February 15, 2002
LONG-TERM CARE WORKER SHORTAGE
By: Helga Niesz, Principal Analyst
Susan Price-Livingston, Associate Attorney
Kristina Diamond Arsenault, Legislative Fellow
You asked what other states are doing to address the shortage of long-term care workers, such as nurses, nurse's aides, and other direct care workers serving the elderly or disabled.
The shortage of long-term care workers is part of an overall health care worker shortage. Experts suggest that demographic changes, low pay, and difficult working conditions are all factors that contribute to this shortage, particularly in paraprofessional occupations such as nursing assistants, home health and home care aides, and personal care attendants. Nurse satisfaction surveys indicate that the shortage of paraprofessionals is a significant reason why nurses are unhappy in their jobs.
States so far appear to have focused most on the shortage of licensed and registered nurses. Many have created task forces or commissions or are otherwise studying the issue. Some have mandated wage and benefit increases, while others have attempted to improve working conditions by limiting mandatory overtime. Several have created educational incentives, such as scholarship or student loan forgiveness programs. Other approaches include tax incentives and special licensing provisions that permit retired nurses to resume their careers. Finally, several have created special licenses for nurses licensed in other states or countries.
For nurse's aides and other unlicensed direct care workers, states are trying (1) "wage pass-throughs" and other ways to increase wages or benefits, (2) career ladders, (3) work environment improvements, (4) incentives for health care employers who offer their staffs additional training, and (5) recognition programs for people working in those professions.
We enclose copies of the National Conference of State Legislatures report, "States Grapple with Nurse Shortages," which describes a number of state programs and legislative proposals and the North Carolina Division of Facility Service's report "Results of a Follow-Up Survey to States on Career Ladder and Other Initiatives to Address Aide Recruitment and Retention in Long-Term Care Settings. "
ATTRACTING AND RETAINING NURSES
States and analysts have given considerable attention to the nursing shortage generally, rather than focus on the long-term care industry in particular. (One reason for this may be that a much larger number of nurses work in hospitals than in long-term care settings. ) A June 2000 Journal of the American Medical Association article predicts that by 2020, 20% of registered nurse positions will be vacant. The reasons the authors identify include (1) smaller nursing school graduating classes, (2) the aging of the nursing workforce (less than 10% of active registered nurses are under age 30), (3) an increase in the size of the elderly population needing care, and (4) lower nursing salaries as compared with other professions.
States have considered several different initiatives to address the nursing shortage. Table 1 shows each initiative and the states that considered it.
Table 1: Recent State Initiatives to Address Nurse Shortages
Mandated Studies/State Planning Bodies Created or Expanded
AR, HI, MD, MS, NC, ND, NH, SC, TX, VA, WV
Education Incentives/Student Loan Repayments
AR, CA, CO, IN, LA, FL, MD, NB, NV, OR, RI, VT, TX
State Income Tax Credits
CA, CO, KS, ME, OR
Limiting Involuntary Overtime
ME, OR, NJ
Special Limited Licenses
CO, GA, FL, IL, KY, MI, UT, VA
Source: NCSL Issue Brief, "Nursing Shortages," 7/20/01
Studies and State Planning Agencies
Arkansas, North Dakota, Virginia, and West Virginia have created commissions or task forces to study nursing shortages in their states. New Hampshire established a committee to look at ways to encourage people to enter the nursing profession. The committee must make recommendations on expanding nurse education programs, providing tax credits to hospitals and nursing homes that offer advanced training, and creating or expanding scholarship programs.
North Carolina created the Center for Nursing in 1991. It is the oldest state-supported agency in the nation whose purpose is to conduct nurse workforce planning. The center's goals include creating a nursing supply and demand database, projecting future needs, recommending systemic changes, creating recognition activities for nurses, and promoting a positive image of nursing in the media. It has developed a planning model to assist hospitals and other health care facilities to meet nursing demands.
A Virginia law creates the Advisory Council on the Future of Nursing and charges it with developing recommendations concerning nurse education, recruitment, and retention. Finally, a South Carolina law directs its Area Health Consortium to include an assessment of recruitment and retention of nurses and nurse's aides in the state's nursing homes and hospitals in its mandated statewide needs assessment for all health professions.
Education Incentives and Loan Repayments
States have also created or enhanced scholarship and loan forgiveness programs for nursing students and licensed nurses. In California, recipients of such scholarships must work in a county-operated facility for at least one year. In Colorado, Indiana, and Louisiana, they must work in underserved areas for specified periods.
In 2001, Florida's legislature modified the state's Nursing Student Loan Forgiveness Program, making its primary purpose to increase employment and retention of registered nurses and licensed practical nurses in nursing homes, hospitals, and other specified facilities by repaying their staffs' existing federal, state, or privately financed student loans.
Maryland increased the maximum dollar amount for nurse scholarships and grants and made recipients of nursing scholarships under the state's Economic Development Student Assistance Grant eligible for other scholarships and awards. Additionally, the state's educational institutions have a statewide "articulation agreement" under which licensed practical nurses who meet certain criteria may enter the second year of a community college's Associate of Science nursing program after completing "Bridge to RN" transition courses.
Nebraska has created a nursing scholarship program for students enrolled in approved nursing programs. Each approved school will receive at least $ 1,000 for at least one student. One hundred scholarships will be awarded statewide in academic year 2001-2002 and at least as many will be awarded every year thereafter. At least half of the scholarship funding will be made available for nontraditional or ethnic minority students. The new law also creates (1) a nursing incentive program that pays nurses $ 1,000 for up to two years if they agree to practice in Nebraska and (2) a nursing loan repayment program that repays loans of up to $ 5,000 per nurse per year in exchange for full-time practice in the state. The latter program requires communities to provide matching funds.
