Building the Tracks: Large-Scale Long-Term Support and Services Rebalancing Programs Will Require Fixing the Chronic Assisted Living Caregiver Shortage

Published in Today’s Geriatric Medicine Magazine (March 2023)

By Jason Bloome

America is experiencing a critical shortage of assisted living and skilled nursing facility (SNF) staff: a chronic problem accelerating as the population ages. Older Americans (65 and older), one of the fastest growing demographics in the United States, will double over the next 40 years, fueled by increased longevity and the Baby Boomers (born between 1946 and 1964). The number of adults over 85, the group most often requiring care, will quadruple over the same time.

An estimated 300,000 assisted living and nursing home staff left the profession in the United States from 2020 to 2022, many due to pandemic exhaustion, lack of advancement, tough working conditions, and low pay. According to the United Disabilities Services Foundation, the national caregiver shortage is expected to reach 151,000 by 2030 and 355,000 by 2040. The Bureau of Labor Statistics indicates home health and caregiving aides are among the fastest growing professionals, but there simply are not enough caregivers to meet the demand.

For decades, much of the demand for caregivers for older adults was met by immigrants, but migration to the United States is at a record low due, in part, to the pandemic, restrictive policies, and politics. There is no year-round temporary visa program available to the older adult living industry for less-skilled workers as there is for other sectors (eg, agriculture, tourism, and child care).

Proposed legislation could alleviate some of the immigrant caregiver shortage and provide a useful template for increasing caregiver staff in older adult care homes in the future. The Workforce for an Expanding Economy (H.R. 4288), reintroduced to congress on June 30 by Rep. Lloyd Smucker (R-PA), would create a new type of H-2C visa classification for nonseasonal, nonagricultural work that does not require a college degree. H.R. 4288 is supported by the American Senior Housing Association, which counts among its members the American Health Care Association and the National Center for Aging. H.R. 4288 and the chronic caregiver shortage was the focal point in the September 2022 Senate Hearing titled, “Flatlining Care: Why Immigrants Are Crucial to Bolstering Our Healthcare Workforce.”

Proposed H-2C participants would be foreign-born essential workers who would enter the country on a temporary status to help employers fill chronic workforce staffing issues in essential industries, including construction, retail, hospitality, and health care fields. The new visa category would allow older adult care facilities to hire entry-level caregivers and dining service and maintenance workers. Applicants with college degrees would be excluded from applying for the visa.

The proposed H.R. 4288 requires certain conditions: the job position must have remained open for a certain amount of time, be in an area where the unemployment is less than 4.9%, the employer must make efforts to first recruit a US-born worker for the job position before filing it with an H-2C worker, and the job must be registered with the Department of Homeland Security responsible for maintaining a publicly available database of all registered positions. The bill proposes, for the first year after the bill’s enactment, the number of H-2C visas would not exceed 65,000 and, for subsequent years, the number of available visas would increase or decrease depending on the quantity of visa slots needed for the previous year and how quickly the previous allotment was filled.

The prospect of new immigrant caregivers would be particularly beneficial in California as it implements its new California Advancing Innovating Medi-Cal (CalAIM) initiative: a $3 billion, five-year innovative model to use state-contracted Managed Care Plans (MCPs) to streamline the delivery of Medicaid delivery health care services, rebalance long term support and services (LTSS) from SNFs to home and community-based services and, by 2027, to fully transition all Medicaid recipients into statewide managed LTSS.

One component of CalAIM is the use of in lieu of services (ILOS), a new tool the CMS authorizes states to use, which are medically appropriate and cost-effective substitutes for traditional Medicaid funded services (eg, payments to SNFs) to avoid unnecessary hospitalizations, emergency department use, and long-term SNF stays. ILOS expenses are covered costs included in the capitated rates paid to MCPs, as determined each year by the California Department of Health Care Services. In California, ILOS is referred to as community supports (CS).

One CS MCPs can offer their members is for SNF Diversion/Transition to Assisted Living. To participate, eligible members must require long term care and be at the SNF level of care while in an SNF (for more than 60 days) or reside at home and are determined to be at risk of premature institutionalization.

In California, the majority of the 7,500 licensed assisted living homes (known as residential care facilities for the elderly or RCFEs) are small six-bed homes where two staff provide 24-hour assistance to four to six residents with custodial care needs (eg, require help with transferring, dressing, bathing, or incontinence; are nonambulatory; and/or have confusion, etc). Small RCFEs with high staffing are good settings for members eligible for SNF diversion and SNF transition (eg, according to the state’s 3rd Quarter MDS 3.0 SNF survey, most SNF residents on long-term Medicaid have only custodial care needs).

CalAIM is still in its infancy, but once CS program systems fully mature (eg, assigning CS teams, creating closed-loop referral systems, marketing the program, developing RCFE networks, etc.), new pathways will open to RCFEs for thousands of members eligible for SNF diversion/transition and, with it, the need for sufficient bed capacity in existing and new RCFEs—and the staff required to take care of the new residents.

The train has left the station as California embarks on an ambitious program to lower long term care Medicaid expenditures from expensive SNFs to more affordable community-based care homes (RCFEs in California are one-half the cost of Medicaid reimbursed SNFs). But states like California that use ILOS to embark on large scale LTSS rebalancing programs will also encounter a vexing impediment as they build the tracks: shifting a large population of older adults from SNFs with low staff-to-resident ratios (1:17) to residential care settings with high staff-to-resident ratios (1:3) will increase the demand for future caregivers by five-fold. Moving forward with LTSS rebalancing systems will require good solutions to increase the available pool of assisted living caregivers. Proposed bills like H.R. 2888, which allows temporary visas for immigrant caregivers, could be one step in the right direction.

— Jason Bloome is owner of Connections – Care Home Consultants, an information and referral agency for care homes for older adults in California.