the tasks in a cursory manner, let alone to take time to talk to residents or individualize their care. Both workers and residents feel frustrated. The work is hard, the pay is low, and aides are not treated with respect. It is not surprising that more than 40 states have critical shortages of direct-care staff.
The annual turnover rate (the percentage of staff who have to be replaced annually due to quitting or firing) for nurse's aides is higher than 90 percent. A study of job leavers by the National Network of Career Nursing Assistants found that even those who like their jobs often resign because they cannot earn a sufficient income to support their families.
Not surprisingly, most nursing homes are chronically understaffed. The average amount of total nursing care per resident-day in nursing homes is 3.2 hours. The National Citizens' Coalition for Nursing Home Reform recommends a minimum of 4.4 hours per day, depending on the caseload mix of the nursing home. This recommendation has been endorsed by several professional organizations in the field.
Training is minimal. The federal government requires that all nurse's aides working in nursing homes complete just 75 hours--not quite two weeks--of training to become certified nursing assistants. This training leaves aides unprepared to handle the specific problems of dementia, restorative care, depression, and other health issues, and doesn't give them time to develop the interpersonal, communication, and problem-solving skills needed to care for residents.
Even among nursing homes certified by the Health Care Financing Administration (the federal agency that supervises Medicare and Medicaid), up to 60 percent have not passed minimum health-and-safety standards in each of the past seven years. Susan C. Eaton, a professor at Harvard University's Kennedy School of Government and an expert on the nursing home industry, estimates that 70 percent of nursing homes are low quality--as defined by care and by treatment of workers.
How Government Creates Substandard Work
Government policy is both the key problem and the potential solution. As Steve Dawson and his colleagues at the Paraprofessional Healthcare Institute point out in a recent study, "the single largest funder of health care, the federal government has in essence created an entire labor market of paraprofessional health care workers--a labor market that would not exist without its funding, a labor market that keeps low-income women in the ranks of the working poor. And yet our government has yet to accept responsibility for creating and maintaining literally thousands of poverty-level jobs."
Some 60 percent of long-term care is financed by Medicaid and Medicare. Few people have private insurance that covers nursing home care, and such insurance is prohibitively expensive. Medicare covers nursing home care for seniors only for a limited period after a hospital stay. Individuals who require long-term care must pay out of pocket until they have gone through their assets, and then Medicaid treats them as medically indigent and picks up the cost. Medicaid is a complex match of federal and state funding that is largely administered by the states. With yearly nursing home charges typically exceeding $50,000, it doesn't take long for most people to run out of money and, with it, any consumer leverage over quality of care.
The low Medicaid-reimbursement levels significantly preclude increasing wages and benefits. For a few years, private, for-profit nursing home chains were seen as a bonanza, but caps on reimbursement rates have ended that boom. Nursing homes that are raising pay and offering career advancement opportunities are often subsidized by private foundations or religious groups. Although a few for-profit providers--such as Apple Healthcare in Connecticut--have been able to raise wages slightly within existing reimbursement rates by reducing turnover costs and temporary staff, they are the exception.
At the federal level, policy is contradictory. On one hand, the government sets reimbursement rates that guarantee poverty-level wages. On the other, several federal training efforts, such as the Department of Labor's Incumbent Worker Demonstration Program, are supporting career-ladder initiatives to create advancement opportunities and higher pay. But easing the transition from welfare to work steers people away from direct-care jobs, which pay so little and offer limited opportunity for advancement.
The states are dealing with the nursing home crisis in a piecemeal manner, legislating a hodgepodge of standards for staff-to-patient ratios, training, and wages. Approximately one-third of the states require more than the federally mandated 75 hours of training for certified nursing assistants. California, Delaware, and Maine have the highest standard: 150 hours. Some states have sought to raise nursing home pay by increasing reimbursement levels and mandating that most or all of the increase be applied to workers' wages.
Eighteen states have enacted such wage pass-through programs. Wage hikes vary from 50 cents to $2.14 per hour. The only state that maintains data on the impact of higher wages, Michigan, reported that turnover rates for certified nursing assistants declined from 74.5 percent in 1990 to 67.45 percent in 1998. But even pass-throughs are no guarantee of living wages: Oklahoma's reform set a minimum hourly wage of just $6.65 for direct-care workers.
Pass-throughs are clearly only part of a solution and don't directly address the quality of care. Nursing homes suffer from interrelated problems that defy any one remedy. Addressing all the major deficiencies will require sustained advocacy from coalitions representing several constituencies that historically haven't seen their interests as coinciding. Labor unions are central to such coalitions because they combine representation of workers with an ability to organize other constituencies and to press legislatively for higher standards and reimbursement levels.
The Beginning of a Policy
In Massachusetts, for example, the legislature passed a $42-million nursing-home-quality initiative in July of 2000. This legislation includes a $35-million pass-through, plus $5 million to create career-ladder programs for direct-care workers, $1.1 million for training scholarships, and $1.1 million for training and post-employment supports for people moving off welfare.
The legislation is the result of the efforts of the Coalition to Reform Eldercare (CORE), a group of labor and advocacy organizations and nursing home operators. The group originally came together to advocate for increased staffing levels but soon realized the need to address factors causing high turnover first. Owing to the efforts of Barbara W. Frank, director of state health policy at the Paraprofessional Healthcare Institute, the diverse groups in CORE began to see how their interests overlapped. Initially, worker pay was not even on the radar screens of patient-advocacy organizations. If anything, direct-care workers were perceived as the problem. But this gradually changed. "The average middle-class person may not be able to relate to the former welfare mother working in a back office," Frank says. "But when that person is taking care of his or her parents, low wages and overwork become issues he or she can relate to." The case was made to employers that investing in better training, career ladders, and better wages made good business sense if they could reduce expensive turnover and use of temporary labor.
