Healthcare Workforce Challenges

(music)

An aging population, a global pandemic and economic headwinds. We'll visit with a couple of health care experts about the status of long-term and direct care in Iowa on this edition of Iowa Press.

(music) 

Funding for Iowa Press was provided by Friends, the Iowa PBS Foundation. The Associated General Contractors of Iowa, the public's partner in building Iowa's highway, bridge and municipal utility infrastructure. Fuel Iowa is a voice and a resource for Iowa's fuel industry. Our members offer a diverse range of products including fuel, grocery and convenience items. They help keep Iowans on the move in rural and urban communities. Together we Fuel Iowa. Small businesses are the backbone of Iowa's communities and they are backed by Iowa banks. With advice, loans and financial services, banks across Iowa are committed to showing small businesses the way to a stronger tomorrow. Learn more at IowaBankers.com.

(music)                                       

For decades Iowa Press has brought you political leaders and newsmakers from across Iowa and beyond. Celebrating 50 years of broadcast excellence on statewide Iowa PBS, this is the Friday, July 15th edition of Iowa Press. Here is Kay Henderson. 

(music)

Henderson: First let's start with some statistics. About 30,000 Iowans live in Iowa nursing homes. Another 20,000 live in assisted living situations. And then about 45,000 or perhaps even 65,000 Iowans are the direct care workers that help those people in those facilities. Our guests today represent those facilities and those workers. Di Findley is Executive Director fo Iowa CareGivers and Brent Willett is President and CEO of the Iowa Health Care Association. Welcome to the show, both of you.

Findley: Thank you.

Willett: Thank you.

Henderson: Also joining in the conversation, Clay Masters of Iowa Public Radio and Erin Murphy of the Gazette in Cedar Rapids.

Murphy: Staffing issues are prevalent everywhere across all industries. We wanted to start with both of you to see how that is impacting health care in nursing homes and assisted living facilities. Di, we'll start with you. What is the staffing situation? And how is it impacting the ability to provide care for Iowans?

Findley: Well, I want to preface this by saying these shortages have been around for a long time, long before the pandemic. And it has just made it much worse, just exacerbated what were some existing problems with shortages and high turnover. But to give you an example, one of our direct care council members told us her story about having experienced the loss of over 30 residents in a month's time where she worked and that is devastating. I remember when I was a nurse aid two people died while I was working and that was in a 13 year period of time. So she is now being treated for Post Traumatic Stress Syndrome. It is having a huge devastating effect on the workforce. They're totally burned out.

Murphy: Brent Willett, what do you see?

Willett: I concur with everything that Di is saying. The strain on the current workforce as it exists is extraordinary. We've never seen anything like what they're going through now. And the real world consequences of the shortages that we're facing is a limit on the access to care, long-term care throughout Iowa. Our association recently surveyed our membership and identified at least 45% of the nursing homes across the state of Iowa are limiting or freezing admissions right now because of a lack of staff. And so that speaks directly to the ability of Iowans who need long-term or post-acute care to access it. And so it could not be a more profound challenge.

Henderson: So, what is the estimate on the actual patients that would impact? It must be thousands?

Willett: Yes, yes. When we look at admissions flows into long-term care facilities you're looking at families, it's not to say that there is an inability to find care, it means that we are likely as a family that is looking for care to be traveling farther away from home and that can create tremendous complications because someone that is in a long-term care or post-acute care situation is someone that the family typically wants to visit very often and so being close to that facility is important. So it has created real family dynamic challenges in addition to economic challenges.

Masters: I want to ask quickly about reimbursement rates and how that affects hiring. The government sets the rate for Medicare, Medicaid, insurance companies do as well. Can you raise pay enough with attracting staff with the way that reimbursement rates are set right now? How does that play into how you attract people into the profession?

Willett: Sure. It plays a direct role. Reimbursement rates, first of all, the Iowa legislature and Governor Reynolds have been tremendous advocates of Medicaid funding for long-term care over the last four to five years. And without their intervention over the last few years we would be in an even deeper hole than we are now. Given the -- the long-term care sector is not immune to the inflationary pressures that the rest of the economy is facing. What is unique for long-term care is that facilities don't have the option of raising prices like most facilities or most businesses due to your point, Clay, because those rates are controlled by the federal and state government. And so we do need a significant reinvestment in Medicare and Medicaid in this country and in this state to enable us to compete for the staff that we need.

Masters: Di, how would you come at that question?

