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Long Term Care Webinar: The Staffing Crisis

Long Term Care Webinar: The Staffing Crisis March 9, 2022

Marketing, research and business development consultant in healthcare, human services and senior living.

Staffing Crisis

Date: 8th March 2022
To watch the recording click here

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    Irving Stackpole

    Dr Michael Wasserman

    • Poels, J., Verschueren, M., Milisen, K. et al. Leadership styles and leadership outcomes in nursing homes: a cross-sectional analysis. BMC Health Serv Res 20, 1009 (2020).
    • Christopher Donoghue, PhD, Nicholas G. Castle, PhD, Leadership Styles of Nursing Home Administrators and Their Association With Staff Turnover, The Gerontologist, Volume 49, Issue 2, April 2009, Pages 166–174,
    • Castle NG, Decker FH. Top management leadership style and quality of care in nursing homes. Gerontologist. 2011 Oct;51(5):630-42. doi: 10.1093/geront/gnr064. Epub 2011 Jun 30. PMID: 21719632.


    The Long-Term Care Staffing Crisis: Intelligent Responses by 3 LTC Specialists

    Facilitated by Irving Stackpole, with Lori Porter from NAHCA and Dr Michael Wasserman from CALTCM

    Irving Stackpole 

    Thank you, Lori, and doctor Wasserman, for participating in this program.

    This is a critical dimension of the health care system in the United States and elsewhere that has suffered this suffering. And what we hope to do today is to talk about very briefly, how we got here.

    We want to hear from the point of view of frontline direct care, workforce, I’ve been chastised for referring to it that way, the people who care. So we want to hear from their point of view, and Lori will offer that. then doctor Wassermann will offer data and examples of why leadership matters during this crisis.

    And overall, what we’re going to be doing is looking at practical steps that operators and managers can take to help reduce the problem and mitigate the crisis.

    So how did we get here?

    Well, there’s, there’s convenient, lies, and harsh truths, and the fact is, that, is, turnover in long term care has continued, has been continuing, for many years. There’s various sources of data about the churn in long term care, but it appears that it’s at least 100% and among the nursing staff and among certified nursing assistants, and it’s a little less among licensed professional nurses.

    But the fact of the matter is, that staffing in long term care has been considered a revolving door, and fungible exchangeable components of care, which are the people have been considered interchangeable.And eminently changeable with a renewable resource, continually available. And that’s simply no longer the case.

    The fact of the matter is that there may not be a system in long term care at all. term care providers and the long term care provision in the United States suffer from ageism in society.

    The dominant attitude toward long term care is highly negative.

    And there’s a debate going on now, all of a sudden about whether or not long-term care is a business or an enterprise.It’s an interesting discussion, one that we’ll have to table for future webinar.

    You then add in on top of this, the Pandemic, which is a precipitating factor, not the causal factor of the precipitating factor.And you have a real difficult situation. I would say you have a crisis.

    So the real question is, what do we do? What can be done about the situation in staffing in long term care?

    We can see that since the public health emergency was declared in February 2020, the nursing and residential care facilities have lost at least 410,000 workers.

    Probably more Lori or Michael may have more updated information. And the question is, where are they going?

    You can see here, that’s the cumulative percentage change in the healthcare employment by setting, since the public health emergency was announced. You can see the loss in nursing care facilities and community care.

    Operations and the gains have been, or the less difficult changes have occurred among office outpatient, home health care and hospitals. So, nursing homes yet, yet, again, residential care facilities, yet, again, are at the bottom of the food chain.

    Then we have what we were talking about just before we started the program, we have the State of the Union Address where the President had actually talked about nursing homes.

    I’ll avoid political commentary. But this may be the first time that nursing homes are directly discussed in a State of the Union Address.

    And in the fact sheet that was issued just prior to the State of the Union Address, there were 21 recommendations to cut our nursing homes, Significant amount of them had to do with staffing.

    There are calls for increased staffing, staffing, ratios, increased inspections, and increased fines, and a call to lower costs. I don’t know how practical that is. I don’t know how feasible that is, This is what the fact sheet called for and the suggestions that were made. So we’re going to be seeing more about this certainly in this year.

