Nurse Playing Cards with Elderly Man

At a time when irregular staffing patterns are the norm, skilled nursing facilities are seeking creative solutions to their staffing challenges.

Innovation and disruption

Moving Beyond Pay to Retain Your SNF Staff

  • Emily Buswell
  • 10/24/2019

The challenge of attracting and retaining caregivers has been an epidemic plaguing the U.S. health care system. For years, skilled nursing facilities (SNFs) have been in stiff competition with area hospitals, which are often able to provide better compensation packages, especially benefits. And with the minimum wage rising in many states, competition has expanded to include restaurants, gas stations, and other base wage jobs that are less mentally taxing on employees and require no certification.

Direct care workers often feel unappreciated, disengaged, and burdened by the stress that comes with living paycheck to paycheck. With immigrants making up nearly 28% of direct care workers, immigration policies also come into play, and cultural differences between caregivers can lead to segregation and isolation among employees.

A study of assisted living facilities shows nursing staff are the least happy of their employees. This is likely true for skilled nursing as well, where employees are often spread too thin. So at a time when irregular staffing patterns are the norm, SNFs must seek creative solutions to their staffing shortcomings.

Our 2019 Cost Comparison and Industry Trends report explores how facilities of all sizes are struggling with retaining and hiring workforce.

Improving employee wages

Direct care employees are looking for improved benefits, including:

  • Medical, dental, and vision insurance
  • Opportunity for overtime
  • Flexible scheduling
  • Retirement savings
  • Continuing education and professional growth opportunities

Research says that direct care employees largely do not have access to the benefits that are most important to them. An obvious fix is increased pay and benefits. But with the costs of providing care often exceeding reimbursement, this is not feasible for most facilities. Other than registered nurses, most direct care workers are making $30,000 or less annually. In some states, advocates are pushing to professionalize, credential, and unionize the industry to drive wages up. But the only way most facilities could afford to pay higher wages would be through an increase in Medicaid funding.

Include staff in decision-making processes

When spending more money on staffing is not an option, an alternative is creating an environment where employees feel valued, appreciated, empowered, and respected. Certified nursing assistants (CNAs) often have the most day-to-day interaction with residents and, therefore, are the people most in tune with residents’ wants and needs. It makes sense that they should be involved when making resident care decisions. Some facilities have recognized this and taken a different approach to care using the Green House and Eden Alternative models, which provide staff with opportunities outside of their normal duties.

Green House model introduces new facility structure

In a Green House model, which is most often adopted by nonprofit and faith-based organizations, residents live in small homes of up to a dozen people with a shared living room, kitchen, dining room, and outdoor space. Residents have private rooms and restrooms, are allowed to decorate their space as they wish, and are encouraged to have plants. Residents may also have children and pets as visitors, which has been linked to lowered blood pressure, reduced risk of heart disease, fewer doctor visits, and reduced stress and loneliness. The typical nursing station is replaced by a private medicine cabinet in each individual’s room, and an adjustable track and roll-in shower allow residents to bring themselves to the restroom.

CNAs, called Shahbazim under the Green House model, are trained to provide more services than those offered in a more traditional facility, including cooking, cleaning, and laundry. Employees work with a small group throughout the day, providing the opportunity to develop close bonds with residents. Because of the frequent direct care interaction, changes in condition are more likely to be noticed and addressed earlier in a Green House setting.

Shahbazim and residents participate together in daily meetings, where residents have the power to make their own decisions, including their schedule for the day. The model has proven to lower Medicaid expenditures and hospitalization readmissions. Staff members are also more engaged because they have more responsibility and influence. Employees also develop stronger bonds with the residents and are happier in their jobs. As a result, facilities adopting the Green House model have seen reduced turnover in direct-care staff.

A study of the financial implications of adopting this model confirmed that direct-care time increased and staffing needs decreased compared to traditional nursing homes. Additionally, there was 68% less administration time with the model, and it vastly reduced laundry, housekeeping, dietary, infection control, and social work staff required.

Green House model considerations

Of course, converting a traditional home to the Green House model is a serious undertaking. A significant amount of capital is needed to construct the project, and capital and occupancy costs tend to increase at Green House homes. Operating costs, on average, are comparable to those at traditional homes due to better leverage of existing resources. Food costs are often comparable, ancillaries and administrative costs tend to decrease, and utilities increase.