Findley: Well, I think there are different ways of getting at raising wages or enhancing wages for our direct care workers, not just those in nursing homes, but the 45,000 to 65,000 that we're talking about, they serve Iowans of all ages and abilities, not just in nursing homes. So somebody who is self-directing their care, somebody with a disability, people in group homes, even those in hospitals. So the shortages are pretty much everywhere. But when it comes to enhancing wages for direct care workers we agree reimbursement is an important piece of it. But it seems like those are the only two, the only two things we can think about when we're talking about wage enhancements is raising reimbursements or minimum wage increase and I don't know where that is going to take us or what that is going to get us. If we raise to $15 an hour we're in, as Brent said, trying to compete with other industries like manufacturing or the restaurant, the association that is on often times talking about raising their wages already to $17, $18, $19, $20 an hour. I don't know how the health industry can compete with those other industries.

Murphy: Are there other ways beyond -- that seems like the best or most obvious way -- there are other ways to try to get more folks into this industry beyond the wage issue, to either one of you?

Findley: I would just say on pay, wage enhancements, another way we could approach that is through the tax system. After all, the reimbursement rates are coming through as a tax payment and so maybe a more equitable way to raise wages for direct care workers across the board and not just silo them by the population they serve or the setting within which they work. So maybe it is in kind of a more direct incentive to the workers themselves?

Willett: Look, pay is really important. We need to find more dollars to pay our health care workers, there's no question about that. But we also have things that we need to do as a state and as a country to make working in a long-term care facility a more viable option for the folks that we need. And by that I mean we need to take a hard look at the existing regulatory infrastructure that we have in place around the public health emergency. Long-term care, skilled nursing facilities in particular, are really the only sector that is left that are facing really direct COVID-era requirements relating to testing, masking and vaccinations. And so we need to examine that, that's a complicated discussion, but in order to compete on a level playing field. It's difficult enough to work comparably with a wage in a different sector, but when you factor in the operational challenges that you face walking into a facility having to test and wear a mask all day long, it already took a special person, it takes a very special person now.

Henderson: I'm wondering if you can tell us a little bit about the demographics of the people who work in your industry? We hear that teachers are leaving and we also hear that for instance principals and superintendents are older and there is going to be a wave of retirements. Di Findley, can you tell us is there an average age? And at what point do people retire?

Findley: Yeah, that's a good question, Kay. The last time in 2019 we contracted with Workforce Development to do a wage and benefits survey and I don't have all of those stats converted to memory but there was a significant percentage of the people who were going to be retiring within the next five years. And the average age was somewhere between 45 and 50 age range. But the other thing that we asked them, those who were going to retire within the next five years, if they would stay in the field under certain circumstances and we were surprised to learn that a large percentage of them said they would continue to stay in the field if we could take some of the physicality out of the work and pay better.

Henderson: Do you have similar statistics?

Willett: We know that workers in long-term care facilities, for example, are disproportionately female, unmarried, many of them are unmarried mothers who have profound challenges associated with child care and finding coverage for other familial obligations. And so that creates even more pressure on a system because that means that employers like long-term care facilities must provide enhanced flexibility for that workforce to meet their familial obligations. And the era of profound staffing shortages that becomes even more difficult. And so with respect to the age of the workforce, it is aging like much of the rest of Iowa's workforce, and we're going to have to find ways to fill those shoes. I think Di's point is important. I talk with staff members every day who really drive home the fact that these individuals are, they're different, they're special, they're willing to work in an industry that they know is incredibly challenging to work in. I was speaking with an administrator the other day in the North Central part of the state and I asked him, why are you doing this? He had shared with me some significant challenges that he had faced in his facility. Why are you still doing this? There's an easier way to make a living is really what I asked him. And he looked me in the eye and he said, I'm doing this so that my kids don't see me as a quitter because this is the hardest time that I can imagine working in this space and we will find another way. But that just speaks to you the kind of people that we're dealing with and if we didn't have that level of sensibility in our workforce we'd be in a much darker place.

Masters: Are there any innovations that are going on right now as solutions that can kind of be seen as a model in the current climate that we have right now? Are there programs going on to attract new people, to help scale up and widen the demographics in the state of those that are working in health care?