In Oregon, the Nursing Services Program pays part of student loans for nurses who practice in shortage areas. Rhode Island's legislature passed a law in 2001 that reduces registered nurses' student loan repayment obligations by 1/3 (R. I. Gen. Laws Title 16-62. 1). Texas also passed legislation last year creating a professional shortage reduction program. It provides grants to nursing programs to increase the number and types of registered nurses in the state. The law also requires the state's Board of Nurse Examiners to establish a nursing workforce data center to collect data on nurses and other nursing personnel, including demographics, areas of practice, supply, dement, and migration.
State Tax Credits
California, Colorado, Kansas, Maine, and Oregon give nurses tax incentives or credits. Some of them tie receipt of credits to working in shortage areas.
Limiting Mandatory Overtime
As a result of the nursing shortage, many hospitals and health care facilities are requiring their nursing staffs to work overtime. Several states have taken up legislation to prohibit or limit the amount of mandatory overtime. Maine enacted a law in 2000 that established the first limits on the number of overtime hours that employers can require nurses to work. In 2001, its legislature passed another law (1) prohibiting employers from disciplining nurses for refusing to work more than 12 consecutive hours (they can be disciplined for refusing to work longer hours during an emergency) and (2) requiring employers to give nurses who have worked more than 12 consecutive hours at least 10 consecutive hours off immediately after that.
Oregon and New Jersey both have laws that prohibit hospitals from requiring nursing staff to work more than their pre-scheduled shifts. At least 11 other states considered but did not pass legislation in this area in 2001. Connecticut and Rhode Island were among them.
Special Licenses for Retired and Nonresident Nurses
Colorado, Georgia, and Florida allow retired nurses to return to work under a special limited license. And Illinois, Kentucky, Michigan, Utah, and Virginia allow nurses licensed in other states or countries to start working under a temporary or limited license while their application for a state license is pending. Their out-of-state training must be similar to the standards of the state issuing the temporary license.
ATTRACTING AND RETAINING DIRECT CARE WORKERS
A recent Urban Institute report identified low wages and benefits, hard working conditions, heavy workloads, and the stigma attached to long term care jobs as factors that make it difficult to recruit and retain paraprofessional direct care workers (Who Will Care for Us? (Stone and Weiner, Oct. 2001). The shortage of workers in these occupations is especially significant in long-term care settings because most direct care workers are paraprofessionals.
A report from North Carolina's Division of Facility Services summarizes 43 states' responses to its survey on their efforts to address paraprofessional recruitment and retention in long-term care settings. Fourteen states created task forces or study commissions. In addition, the respondents identified the following approaches as being tried or considered in the past two years:
1. career ladders/increased scope of duties (14 states);
2. wage increases/wage pass-throughs (13 states)
3. Medicaid rate increases tied to an entity's offering additional training, accreditation, and other career advancement opportunities (6 states); and
4. efforts to improve access to health insurance (five states).
Table 2 shows each initiative and the states that considered it.
Table 2: Recent State Efforts to Recruit and Retain Long-Term Care Paraprofessionals
Career Ladders/Scope of Practice Expansions
MO, NV, WA, MN, MT, ME, NC, NJ, OR, WI, MA, VA, DE, MI
Task Forces/Study Commissions
CO, GA, IA, KS, MI, MO, NV, NC, OR, PA, RI, VA, VT, WI
AK, ME, MA, MN, MO, MT, NJ, ND, PA, RI, VT, WA, WI
Improved Access to Health Insurance
GA, NC, NJ, PA, VT
Medicaid Rate Increases Tied to Professional Development Efforts
AK, GA, ME, MN, NC, RI
Source: N. C. Div. Facility Services Follow-Up Survey, September, 2001
Fourteen states reported career ladder initiatives. Minnesota, Montana, and Nevada have developed programs to prepare certified nursing assistants (CNAs) for the licensed practical nurse (LPN) examination. Maine, North Carolina, New Jersey, Oregon, and Wisconsin have created medication aide credentialing programs, authorizing specially-trained medication aides to give medication under nurse supervision in some health settings. Massachusetts, Virginia, and Wisconsin have created programs focused on skill upgrade training, and Delaware and Michigan have created senior CNA programs to encourage career growth and satisfaction for CNAs.
Wage Increases and Pass-Throughs
During the period covered by the survey (2000 through July 2001), 13 states reported that they either considered or have implemented measures to increase wages. The most common method of doing this is with wage "pass-throughs," raising state Medicaid reimbursement rates and directing facilities or home care service operators to use some or all of the increase to raise wages or enhance benefits for their workers.
Improving Access to Health Insurance
Five states have provided or improved access to health insurance for paraprofessional workers. New Jersey's Family Care Program enables health care access through low premiums in a managed care plan. Efforts are underway in Pennsylvania and Vermont to increase consumer and provider awareness of health plans for low income workers. Georgia's Department of Community Health intends to include uninsured and underinsured health care paraprofessionals in a newly authorized state-subsidized health insurance program. As of July 2000, Rhode Island established a public/private partnership to help low-income families with children enroll in employer-sponsored health care plans under its Rite Share program. Finally, North Carolina has publicized its state children's health insurance program by sending a flyer to newly registered CNAs. It plans to expand this informational campaign to other paraprofessional aides.