LACONIA — Jane Sharp, a health care veteran, has worked for 35 years in a role that is usually underestimated, frequently undervalued and perpetually in high demand. She is a licensed nurse’s assistant.
Sharp relishes her job at Belknap County Nursing Home. She works on the front lines of personal care, a hands-on and demanding trade, especially since it also requires providing companionship to older patients who are lonely.
During COVID and its withering aftermath, her mission became more critical and complex – at the same time nurse’s aides were in tight supply where they were desperately needed – in nursing homes, helping the elderly with the activities of daily life, and providing interaction such as listening, talking, laughing and showing that somebody cares.
Sharp is one of nearly 13,000 LNAs in New Hampshire – a number not close to being enough, now or in the future. It’s a dearth that may become dire as the average age of the state’s population continues to rise, and a swelling population turns 65 or older, changing from caregivers to people who need care themselves.
“We’re their family inside, really,” said Sharp, who helps residents with grooming, dressing, feeding, toileting, and getting from one place to another, including from bed to chair. “They tell you their kids’ and grandkids’ names. They share life when they were young, their recipes and crafts they used to do, including quilting and knitting. A lot will reminisce about the past and want to know about your life, too. It’s everyday talk – including what the weather is like.”
The conversation widened and deepened during the pandemic, a nearly year-long stretch without in-person visits from family.
“It got lonely for them,” Sharp said. “You had to be there if they wanted to cry and be upset. They wanted someone to talk to, just be there with them. They looked to us for a lending ear.”
It’s a highly strategic and personal job – a career fueled by purpose and caring.
“To see a smile on someone’s face. To let them open up and tell you when they hurt or have a problem. To do what they can’t do for themselves,” Sharp said. “Yes, you can go to McDonald’s and work for $14 an hour. But this is a profession I chose and want to stay in.”
It’s also a profession well known for low pay. It's a challenge to lure more enthusiastic entrants and have them stay, when the costs of living and housing in New Hampshire keep climbing. A larger direct-care workforce is increasingly needed to provide hospital, home and long-term care in the nation’s second oldest state.
In nine years, roughly 31 percent of Lakes Region residents will be 60 or older, according to census projections. That’s just the beginning. From 2016 to 2060, the population of U.S. adults 65 and older will nearly double, from 49.2 million to 97.4 million, while the census of adults age 18 to 64 will remain relatively constant, according to U.S. population and demographic data analyzed by PHI, a policy and research group that tracks the direct care workforce.
Like many workforce challenges, the shortage of licensed nurse’s assistants has been exacerbated by COVID-19 and its myriad effects on employment and personal safety. But the LNA shortage has been brewing for decades.
“Right now we’re in a vicious cycle of having a desperate need for staff," said Roxie Severance, a former nursing home administrator who heads the state’s sector partnership for developing the healthcare workforce. "Everyone is so stressed with COVID and the new requirements change every day.” To combat the shortage of LNAs, nursing homes are hiring expensive per-diem staff from agencies, and at rates that became exorbitant during COVID, and are unsustainable going forward. The state allowed nursing homes to train support workers on the job, filling gaps as needed. “People who are non-clinical are providing services that LNAs provided,” said Severance. “It’s an all-hands-on-deck approach that can’t be sustained. This shortage has no end in sight.”
COVID exposed weak links in the highly stressed, financially precarious chain of health care, including the operations of nursing homes. Finding adequate, qualified staff remains a hurdle for most of the state's 74 long-term care facilities. It’s one of the reasons many are operating at two-thirds or lower occupancy in the aftermath of the coronavirus – in a business known for long wait lists.
Currently, the New Hampshire Veterans Home, the state’s assisted living, skilled nursing and dementia care provider for veterans, is operating at 50 percent capacity, with roughly 100 residents, down from a high of 205 in previous years. Admissions are down and empty beds are common elsewhere, for reasons that often include insufficient staff. At present, Belknap County Nursing Home, with space for 92 residents, has 64 occupants. The Merrimack County Nursing Home, with 290 licensed beds, has 211 in use. All say they are in the process of admitting more patients as they are able.
Merrimack County Nursing Home administrator Matt Lagos said staffing isn’t the current reason his facility's beds are offline. Two units totaling 44 beds are now required to be set aside for COVID-positive residents, new admissions who are not vaccinated or current residents who show signs of being sick. But getting LNAs was a problem long before COVID hit, and there has been a shortage for years, said Lagos.
“It’s one of the toughest jobs, if not the toughest one in the nursing home. There are a lot of people who have left the field to work outside of health care. With low unemployment, private companies offer higher rates of pay. We have seen this cycle repeat itself time and again. When the economy is in worse shape, health care sees a return of the workforce. When it’s good, we see the struggle getting applications in,” Lagos said.
The Merrimack County home currently has openings for 18 full time and 37 part time LNAs, which are filled by outside agency hires – which means less continuity for patients and higher costs for the facility.
Correct staffing, including nurses and LNAs, “has been an ongoing challenge for all facilities, even before COVID” and it continues to hinder admissions, said Shelley Richardson, administrator at Belknap County Nursing Home. The situation plays out locally and nationwide.
A statewide problem
Severance can’t help but panic when she thinks of worst-case scenarios that could materialize if the shortage of trained, available staff continues or gets worse.
“There must be 6,000 nursing home beds statewide. What if that went down by 3,000? We’d have 300 people in each county with no place to go,” Severance said. “You’re only going to accept residents that you can take care of.”