    So what can be done? What about what can operators do?

    Well, first is to recruit what we the current recruitment models are replays of older legacy models trolling for candidates.

    And the second is to retain the recruitment models Haven’t necessarily worked very well because there are other options now in most marketplace areas available for low wage, employees, and pretension models.

    It hasn’t, retention in nursing homes hasn’t been an issue, because managers haven’t had to care about retention and now we do.

    So, there are ways to reach, both recruit and retain more effectively.

    And we’ll be talking about that further in it in another webinar, but with regards to recruitment, this is an example of a typical recruitment ad for a certified nursing assistant.

    You’re all familiar, many of you are familiar with this, many of you probably have recruitment ads that look like that.

    Well my, my hope is that we will very soon abandon this model of recruitment and in fact, we should be talking to our targets, we should be talking to the audiences whom we wish to recruit.

    Where they are and where they are on social media. Here is a tick tock ad that I’ve got up on the screen here.

    As you can see it’s at 38,800 views as of the point where I loaded this particular image with 64 comments and 2000 likes. I’m sure we’d all like to have advertising that’s effective.

    Here’s another example of an ad that appeared for CNAS. Love your job and your team members, too. The reason that recruitment those recruitment messages work better is that the critical ingredient in retaining direct care workforce in long term care settings are relationships.

    There’s lots of data about this. It’s not necessarily pay, it’s relationships.

    And the challenge for nursing centers is to engage with and listen to frontline workforce relationships in many settings that are more important than pay.

    And the single most effective recruitment method that we can employ is our referral system.

    Most Nursing Centers that I’ve talked to, and I talk to quite a few, the employee referral system is not Energized, it’s not refreshed, it’s not looked at in a novel manner, it’s not developed by the people affected by it most, which are the frontline workforce. So, the referral system.

    The second is, why do people leave in the model of retention, the critical pieces? Why are you leaving? Well, there’s some people who leave for life cycle issues like lifestyle issues, changes, and look for relocation.

    But in every case, we should be asking, when people leave, will you recommend, would you recommend, would you refer people? And if they wouldn’t, we should understand why, because that is an extraordinarily telling question.

    Then, there’s three things that the government should do and should do. First, is Data, data, more isn’t always equal to quality.

    We should intervene.

    It’s my personal belief that the government can and could intervene to stop recruitment bonuses, which is just a race to the bottom in most marketplace areas.

    The governments can, through local agencies, like the Medicaid agency, State Department of Health, enlist the cooperation and collaboration of agencies to build job banks to cooperate and coordinate staffing instead of having wars and battles inside of a particular marketplace area. And then finally, creating sustainable careers. So with that and I know that I’ve talked about quite a few things.

    With that, I’d like to turn it over to Lori Porter where she can discuss with you the, um, the caregivers direct caregiver care workers point of view.

    Lori Porter 

     I don’t have any slides to share with the group today because I’m here to talk more about the floor level frontline view because one of the things that has been difficult is the fact that every well meaning person thinks they know what’s best for CNAS. And no one ever bothered.

    And, one of the things is if you put people in a box for four decades, and then you ask them what they’d like, they have no idea, they’ve been in a Box, they didn’t realize they had an opportunity to choose. 

    Nowhere else in healthcare are CNAS, so undervalued, but at nursing. So, instead of us telling and preaching and banging on management of how they can do better or what they should be lying because not everybody’s a luvvie, touchy feely person, and I love this spot about business or enterprise.

    When I speak to administrators and I’m a former administrator, I kind of see this from all sides from a CNA, from a dishwasher, from a housekeeper, from a med tech, from a nursing home administrator and regional operations director.

    So, I’ve spent 42 years looking at this from about every angle. And Long term care is the only place for my members.

    For 27 years, I’ve run this association of CNAS across the nation and my hospice members, my home care members, my pace members, my even assisted living, are happier than they are in skilled nursing. So, I think we should be asking questions of the leadership. What’s preventing you from building these relationships?

    You see, I never used the business skill when you’re. Most people don’t realize that an administrator in the United States of America of a nursing home can’t make a $500 decision without calling up the chain.

