LeadingAge Magazine · July/August 2016 • Volume 06 • Number 04

Seeking Solutions to Worker Shortages

July 13, 2016 | by Dianne Molvig

Worker shortages—always a problem, but now becoming more acute in many areas—are forcing employers to boost retention efforts and rethink recruiting strategies.

What keeps aging-services leaders awake at night? To assess its members’ concerns, LeadingAge Wisconsin conducts regular surveys. Topping members’ worry list in last year’s survey was the shortage of workers.

Interestingly, in the same survey done in 2013, “the workforce issue didn’t even rank among the top 3,” reports John Sauer, president/CEO of LeadingAge Wisconsin. “But in 2015, it rose to No. 1.”

That finding spurred the organization to take a deeper look at what is happening. The resulting follow-up in-depth survey of some 700 long-term and residential care communities for older adults and disabled persons found that:

  • One in 7 caregiving staff positions went unfilled.
  • Nearly half of the providers had no applicants for vacant caregiver positions.
  • These organizations compensated for staff shortages by using overtime, double shifts and other strategies, thus placing additional stress on existing staff.
  • Even with those make-do measures, providers had to turn away 5,335 potential residents during the previous year because of insufficient staffing. (That compares to some 87,000 Wisconsinites living in long-term and residential care communities.)

The Wisconsin scenario is typical. “We’re definitely seeing this happening everywhere across the country,” says Robyn Stone, senior vice president of research and executive director of the LeadingAge Center for Applied Research.

The Wisconsin survey, published in early 2016, is one of the most recent among several done in the past decade to assess the worker shortage problem in long-term care. The numbers may vary somewhat from one survey to another, but the same conclusion prevails: There’s a gap between the numbers of elderly people who need care and workers who provide that care, and that gap continues to widen.

Observers point to several factors contributing to the problem, such as:

  • Economic cycles. During the 2008-2009 recession, people were more inclined to hold onto the jobs they had. Now that the economy is recovering, they feel free to leave one job for another.
  • Demographics. The population needing care will surge with the arrival of aging baby boomers, while the size of the working-age population will shrink. Many dedicated, long-time direct-care workers are now themselves reaching retirement age and must be replaced. Plus, the number of family caregivers also is expected to decline, which will put even more demand on the formal care system.
  • Occupational stigma. Old stereotypes about long-term care linger, causing many workers to shun jobs in this sector. They’d rather work in hospitals, clinics or hospitality businesses, which often offer comparable jobs for better wages and benefits.

Still, the situation here is less dire than in other developed countries such as Japan and in Europe, that have a severe lack of younger workers and burgeoning older populations. “We’re still a relatively young nation,” Stone explains, “so we have some time to find solutions. But we don’t have a lot of time.”

And those solutions, she emphasizes, must not rely on simply finding enough “warm bodies” to fill the openings.

“Even though we’re in sort of a crisis mode now,” Stone says, “providers need to pay attention to the hiring, training and support of a competent, quality workforce that can be retained. That’s what’s going to save us and lead to better outcomes.”

“From our experience in Minnesota, based on the overwhelming feedback from our members and the demographic trends captured in our environmental scan data, the top priority issue cutting across all geographic regions and service lines is the recruitment, retention and development of a well-trained workforce,” says Adam Suomala, vice president of membership and strategic affiliations for LeadingAge Minnesota.

The organization, in response to rapidly growing concerns about worker shortages, has worked aggressively on a variety of fronts to understand and address the challenges.

According to a report presented at LeadingAge Minnesota’s 2nd annual Workforce Solutions Conference in May, nearly 2,900 nursing and nursing assistant FTE positions were open in the state’s care centers alone. The average care center now has 7.9 vacant FTE positions, representing a 5% increase over the previous year. Housing and community services fares slightly better, but also faces rapidly rising turnover and vacancy trends. Surveys showed what LeadingAge Minnesota members attributed vacant positions to, and the 3 highest-rated factors were:

  • No applicants: 70.1%
  • No qualified applicants: 51.6%
  • Competition with other employers: 75.8%

“In all communities, we’re seeing efforts to build pipelines with education and marketplace competition. In some, particularly rural communities, organizations are exploring strategies such as international recruitment,” says Suomala.

