By Sean Slone, CSG Senior Policy Analyst
Four notable strategies supporting Pennsylvania’s long-term care workforce served as the foundation of the Bucks County Long-Term Care Summit on June 21 in Newtown. Identified by event organizers as being areas where change was possible at the local level, the strategies aimed to enhance training and education, bolster employment supports and support family caregivers.
Enhancing Training and Education
For inspiration on how a state can enhance training and education opportunities, recruitment and retention efforts, and expand the playing field of those available to work in long-term care, Bucks County officials turned to the state of Wisconsin.
Kevin Coughlin, a policy initiatives advisor at the Wisconsin Department of Health Services, told attendees about the state’s new certification program for certified direct care professionals, on which the state partnered with the University of Wisconsin-Green Bay.
“We’re really excited about that,” Coughlin said. “We launched it officially in July [2023] and we have over 8,000 individuals seeking to become [certified direct care professionals].”
Additionally, the state has been able to sustain funding for the WisCaregiver Careers “earn and learn” program for certified nursing assistants.
“It’s never been easier to enter the health care career. We’re able to promote and approve individuals to look at a health care career and they can make a decision [of whether] to work in a community setting, [as] a certified direct care professional or … a certified nursing assistant and go that route.”
— Kevin Coughlin, policy initiatives advisor at the Wisconsin Department of Health Services
Wisconsin has also taken an active role in marketing health care careers to prospective workers, creating a recognizable brand, image and message, Coughlin said.
The state has a one-stop career resource, “WisCaregiver Connections,” a workforce IT platform to match jobseekers with employers.
Employment Supports
Career opportunities are often only the beginning for those who might be willing to work in long-term care. These individuals often need other supports to allow them to choose such a career and stay on the job, said James Vander Hulst, president of the Employer Resource Network.
“If an employee is just getting by, if they’re on public assistance … they’re constantly struggling with the basic needs of shelter, food, safety, [or] if they’re in that kind of reoccurring crisis mode, we can never get to the opportunity for more aspirational things like skill development or training or helping them achieve personal goals like maybe buying a house someday,” Vander Hulst said. “And so our primary focus is to stabilize the employee at work and help them solve any of those life balance issues like transportation, eviction notices, utility shutoffs, those types of things right at the workplace, instead of having to go out to an agency.”
CSG presented innovative examples of employment supports in other states, including:
- Iowa, where unused farmland is used to build housing for workers.
- Massachusetts, where community leadership philanthropy was tapped to build workforce housing as part of a senior housing project on pricey Martha’s Vineyard.
- Minnesota, where two grant funded programs are used to pay for child care, transportation, meals and housing for long-term care workers.
- New Jersey, where some assisted living facilities are providing subsidized housing and transportation for employees.
- Washington, where some long-term care facilities have co-located daycares for workers with small children.
Supporting Family Caregivers
It’s also not just a professional long-term care workforce that is called on to care for older Americans and those with disabilities. Family caregivers play an important role as well, even as they’re trying to maintain their own lives and careers, said Marvell Adams Jr., CEO of the Caregiver Action Network:
“Caregivers are really foundational to our entire system of long-term care aging services,” Adams said. “And really even across the lifespan spectrum, because there are plenty of individuals out there that are under the age of 55 or 65 that need long-term supports and services, and there are many millions of individuals that are under the age of 55 and 65 that are serving in caregiver roles, even in some instances, under the age of 18.”
Adams told summit attendees that employers need to take a holistic approach to supporting working family caregivers.
“If you force an employee to choose between their loved ones in their caregiving role and their job, they may try to do both,” Adams said. “They may try to put their job first, but eventually diminishing returns start to set in, and that individual is not going to be able to show up.”
One challenge with providing support to these family caregivers is that often it’s difficult to know who they are and what their specific needs are because they don’t recognize themselves as caregivers, just as a grandchild taking care of a grandparent.
“If you’re not even classifying yourself as an unpaid caregiver, there may be things that you are missing that wouldn’t even occur to you, resources that may be available, support groups that may be available,” said Nancy Fitterer, president and CEO of the Home Care and Hospice Association of New Jersey, who chaired a Caregiver Task Force that issued recommendations in 2022. “There are so many resources that are available in New Jersey and across the country … that people don’t know about.”
Expanding the Pipeline
State and local officials in Pennsylvania told summit attendees the commonwealth is actively engaged in strategies to expand the pipeline of available workers for long-term care settings, including by helping to develop apprenticeships.
“Registered apprenticeship is actually a way for employers to train their own full-time employees into positions where they need mastery when it’s hard to find people for these positions or it’s hard to train them appropriately within your organization,” said Adina Tayar, apprenticeship coordinator for Bucks and Montgomery County CareerLink.
But several speakers noted that it is somewhat more difficult to get an approved apprenticeship in Pennsylvania compared with other states, so there may be a need for process improvements.
