On a given day, David Ross, administrator at Hillsborough County Nursing Home in Goffstown, can be found delivering meals to residents, folding laundry and washing floors. It’s not just a sign of Ross’s dedication to overseeing the operations of the skilled nursing facility, but a reflection of just how short-staffed the home has become.
“We prioritize departments in the building that are most critical for us by reassigning staff from [other] departments… including me,” Ross says. “That has become normalized business for us.”
Hillsborough County Nursing Home isn’t alone. Health care agencies throughout the state and the country are facing staff shortages that have the potential to affect care for the state’s most vulnerable residents. Nationally, 86% of nursing homes are facing moderate to severe staffing shortages, and 96% are having trouble filling vacancies, according to a January report from the American Health Care Association. In NH, where the state unemployment rate was just 1.8% in June, long-term care facilities are unable to recruit and retain staff in part because, despite increases this year, the state’s low Medicaid reimbursements limit how much the facilities can pay staff, leaving them unable to compete with other employers, experts say.
“When a dishwasher at a nursing home can make a heck of a lot more money working for a distribution warehouse, [changing jobs is] an economically rational decision,” says Brendan Williams, president and CEO of the NH Health Care Association.
That has left NH long-term care facilities in the lurch, paying more than ever, but still unable to hire and retain the staff that they need. Ultimately that leads to care atrophy, Williams says, with facilities limiting the number of patients they admit because they simply don’t have the staff to care for patients in every bed.
“Care is going offline, bed by bed,” he says.
Temporary Staffing Tensions
Across the country, health care facilities lost workers during the pandemic as people stayed home to care for their children or opted not to work in high-risk health care settings.
To fill those openings, health care facilities turned to temporary agency workers, including travel nurses. Agencies pay nurses and other workers, like licensed nursing assistants, up to three times what they make working directly for a health care facility, attracting highly qualified candidates. The agencies then charge the facilities even more, profiting off the difference.
“These arrangements are contracts of adhesion because there’s a real imbalance in the bargaining power,” Williams says. “Providers are really at the mercy of the agencies.”
Demand for travel nurses jumped 35% in 2020, and another 40% in 2021, according to The Washington Post. National hospital spending on contract employees rose 257.9% from 2019 to 2022, according to a 2022 report from the American Hospital Association. Similar data isn’t available for nursing homes, but administrators in NH say that the costs of hiring temporary staff have skyrocketed.
“In fiscal year 2022, we spent about $300,000 on temporary agency staff, which was a lot of money for us,” Ross says. “In fiscal year 2023, that was over $3 million.”
To cover the costs, Ross has reallocated money from different budget lines. Some of the funds are redirected from benefits not being paid because of vacancies, he says, but paying travel agencies also means that the facility must forego capital improvements, renovations and new equipment.
Maplewood Nursing Home. (Courtesy of Maplewood Nursing Home.)
At Maplewood Nursing Home in Westmoreland, about half of nurses and nurses’ aides are temporary workers, says Kathryn Kindopp, administrator of the Cheshire County-run facility. Kindropp is working to reduce the amount she pays to contractors, but doing so is worrisome for her.
“It’s risky if we don’t find travelers willing to come up here for what we are willing to pay,” she says. “We must always provide the necessary care, and these agencies know this.”
While costs for acquiring travel nurses and clinicians rose significantly during the pandemic, it was due to market demands, says Aram Hampoian, president and CEO of Core Medical Group, a Manchester-based health care staffing agency that provides travel, permanent, interim and locum tenens staffing services.
“Demand increased because health care workers were leaving the market,” he says, adding that those who stayed could command a higher rate of pay due to the shortage of workers and the higher health risk. While hospitals and health care staffing agencies could afford to pay those prices and attract that talent, many long-term care facilities that tended to pay lower rates were left with higher vacancies, Hampoian says.
He points out his agency places nurses and clinicians across the country for temporary positions and, as such, those professionals were able to set their price that hospitals and other organizations were willing to pay. He says some in the health care industry have accused staffing agencies of price gouging, “which I find frustrating,” Hampoian says, explaining the agency margins are not as large as they may think as the agency has to cover the cost of the person’s salary, licensing and insurance. And those professionals were demanding more money to move temporarily across the country during a pandemic, costs that escalated again when the omicron variant hit, he says.
This year, the state budget included a “significant” increase for Medicaid reimbursement, Williams says, which could allow facilities to raise their wages. But he is concerned that in response, agencies will increase their rates even more to maintain their hold on the workforce.
“It’s a game of keep away,” he says.
Some states, including New York, have implemented caps on the amount that temp agencies can charge health care facilities, according to Kaiser Health News, while others have called for more transparency, including allowing health care facilities to see what agencies pay their staff.
Senate Bill 149 would increase oversight in the Granite State, making it illegal for agencies to recruit staff at health care facilities or double book staff at two different health care facilities, causing them to bid for the worker.
“We just want to try to level out the playing field,” Williams says. “There is a role for agencies to play. There just has to be some reasonable limitations, otherwise they’re going to bankrupt care in New Hampshire.”
