An executive order signed by President Joe Biden Tuesday afternoon will trigger broad, cabinet-level activities intended to improve nursing home and other caregiving jobs and hold providers accountable for workforce quality.
Elements billed as promoting access to long-term care and strengthening the sector’s workforce are part of an extensive effort to bolster caregiving for both older Americans and the nation’s children.
“Right now, the cost of care is too high for seniors in nursing homes, for working families with young children, and the pay for care workers is too low, and that’s why so many are leaving the whole endeavor,” Biden said in a Rose Garden signing ceremony, where he noted that about half of skilled nursing workers leave their job each year.
“The actions we’re taking today are about dignity, security and peace of mind for working families and caregivers all across the country, and they’re good for the economy as well,” he added.
A White House fact sheet issued Tuesday morning said the 50-plus directives would “build on” an as-yet undisclosed staffing mandate and tie nursing home Medicare payments to retention.
Providers leery
The president’s focus on improving caregiving won some praise from LeadingAge President and CEO Katie Smith Sloan, who attended the signing ceremony at the White House. She said the executive order brought much-needed attention to caregiving but that the proposals did not represent “adequate solutions” for the long-term care sector.
“LeadingAge has long advocated for an all-of-government approach to ensuring greater access to aging services — and addressing the workforce crisis must be the top priority,” Sloan said in a statement. “Today’s announcement shows that the Biden White House has been listening — but, sadly, the order does not meet the ever-growing needs of America’s older adults and families.”
She said the approach appears to favor one part of the long-term care continuum over others, prioritizing innovations and program expansions for home and community-based care and family caregivers over support for those who work in nursing homes, assisted living and hospice.
“The order bolsters the home care workforce, while punishing nursing home providers for shortages — despite the reality that employers in both care settings navigate the same challenges in a competitive labor market,” Sloan said.
The American Health Care Association/National Center for Assisted Living praised the administration’s goal of supporting long-term care workers as the sector continues to face a historic workforce crisis. But leaders remain leery of a staffing mandate and other punitive approaches.
“We are supportive of incentivizing providers to improve on key quality metrics, including staff turnover,” the organization said in a statement. “At the same time, we need policymakers to offer programs and solutions that will help us attract and retain caregivers to ensure residents are well supported. Turnover metrics are important, but we need significant meaningful aid to help address the root causes of turnover and offer more competitive, good-paying jobs.”
Questions on turnover-Medicare link
The White House earlier on Tuesday called its package of 50-plus initiatives the “most comprehensive set of executive actions any President has ever taken to improve care for hard-working families while supporting care workers and family caregivers.”
An early morning announcement noted that many workers providing long-term care “find themselves in low-paying jobs with few benefits,” leading to high turnover. It said the order directs the Department of Health and Human Services to consider issuing “several” regulations and guidance documents to “build on the minimum staffing standards for nursing homes and condition a portion of Medicare payments on how well a nursing home retains workers.”
The official order was published Tuesday afternoon, but did not add much detail to those two items.
Tuesday evening, the Centers for Medicare & Medicaid Services confirmed to McKnight’s Long-Term Care News that the turnover metric touted by the White House was in fact referring to a staffing turnover measure proposed in early April.
The metric’s expected addition to the nursing home value-based purchasing program could trigger additional payments to high-performing providers starting in fiscal 2026, if it gets final approval.
“This means that the ‘game is already on’ for this measure since the baseline period was FY 22,” said Steven Littlehale, RN, chief innovation officer at Zimmet Healthcare Services Group, who put national nurse staff turnover at 54%.
“Whatever support the government can offer to providers to incentivize staff retention is appreciated; however, we need more carrots and fewer sticks,” Littlehale told McKnight’s. “Additional regulation is not the answer to this quagmire.”
In addition, the SNF VBP metric for turnover would be one of four measures providers would need to excel in to earn a full 2% incentive payment. That may not be enough to move providers to drastically change working conditions for frontline caregivers.
“Improving retention may require making changes to operations, management or wages and benefits,” added Ashvin Gandhi, PhD, a UCLA researcher assistant professor who has studied nursing home turnover extensively. “My understanding of the evidence on value-based purchasing is that 2% is unlikely to be enough to drive major changes. Regardless of implementation, this may represent a valuable step in thinking about staffing in more nuanced terms than ‘hours per patient day.’”
Worsening a crisis?
The administration’s fact sheet said the connection between Medicare payments and turnover would build on a still-unpublished staffing mandate. But Sloan, who sat in an audience packed with union members, caregivers and individuals with disabilities, said the White House “is still getting it wrong on nursing homes.”
“Over a million older adults rely on the specialized care only nursing homes provide. Already, nursing homes around the country are closing or limiting admissions due to staffing shortages,” she said.
“Why take that option away from the people who need it by implementing punitive policies that potentially worsen, rather than remedy, the ongoing staffing crisis? We are particularly concerned by the threat of withholding Medicare payment if providers don’t have workers — when workers simply don’t exist.”
