Don’t expect an increase in nursing home staff anytime soon

With much fanfare, the Biden administration recently announced new regulations aimed at increasing nursing home staffing levels and raising wages for some home health care workers. The laudable goal: to improve care for vulnerable elderly people and young people with disabilities. But don’t expect changes anytime soon. It will take years before any of these rules are fully implemented.

The new nursing home rule requires facilities to have sufficient staff to provide an average of at least 3.48 hours of daily care to each resident. In addition, home health agencies will be required to spend 80 percent of their Medicaid payments on employee compensation.

The small print

The fine print in the nursing home rule appears to acknowledge the nationwide workforce shortage that is affecting not only nursing homes, but also hospitals, home health and care agencies, assisted living facilities and doctors’ offices.

Regulations adopted by the Centers on Medicare and Medicaid Services (CMS) require nursing homes to have enough nurses and aides to provide a total of at least 3.48 hours of daily care per resident. A minimum of 0.55 hours must be provided by a nurse and 2.45 hours by an assistant. The remaining 0.48 hours of care comes from a mix of nurses, certified practical nurses, certified vocational nurses or assistants. Additionally, nursing homes must have an RN on site 24/7.

The research organization KFF estimates that only about one in five nursing homes could fully comply with the new standards. As a result, CMS will phase in the new rules over a number of years.

To start, the facilities will have three months to complete a staff assessment that will take into account the interests of employees and residents.

Institutions then generally have two years to comply with the new combined standard of 3.48 hours for nurses and assistants. Within that two-year period, registered nurses must be on site 24/7. Rural facilities facing particularly difficult staffing challenges will have three years to achieve these goals.

Facilities generally have another year, until 2027, before they must meet specific, separate staffing goals for nurses and nursing assistants. Rural facilities will have an additional two years, a total of five years, before they have to meet all standards. That would be in May 2029.

In addition, facilities can apply for waivers from the 24/7 RN rule or request temporary waivers if they are unable to meet other new requirements due to a shortage of available healthcare workers in their community.

In fact, even the initial staffing needs won’t kick in until after Biden’s first term ends. Donald Trump has not said whether he would repeal the rules if he is elected in November, but that would not be surprising.

Solutions for shortages

Some solutions to the workforce shortage, such as raising wages and improving working conditions, lie in the hands of facility operators themselves. Some can afford wage and benefit increases, others cannot.

But other restrictions, such as strict immigration laws, nursing teacher shortages and a growing reluctance among workers to take on increasingly dangerous direct care work, are largely beyond the facilities’ control.

The administration is taking several steps to help nursing facilities recruit staff. Last September, it committed $75 million to encourage nurses to work in nursing facilities. One program offers tuition reimbursement to nurses who agree to work in an eligible nursing home or state inspection agency. It will also encourage states to provide financial incentives for people to become nurses.

CMS also said it would make it easier for aides to enroll in training programs and get jobs in nursing homes. It also promised a marketing campaign to encourage people to train as nurses or care workers and look for nursing home jobs.

The home care staff job

In a separate rule, CMS said it would give states six years to comply with the new requirement that Medicaid home health agencies allocate 80 percent of their Medicaid payments to workforce compensation. That would delay compliance until 2030. The rule also gives states, which set their own payments and generally enforces Medicaid rules, additional authority to grant waivers and create separate rules for small home health care businesses.

Although states are required to provide long-term care in nursing homes through Medicaid, they also receive waivers from the federal government to provide support and services to those living at home. The new rule applies to companies that provide home care services to these Medicaid recipients.

Many states have long waiting lists for Medicaid home care, but it is difficult to compare them because reporting is so inconsistent. The new payment rules require states to make public these wait lists, as well as the wait times for the provision of physician and personal care services.

Biden’s new personnel rules are ambitious, but it will be many years before we know whether they are successful.

Full disclosure: I am an unpaid board member of a nonprofit senior living organization that operates nursing facilities.