    So we held our summit, as you know, last week and this is I’m gonna give you an example of something. So simple.That may be and not just take anything away from you or doctor Wasserman, but it is the simple things, right?

    It’s not academia, and, you know, it’s helpful. Data and research are not to be lessened.

    But this is a simple, simple problem of why we can’t treat people right in nursing homes.

    There’s a reason, because, as an administrator, my staff said, I didn’t treat them right, and you won’t find a bigger CNA advocate in the United States of America, I don’t think, than myself.

    And so, if they did that to me, we never get any recognition around here.

    That’s painful.

    But, you know who you are hearing that from the five people you wish you didn’t have on staff anyway. And, we are, we have been for three decades. At least, we have not been able to even practice our disciplinary procedures because we’re so desperate for staff. CNAS have been running amuck for many, many years now.

    And, you know, they’ve been in control of the narrative in terms of what happens on a daily basis and at the facility. Let’s look at this. CMS requires every facility to have a disaster plan. They have one for every disaster that happens in their part of the United States, whether it’s hurricane tornado, what required, but they never have to be required to have a plan for the disaster. That happens every day, and that Disaster’s called staffing.

    So right now, I like to give people some things they can take away, and also look to where we’re going in the future. But CNA is a profession. It’s not to be called a valet. It’s not a direct care worker. That’s not a profession. If doctors were called direct care workers, it wouldn’t be prestigious to be a doctor.

    I tell my members, you know, I tell him to dress in white still, I tell him the wire stethoscopes, lab coats. 

    One, CNA said to me if I dress like that when I go pop my gas at night, The attendants gonna say what are you, a doctor?

    And I said, what am I supposed to say? He said, I said, here’s exactly what you say.

    No, sir.

    I am not a doctor. I’m more important than the doctor.

    You see, I work down at ABC Care Center and they’re only required to see the doctor once a month.

    They have to see us every day.

    We’re more important than that.

    There’s no measurements that let us see.

    And, I know if they’re doing a good job or a bad job, because long term care historically has not done timely evaluations for their employees. So, there’s no way to know if you’re valued or not.

    Group praise has always been what nursing homes use to recognize their staff and group praise is a big failing proposition.

    Sometimes, it’s great, but not if you’re going to tell the team in front of you that I couldn’t run the place without doing it. This efficiency pre survey, is yours, baby, yours. And they said they’re like, ah, we were told, not even to speak to the surveyors. We were told not even to speak to the families.

    This is marginalizing. People who know more about the resident than anyone, it’s not marginalizing. It’s controlling. There’s no marginalization to it, let’s control them.

    And so I never did everything we ever did as this when I was a CNA and everything I’m hearing from my members is their many of them. The reason for the exodus is they can no longer stand the human suffering.

    They know that things are fudged in documentation often, but no one will believe them.

    They know the inside secrets, they are the eyes and ears of the residents, but they won’t even tell those neglect stories because they’ve been told it’s their fault, your fault there, So, CNAS carry a lot of baggage. Most people don’t even know and you’re right.

    Money was never the top number one spot until the pandemic.

    And since we’re in a mutual business with the government, this enterprise, or whatever we want to call it and the, the greatest skill, a nursing home administrator needs is relationship building.

    Nowhere else is there as much negativity in health care, as there is inside the walls of the nursing home, we have beat the staff, from the, from the marvelous dishwashers and dietary attendants we have to leadership, and we’ve always made it about leadership needs to do better leadership, needs to change.

    What do we want to fix in this, and, I believe, staffing?

    And the reason you’re holding this is because we can no longer pay CNAS must be paid. I’m watching things go in the opposite direction. I saw today, Florida’s closer to having their hours reduced to one CNA hours. TMA Program is just applauded over and over by the industry. How can you be a skilled facility and not have skilled labor?

    We should not be reducing standards at this time, because that’s why we’ve lost people, home care, hospice, hospitals. They have standards and processes that nursing homes simply do not have.

    And I don’t believe we ever have, we’ve all been flying by the seat of our pants. So, when I go back to the staffing disaster, here’s another little simple thing. They have no business recruiting. You see the experts on the outside of long term care. That’s what the commission report was about, how the exterior, the parameter of long term care can come together to fix this.

