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US nursing homes have a staffing crisis. Here’s one way to fix it.

Staff turnover at nursing homes is appalling. Raising the minimum wage could help.

A resident watches television in her room at the Gordon Manor assisted-care facility in Redwood City, California, on January 28, 2021.
New research finds nursing staff at long-term care facilities churns constantly, leading to worse care. A minimum wage increase could help fix that.
Gabrielle Lurie/The San Francisco Chronicle via Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Raising the minimum wage is one way Congress and the Biden administration could start to fix America’s long-term care crisis.

The minimum wage will not be increased as part of the Covid-19 relief bill passed by the Senate this weekend and expected to be approved by the House this week. It did not comport with the Senate’s finicky rules about what provisions could be included in a bill passed under the “budget reconciliation” process. But there is still some optimism that a minimum wage increase could pass this Congress, and with bipartisan support; a handful of Republican senators have expressed interest in the issue.

And if Democrats and Republicans did manage to reach a deal on raising the minimum wage, it could make a real difference addressing a problem identified in new research published this month in Health Affairs: The constant turnover of the nursing staffs at America’s nursing homes, which erodes the quality of care received by the 1.5 million patients who live in long-term care facilities.

The study’s authors — Ashvin Gandhi and Huizi Yu of UCLA, along with David Grabowski at Harvard — made a startling discovery after examining data from more than 15,500 nursing homes: On average, there is near-total turnover in nursing staff at long-term care facilities every year. Turnover rates either approach or exceed 100 percent for registered nurses, licensed practical nurses, and certified nursing assistants, depending on the metric used.

Ashvin Gandhi, Huizi Yu, and David C. Grabowski/Health Affairs

Patient care is likely suffering as a result. During the Covid-19 pandemic, the researchers wrote, more infection control violations might have resulted from new staff members who were less familiar with the protocols. At least 172,000 nursing home residents and workers have died during the pandemic.

But the risks to patients if their nurses are constantly changing were already well substantiated in the research literature before the current public health emergency.

“New staff members might not be as familiar with the facility’s residents and practices, which may lead to quality problems,” the authors explained in their introduction. “For example, high rates of turnover have been found to lead to more rehospitalizations and more frequent use of physical restraints.”

The retention problem is bigger than compensation: Registered nurses, for example, make $35 an hour on average, well beyond the scope of any minimum wage hike. Burnout is one likely culprit, given the emotional and physical difficulty of this work. The researchers also found that for-profit facilities, and those owned by large chains, saw higher turnover rates.

But low pay has been a chronic problem for retaining nursing-home staff, which is why raising the minimum wage could help to alleviate — if not solve — the problem described in this study.

In particular, certified nursing assistants could benefit. CNAs, who work under more senior nurses, provide basic care to long-term care patients and help them with daily activities. Those duties include helping patients with bathing, measuring vital signs and conveying any worrying information to nurses, serving meals and helping patients eat, and turning or repositioning less mobile patients.

For that work, they often make wages near the minimum. The average hourly wage for a CNA in 2019 was $14.25, according to the Bureau of Labor Statistics, below the new $15 minimum wage that many Democrats want to set. But some make as little as $10 an hour, according to BLS, which means even a more modest increase from the current $7.25 federal minimum wage could provide those health workers with more economic security.

“Nursing home work is demanding and it stands to reason that many staff can make similar wages working other jobs,” Grabowski told me. “Low wages are not only the reason for staff turnover but raising wages would have a major impact on staff retention.”

It would cost money: A Congressional Budget Office estimate on Democrats’ Raise the Wage Act found Medicaid spending would increase by $16 billion over 10 years, in part because Medicaid covers a lot of long-term care in the US.

The Health Affairs study’s authors propose other suggestions for addressing retention, including making this information easily available both to give patients more transparency about specific facilities and to encourage those facilities to work on retaining their workers. Lawmakers could also mandate other benefits, such as health insurance and paid leave, or incentivize continuing education to give CNAs specifically upward mobility in their work.

Raising the minimum wage might, broadly speaking, create some benefits and some tradeoffs. But this new research indicates it would also be one way to ensure the most vulnerable patients get the care that they deserve.

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