Staff Shortage Gets Worse

An acute staff shortage among home care workers across the country is threatening care for disabled and elderly individuals. Many agencies are struggling to retain employees. Scheduling is also difficult, as as agencies move around a shrinking pool of workers to cover open positions.

The staff shortage endangers a vulnerable population. In Minnesota and Wisconsin, nursing homes denied admission to thousands of patients because they lack essential staff. Patients living in rural ares of New York have injured, soiled, and starved themselves because paid caregivers aren’t available. In Illinois, the independence of developmentally disabled people is being compromised, as agencies experience staff shortages of up to 30 percent.

The emerging crisis has several causes. First, state Medicaid programs are unable fund higher wages. Second, the pool of workers willing to perform this physically and emotionally demanding work is shrinking. These problems portend even worse difficulties to come. Experts warn that America’s senior population will swell to 88 million people in 2050, up from 48 million currently. They will also require more assistance with chronic health conditions and disabilities.

“If we don’t turn this around, things are only going to get worse,” said Dr. David Gifford, senior vice president of quality and regulatory affairs for the American Health Care Association.

Rising Demand, Stagnant Wages Contribute to Staff Shortage

For years, experts have been predicting that demand from a rapidly aging population will outstrip the capacity of the direct care workforce. The U.S. Bureau of Labor Statistics estimates an additional 1.1 million workers of this kind will be needed by 2024 — a 26 percent increase over 2014.

Yet, the population of workers who tend to fill these jobs, overwhelmingly women ages 25-64, will increase much more slowly. After the recession of 2008-2009, Medicaid-funded agencies filled positions rather easily. Now, however, the improving economy has led these workers to pursue other higher-paying alternatives. In response, turnover rates are soaring. Falling immigration and refugee rates may make the situation even worse in the future.

At the same time, wages for nursing assistants, home health aides, and personal care aides are stagnant, making recruitment difficult. The average hourly rate nationally is $10.11. This rate is a few cents lower than it was a decade ago, according to the Paraprofessional Healthcare Institute. Workers in a handful of states are pushing to raise the minimum to $15 an hour.

Hardest to cover are people with disabilities or older adults who live at some distance from a city center and need only one to two hours of help a day. Workers prefer longer shifts and less time traveling between clients, so they gravitate to other opportunities.

Hard Times in Wisconsin

Some of the best data available on the staff shortage comes from Wisconsin. Here, several long-term care facilities and agencies serving disabled and elderly individuals surveyed their members over the past year.

One of seven caregiving positions in Wisconsin nursing homes and group homes remain unfilled, one survey discovered; 70 percent of administrators reported a lack of qualified job applicants. As a result, 18 percent of long-term facilities in Wisconsin have had to limit resident admissions, declining care for more than 5,300 vulnerable residents.

The situation is equally grim for Wisconsin agencies that send personal care workers into people’s homes. According to a separate survey in 2016, 85 percent of agencies said they didn’t have enough staff to cover all shifts, and 43 percent reported not filling shifts at least seven times a month.

“The words ‘unprecedented’ and ‘desperate’ come to mind,” said John Sauer, president and chief executive of LeadingAge Wisconsin, which represents not-for-profit long-term care institutions. “In my 28 years in the business, this is the most challenging workforce situation I’ve seen.”

Reaching a Breaking Point

Sauer and others blame inadequate payments from Medicaid, which funds about two-thirds of nursing homes’ business. In rural areas, especially, operators are at the breaking point.

“We are very seriously considering closing our nursing facility so it doesn’t drive the whole corporation out of business,” said Greg Loeser, chief executive of Iola Living Assistance. Iola offers skilled nursing, assisted living, and independent living services about 70 miles west of Green Bay.

Like other short-staffed operators, he’s had to ask employees to work overtime, increasing labor costs substantially. A nearby state veterans home, the largest in Wisconsin, pays higher wages, making it hard for him to find employees. Last year, Iola’s losses on Medicaid-funded residents skyrocketed to $631,000 — an “unsustainable amount,” Loeser said.