“Long term care facilities are slow to adopt apprenticeship programs due to a variety of factors, including the upfront time investment needed to apply for and establish a program in a facility,” said Felicity Wood, a consultant for Health Quality Innovators. “And facilities generally don’t have the expertise and knowledge to put a registered apprenticeship program into place, and many are not even aware that this is an option.”
Wood added how Pennsylvania does not allow individuals serving in apprenticeships to become certified nursing assistants to immediately work in a position, apply their knowledge and earn wages. High turnover in leadership positions often leads to the discontinuation of apprenticeship programs and a slow certification process for certified nursing assistants means that long-term care facilities risk losing candidates to other job opportunities. Moreover, Wood said, there is a need for better data to demonstrate the return on investment from these programs to ensure their longevity.
One reason expanding the pipeline of available workers will be important in the years ahead is that minimum staffing standards for all skilled nursing facilities have been issued at both the state and federal levels. Pennsylvania regulations that kicked in last year required that nursing home patients must receive 2.87 hours of direct care per day, a requirement that increased to 3.2 hours on July 1 of this year. Meanwhile, the federal Centers for Medicare and Medicaid Services moved forward with a final rule this year to require a total nurse staffing standard of 3.48 hours per resident day.
“Seventeen of the 31 Bucks County Nursing Homes … have staffing hours currently below the federal rule mandate of 3.48,” Wood said. “So, there’s a lot of recruitment and retention of future staff that must be done for all Bucks County nursing facilities to be compliant with this mandate. … The average bed count is about 120, and the largest facility has 360 beds. … Just the increase of staff that’s going to be required is going to be astronomical.”
Despite Pennsylvania’s strong labor market for nursing assistants, Wood said almost 18% of nursing facilities are using staffing agency contract staff rather than their own employees to try to meet the labor demands.
What’s Ahead for Pennsylvania
Two organizations representing many of the state’s nursing facilities and aging services providers are also concerned about the new federal and state staffing requirements.
“We estimate upwards of well over 6,000 new caregivers in Pennsylvania alone to meet the ratios and the requirements in the federal rule overlaid with the Pennsylvania rules,” said Tim Ward, director of advocacy and government relations for the Pennsylvania Health Care Association, representing nursing facilities, assisted living and personal care homes across the state. “And that’s on top of the current shortfall that we face in Pennsylvania and … just to put a monetary value on that: about $550 million is the … calculation for how much it would cost.”
But Ward also believes those numbers may just be the tip of the iceberg.
“These are just minimums,” Ward said. “These are what providers must meet. But to meet those, you’re talking about scheduling at much higher levels, because everyday life gets in the way. … You’re staffing well above these minimums in case someone does call off or have an emergency and they can no longer get to work.”
Ward and Austin Cawley, his counterpart at LeadingAge PA, the organization that represents aging services providers, pointed to several pieces of legislation under consideration by the Pennsylvania General Assembly that they believe could make a difference:
- Senate Bill 1102 (2024), which would revamp training for nurse aides, developing a new curriculum and establishing a “train-the-trainer” program model among other changes. It allows nursing students and nurse graduates to use their prior education and clinical experience as a prerequisite to certified nursing assistant examination and certification. The measure, which passed the Senate, was awaiting action in the House.
- Senate Bill 1103 (2024), which directs the Pennsylvania Department of Human Services to offer a skill competency examination in lieu of a high school diploma or GED for direct care workers. The measure is currently still held up in a Senate committee, Ward said.
- Senate Bill 1104 (2024), which would allow 11th and 12th grade students who work in a congregate care setting to receive elective credits. The measure passed the Senate and awaits action in the House.
Ward said the third bill was something Pennsylvania borrowed from a measure enacted recently in Minnesota.
“We’re trying to expose the next generation of Pennsylvanians, who are getting ready to go to college or go to vote, or really trying to think about what their next move is after they graduate high school to get them immersed in long term care, and give us a little bit of a leg up on other health care outlets, but also other industries, by awarding credit towards graduation for working or volunteering in a long-term care setting,” Ward said.
Pennsylvania lawmakers were also considering measures to implement the second phase of the Nurse Licensure Compact, establish the position of medication aide in nursing homes (SB 668 [2023]) and expand the regulation of temp staffing agencies to other settings (SB 1117 [2024]).
“Temporary staffing agencies and the costs that they’re incurring upon providers is astronomical,” Cawley said. “With the staffing mandates that providers are having to meet, temporary staffing agencies have certainly taken advantage of the opportunity to charge very exorbitant prices for their services that are critically needed for our residents.”
This is the second of two articles highlighting efforts in Pennsylvania to support the long-term care workforce. The first article, “Long-Term Care Workforce the Focus of Pennsylvania Summit,” is available at https://csgovts.info/3XppSJK.