5 Biggest Challenges of Long-Term Care

Last Updated on June 14, 2024

The Biggest Challenges of Long-Term Care in 2023

Even before the pandemic, the long-term care (LTC) industry faced serious challenges with staffing, funding, and other longstanding issues. While new regulations seeking to improve the situation may indeed offer new funding opportunities, they also impose strict obligations, particularly around staffing. Here’s a closer look at the biggest challenges of long-term care today, and what leaders can do to address them.

Top Challenges and Issues with Long-Term Care

#1: High Turnover

Turnover has always been high in long-term care, with a 2001 study finding an average rate of 56% for RNs, 54% for LPNs, and 78% for CNAs. The Covid-19 pandemic only made matters worse, with the most recent survey from the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) reporting that an enormous 98% of nursing home providers were “experiencing difficulty hiring staff,” while 87% face “moderate to high staffing shortages.”

As a result, staffing and workforce management have been persistent issues for LTC organizations. This struggle also impacts many other issues with long-term care, including “unmet resident needs, quality problems, worker training and competency, and lack of integration with medical care,” as defined by the Kaiser Family Foundation in 2017.

The Centers for Medicare & Medicaid Services (CMS) has responded to the latest surge in turnover with new minimum staffing requirements, stemming from a 2022 presidential mandate. Released in April 2024, the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting final rule mandates a “total nurse staffing standard of 3.48 hours per resident day (HPRD), which must include at least 0.55 HPRD of direct registered nurse (RN) care and 2.45 HPRD of direct nurse aide care,” according to a CMS statement.

White Paper: Preparing for LTC Staffing Requirements

Offering some flexibility, the new final rule also allows facilities to “use any combination of nurse staff” like RNs, LPNs/LVNs and aides “to account for the additional 0.48 HPRD needed to comply with the total nurse staffing standard,” the statement clarified. In addition, a long-anticipated mandate requiring the presence of a registered nurse on duty 24/7 is still being finalized.

#2: Higher-Acuity Patients

In addition to workforce issues with long-term care, providers are facing an influx of resident referrals who are at higher levels of acuity than before — the result of an ongoing trend to move post-acute care out of the hospital and into less expensive settings. Concurrent with this trend is the drive to further reduce expenses by shifting residents from skilled nursing facilities into home-based settings.

The result is new and different responsibilities and obligations for facilities that may already be stretched to the max. Essentially, these facilities treat “two distinct populations,” as one pre-pandemic analysis describes it: patients who are there temporarily to recover from injury or illness, and permanent residents who “require skilled nursing care to live.”

Some larger organizations have expanded their SNF services and resident capacity with new home care options, aided by available funding. However, many others have struggled to implement these requirements due to a lack of resources or skilled workers in their areas.

#3: Lack of Funding & Public Awareness

Industry representatives have called upon Congress to help solve these issues with long-term care for decades, especially in the years since Covid-19 struck. With some regulatory changes and federal dollars — as opposed to the patchwork collection of state rules and assistance — LTC organizations could work to correct its labor shortage with higher wages, programs for overseas workers, and other initiatives.

Indeed, chronic underfunding has long been one of the key challenges of long-term care in the United States. Even back in the 1980s, experts warned that “the current system as structured is being stressed to its limits and that its functioning is inadequate, with serious problems in cost and financing, and in access to and quality of, long-term care services.”

“To the surprise of many, Medicare does not cover LTC expenses,” as one expert has pointed out. Writing in National Affairs, Robert P. Saldin explained that the LTC industry remains largely unsupported by the federal government. The cause? A lack of political will stemming from an American public that’s “generally ignorant about the issue and ill-prepared for the financial risk it poses.”

#4: Stricter Staffing Mandates

This disconnect may explain why so many new staffing mandates — including the 2024 CMS final rule — lay out requirements that facilities simply cannot meet. In an analysis of the new rule, the AHCA/NCAL points out that only six in every 100 nursing homes currently meet the requirements. And a whopping 80% of providers will need to hire more RNs as a result, including 92% of facilities in rural areas.

On top of new state-level staffing mandates, the new CMS rule increases pressure on LTC facilities to boost their workforce at a time when that’s more difficult than ever. As hospitals and other facilities leverage economies of scale and vast budgets to overcome post-pandemic shortages, many long-term care facilities remain in dire need of staff. In some areas, there simply aren’t enough workers, as CMS leaders themselves admit.

“Most nursing homes cannot currently meet these new requirements,” the AHCA/NCAL analysis adds. As a result, almost one in four “nursing home residents (more than 290,000) may be at risk for displacement, as facilities are forced to reduce their census in order to comply with the mandate, or ultimately close altogether.”

#5: Regulatory Roadblocks

So, while the federal government has indeed stepped in and implemented a series of changes in recent years, the resulting rules aren’t always welcome within the industry itself. Like the new staffing mandates, new funding requirements could simply further complicate matters for the nation’s LTC providers.

For instance, $150 billion in federal funding recently allocated to help provide “higher wages and increased standard of living for the direct care workforce” may not always be easily accessible to the those who need it. Providing a permanent 6% increase to each state for in-home and community-based services, the law requires states to create a plan “for strengthening and expanding services” before facilities can claim eligibility.

That requirement means that many facilities — and especially those in underserved areas — may still struggle to claim the funds. Similarly, a CMS plan to increase Medicare payments to skilled nursing providers by 3.7% in FY 2024 could incentivize job growth, but also comes with a series of required “adoptions” including new reporting rules for turnover, discharge function scores, and more.  

For its part, CMS does acknowledge that its new rules may be difficult to some, conceding that “in some instances, external circumstances may temporarily prevent a facility from achieving compliance.” The statement then outlines “hardship exemptions” with very specific qualifications, including a “combined licensed nurse and nurse aide to population ratio” that’s at least “20% below the national average.”

How Can Leaders Overcome the Challenges of Long-Term Care?

Given these challenges, how can LTC providers stay ahead of the staffing challenges in long-term care and prepare for more industry shifts in the years to come? One critical step is to enlist the help of a healthcare staffing and recruitment company that specializes in long-term care — and especially one with a nationwide footprint, offering thousands of workers available all across the United States.

In addition, workforce solutions providers can help LTC organizations stretch their budgets by better managing and even automating certain administrative duties. For instance, a healthcare managed services provider (MSP) can help streamline tasks related to hiring, billing and scheduling. This can help healthcare employers accomplish much more with added efficiency.

Prepare for the Challenges of Long-Term Care Now

As a leading provider of healthcare workforce solutions, CareerStaff Unlimited is here to guide you to the solutions that best meets your facilities’ unique needs. How can we help your organization meet the growing challenges of long-term care? Contact us today to learn more, or submit a staffing request now.