Efforts to boost workforce development investment in Minnesota were helped by legislative victories in 2015. A variety of new spending focused on workforce and championed by LeadingAge Minnesota members, included a new cost-based reimbursement system for nursing homes that increased average rates by up to 23% as well as a new scholarship program for HCBS workers and expansion of the Nursing Facility Scholarship fund to cover expenses for more staff seeking to advance their training and career pathways.

“In addition to developing new grant programs, several existing state and regional programs can be adjusted or enhanced to focus on aging services careers,” says Suomala. “This was also the first time we broke out of the health and human services budget box. Our priorities were being heard by other legislative committees and traveling in other bills. It’s crucial we start thinking about these issues as a statewide workforce issue, not just a health care issue.”

Suomala has witnessed a surge of interest in ways to solve workforce problems from the aging-services field: “In Minnesota, [we had] a decade-long dry spell in funding that saw many organizations reducing training dollars and staff development opportunities. But in the last year, we’ve seen providers asking substantially more savvy questions about onboarding, healthy workplace practices, staff development resources and supports and cutting-edge operational processes that appeal to staff spanning all ages. The level of interest and the early results around these projects has come a long way in just a year.”

The organization’s Workforce Solutions Conferences, first launched in 2015, are devoted exclusively to recruitment, retention and workforce development issues. With an initial grant from HealthForce Minnesota and major expansion resources from the Margaret A. Cargill Philanthropies, LeadingAge Minnesota also offers an example of how to leverage collaborating partners to create solutions, such as a Health Support Specialist (HSS) Registered Apprenticeship Program that cross-trains apprentices in all areas of caring for older adults, with material presented online and paired with on-the-job learning experiences.

The organization’s Workforce Center offers tools for both workers and employers, including resources for job searching, staff recognition programs, recruitment and retention, finding mentors, educational opportunities and more.

Guiding this work, LeadingAge Minnesota has a Workforce Solutions Council made up of members and stakeholders from outside aging services, including government officials. Suomala believes there is ample opportunity to partner with other sectors to solve common problems. He also believes our field, as a major employer, has more clout than we sometimes think.

“There are amazing partners out there ready to help us leverage existing resources. Just getting people open to the idea of working in our field is opening hearts and minds! We’re very excited about the power and potential of partnership opportunities going forward to produce meaningful impact in our ability to serve our state’s older adults.”

- Gene Mitchell

Resolving the worker shortage in the aging services field, while also maintaining workforce quality, demands multiple strategies.

Develop an employer brand: The premise of employer branding is that just as an aging-services organization must brand itself to appeal to prospective residents or clients, it must also have an employer brand that attracts and retains employees.

With employer branding, “you create a business case for why people want to come to work for you and stay,” explains Gene Dolloff, chairman of Morrison Community Living in Atlanta, which does in-depth research on various aspects of aging services. From its studies on workforce challenges, “what emerged as a robust solution is employer branding,” Dolloff says.

You can think of this as becoming an “employer of choice” or “a great place to work,” he adds.

At the center of the employer brand model is what Dolloff calls “the employee value proposition.” It’s the notion of defining, from an employee’s perspective, the reasons to take a job and stay in it. Supervisors and managers then must do their jobs in a way that honors the employee value proposition. As Dolloff points out, employees typically don’t leave organizations; they leave supervisors and managers.

In the end, that affects an organization’s success. “Resident and family satisfaction is tied directly to the frontline staff,” he says. “If those employees are happy and feel good about what they’re doing, that enhances and differentiates your organization in the marketplace.”

Combat the stigma: Negative impressions still persist about what it’s like to work in a nursing home, assisted living community or other senior housing setting. Turning that situation around requires presenting a more positive picture.

“I encourage long-term care and senior care professionals to speak more highly about their work to others within their community, to their family and friends,” says Cara Silletto, founder and president of Crescendo Strategies in Louisville, KY. “They can talk about the mission and purpose of what they do. That is tremendously powerful.”

More formal tactics also can be effective. For instance, LCS in Des Moines, IA, encourages its communities to reach out to local universities, colleges and technical schools.

