Ideas Emerge to Overcome Workforce Shortages

Oct 31, 2023 | Minimum Staffing, Nursing HPRD & Turnover

News Digest: Minimum Staffing Rules Incent Plan to Hire More Nurses

As some view a minimum staffing requirement as almost an inevitability, strategies begin to emerge to accomplish tactics such as increasing the available pool of nursing, lowering turnover of current staff, and improving hiring practices.


Do I Have This Wrong?

Recently I published a three-article series about the proposed staffing mandates for nursing homes. My bottom line was — and remains — that the industry should support staffing minimums done right and reasonably. This means a bunch of things:

  • The minimums need to be just that — minimums — but that if a nursing home is well run, it would mostly operate at above the minimum.
  • They have to take into account the variability in acuity. So for instance, rural nursing homes tend to have residents with less acute needs, and their minimums should be lower.
  • The regulations should not be implemented unless there are really enough people to fill all the positions. While a concern for all, the staffing shortage is a particularly difficult problem for rural operators.
  • There has to be enough money to not just meet minimums but to be able to staff at a level that allows for good care.
  • There needs to me some wiggle room for people trying and doing innovative things that might actually provide better care with lower staffing.


Moran, Steve. “Do I Have This Wrong?” Senior Living Foresight, 7 Nov. 2023,


Moving Forward Coalition Members Discuss Nursing Home Staffing Issues, Action Plans

As the comment period for the federal government’s staffing proposal winds down, advocates for both nursing homes and residents alike are looking at ways to reach a middle ground.

Among these advocates for measured change are members of the Moving Forward Coalition – an organization formed in April 2022 following the National Academies of Sciences, Engineering and Medicine (NASEM) report aimed to improve nursing home quality. The organization completed its first year of formation in the summer by issuing a set of action plans that develop, test and promote ways to improve how the country finances, delivers and regulates care in nursing homes.

Its leaders stress the importance of a holistic approach to maintaining the nursing home sector’s wellbeing and resolving problems ranging from staffing, surveyor shortage, and even unappealing post-acute care spaces, among other issues, by putting the resident voice as well as that of certified nurse aides (CNAs) and other clinicians at the center of the coalition’s recommended solutions.


Amy Stulick. “Moving Forward Coalition Members Discuss Nursing Home Staffing Issues, Action Plans.” Skilled Nursing News, 3 Nov. 2023,


Trilogy, Avamere, Ignite Execs: Mandate Would Require New Staffing Incentives, Worsen Wage Pressure

With nursing home operators having a couple months to process the minimum staffing proposal, many are taking a hard look at what would need to change to meet the proposal in its current form, and what revisions would make the most sense.

Leaders with Trilogy Health Services, Avamere Living and Ignite Medical Resorts caution that the mandate would worsen wage pressure that is already becoming hard to sustain. Meanwhile, suggestions for improving the proposal include an outcomes-based process rather than static ratios, and ensuring the Centers for Medicare & Medicaid Services (CMS) creates a pathway toward building the workforce needed to meet the mandate.


Amy Stulick. “Trilogy, Avamere, Ignite Execs: Mandate Would Require New Staffing Incentives, Worsen Wage Pressure.” Skilled Nursing News, 27 Oct. 2023,


Marquis CEO Fogg: Negotiating Power with Medicare Advantage, Big-Picture Staffing Strategy Key for Nursing Homes’ Future

The proposed federal staffing mandate is a potential “kill factor” for nursing home providers, while the rise of Medicare Advantage (MA) is a “major challenge” — and how well the sector responds to these threats will play a major part in shaping the future.

This is the perspective of Phil Fogg Jr., CEO of Marquis Companies and the immediate past chairman of the American Health Care Association (AHCA). He took to the stage Wednesday for the skilled nursing keynote session at the National Investment Center for Seniors Housing & Care (NIC) Fall Conference in Chicago.


Tim Mullaney. “Marquis CEO Fogg: Negotiating Power With Medicare Advantage, Big-Picture Staffing Strategy Key for Nursing Homes’ Future.” Skilled Nursing News, 26 Oct. 2023,


Parkinson says proposed staffing mandate a ‘death sentence’ for rural nursing homes, offers answers

Long-term care industry advocates pulled no pessimistic punches Wednesday when asked about likely outcomes facing rural operators if the Centers for Medicare & Medicaid Services’ proposed minimum staffing mandate becomes a rule.

But the increased potential to collaborate on solutions across the healthcare sector may bring relief, they said while taking part at the Summit on the Future of Rural Health Care in Sioux Falls, SD.