    These are simple problems to fix. They truly are.

    So, what do CNAS really want?

    You can’t recruit them to do it? You know, many of you know, we started a school, an online platform called the National Institute of CNA Excellence. Do you know what our number one challenge is? Mike knows, I don’t know, Irving if you do, and I’m certain our audience doesn’t. But to get to hire one of our graduates, a long-term care facility has to be able to identify two CNAS in house to have become preceptors through our program. We have 300 facilities signed up, and none of them can get to compliance.

    There’s no shortage of people who want to become CNAS, but you have to know what the right message is.

    And I love your tick tock ideas, but I also think this CNAS are treated like children and we really really resent that.

    The gold star you get when you get to, you know, you get five gold stars, you get to go to the administrator’s office and get a candy bar. 

    Are you serious? Is that as inventive as we can get?

    And then, you know, there’ve been a lot of jokes about pizza parties. And we chimed in on that too until one of my board members said to me, Hey, I know that we make a joke about that, but I know some CNAS, that’s the only meal they’re getting.

    Now, we can continue to treat them like they’re binney this.We can continue to treat them that they’re not worthy or they’re not smart enough. And we’ll continue to get what we’ve been getting, which is very little, and we will lose all of our decades long experience in NHANES.

    I’ve lost two off my board that have one left health care altogether after 22 years, and another one went to hospital, where she says the nurses vite over getting to work with her.

    But at some point in time, when your nurse doesn’t seem to care, your administrator doesn’t, how in the world can you continue to care?

    So, my big question, if, if anyone could ever answer it is, what do administrators think they can do to become relationship builders, because you have to have one with the families, the residents, the vendors, the community you live in as a marketing person?

    These are all the skills, so there is now some momentum and not to get controversial. I won’t speak on it, but there’s some momentum now.

    And, without focusing on this area, we’re dead in the water. Our residents don’t stand a snowball’s chance.If we can’t figure this thing out, and it’s not rocket science to treat people as professionals, we have to model with nursing and physicians. We should be able to follow that model with certified nursing assistants.

    Michael has some observations about leadership.

    Dr Michael Wasserman

    I want to start with something positive, and I love to tell stories.

    And, a few years ago, when I was running a large nursing home chain, I got in my car over six weeks and literally visited 74 facilities, seeking out the CNAS.

    And, I love to tell this story because it just reinforced something that Lori just talked about.

    These are not only incredible human beings, but they love what they do, and she’s right about the five people who don’t love what they do, who want to complain, But the reality is, there’s a ton of folks working in nursing homes who love what they do. and, and, to me, have the highest degree of compassion of, of anyone in the healthcare industry. So I just think it’s important to point that out.

    I think Irving talked about leadership. I’m going to talk about leadership.

    Laurie talked about leadership.

    The other thing I did learn, and I think it’ll resonate with all the administrative votes on this, on this webinar, if you have a facility with poor culture and poor leadership, a CNA will go to another facility for 25 to 50%.

    If you have a facility that has great culture, great leadership, it’s closer to $2. Now, that doesn’t mean that those dollar amounts are right or wrong.

    I’m gonna talk about that a little bit, but it doesn’t mean we don’t value seeing NAs. Valuing them matters but so does respect. And I think to that point, I’m going to talk about leadership and I’m going to start, um, with the concept. Oh, leadership models and I like to do this because it defines things and also, over my career as a Geriatrician folks are always saying, Well, what data do you have?

    Well, no, Lori can talk and from an experiential perspective, I can talk from an experiential perspective but how about some data? And I’m going to share some data with you.

    Um, so one of the leadership models, events that defined some of the data, is the three types of leadership being transformational, transactional, and passive avoidant. Being transformational is motivational. And passive avoidant is essentially an absence of leadership.

    So, transformational leadership is the type of leadership where you increase levels of motivation, you inspire people, they go above and beyond.

    It’s also based on studies in nursing homes associated with increased well-being from staff.

    Increased feeling’s, increased job satisfaction, decreased intention to leave, decrease burnout rates from a health outcome for nursing homes. It’s also associated with higher patient satisfaction, higher quality of care.