“We try to get in front of students to talk to them about the options available in this field,” says Yvonne Rickert, LCS’s vice president/senior director of human resources. “We also ask our communities to hold clinical rotations on site for RNs, LPNs and CNAs, so they can get hands-on experience” and see for themselves that the old stereotypes are passé.

Says Rickert, “It’s important to excite and motivate people about coming to work in this [field].”

Motivating the millennial generation (usually, but loosely, defined as those born between the early 1980s to about 2000) is a special challenge. These 20-to-30-somethings want more than a job.

“They need to have a mission or cause to get behind,” Silletto says. “That’s one of the top reasons they go to work for and stay at certain organizations. They want to feel they’re contributing to something greater than themselves.”

Immigration is a controversial issue in this country, as evidenced by the rhetoric in the current U.S. presidential race. It’s also an issue that affects the long-term care field, says Robyn Stone, senior vice president of research and executive director of the LeadingAge Center for Applied Research.


“A large proportion of particularly our front-line workers are immigrants,” she says. According to a 2009 study, about 20% of the U.S. direct-care workforce was foreign-born at that time, she notes.

Another study from 2010 found that 79% of the overall foreign-born workforce is in the U.S. legally. In recent years, President Obama issued executive actions that aimed to allow more immigrants to become legal by fulfilling certain requirements. Those executive actions now are in limbo due to a 4-4 split U.S. Supreme Court decision on June 23, 2016.

As for the long-term care field, “If we don’t recognize that immigration policy has a short- and long-term impact on the availability of direct-care workers,” Stone says, “we’re making a big mistake. Immigrants are not the only solution to our worker-shortage problem, but they’re part of the solution.”

Be flexible and adaptable: Many aging services organizations still do their staff scheduling the way they’ve always done it. “We haven’t adjusted to our society,” Silletto points out. “We have a lot of working single parents within our organizations, as well as many aging workers who would love to continue in a nursing role, for example, but they can’t do an 8-hour shift.”

She suggests that more organizations examine staffing arrangements such as job sharing and 4- or 6-hour shifts. She knows of some who are trying split shifts, in which workers come in for a few hours at a peak time in the workday, and then return to do a few more hours later. That may be helpful to a parent, for instance, who needs some midafternoon time to pick up kids from school.

“There are unlimited opportunities for flexibility,” Silletto says. “We have to be open-minded about this.”

Not only do such solutions appeal to many workers, of all ages, but employers also can reap savings by better matching workers’ hours with the work to be done.

“This can benefit your organization’s bottom line,” Silletto explains, “because you don’t have to have everyone on 8-hour shifts. That may not be the most effective way to provide care for your residents.”

Advocate for change: Employers can take steps to reach out to prospective workers and to make their workplaces more inviting to employees. Such factors are within their control. But outside factors also play into the worker shortage crisis.

“Unfortunately, because our business is so heavily reimbursement-based,” Silletto says, “there is the reality that our wages are low. So I urge people to work, particularly at the state level, to try to raise Medicaid dollars. We need to take the numbers to our state houses to show that turnover is increasing and the battle for talent has gotten fierce.”

That strategy is now underway in Wisconsin, where LeadingAge Wisconsin launched an advocacy campaign in April of this year. “We realized we need to create more public awareness of the challenges care providers face with respect to workforce shortages,” says Sauer.

He notes that Wisconsin now has the worst Medicaid reimbursement in the country, according to one study. Long-term care providers take a loss of $55 per day for each Medicaid resident, which affects what providers can pay employees. Plus, in order to offset the shortfall, providers must charge higher rates for private-pay residents, who “in reality are paying a not-so-hidden tax,” Sauer says.

Getting the public, and especially state government officials, to understand this crisis—and be willing to take action to solve it—is the point of the campaign. LeadingAge Wisconsin acts as campaign coordinator and provides advocacy tools such as a PowerPoint presentation.

The most powerful strategy, however, is storytelling. “What really resonates with the public, the governor and the legislature,” Sauer says, “are real-life stories from real-world people” including both those giving and receiving care.