With vast discrepancies in access to care between rural and urban communities and ongoing staffing shortages, CMS’ mandate as proposed is impossible to achieve, and “literally a death sentence for nursing homes in rural areas,” said Mark Parkinson, president & CEO of the American Health Care Association/National Center for Assisted Living.


Lasek, Alicia. “Parkinson Says Proposed Staffing Mandate a ‘Death Sentence’ for Rural Nursing Homes, Offers Answers.” McKnight’s Long-Term Care News, 19 Oct. 2023,


Staffing Mandates Done Right

This is a powerful and important opportunity for the nursing home industry to take control of their own future and make the lives of residents, team members, family members, and owners and operators better. It is time for the industry to step up to the table, demand change, and propose a new way of doing things that is fair and reasonable to everyone.

Specifically with respect to mandates, the industry should propose its own set of mandate rules that would follow this format …

We 100% support mandates, and this is what they should look like:


Moran, Steve. “Staffing Mandates Done Right (Part 3).” Senior Living Foresight, 23 Oct. 2023,


Loan Reimbursements and Forgiveness May Help Aid Nursing Home Staffing Crisis

With the minimum staffing mandate coming into effect soon, nursing home operators may be looking for creative ways to increase staffing and retain employees.

Dr. Jasmine Travers, a gerontological nurse practitioner and assistant professor of nursing at New York University Rory Meyers College of Nursing, told Skilled Nursing News that a program that the Centers for Medicare & Medicaid Services recently announced could be adopted for nursing homes to increase staffing.

The program allows for those in pediatric specialties to receive loan reimbursements and loan forgiveness for working in underserved areas.


Shelby Grebbin. “Loan Reimbursements and Forgiveness May Help Aid Nursing Home Staffing Crisis.” Skilled Nursing News, 25 Sept. 2023,


Inside SNF Models of Care Used to Tackle Higher Acuity with Medical Resorts, Staffing Initiatives, Technology

The skilled nursing industry is experiencing a profound shift in patient acuity, presenting both challenges and opportunities for operators.

Given this trend, experts at Skilled Nursing News’ RETHINK conference last week shared ideas on how to tackle rising acuity, including by creating “medical resorts,” using telehealth and predictive analytics to streamline care, creative staffing initiatives to reduce burdens as well as varied payment methods to improve reimbursement.


Shelby Grebbin. “Inside SNF Models of Care Used to Tackle Higher Acuity With Medical Resorts, Staffing Initiatives, Technology.” Skilled Nursing News, 20 Sept. 2023,


The Future of Nursing Homes: CEOs of Brickyard, Bartley, HDG Talk Medicare Advantage, AI and Staffing Proposal

The landscape at skilled nursing facilities is evolving rapidly, influenced by factors such as changing regulations, workforce challenges, and the rise of Medicare Advantage, and the minimum staffing proposal only complicates matters.

This view was expressed by industry leaders in the opening session of the Skilled Nursing News’ RETHINK conference Wednesday. Panelists – Wesley Rogers, CEO of Brickyard Healthcare, Phil Scalo, CEO and founder of Bartley Healthcare and Vice Chair of the American Health Care Association (AHCA), and Erin Shvetzoff Hennessey, CEO of Health Dimensions Group – shared their perspectives during a discussion on the topic.


Shelby Grebbin. “The Future of Nursing Homes: CEOs of Brickyard, Bartley, HDG Talk Medicare Advantage, AI and Staffing Proposal.” Skilled Nursing News, 18 Sept. 2023,


What the 'new nurse' needs from health systems: Flexibility, not constraints

Do you feel like you’ve seen more nurses with side hustles lately? Does it seem like more nurses are going per diem or getting additional education?

You aren’t imagining it. Between nurse burnout, the rising cost of living, and professional and personal growth concerns, nurses are getting creative to make ends meet and feel fulfilled in their careers.

This is why connectRN, a leading nurse staffing community that offers flexible shifts and resources to clinicians, partnered with The Nursing Beat to poll over 1,300 nurses. The sample population included certified nursing assistants, licensed practical nurses, and registered nurses, and revealed today’s nurses are interested in pursuing non-traditional career paths in pursuit of professional satisfaction.


Modern Healthcare. “What the ‘new Nurse’ Needs From Health Systems: Flexibility, Not Constraints.” Modern Healthcare, 1 Sept. 2023,


Fixing long-term care’s staffing crisis

So here we are, on the cusp of a first-ever staffing mandate for skilled care facilities and things are getting a bit testy.

How testy? As my colleague Kim Marselas reported Thursday, providers are threatening to sue CMS if the new minimum requirements turn out to be overly prescriptive. As for what overly prescriptive actually means: I suspect we’ll have that answer soon enough.

