3 in 5 Wisconsin nursing homes will have to hire more nurses, aides to follow new federal rule

Most nursing homes in Wisconsin will need to hire more nursing aides to meet minimum staffing requirements newly announced by the federal government, a mandate that some nursing homes worry they will struggle to meet amid staffing challenges exacerbated by the COVID-19 pandemic.

The requirements, which will be phased in over the next few years, are the first time the federal government has mandated a minimum staffing standard for nursing homes, a move that resident advocates have been urging for decades as mounting evidence showed a close link between staffing levels and quality of care for residents.

“This is the most important nursing home reform in decades,” said David Grabowski, a professor of health care policy at Harvard Medical School. “We need more staff in nursing homes."

Under the requirements, nursing homes will be required to provide staffing that, at a minimum, is equivalent to nearly 3.5 daily hours of care per resident. The change comes in the wake of the COVID-19 pandemic, which exposed chronic understaffing at many nursing homes that contributed to widespread outbreaks and deaths from COVID-19. It was announced last month by Vice President Kamala Harris.

But some Wisconsin nursing homes and their trade groups are worried they won't be able to find the nurses and nursing aides required to meet the new requirements, especially as nursing home employment continues to lag behind pre-pandemic levels.

"There are circumstances where it’s impossible to meet the staffing requirements, particularly in rural areas," said Rene Eastman, vice president of policy and finance at LeadingAge Wisconsin, a trade group that represents mostly nonprofit nursing homes in Wisconsin.

They also warn about potential unintended consequences of the rule, such as nursing home closures that limit patients' options and could have ripple effects across health sectors. If nursing homes close, they say, hospitals might not have anywhere to discharge patients in need of nursing home care. That, they say, will contribute to crowding in hospitals that, in turn, affects other patients.

Nursing homes that care for a large number of residents on Medicaid, which does not pay homes as much as Medicare or residents who pay out-of-pocket, may also struggle to meet the requirements, they argue.

"This is an unfunded mandate," said Pam Klingfus, CEO of Christian Community Homes and Services, a nonprofit with two nursing homes in northwestern Wisconsin. "As much as we support the idea of quality, I would say the federal government missed the mark by creating the mandate without giving the funds to support it."

Funding prospects to meet mandate unclear

It's unclear whether existing funding is enough to support the extra hiring needed under the requirements, said R. Tamara Konetzka, a public health sciences professor at the University of Chicago. There is a lack of transparency, she said, in nursing home spending and profits that makes it difficult to follow the money and ensure enough is going to resident care and that profit-taking is not excessive.

"How much extra money is there in the system? No one really knows," she said.

Some researchers argue that nursing homes overstate their costs and that they are much more profitable than they appear. A paper published in March by the National Bureau of Economic Research estimated that 63% of nursing home industry profits are secretly funneled to owners through inflated rents and fees paid to related entities that share a common owner with the nursing home.

For example, nursing homes that own their building may sell that building to a related entity, with whom they share a common owner. The nursing home then pays an inflated rent to that entity. The rental payments appear as an expense on the nursing home's books, but the owners, the paper argues, likely are collecting that revenue after it is funneled through the related entity.

About three in five nursing homes in Wisconsin do not meet the newly announced federal standards and would need to hire more nursing aides or nurses in order to fulfill the requirements, according to a Milwaukee Journal Sentinel analysis of staffing data reported for the year 2023 to the federal government.

Nursing home aides are critical part of patient care

Most nursing homes don't have enough nursing aides. Aides are the ones who work most closely with residents and help them — some of whom cannot move freely or control their bladder or bowels — get out of bed, go to the bathroom, bathe, eat and more. Not having enough aides can result in residents becoming seriously dehydrated, sitting in soiled diapers or sheets for hours on end, or developing bedsores, which can be deadly.

About 75% of Wisconsin's 190 for-profit nursing homes do not currently meet the requirements, according to the Journal Sentinel's analysis. Meanwhile, about 40% of the state's 90 nonprofit nursing homes do not meet the requirements.