Due to the appeal of the hominess and privacy of a Green House, occupancy has shown to increase by an average of 8%. Additionally, these homes tend to attract more private pay residents, which further offsets the increased costs. Even Medicaid revenue can be expected to exceed the cost of care under this model. Additionally, due to the concentration of residents into small homes, there is opportunity to provide very specialized care.

However, the model can be difficult to adhere to at first, as workers from traditional homes struggle to break the habit of making decisions for residents and falling into routines, especially at bath time. And facilities must consider how to transition residents when more intensive medical care becomes necessary.

Eden Alternative model offers cultural change

Similar to the Green House model, the Eden Alternative aims to better the lives of residents by eradicating loneliness, helplessness, and boredom. But unlike the Green House model, the Eden Alternative is easier to implement and can be applied anywhere. Rather than a physical change to the layout of the facility, this model is built on a philosophy of ten guiding principles. These principles are centered on giving maximum decision-making power to elders, as well as incorporating spontaneity, variety, and compassion into their everyday lives.

A study published by the Journal of Nursing Home Research found that loneliness, which is alarmingly common in nursing homes, was especially prevalent in residents with a higher mental capacity. The study also shows that lonely residents, including those who don’t live alone, are more depressed, feel as though they are in worse health, and have increased mortality. People identifying as lonely posed a 59% greater risk of decline. Deteriorating health, decreased mobility, and boredom also led to depression in older adults.

With the Eden Alternative, nursing home staff are given a three-day training on the Eden principles, which they leverage to apply a cultural shift within their facility. The model encourages caregivers to live by the golden rule — treat others how you would want to be treated. Caregivers are partnered with residents and empowered to build strong bonds that focus on the residents’ identity, joy, autonomy, and growth.

A study of the impact of the Eden Alternative shows significant decreases in behavioral incidents, use of restraints, and employee injuries. The need for agency staffing was eliminated, and overtime was cut in half. There was a 48% decrease in staff absenteeism, and staff turnover decreased immensely, from 46% to just 4%.

One study warns that the first year of implementing the Eden Alternative can be tough, and turnover might increase at first. But the long-term outlook of adopting the approach appears promising. A staff member at one facility observed almost unbelievable differences in the attitudes of residents after the culture shift, and even heard a depressed, nonverbal resident speak for the first time when a cat was brought in to visit.

Finding the best strategy for your facility

What these two patient-centered staffing models have in common is that they make employees feel more valuable. In these models, employees have more variety in their duties and develop better relationships with the people they serve. In a facility where all employees have a chance to be creative, make decisions, and be heard, staff are more likely to feel supported and less likely to look for employment elsewhere.

For some facilities, a whole new staffing model may be out of reach. But there are many ways that operators can engage and empower employees, like CNAs, to be more involved in the lives of residents. These options can be implemented anywhere. For example, one facility in Ohio created a Slip 'N Slide for their residents. Another facility in Minnesota attached a seat to the front of a bike and took residents for a ride around the city. A column by US News recommends therapeutic cooking as another way for residents to connect over fond memories.

Some facilities are recognizing their residents’ passion for gardening, as well as its health benefits, and have created modified gardens for nursing homes, including benches, raised narrow beds, wheelchair-accessible paths, and the use of arbors and trellises to reduce the need for bending. Food produced through therapeutic cooking and community gardening can be donated to low-income seniors, police and fire stations, or even local animal shelters, making these activities fulfilling to residents and staff.

Another innovation, related to the design of the facility, is based around the belief that senior living residents are depressed because they do not spend enough time outdoors. Lantern Assisted Living of Madison, Ohio, has renovated its hallways so that residents feel like they are outside when they leave their rooms. Doors have been painted to look like the front doors of houses, rooms have front porches, the carpet looks like grass, and the ceiling is painted blue with fluffy clouds. They have even replicated sunrises and sunsets.

Nursing homes have a reputation for being old fashioned. That perspective is shifting as many organizations develop a culture of innovation where all employees, including CNAs and other direct care staff, can be heard and have their ideas implemented. In turn, staff feel valued and respected, which leads to happier residents and better quality outcomes. If you cannot pay your staff more, consider injecting fun, decision-making power, respect, and innovation into your SNF.

How we can help

CLA’s health care team has deep experience helping facilities attract the right people. We can examine how your facility’s staffing patterns impact your business in comparison to others through a benchmarking analysis. And CLA’s Clarity tool can compile data from across the country, which we can then translate into actionable insights for your facility. Whether you’re looking to develop a new strategic plan as you gear up for a substantial project, or want to assess your current operations, we can help.