The next phase of Wisconsin’s effort involves teaming up with other care provider organizations to present to the governor and state legislature a dollar amount for bolstering Medicaid reimbursements. In addition, LeadingAge Wisconsin will focus on noneconomic factors to counter the worker shortage.

“We have a web page where members can share best practices for mentoring, training, peer support and recognition,” Sauer says. “Wages and benefits are parts of what determines whether people will come to work for you and stay. We also have to be smart about how we treat people.”

The shortage of workers in aging services reflects a combination of factors—demographics, public policy, the employment outlook for workers and generational attitudes—that combine in various ways to make recruitment difficult and to make good retention policies ever more important.

OnShift, a software company that makes a suite of products for hiring, scheduling and workforce analysis in health care, sees how providers struggle with workforce issues. LeadingAge spoke with Peter Corless, OnShift’s executive vice-president, about what he’s learned from clients in senior living.

LeadingAge: What can you tell us about your data on workforce shortages?

Peter Corless: Coming out of the Great Depression there was a baby bust, and so if you look over the last 5-plus years, there has been very little growth in the percentage of the population now aged 80-85, but moving forward, the number of 80-85s will increase dramatically in the next 20-30 years.

There have been a number of studies. One projects a need for an additional 1.2 million senior living workers by 2025.

Another study, published in Health Affairs, says at least 2.5 million more long-term care workers will be needed by 2030 in order to keep up with the growth of America's aging population.

There aren’t enough spaces in nursing schools to fill the need for retiring RNs. Coming out of the recent recession a lot of RNs postponed retirement. Now we’re looking at a lot of people retiring in the next few years. There are not enough people coming in behind them to fill the need. And, a lot of those people have moved more into acute care as opposed to the senior living space.

It’s clear that there’s going to be a lot more demand and insufficient supply, and to compound that there’s fairly high turnover. In recent surveys millennials have said their employers shouldn’t expect them to stay more than 2 years or so. You take high demand, low supply and high turnover, and it creates a real workforce challenge for employers because of the high costs associated with recruiting and retention.

LeadingAge: Can you characterize the sorts of things you’re hearing from your clients? Where do they really need help?

Peter Corless: Two overarching concerns we hear from our clients have to do with the workforce shortage and wage pressures.

Not only is there not enough available talent, but those people who have put off retirement coming out of the recession are now retiring. I know of a community that put a ban on admissions for a while because they were short of labor and couldn’t provide the level of service they wanted to. They had to stop admissions until they could get staffed up again; it’s very common.

Providers are also dealing with escalating wage pressures. When you consider the movement toward a $15 minimum wage, we’re seeing that organizations will have a hard time competing at those levels because of the cost structure, and we’re seeing it acutely both on the clinical side and in housekeeping and dietary.

LeadingAge: What advice are you offering clients now?

Peter Corless: Retaining employees is not only cheaper than recruiting new ones, but a stable staff also leads to better care and satisfaction. The initial focus should be on how to retain and engage them. Having an open dialogue and having meaningful relationships are important. People who move jobs do so because they feel their supervisor doesn’t care about them or they don’t have good relationships.

People don’t want to move jobs if they’ll move away from friends they have at work, so cultivating a better social environment, keeping open lines of communication, doing employee surveys and [building] employee engagement and recognition are important. Those things are important to building a culture that’s cohesive and [where] there is camaraderie—where people won’t move for a little bit more money.

Millennials want, first, a sense of social well-being and contributing to the greater good, and they are attracted to our field because they are doing good for the elderly. Second, they want to know the employer is taking an active interest in their career, offering ways to move up.

LeadingAge: What are you telling clients about recruiting? Are there untapped sources of workers that senior living isn’t looking at?

Peter Corless: Companies have to be focused on … differentiating themselves from other employers in the space. Millennials are concerned about a social conscience and how you’ll help them to develop and move ahead. Companies using that in their recruiting will have a better shot at attracting millennials in the future.

There’s a renewed focus on how we get our profession in front of young people. How do we get into high schools, colleges, to guidance and career counselors, and make them understand that senior living is a huge employer? It’s a valued and growing profession, and is a true profession where people have career paths and can move up. There are a lot of good entry-level positions and employers who will provide additional educational assistance to help people move up.

- Gene Mitchell