CORE members conducted community meetings throughout the state to raise public awareness of the issues and worked with the media to get more coverage. They also participated in a state task force on staffing needs and testified at state legislative hearings to support increases. CORE effectively sold the public and the legislature on the proposition that targeting workforce-development dollars to health care provided two benefits for each dollar spent: stabilizing the health care system and supporting advancement for low-wage workers.
It is too early to tell whether that claim is true, but early results are promising. Thirteen nursing homes in Massachusetts have received round-one demonstration grants. Each home is developing career-ladder training programs that create three tiers of certified nursing assistants and focus on specializations such as dementia, rehabilitation skills, and peer mentoring. Course completers are promoted and receive a pay increase of 25 cents to $1.00 an hour. This may not have the dramatic effect hoped for by advocates. Round-two grants require nursing homes to work with consortiums of long-term-care providers and workforce-development organizations in order to integrate the training programs more systemically with local workforce-development policy. In round three, individual homes will continue to develop training programs. By the end of the third round, 10 percent of the commonwealth's 500 nursing homes will be providing career ladders.
I recently sat in on a meeting of nursing home staff participating in the round-one discussion. They reported that aides who had completed one set of classes were eager for more training. Several of the managers said that the nurse's aides were attracted not just by the admittedly modest pay raises but by the prospect of personal- and professional-growth opportunities. Although evidence is only anecdotal at this point, it appears that turnover rates and use of temporary-employment agencies has declined in several nursing homes. Staffers attribute this improvement to nurse's aides seeing that they have growth potential, even if they haven't yet had a chance to realize it.
But despite the enthusiasm generated by the wage pass-through and the prospect of career advancement, wages among the round-one homes average between $8.50 and $9.50 after the raises for training--well below the "self-sufficiency standard" of $13.50 to $18.50 (depending on region) for the average single mother of two children in Massachusetts that was established by the Women's Educational and Industrial Union. In that state as elsewhere, the presence or absence of a union has more impact on wages than the pass-through program. But of course, even at unionized nursing homes, wages are constrained by reimbursement levels.
Other states are having a difficult time passing much less comprehensive legislation. In Florida, patients' rights and quality of nursing care have long been pressing issues. But a majority of legislators have failed to make the connection between the quality (and pay) of the workforce and the quality of care.
The Aging and Long-Term Care Committee of Florida's senate has approved legislation that would increase minimum direct-care staffing levels in nursing homes. But at the same time, there is a massive push by the nursing home industry to weaken a patients-rights law enacted in the 1970s that responded to scandalous nursing home conditions and created a right to sue if a patient suffered deficient care. These lawsuits created an unreliable remedy and left nursing homes unable to get affordable liability insurance.
Patient-advocacy groups see maintaining current rights as essential to checking abuses that are still too common. But a focus on patients' rights and minimum-staffing ratios alone--without better pay and professionalization of staff--will not solve the problem. Nursing homes will still have high turnover as well as poorly trained and motivated staff, and breaches of good care will inevitably continue.
The Service Employees International Union (SEIU) has stepped up organizing efforts in Florida, increasing the number of union nursing homes from 25 to 60 in the past three years. The average nonunion direct-care wage in Florida is $7.80, compared with $8.50 for workers in unions. But so far, the pieces of the larger coalition have not come together. Dale Ewart, deputy director of SEIU 1991 in Florida, says the crisis in nursing home care is beginning to increase public awareness of the connection between wages and quality of care. SEIU is promoting a wage pass-through and recommending a $1.00-an-hour raise, of which the state's share would cost $45 million. But this is a lower priority for most legislators: A bill in the state house includes a wage pass-through, but the Florida senate's version was stripped out by the Judiciary Committee.
California offers an illustration of what is possible, though it is home-care workers who have made the most progress to date. There, a drive organized by the SEIU led to a change in state policy that will transform home-care workers from poverty-wage freelancers into paraprofessionals who will earn as much as $11.50 an hour. Home-care workers in California are paid by various state and local agencies. But until 1997, no agency would assume the responsibility of being the employer of record, since such a move would entail legal liability and setting standards. The SEIU promoted a policy change, in which California's larger counties took on the home-care workers as direct employees and the state guaranteed higher wages. This effort, coordinated by SEIU's David Rolf, required a $3.5-million, three-year campaign, with 40 full-time organizers who built a coalition of senior citizens, activists, consumer groups, and religious organizations.
The California breakthrough offers a rough model of how state--and ultimately, federal--policy could professionalize direct-care workers in nursing homes. A federal mandate for better training, career opportunities, and improved staffing ratios, coupled with additional funding, could restructure the nursing home workforce and dramatically improve the quality of care. In ordinary times, this would be a hard sell politically. But while the government is awash in a surplus that the Bush administration proposes to give away in tax breaks, it ought to be attractive politics. The tens of millions of baby boomers--who are beginning to contemplate retirement and are watching parents in old age--have a great deal in common with the poverty-wage workers in nursing homes. They are part of a coalition for change, if they'd only realize it.
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