Wisconsin Gov. Scott Walker proposed a 2 percent Medicaid increase for long-term care facilities and personal care agencies for each of the next two years. However, that won’t be enough to make a substantial difference, Loeser and other experts say.

Due to the staff shortage, it is increasingly important for agencies to have the right workforce management tools to help retain employees and manage the changing schedules of a shrinking workforce. To learn more about how workforce management can help your agencies minimize turnover and improve retention rates, contact MITC.

Does Your Company Have a System for Making Decisions?

An organization can miss wonderful opportunities if it struggles to make decisions. And yet, many businesses do not have the tools or policies to make decisions effectively.

A few influential business owners have surprising ways to foster a culture of healthy decision making. In an interview with The Wall Street Journal, the new CEO of Coca-Cola Co. said that he is hoping to “shake off a culture of cautiousness” within the company and encourage his team to “make mistakes.” Amazon founder Jeff Bezos once noted that when making decisions with his team, he relies on one philosophy: “disagree and commit.” This means that if the leadership team does not reach a consensus, it still makes a decision. Then, Bezos asks each member of the leadership team to make his or her objections known. After that, everyone commits to the chosen plan, whether they like it or not. This allows the organization to move ahead without consensus, and it allows everyone to have a voice.

Both of these leadership philosophies revolve around the idea that failure is a necessary piece of any business. Think about it: in a competitive market, sustainable businesses are always developing new services and diversifying revenue streams. However, not every new idea works — and that means that failure is an inevitable part of market-driven strategy. Therefore, businesses that embrace failure are more likely to foster a healthy atmosphere for decision-making.

Why businesses fail to make decisions

Some organizations fail to act in the face of new challenges or opportunities. This causes their market position to erode and their cash reserves to dwindle. They either fail to decide on a plan or they do not implement their plan in a timely manner. Why does this happen?

This is where it gets complicated. Often it is because the contractor doesn’t have the workforce management tools to accurately analyze the business’s posture and to manage new projects well.

  1. The CEO doesn’t have the right environmental or financial information to make market-oriented strategy decisions.
  2. The company does not understand either the degree of downside risk or the return-on-investment. Doing nothing can be more risky than embracing change.
  3. The organization is risk adverse because of past failures and will not approve a proposal with downside risk.
  4. The management team lacks the tools (metrics-based performance analysis, real-time project management control, and service reporting) to go from idea to service.

Tips for making decisions

Here are some rules of for effective decision making:

  • Don’t allow looming decisions to paralyze your team. Launching a new service line, agreeing to a value-based contract, investing in new technology, initiating a new merger or acquisition, creating a partnership — these are big decisions that require decisive action. Decide yes or decide no, but do not decide nothing. As Mr. Bezos said, that doesn’t mean everyone has to agree with every decision you make; but it does mean you need to actually make a decision.
  • Once you’ve made your decision, find a way to help your internal stakeholders embrace it. This includes telling your team reasons for the change, building a culture that embraces change, and developing the talent to manage change.
  • Use metrics to manage the change. Effective workforce management technology can provide these metrics. If managers do not have real-time information on time and attendance, schedules, orders, inspections, and other critical metrics in good time, problems may go undetected.

Richard Edley Reflects On What Managed Care Means for Pennsylvania Providers

Managed Care is coming to Pennsylvania, like it or not. Many agencies in Pennsylvania will soon need to interact with Managed Care organizations for the first time. Providers will require authorizations, new technologies, and new systems; they will also start working with new organizations. This is uncharted water for many providers. Richard Edley, President and CEO of RCPA, has been working with the state, MCOs, and agencies regarding the expansion of Managed Care in Pennsylvania. Since 1994, Richard has been working to support health care in Pennsylvania.

When asked what challenges he foresees when adapting to Managed Care, Richard notes that Managed Care isn’t actually new to Pennsylvania. “Behavioral and physical health care providers have had Managed Care for a long time. It is the move toward Managed Long Term Services and Support (LTSS) that is a new initiative. You’re now talking about social services, rather than medical services. The expansion of Managed Care does not apply to the Intellectual/Developmental Disabilities agencies, even though there has been a lot of talk over the years. It’s bound to come back.”