    Lower mortality, few her medication errors, I mean, if this were medication, no, Who wouldn’t use this? And so, in one study on transformational leadership styles versus passive avoidant, nurses scored significantly lower on transformational and transactional leadership styles insignificantly higher on passive avoidant leadership styles.

    And then we ask ourselves, Why do we have 100% turnover? Well, there is a correlation that goes directly back to leadership, and the data shows us that it does.

    With that, I want to introduce another Description of leadership types.

    It’s Consensus Management Style, which actually leans more towards a Servant Leadership style. The Consultative Autocrat, the autocrat, and the Shareholder Manager, and lorries pulling about.

    A lot of nursing home administrators aren’t just given their budget, and really don’t have the opportunity to make any changes. I would actually lean into changing that.

    I think, even if we provide great leadership, if the CEO of an incredibly complex business, or mini hospital can’t have flexibility on the budget.

    I’m not sure how you make it work, but that’s, that’s then maybe that’s for the Q and A or for another, another webinar.

    Um, not surprisingly, this study was done a decade ago, but it still, I’m sure it holds true, 70% of nursing homes had administrators and deal ends who met the autocratic Shareholder Management style, and only 30%.

    We’re consensus style leaders. Now, why does it matter?

    Laurie was talking about the type of leaders we need.The type of leaders to interact with with their. who walk the floors regularly, who hear the concerns of their CNAS and include them in helping to develop solutions to problems and issues, and, as she said, who will go fight for them with, with ownership in terms of paying and things like that.

    OK, this study was done a decade ago in facilities that have consensus style leadership.

    There was significantly lower staff turnover.

    And so while everyone’s talking about how we reduce staff turnover, the data shows, one of the ways of doing it is to have consensus style leaders.

    But let’s go one step further. How about health care outcomes?

    The same study in this study was on a couple thousand if not more nursing homes in the United States. So this was not a small study.

    This was a large study. Still boggles my mind that this study has never gotten more play or interest because it’s sound lower restraints, less pain, Lower pressure sores, Lower use of urinary catheters. Higher five Star Q With higher five style inspection scores.

    That’s what transformational consensus style leadership in nursing homes brings, Lower staff turnover, improve quality outcomes, what’s not to, like, what’s not implement, and, and, you know, that’s the question I would pose.

    And I always close every talk I give with a photo of my dad, and everyone thinks that’s Albert Einstein. But my father’s, actually, an Albert Einstein look alike, he’s 88 years old. He embodies positive aging by going to the batting cages every week to hit 90 mile an hour fastballs, gotta get in my anti ageism plug and with that, I guess we can go to the Q and A’s.

    Question 1: So how can we come back to the staffing crisis in at home care.

    Well, number one, you know it’s to me that we wouldn’t have so much easier time recruiting for those areas but typically when you know you have a caregiver’s soul, you need to be sending messages around the value of the patient.

    What your commitment is to the patient, your mission statement.

    And, of course, people do look for pain these days, but the heart of a CNA, the heart of caregivers, it is the heart, more than anything.

    So, if, here’s, you know, if you can articulate your mission in a way that other people can articulate it within the company, it will go a long way to send messages to prospective employees of what their role and responsibility is, and the value of it.

     I think we need a nationwide mission to grow this workforce as the population continues to age. And despite the blip that told me his call, cause, in the 85 and above population. That, historically, in the last few decades has been the most rapidly growing segment of our country, and so we’re going to have needs across all of long-term care, and I think we must all focus on it.

    It’s clear that the demand is going to be there. The need is there.

    One of the things that we’ve discovered through our research is that the psychographic profile of a person who prefers to work in a nursing home or a hospital, it’s very different.

    And the psychographic profile of an individual who prefers an at home setting is also distinct.

    And our recruitment in the past for decades now has not differentiated effectively. Certain companies who’ve invested in the research and understand profiling have done a better job at this, but they are not the same person.

    You can lure someone out of a hospital setting to work in an at home setting by offering them lots of money. We would call those job hoppers. And the bad news about hopper’s, is that they can hop away, as easily, as they can hop in.

