Assisted Living: Needs, Practices, and Policies in Residential Care for the Elderly

4. Staffing Problems and Strategies in Assisted Living

4 Staffing Problems and Strategies in Assisted Living R. Tamara Hodlewsky, M.S., M.A. Staffing is one of the most important challenges facing the residential care/assisted living (RC/AL) industry today. Clearly, direct-care staff are responsible for delivering many of the services that define RC/AL, and they play a key role in determining the quality of care that residents receive . As the demand for long-term-care services grows in years to come, the demand for nurse aides will grow dramatically; specifically, the U.S. Department of Labor predicts a 58 percent increase in the number of nurse aide jobs between 1998 and 2008 (U.S. Department of Labor, 2000). However, facilities are already having substantial trouble recruiting and retaining appropriate numbers of qualified direct-care staff, especially nurse aides. The staffing problem has been attracting attention for a number of years and results in concerns about quality. Turnover rates in RC/AL range from 30 percent to more than 60 percent (NCAL, 1998), leading to high search and training costs—funds that could be used to improve the quality of care. A recent General Accounting Office report declared inadequate staffing to be one of the most commonly cited quality-of-care problems in the industry (US GAO, 1999). The Senate Special Committee on Aging held special hearings on the staffing problem in nursing facilities in late 1999, and interest in other segments of the long-term-care industry is usually not far behind. Unfortunately, the staffing shortage does not appear to be a temporary situation, and this leads to concerns among providers, regulators, and consumers that providing the highquality care that is at the heart of the philosophy of assisted living will become more difficult. The difficulty in finding sufficient numbers of qualified staff has several causes and no clear solution. Nurse aide jobs in long-term care generally offer low wages (minimum wage or slightly higher), few benefits, and the risk of injury while lifting or moving residents who need assis- tance. The currently low unemployment rates exacerbate the problem, forcing long-term-care settings to compete with other service sectors for an increasingly tight labor pool. Of course, there are thousands of dedicated and qualified nurses and nurse aides fulfilling the care needs of RC/AL residents today, despite the less-than-optimal tangible rewards. The challenge lies in attracting enough such individuals to care for a growing elderly population. This chapter overviews four perspectives (regulatory, economic, labor, and management) that offer four different— but not mutually exclusive—approaches to facing the staffing challenge in RC/AL. The Regulatory Perspective The regulatory approach to ensuring sufficient quantity and qualifications of staff focuses primarily on consumer protection. It places the responsibility for attracting and retaining quality staff on the facility, regardless of economic conditions and the adequacy of government reimbursement or other payment. Although the fundamental logic behind this approach is appealing, implementation is inherently difficult. How can regulators de- fine the appropriate number of nurses and nurse aides per facility or per resident when facilities vary widely—both among states and within states—in the acuity level of residents? How do staffing requirements change when there are more residents with dementia in the facility or when residents are chair-bound or bedfast? Even assuming that regulators could determine appropriate staffing ratios for different acuity levels, it would be impossible to accommodate each potential combination of residents ’ needs in a meaningful way. Thus, most attempts at regulating staffing levels have focused on minimum staffing requirements that are binding constraints only for facilities with the lowest acuity levels. Staff Levels The challenge in regulating sufficient staffing levels or ratios is exacerbated by the complex organizational structures that exist in the industry today. Approximately 69 percent of RC/AL facilities nationwide contract, or allow residents to contract, with home health agencies to provide nursing care; two-thirds contract with hospice agencies (NCAL, 1998). Home health and hospice services are regulated separately. Therefore, staffing ratios dictated by RC/AL regulators should account for the probability Staffing Problems and Strategies in AL 79 that nonfacility staff may be contributing to resident care regularly or when called upon in case of need. Since there is no federal regulation...