“However, while Managed Care isn’t new to Pennsylvania, there are new challenges presented by Managed Care for LTSS. Physical health has its challenges, but it is much more standardized. If a patient has symptoms that meet a certain criteria, and the treatment suggested is criteria based, the process of submitting for approval is fairly straightforward. With long term care, you’re talking about such things as in-home services, supports for people to get employment, or care for the elderly, so applying criteria and authorizing services is a grey area. It is much harder to manage.”

“Managed Care Organizations (MCOs) have to learn about how the system works to focus on efficiency and services. It’s a very complex system, and MCOs will have a learning curve.”

“In the previous structure, clients would seek out agencies. The agencies would then get authorization through the state. Now, clients will seek out the MCOs or an agency. If the client contacts an MCO, the MCO will put the client in touch with an agency and work directly with the state. If the client contacts an agency, the agency will have to contact the MCO to get an authorization.”

“For many of the affected agencies, this is the first time they’ll be touching managed care in any way. This is the first time they are dealing with the notion of getting credentials/accreditations, submitting for authorization, tracking, submitting claims that match, need for appeal, or the need to submit for additional services. This is a whole new world.”

“From the IT standpoint, many providers are still very much paper and pencil. A few may have relied on a very basic system or the state system to help them. Now, these providers are going to need Electronic Visit Verification (EVV), electronic health records, and need to get the data to the MCOs in real-time. It will be stressful for small providers, and they’re going to face a real struggle.”

“The way it works right now for agencies without EVV, a person goes into the home and there is no way to verify the visit. If the provider sees a problem with the time, they have someone go back to the office, fill out some things in a system, submit a fax, and eventually authorization happens. If that’s the situation, you are losing valuable time. Technology can be given to attendants to verify the presence of the caregiver and submit requests online. It speeds everything up, saves money, and prevents delays in receiving necessary treatment. Agencies need to be better prepared to take on the technological burden.”

“There is an additional pressure on agency providers: this is the first time the state Community Health Choices has released a procurement where the MCOs do not need to have an Any Willing Provider Network. If a Pennsylvania service area starts with ten providers, after the six month transition period the MCO may only use two.”

“We have to ask providers, ‘How are you going to differentiate yourself?’ We’ve looked at raising the bar on credentials and standards as well as data outcomes. If agencies could track in real-time, it could help them survive the transition period. There is an uncertain future for providers. There is risk for personal attendant services and service coordination entities; some might not survive.”
“In terms of resources, no one is talking about funding as of yet. The state and MCOs are going to be hosting a lot of trainings and meetings. But providing resources for agencies to learn about managed care is also the role of the associations.”

“RCP-SO is being organized to represent the providers who are affected. In the mid-1990s, the precursor to RCPA founded Community Behavioral HealthCare Network of Pennsylvania, Inc. I worked there as CEO for many years before coming to RCPA. It was a provider owned company, and it proved that if you have managed care coming to a state, providers can come together and manage it themselves, rather than wait for whatever MCOs mandate.”

“With that background, it wasn’t out of left field for RCPA to meet with providers, or suggest building a company managing CHC. However, we aren’t competing against large physical health plans. Community HealthChoices has billions in expenditures; that wouldn’t be feasible. We are coming together to create specific products to improve quality and be more cost-effective proving viability in the long-term for MCOs.”

“We’re seeking to help providers in four fields: Brain Injury, Service Coordination, Personal Attendant Services, and Vocational and Day Programs.”

“All of the products, at a high level, streamline administration and work toward alternative reimbursement and unified quality indicators. As an example, with Brain Injury providers, we represent all the post-acute care providers in the state. They have their own outcomes measure and tools, and are all CARF accredited. It wasn’t hard to go to the MCOs and tell them we can manage Brain Injury services for them.”

“It would be more difficult for MCOs to manage Brain Injury providers on day one because they aren’t familiar with how they operate, and there are so many competing interests and priorities (e.g., nursing home admissions). MCOs are contracting with us to standardize quality outcomes, and define quality reimbursement services.”