The industry’s saber-rattling comes at a time when some interesting suggestions for easing labor woes are making the rounds. Among the most popular are more job training and additional provider payments. Both are probably good ideas, by the way.

But here’s an even better one: Take a lesson from Japan.


O’Connor, John. “Fixing Long-term Care’s Staffing Crisis.” McKnight’s Long-Term Care News, 11 June 2023,


As staffing minimum looms, other workforce solutions simmer on back burner

A long-awaited federal rule that could rewrite how nursing home owners and operators staff their buildings is in the final stage of review before being released publicly.

The Centers for Medicare & Medicaid Services’ Minimum Staffing Standards for Long-Term Care Facilities proposed rule was received by the Office of Management and Budget on Monday. Its cost implications are being reviewed by the White House team, and it’s next stop should be the Federal Register.

CMS has given little insight to its general approach to the mandate, it potential structure or any conditions that would allow providers to be phased in or seek waivers until local labor shortages improve.


Marselas, Kimberly. “As Staffing Minimum Looms, Other Workforce Solutions Simmer on Back Burner.” McKnight’s Long-Term Care News, 1 June 2023,


Get Real on Ratios

As planned CMS staffing ratios near, nonprofit nursing homes offer a realistic approach to staffing in the current workforce crisis.

As part of the Biden Administration’s nursing home care initiative, the Centers for Medicare & Medicaid Services (CMS) is poised to impose staffing ratios. For the first time in decades, our federal government is committed to meaningful action to ensure America’s older adults and families can receive quality nursing home care—a goal that LeadingAge and its nonprofit, mission-driven nursing homes have long shared. But at a time when providers are operating under severe workforce shortages ​​and inadequate reimbursement, staffing mandates will undoubtedly force closures and limit older adults and families’ access to care and services.

To ensure that federal action is realistic and can achieve its intended effect, LeadingAge proposes a new framework and perspective for federal legislation concerning staffing ratios in nursing homes.


LeadingAge. “Get Real on Ratios.” LeadingAge, 16 Aug. 2023,

More News in this PBJ Topic

LPN Exclusion Triggers Confusion & Questions

News Digest: Mandated Nursing Minimums Ignores Key Nursing Role CNA's, LPN's and RN's form the backbone of skilled nursing facilities.  All three roles are used in calculating and determining a facility's Five Star staffing rating.  Yet the...

read more

Understanding Staffing Compliance Issues & Exemptions

News Digest: Proposed Rule Includes More than Minimum Staffing Lost in the uproar over minimum staffing requirements for RN's and CNA's are a number of additional provisions in CMS' Proposed Minimum Staffing Rule.  A delayed rollout and provisions...

read more

Comments on Staffing Rule Pour in to CMS

News Digest: Overwhelming Response to CMS' Proposed Rule on Minimum Staffing The 60 day comment period for the Proposed Minimum Staffing Rule ended November 6, 2023.  AHCA and Leading Age associations led efforts to generate industry response. ...

read more

Plans to Defeat CMS’ Proposed Minimums Rule

News Digest: Various Strategies Floated to Avoid Proposed Minimum Staffing Rule With widespread opposition to CMS' Proposed Rule, a variety of tactics are under consideration to overcome the potential regulations.  Both a Congressional over ride...

read more

Congress Weighs in on Proposed Staffing Rule

News Digest: Legislative branch questions proposed executive rule Federal legislators in Congress vocally responded to CMS' proposed rule.  While CMS considers public comments and works on the Final Rule in 2024, the congressional push back can...

read more

Supporters of Staffing Mandate Speak Out

News Digest: Consumer Advocates, Unions and Some Congressman Support the Staffing Mandate With the loud and consistent negative reaction to CMS' proposed minimum staffing standards, one could fail to recognize that supporters of the new rule...

read more

Scrutiny on Private Equity & REIT Staffing Performance

News Digest: How does private equity investment affect nursing home staffing and minimum staffing requirementsOnly 6% of real estate investment trust (REIT) assets are in compliance with the federal minimum staffing proposal for nursing homes,...

read more

Analyses predict high cost of staffing mandate

News Digest: Billions needed to comply with minimim staffing mandate Competing estimates of the cost to get all skilled nursing facilities to a minimum staffing level all come in with multi-billion dollar price tags. From CMS' estimate of over $4B...

read more

Union Impact on Minimum Staffing Rule

News Digest: Unions play a role in the minimum staffing pushHealth and Human Services Secretary Xavier Becerra this week took part in a national union event supporting the proposed nursing home staffing rule, giving the labor audience and their...

read more