    So, for at home care, it’s important to understand who, who your market is and the difficulty at this time is, of course, competing against options. For options that are being offered in marketplace areas, such as Amazon and other entry level employee, employment situations.

    need to focus on the mission.

    Why someone wants to do this work is profoundly different from whether or not they will do the work and I. We need to focus more on that. I believe leaders fail to communicate their vision, to their teams Every day, and our passion. Right, again, so, you know, every facility, I am a sports person, I mean, I was, when I was, I didn’t like to watch, and I always enjoyed playing it.

    It happened to me, the point guard, and we didn’t keep running, playing two as I dribbled down the court if two was getting shut down, right? Multiple plays in our playbook and that’s what so, selling that vision is one of the most important, because people who care want to know where you want to lead us, right? How can you be a leader without sharing a vision?

    Question 2: I’m curious to know how staff development impacts staff retention and recruitment 

    What’s sad to me is as a professional association of CNAS that they have to pay for their own education. They get through us because it’s not sponsored. CNAS are given 12 hours of compliance education, which is nothing more than a checkbox, that is not important, valued education by them.

    However, I’ll just for reference in 2019, we had over 79,000 hours of continuing education, going far beyond compliance, completed by CNAS in this country who are willing to pay for it out of their own pocket.

    So continuing education does matter. They want it desperately, but they’re insulted by the current platform of compliance for the last 40 years, about a checkbox.

    All right, I completely agree with you.

    And I, we have quite a bit of data. Staff development is really relevant for retention, and not necessarily for recruitment, the dimensions associated with why someone takes a job, are quite distinct from the dimensions as to why somebody keeps a job.

    And interestingly, poor onboarding is very highly correlated with willingness to leave, with willingness to look at, or take another job. So, poor onboarding, which I would include staff development, because if you’re doing a good job of onboarding, that includes good staff development. You wanted to add something, Michael?

    Yeah, you know, so California Association of Long-term Care Medicine has a leadership and management training program for nursing homes, where we bring together the leadership team, and I’m a huge proponent.

    An administrator alone cannot successfully run and manage inertia.It is a team and that team, The definition of that team, to me, has always been the administrator of the D O N, the medical director and the director of staff development.

    And I actually think the director of staff development plays an incredibly important role and needs to be included and not just sort of set aside and siloed and told what to do, because it takes a team, it takes an interaction. The last person, who’s now, probably needs to be involved in that team, is the infection prevention, as to who has a role now, that should embody.

    Ongoing education and training on a daily basis of all staff, So, I do. I think the role of the Director of Staff development is absolutely essential.

    Question 3: What suggestions do you have for a company? who has reviewed an increased wage by nursing, stopped twice, and given them multiple bonuses over the last two years to serve our appreciation. Yet, we still have staff upset because there are rules in place that they must follow and they don’t like disciplinary action.We still have CMS regulations to follow. So what can we do to help?

    I’m going to jump in on that one. I think it’s easy, and I think we’ve all said it. If you just increase pay and you don’t know, demonstrate your appreciation of the value of your staff and demonstrate respect. And that all does come back to leadership.

    And I, I think if you’re getting that response, each and every member of that team needs to look in the mirror and say, do we just know or are we blaming the staff? Or do we need to look at how we are treating them and how we are acting as leaders? And I would strongly suggest leadership and management skills.

    Oh, the frontline and the frontline leadership and nursing homes need to be upgraded, I think, to ignore leadership training, and that’s why I showed all the data on consensus style and transformational style leadership.

    And, also the data that doesn’t exist to a large degree.

    So, yeah, Laurie’s point, you know, doing the same thing over and over again and looking for the sick, you know, looking for different results, is the definition of insanity. I think we all have to look in the mirror and say, what more can we do?

    And I think part of that answer is leadership. There’s no leader of that team. There’s no one who deserves more respect or less respect than anyone else.

    And if I were going to choose one thing to operationalize from what Laurie said about giving CNA, something to be involved with, if your CNAS are not involved in copy, you’re missing a huge opportunity.

    Question 4: Do you see electronic health records contributing to staff burnout and dispatch dissatisfaction?

