Finding solutions to high staff turnover rates and persistent retention and recruitment challenges will take a combination of strategies — forcing nursing home operators to be creative and nimble to find out what works best for them.
What can often get in the way of finding the right set of solutions for a provider is relying too heavily on “traditional recruitment mechanisms,” according to Todd Kiziminski, vice president of talent acquisition for Trilogy Health Services.
“The biggest thing that we could do is focus on finding our own niche, our own strategies, whether it’s your website or it’s your employee value proposition,” Kiziminski said during a panel discussion on Wednesday during the Skilled Nursing News Staffing Summit.
A survey of 759 nursing homes recently released by the American Health Care Association revealed that 60% of facilities are experiencing worse staffing situations than they were at the start of the year.
While the latest employment data shows the health care sector grew by 28,000 jobs in May – including 1,300 nursing home jobs – employment in health care overall is still down 223,000 jobs since February 2020, according to the Bureau of Labor Statistics (BLS).
Even before COVID-19, the median staff turnover at US nursing homes was nearly 100%, but Trilogy has been able to keep its turnover rates down in part because they don’t just rely on the “Indeeds of the world” to do their recruiting.
“It’s a crowded marketplace right now and I don’t think there’s a magic bullet on some new website or some new thing. I think it’s to establish your identity, build a strategy, drive referrals, and I think it’s a long haul but the future’s still bright in my opinion,” Kiziminski said.
Trilogy utilizes an “aggressive hiring strategy” and a three-phase approach that starts with building a strong employee services team and using what the company calls a “flex force” that can support growth and keep the focus on retention. The approach has led to an “upward trajectory” for the company’s staffing.
“We’ve netted over 1,200 FTEs [full-time equivalents] in the past four months, 67% of which are care. All of these strategic initiatives seem to be continuing to propel us forward,” he added.
David Grabowski, professor of health care policy at Harvard Medical School who joined Kizminski on the panel, said staffing woes are not a “new phenomenon” for nursing homes but the issue has certainly been exacerbated by the pandemic. Simply raising pay is not going to solve the problem either, he added.
Skilled nursing facilities boosted wages by 9.5% in 2020 and 6.3% in 2021 – the largest wage increase over the course of the first two years of the pandemic. Despite this, the industry saw the greatest decline in employment of any health care sector.
Kiziminski believes the best recruiters during this “Great Resignation,” as some have called it, are often the staff already working in the facilities.
“This is about setting up a culture where staff want to work in this setting and want to keep working in it,” Grabowksi added.
Some operators are even offering profit sharing to all staff members as a way to help them feel like they have an ownership stake in their workplace, Grabowski noted.
“There’s the in the box approaches like pay and then there’s the out of the box ones and it’s going to take both … to really move the needle on staffing,” Grabowksi said.
Making it work without outside agency
One way Trilogy has been able to manage some of the staffing challenges during the pandemic is by not using outside agency staff.
“We’re very optimistic that we can continue down that path,” Kiziminski said. “We used agency for about six weeks during the height of the pandemic and it was pretty clear that was not a sustainable solution.”
Trilogy utilizes what it calls a “flex force” which are essentially set up as internal agency staff but are treated as company employees who go through orientation and wear Trilogy uniforms.
Several states have looked to put caps in place for staffing agencies to limit the amount they can charge facilities, but Grabowksi isn’t sure how much of a long-term solution that really is.
Minnesota specifically has had legislation to cap agency rates in place for decades.
“The big agency providers don’t go into those states,” he explained. “They stay out of the Minnesotas because they aren’t able to get the big returns they might get in a nearby state.”
Agency staff can also be bad for morale, according to both Grabowski and Kiziminski.
“More turnover in a building has been shown to lead to worse quality for the residents and think about the older residents living with dementia,” Grabowski said. “And if I wanted to upset one of my staff, I imagine the worst thing I could do is bring in these agency staff and overpay them … There’s nothing worse for morale than bringing in agency staff.”
However, it’s going to take a lot more than just targeting agencies to solve the staffing problem, he said.
Legislative headwinds out
Operators over the last several months have seen a handful of legislative packages and policy changes proposed for nursing homes including the ending of the temporary nurse aide (TNA) program, which allowed TNAs to work in nursing homes past the mandated four months before being certified and tested.
When it comes to preparing for things like the end of the TNA waiver, Kiziminski pointed to a Mike Tyson quote: “Everybody’s got a plan until you get punched in the face.”
Some of the legislative changes proposed over the past several months have shown how important it is for operators to be nimble and plan and prepare for the worst when looking ahead, he said.
Trilogy is using a “phased in” approach to ensure that the TNAs they’ve utilized during the waiver will stay on to become CNAs.
A minimum staffing standard for nursing homes is another way lawmakers are looking to change the way nursing homes operate, and while Grabowski thinks such a mandate could be worth exploring, he thinks it must come with federal funding to back it up.
“The real tension in terms of policy is how much new reimbursement is it going to take versus how much is it just tightening the belt with better accountability of existing funds,” he said. “I think it’s going to take both and it’s largely going to be the former.”
Investing in training remains key
Kiziminski thinks that defining flexibility is one of the biggest short-term opportunities that operators can capitalize on.
“Making a hybrid workforce that can work from home is important for nursing homes, but flexibility means different things to different people. For one person it means to be able to come and go a half hour earlier, for someone else it may be I need to work three [12-hour shifts],” he said.
Trilogy has also been able to flatten its 30, 60 and 90-day turnover in part by investing in training.
“We’ve got a nurse, mentor and caregiver program preceptor program that really develops our nurses and our caregivers to help onboard those new clinical employees,” Kiziminski said.
In fact, investing in employees has been one way Trilogy has been able to keep its turnover numbers low.
“We have 2,735 employees enrolled in at least one apprenticeship [program]. For an organization with 12,000 employees, we’re pretty proud that we’re continuing to grow people throughout those programs,” he said.
Trilogy continues to further develop these programs by adding additional resources with new internal certifications like wound care and infection prevention.
Grabowski added that it can be a scale issue for some providers in setting up similar programs.
“When you have 10 or 20 facilities or even a handful, you’re playing a different game,” he said. “I think that speaks to some of the assistance that policymakers might be able to provide with setting up some of the infrastructure here to really partner with facilities to set up these analysis training models.”