Findley: Well, the state has had a lot of federal funds, recovery funds coming in and some of those dollars are being spent on home and community based service in that area, a lot of it is being spent in that area. And one of the things that they're doing with some of that money is providing bonuses for direct support professionals but it's only for some direct support professionals or home care aids. That is good for them, that's a good thing. But what kind of concerns us about all the federal money coming in, it's good, but it's short-term, one-time money. And what are we going to do when that goes away? So I've been around long enough that I have seen so many innovative programs begun and end. It's a grant, you get a federal grant, you develop this wonderful program, you test it, it becomes evidence-based and then there has not been the political will to invest in those programs to really bring them to scale. And what we had hoped or what we still hope is that some of those funds will be used to bring some of these initiatives to scale, not reinvent the wheel and not just quick Band-Aid kind of fixes. We need long-term systemic change.

Willett: Much like we learned across the rest of the economy during the pandemic that working from home really worked, it's kind of a miracle that it worked as well as it did. One of the other things that we learned in health care is how well telemedicine worked. And we hadn't had the political will at a national level, at a federal level to really push the kind of regulatory waivers that were necessary to do that until the pandemic forced our hand and we learned a lot in that experience. We have a tremendous opportunity and a lot of this is held at the federal level to codify those telemedicine waivers to allow an enhanced telemedicine process across the health care spectrum. Unfortunately, the administration at the present moment has indicated that they will let those telemedicine waivers expire. We don't think that's wise. We think that there are a lot of innovative ways to do this both in the skilled nursing side but also we represent home health providers as well and the state has been involved in discussions with providers about how to enhance telemedicine roll out for home health providers.

Murphy: You both have touched on this a little bit already but we wanted to have a little discussion about the ongoing and lasting impacts of the pandemic on this industry. Brent, I'll start with you, because you touched on some of the requirements that are in place for workers. So let me ask as a follow up to that, is what you're saying that you'd like to see some of those regulations or requirements regarding testing and masks relaxed? So do you feel that that can be done now at this point in the pandemic and still be safe with your employees and residents?

Willett: We do and we don't say that flippantly. We have looked and we have observed the rest of the health care system, it's really only the post-acute side, so after the hospital, that has these regulations that remain in place. Hospitals, clinics are all on an individual choice basis, not a government mandate. And we haven't detected significant COVID activity related to the reduction of mask usage and testing. We anticipate and expect and should expect that those kinds of protocols, testing, masking, will be pulled back and reanimated as virus activity moves throughout the country and the state indefinitely moving forward. But having a flat mandate that is irrespective of viral activity seems to be fairly heavy-handed and we think we can be smarter now that we have the lessons that we have all learned.

Murphy: Di, to that, I remember at the time the warning was those kinds of requirements will make it harder to retain or attract workers, which is something we've been talking about separately from this. Has that been your experience? Have you seen that it makes it harder to bring or keep people on with these rules in place?

Findley: Yeah, well it has been a while since we did that survey asking health care workers if they were more likely to leave or stay because of the mandates. A lot has changed since then. But at that time it was, again I don't remember the exact percentages, but there was a significant percentage, there were more who said that they were more likely to stay in the field because of the mask mandates and vaccine mandates than not. But yet the majority of people still opposed the mandates. So we can't assume that just because you oppose the vaccine mandate, that doesn't mean that you haven't been vaccinated I guess is what I'm trying to say.

Murphy: How about supply chain issues? The pandemic has caused stress on that and now inflation contributing to that as well. Di, I'll start with you on this one. Has your industry seen issues related to supply chain and making it difficult to provide care?

Findley: Well, early on we heard that and probably Brent would be the better person, he would know better the supply chain issues that we would. What we hear is directly from direct care workers and early on there were problems. They did not have access to the supplies that they needed.

Murphy: Brent?

Willett: Supply availability, access is back online. Really it is the inflationary price pressures that are making supply shortages seem like a walk in the park now. But supplies are available to the greater health care sector at this point.

Murphy: How serious is the inflation issue?

Willett: Extraordinary. Medical supplies are up 30%, 35%, certainly wage pressures are significantly higher than that and across the spectrum. And again, long-term care facilities just don't have the option that the rest of the economy does which is either limiting hours, we can't shut down, we can't raise our prices because those prices are controlled by the federal and the state government. And so we are incurring ongoing and devastating financial losses, which unfortunately has begun to result in the closure of nursing homes across the state of Iowa. We've seen a dozen closures in the last seven months in Iowa and we're fearful for more.

Henderson: And they're closing because of supply chain, inflation, workforce?

Willett: Correct. They're closing for financial reasons. They're out of money and the inputs on that are everything that you just listed off.

Masters: I want to circle back, we were talking about aging at home, kind of started to touch on that when we were talking about different innovations. Why has that been so important as of recent and how is it going?

Findley: Aging at home?