Hampoian says legislation that caps fees has the unintended consequence of deterring travel nurses and clinicians from taking jobs in those states. “There are travelers who go where they can get the best pay. If there is a cap, clinicians won’t go to that state,” he says.
Attracting and Retaining Workers
Ross is optimistic that with time, the power that agencies wield will diminish. Right now, he says, workers are taking advantage of an unprecedented opportunity to make lots of money by working with an agency. But eventually, the allure of stability, guaranteed hours and benefits will become priorities, he says.
“We have folks telling us that: I’m doing this [agency work] for now, and when I can, I’ll come back,” he says.
Hampoian says nurses and clinicians are attracted to agencies like his because they can offer higher pay and flexibility. “Every month we break records with how many people apply to our agency,” he says. However, he says demand for travel nurses at CoreMedical is down 300% compared to a year ago as health care organizations have reached a limit on the premiums they will pay for travel professionals. And travel is not for everyone with some nurses and clinicians now choosing to stick closer to home. While some are returning to their local hospitals and long-term care facilities, some of them have chosen to do per diem work, Hampoian says.
As fewer people enter the nursing field and retirements rise, he says there needs to be systemic changes, starting with hiring more nursing educators and producing more nursing graduates. And hospitals and long-term care facilities need to offer better pay and more flexibility to compete for talent. “Facilities need to get progressive to attract and retain top clinical talent,” Hampoian says. “I wish facilities would take a different approach than what they are.”
And some are doing just that. Hillsborough County has begun paying for people to get their licensed nursing assistant certification, and also paying them a salary while they’re in school. Ross likens it to the way that police and fire departments have long paid for their employees to go to the academy. This creates more qualified employees and fosters good will, he says. In addition, graduates are contractually obligated to work for the county for one year. The county plans to expand the program to help train licensed practical nurses (LPNs).
“It’s a way to grow more of our own workforce,” Ross says. “We hope to reach a pivot point, where there are not enough hours available for people who are working in a gig role…so they’ll look to return” to full-time employment.
He’s also adapting his hiring to accommodate workers who want more control over their scheduling and work hours on a per diem basis.
Still, those concessions can make it difficult to keep the facility full staffed, especially for overnight and weekend shifts. “It’s really trying to make sure that we are balancing the needs of our workforce with the needs of our residents,” Williams says.
The Morrison, a nonprofit senior living community with two campuses in Whitefield, has found a way to attract the staff it needs and no longer rely on agency workers. In 2022, The Morrison had 27% of its positions unfilled and its second shift was filled with temporary agency LNAs and nurses, which was a huge expense, says Executive Director Shannon Lynch.
Lynch and her leadership implemented a four-day workweek to entice new workers and help retain their existing staff, which required a 16% increase in their workforce to ensure enough staff to cover all shifts. It took five months to fully transition to a four-day workweek, but within six months, The Morrison, which has 180 employees, went from 73% of positions filled to 95% and no longer needs staffing agency employees.
Such strategies are necessary for the future of the long-term care industry. Williams worries that the number of people choosing contract work will erode one of the benefits that attracts permanent employees: the New Hampshire retirement system. More people contracting and not contributing to the retirement infrastructure could have a “cascading impact” on the very incentive that’s designed to draw people into the role. “What does that mean for tomorrow’s retirees and the viability of that system?” he says.
The Inn at Edgewood. (Courtesy of The inn at Ledgewood.)
Unable to Maintain an Independent Business
Prior to 2020, Patricia Ramsey, former owner of The Edgewood Center Skilled Nursing in Portsmouth, was already making a transition plan for the business her father started. But when the pandemic struck and she lost many staff, she realized she didn’t have the resources to recover from the impact of COVID-19 on her business.
“From a financial standpoint, I couldn’t do it anymore,” she says.
So, after 37 years at helm, Ramsey sold the skilled nursing facility to Green Tree Healthcare Management, a New Jersey-based company that owns seven other facilities in Rhode Island, Maryland and Missouri. Green Tree had the operational resources—especially around hiring and recruiting—that Ramsey simply couldn’t access as an independent business owner, she says.
“It took the resources of a bigger company to get things moving back on track,” Ramsey says.
Nationally, only 42% of nursing homes are independently owned, according to the American Health Care Association. Just one in three nursing homes that accept Medicaid are independent, according to federal data.
“I think it’s harder in the health care space for independent facilities to function,” Ramsey says. “The economics of scale in a bigger company are quite helpful…. They have savings on the expense side that I just can’t materialize as an independent facility.”
That includes everything from spreading the cost of employee’s health insurance to lowering recruitment costs and saving on supplies bought in bulk.
Ramsey kept ownership of The Inn at Edgewood Assisted Living, a 16-bed facility. Staffing for assisted living is somewhat less complicated, she says, since there’s less need for nurses and nurses’ aides.
Although she’s still in the industry, Ramsey acknowledges that residents and their families lost something when The Edgewood Center Skilled Nursing was no longer independently owned.
“They knew where my office was, and they could stop in,” she says. “To be able to put a face to that ownership and management piece meant a lot for people. They knew you were truly invested in taking care of mom and dad.”
Executive Editor Matthew J. Mowry contributed to the reporting in this article.
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