    Ah, friends who resent complex, rigid systems that take too much time from keeping them from doing that shelter caregiving work, depending how it’s sold to them. Yes. It, or if it’s part of sustaining life, they’ll understand that if it’s put out as a chore, they’ll resent it.

    long term care.It’s the land that technology left behind, or they lever, or they didn’t go for a tag were specifically excluded from legislation.

    And regulations that promulgated electronic health records, meaningful use, has no meaningful results in long term care.Home cares got good technology because the government required it.Long term care is the land that technology left behind.

    Grocery stores have better technology than nursing homes, and that’s just a fact. And the reason, one of the reasons for that is that the owner operators have not demanded of the vendors.

    The idea that you’re going to improve a CNA’s life, by giving her a kiosk tablet that’s screwed to a wall So nobody can steal it and that he or she has to then walk out to the tablet and instead look at a slip of paper and put it into the test.

    You’ve just increased the opportunities for errors in a real CQI, quality, continuous quality improvement environment. You have actually introduced opportunities for error.So what we need is seamless ambient technologies.And the good news is, that because we don’t really have health care, information, technology, infrastructure. 

    But we there needs to be investment in infrastructure, and that’s one of the things that I, I was sadly disappointed with the White House fact sheet. There was no call for that investment, no methodologies suggested or pointed to as to how that investment would occur.

    I’ll make two comments on this. This is something near and dear to my heart. Electronic records across the board historically are billing centric. So, we need care centric electronic health records, number one. Number two, and I’m glad Irving mentioned grocery stores because Amazon has grocery stores where you can walk in, get your groceries and leave without ever going through any Iowa because they have sensors, they have technology.

    I don’t know why The future of long term care isn’t that CNAS and nurses and doctors go about their day, the CNAS change, the residents do all they can and everything is captured so that they don’t have to go sit in a dark corner live with with a tablet at the end of the day and try to remember what they did.

    The technology exists. We’re not you, because that’s really the ball. It does scare long term care a little bit, though, to have more information out there than what they can control the narrative of what’s. Now that’s an interesting point, 

    My personal take on this is that families only know that the center is understaffed, because the staff tell them that the center is understaffed.

    Now there’s some obvious things, and certainly with 100% turnover and losing almost a half a million workers, there are some obvious things that are occurring that people can see.

    The information that needs to come out from nursing homes is not the information that’s put out if we stop and think about it.You know, CMS has a reason for collecting the data they do, But it is wholly insufficient to what the consumer needs, that data is not helpful to the consumer, too.

    And neither is the five Star system. Because if you’ll remember, the facility Kirkland wasn’t that we’re like, oh, that burst appeared. They were five star deficiency, three a few weeks 

    Then they got hit with a $700,000 fine, or something like that. So, you know, the investment in long term care. I’ve said recently that two things are true. Reimbursement has never paid for quality care, if it pays for minimum care. And the government has to go far beyond compliance because they’re in this together, and that’s the only fix there is facilities can afford to pay the kind of money CNAS requires now.

    Every facility deserves to get $22 an hour out in quality if that’s what they’re willing to pay.

    The problem is if we don’t create systems of accomplishment, a poorly performing CNA makes the same as an excellent performing CNA and that is a very big downer.

    So I don’t know if that was the answer, but I just see many, many solutions, that if nursing homes are worth pointing fingers at and the government pointing fingers at one, that’s the holding pattern.

    So we progress. And we must educate the consumer so that they will know how to follow along to what is a good facility and not, But to have a five star facility deficiency three with a two star staff, To me, is the big headline because that’s why there’s been no investment.

    If you can be perfect, perfect according to the government, five star deficiency three, but your staff rating is a two, what more do any of us need to know? That staffing is not important in this area? And so, that narrative is, should not even be out there right now. I have to say when, when everyone needs to, well, we don’t have enough staff?

    Thank you, Dr Wasserman, thank you, Laurie Porter, this is terrific. Thank you, Romilly and for all of those who hung in here with us to the end, Thank you all very much and have a great day. The conversation is far from over. We will continue.


    Stackpole & Associates is a marketing, research & strategy consulting firm focused on healthcare and seniors’ services markets. Irving can be reached directly at

    Marketing, research and business development consultant in healthcare, human services and senior living.

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