While nursing homes will have to provide the equivalent of nearly 3.5 hours of care per day to each resident, at least 0.55 hours must be provided by registered nurses, and 2.45 hours by aides.

For a home with 100 residents, it would need at least two or three registered nurses and at least 10 or 11 aides on duty each shift to meet the minimum standards for RNs and aides, according to a fact sheet from the White House.

Nursing homes also will have to have a registered nurse on duty at all times. Currently, homes are required to have an RN on site for only eight consecutive hours a day. A 2022 USA Today investigation found that most nursing homes in the country failed to meet even that requirement in past years.

Rules dictate the numbers of aide and nurses

Until now, the Centers for Medicare & Medicaid Services, the federal agency that regulates nursing homes, never required a specific number of nurses and aides. Instead, the agency had only required "sufficient" staffing to care for residents.

Wisconsin has a minimum staffing standard in state law, but it is lower than the new federal standard and it does not specify a minimum number of hours for aides.

Some resident advocates say the new federal standard doesn't go far enough. A 2001 study prepared for Congress found that the nursing home quality of care improved when there was enough staff to provide each resident with up to 4.1 hours of care per day.

The government may grant exemptions to the new rule "in limited circumstances." Nursing homes may seek an exemption to the minimum staffing rule if they truly try but can't hire enough staff and if the area has very few nurses or aides. They also may seek an 8-hour-a-day exemption from the 24/7 registered nurse requirement if the home is in an area with very few registered nurses.

The requirements are a bare minimum. The rule notes that nursing homes may need to provide more than the minimum hours of care if they care for residents with complex needs who require extra care.

Lingering impacts of pandemic reduce employment, beds

Nursing home employment has been slower than other health care sectors to recover since the pandemic and remains below pre-pandemic levels. In fact, nursing home employment has dropped by a little over 8% since February 2020, according to an analysis by KFF, a nonprofit group that conducts health policy research.

Some nursing homes that closed wings of their buildings during the pandemic and lowered the number of residents they would take have not been able to reopen those wings because of a lack of workers, said Eastman, of LeadingAge Wisconsin.

During the pandemic, both of Christian Community's nursing homes in northwestern Wisconsin had to cut back on the number of residents they would admit, said Klingfus, the CEO. They now average between 70% and 80% of the residents they had before the pandemic.

"If we wanted to get to capacity my concern would be, where are the (workers) going to come from?" Klingfus said. "They're just not there."

Klingfus said it's very difficult to fill openings, especially at their campus in rural Polk County. She's recently hired a full-time recruiter to help fill existing openings. She said wages have increased by close to 25% in the last three years and the company regularly reviews wages to make sure they are competitive. The company also offers bonuses and other incentives to try to keep workers. She is working with a recruitment agency to hire international workers to fill openings she anticipates as some workers get ready to retire.

Wages might need to increase to attract workers

If workers are scarce, nursing homes will have to raise wages to bring in the nurses and aides they need to meet the requirements, Konetzka, the University of Chicago professor, said. Wages for nursing home workers have gone up since the pandemic, but they remain below what a registered nurse or an aide makes working for a hospital or in home health, according to average wages reported by the Bureau of Labor Statistics. Nationally, aides working in nursing homes make nearly $19 an hour, while registered nurses make nearly $40 an hour, according to BLS statistics.

As of last year, both of Christian Community's nursing homes met the new minimum staffing standards for registered nurses, aides and all staff that will be phased in over the coming years, according to the Journal Sentinel's analysis.

But Klingfus is most worried about meeting the requirement to have a registered nurse on duty at all times.

The new requirements will be implemented in phases to give nursing homes time to hire more workers. Nursing homes located in urban areas will be expected to comply sooner than rural ones.

Reporter Ken Alltucker, of USA Today, contributed to this story.

This article originally appeared on Milwaukee Journal Sentinel: 3 in 5 Wisconsin nursing homes need to hire more staff under new rule