During COVID, “a lot of nursing homes weren’t admitting, and that extended the wait lists,” said Pamela DiNapoli, director of the NH Nurses Association. “The nursing assistants are really the ones who provide hands-on care.” The LNA shortage is “definitely a statewide problem, and it’s worse in long-term care.”
Initially, COVID shortened the nursing home wait list. But because employee counts remain lower and beds are still offline, Severance wonders how many elderly patients are being kept longer by hospitals because there’s no place to send them – and how many at-risk elders are making do at home, potentially without necessary support.
“People are being kept at home. I think people are living in situations they probably shouldn’t, and families are trying to fill in the gaps that health care can’t provide right now,” Severance said.
Home care agencies are similarly strapped, unable to fill requests because they don’t have enough personal care workers, LNAs and home health aides to send out, she said. Home care often substitutes for more expensive long-term care, or postpones it.
Reasons for the uptick in vacancies at nursing homes post-COVID include families hesitating to admit frail elders for fear of increasing their vulnerability, and not being allowed to visit frequently enough – worries that can discourage close-knit families from seeking timely admissions. Other factors include insufficient staff to handle greater numbers of high-need, delicate patients. The allocation of staff to screen visitors, new requirements for stepped-up hygiene, and the dedication of space for quarantining also stresses the system.
As more beds have gone offline, an unknown and increasing number of older people debilitated by chronic conditions have become candidates for round-the-clock care – and compassionate but unskilled family members cannot sacrifice their time or manage high-demand situations indefinitely, nursing experts say.
Family vs. career
There’s another workforce math problem: the pool of incoming nursing home workers is not filling fast enough to offset the loss through retirement, burnout and career change. Some who begin as LNAs move up with training to become nurses, which removes them from the LNA pool. Others work as LNAs during college and exit for completely different careers when they graduate. Some who worked during COVID and underestimated the intensity of the job, left or chose not to renew their licenses.
“It’s a challenging job, and a lower-paying job. Even before COVID, it was very challenging to recruit and retain LNAs,” said Lynn Carpenter, program director of NH Needs Caregivers, which has received federal grant funding to recruit and train 700 LNAs to work in New Hampshire. Hourly wages for LNAs range between just under $13 and roughly $15.70, depending on the facility and the part of the state. Since it started in 2019, NH Needs Caregivers has attracted 102 new LNAs.
“Adding COVID to that, there are a lot of single women with children at home, not going to school with day care closed, who were forced to – or chose to – be moms at home,” Carpenter said. Bumped-up pay for unemployment was higher than many LNAs earned in the workplace.
An obstacle for keeping sufficient numbers of nurse’s aides remains the lack of affordable child care (another problem highlighted by COVID), especially for young, single moms who have no other source of income.
“The cost of child care can equal what you get paid,” said Howard Chandler, administrator at the Peabody Home in Franklin, and former head of Mountain View, Carroll County’s nursing home in Ossipee. “If the cost of child care can be reduced, I think more people will get into the workforce, including the caring professions. The marketplace hasn’t responded the way it should.
“A large portion of LNAs are younger women,” Chandler said. “When their child care closes, they have to make difficult choices and they pick family over work.”
In order to lure LNAs during COVID, some long-term care facilities raised wages and offered bonuses and education benefits, approaching what hospitals offer. But hospitals rely primarily on private insurance income, while nursing homes overwhelmingly depend on Medicaid reimbursement, which doesn’t shoulder the bill.
Depending on the year, New Hampshire jostles between having the second- or third-lowest Medicaid reimbursement rate in the country – even though the quality of nursing home care is near the top compared to other states, according to evaluations conducted for the Centers for Medicaid and Medicare. Currently, the state’s Medicaid reimbursement rate falls short of costs by $40 to $50 per resident per day, said Brendan Williams, president of the NH Health Care Association, which represents 60 nursing homes and 20 assisted living facilities.
Adding to the staffing dilemma is New Hampshire’s economic success, even in the wake of COVID. In April 2020, the state’s unemployment rate topped 17 percent. Now it’s 3 percent – the fifth lowest in the country, behind four states that are tied at 2.9 percent.
“It’s kind of a perfect storm,” Williams said. “Even when unemployment went up, the imperative was always to find licensed staff. We couldn’t be in a worse situation now. We have New England’s worst gap between staff costs and medical costs and the state payments” for nursing home patients who receive Medicaid – which accounts for most nursing home residents. “We’re the only state in New England that didn’t increase the daily rate” of reimbursements to nursing homes during COVID, said Williams. “We’re terminal in terms of keeping ourselves going.
“We hear a lot of talk about the heroism of long-term care workers, but we don’t see a lot of support coming from government to reward that heroism,” Williams said.
He hopes a chunk of the bounty coming to New Hampshire under the American Rescue Plan of 2021 can go to providing scholarships and tuition forgiveness to community college students who make a commitment to work in long-term care.
“We lose a lot of nursing graduates to Massachusetts” where wages for LNAs, LPNs and RNs are more attractive. “We have a net exodus every day of health care and social service workers,” who find more remunerative positions in the Bay State, said Williams. “Maybe the answer is they go to college for free.”
PHI reports that it’s difficult to quantify the nationwide need for personal care assistants, home health aides and licensed nursing assistants because states and facilities differ in their information collection, and some hiring takes place outside the health care system, by families and older individuals.
One of the frustrations to gathering accurate information about staffing needs at New Hampshire's nursing homes is that when asked to complete a survey, only 30 percent of the state's nursing homes responded.
That makes it difficult for New Hampshire to plan, and for colleges to provide adequate programs, Severance said.