Masters: Yeah.

Findley: Well, I think they're experiencing the same challenges as nursing facilities, the same workforce issues. And I think that is one of the fundamental flaws in our system is that we continue to define, pay and train this workforce based on the setting within which they work or the population they serve and we really need to step back and look at the entirety of this workforce because it is so fragmented and they need portable training, credentials so that they can move more easily between different settings and populations. So I think until we get a system in place that will allow that we're going to continue to have those challenges regardless of the setting.

Masters: And so it's an opportunity that folks that are working in this field feel just as comfortable or interested in being an at home worker and helping people age at home? 

Findley: Yeah, I think that does create, provides some additional opportunities. And there's certainly a push for more home and community based services. Closing Glenwood in 2024 and then the Department of Justice report that was released last year indicating or saying that Iowa was out of compliance with Olmstead. So yeah, it's a high priority I know for Directors Garcia and Matney to get people out of institutions and into home and community based settings. So again, I don't know who is going to do that work.

Murphy: And that is literally next on my list to ask about was Glenwood. Great minds. What has been your observation because that is what the state has said they're going to work to find either home-based settings for the folks who are getting care there or at another facility. Have you been able to observe at all how that transition is going?

Findley: We have not.

Murphy: Do you think it was the right move? Do you think that that's a good thing ultimately for the people who were receiving care there?

Findley: Yeah, I think there are families who are maybe not equipped or there may be some consumers, it's about choice right, so they should have the choice of where if it's in the community or otherwise. But I don't know, it remains to be seen. I have very serious concerns about how people are going to access good care in the home, keep them safe.

Henderson: And Brent, it sounds like a transition to assisted living or long-term care is not really an option given that you were telling me that they're limiting admissions in many facilities.

Willett: Right. And certainly with the transition of the individuals at Woodward and Glenwood, the priority is being placed on placing them in the community, which we absolutely support. The concern that we have is that the infrastructure is simply not there and the timeline is aggressive just for these folks. We represent more home and community based service providers than not at our association and so we would like to see deep new investment in the HCBS system, but we also need to recognize that the 30,000 people in nursing homes across the state of Iowa have some of the highest acuity levels, which is their level of illness, than any other state in the country. And so folks, we need to face that reality that folks that are in nursing homes overwhelmingly cannot return home. They're too sick, they're too frail and too old to be able to return back to the community. And so we simply cannot have a long-term care continuum without a robust nursing facility system to support and care for those individuals.

Masters: How can people just watching this home, in the remaining time that we have, show respect in their day-to-day to the people that you represent in your organizations? Brent?

Willett: That's a wonderful question. I mentioned that much of our workforce, our direct care workforce, are women and a lot of single moms. If you know those individuals, they're in your community, they're in your neighborhood, talk with them about how you might be able to support their familial obligations. And certainly talk with your elected officials about the reimbursement system in Iowa and why we need to invest in this space because there's a lot of mouths to feed when it comes to the state budget, but we are facing a crisis of access to care in Iowa that I fear will get much worse if we're not able to reinvest in the system and continue the job and finish the job that the Iowa legislature and Governor Reynolds have championed over the last few years.

Henderson: Di, you get the last half minute.

Findley: Stop viewing the direct care workforce as entry level, low-skilled workers. They are not. They are professionals and we need to build a system that will recognize them as professionals.

Henderson: I'd like to thank both of you for joining us today and having this conversation.

Findley: Thank you.

Willett: Thank you.

Henderson: And for those of you watching at home, just an advisory here, the team here at Iowa PBS is preparing to cover the State Softball tournament so there will be no Iowa Press next week. We are on hiatus. The next Iowa Press episode will air on August 19th. After Softball, these folks at Iowa PBS are going to be preparing to cover the Iowa State Fair and their coverage will continue in August. For everyone here at Iowa PBS, thanks for watching.

(music)

(music)

Funding for Iowa Press was provided by Friends, the Iowa PBS Foundation. The Associated General Contractors of Iowa, the public's partner in building Iowa's highway, bridge and municipal utility infrastructure. Fuel Iowa is a voice and a resource for Iowa's fuel industry. Our members offer a diverse range of products including fuel, grocery and convenience items. They help keep Iowans on the move in rural and urban communities. Together we Fuel Iowa. Small businesses are the backbone of Iowa's communities and they are backed by Iowa banks. With advice, loans and financial services, banks across Iowa are committed to showing small businesses the way to a stronger tomorrow. Learn more at IowaBankers.com.