The Math Doesn’t Work: Nursing Home Staffing Woes Unsolved Without Immigration Action

The Math Doesn't Work: Nursing Home Staffing Woes Unsolved Without Immigration Action

As nursing home operators scramble to recruit direct care workers during a historic staffing shortage, many in the sector believe there is one obvious solution that has yet to gain meaningful traction, in part due to legislative gridlock: immigration.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) has honed in on minimum staffing ratios, and is incorporating staffing data into surveys as well as the five-star rating system. Such initiatives come at a time when the sector is operating with 14% less of its pre-pandemic workforce, according to data from the Bureau of Labor Statistics (BLS).

Providers have taken it into their own hands to bring direct care workers in from overseas, with little success. The Evangelical Lutheran Good Samaritan Society has only been able to bring one nurse over to the US; the nonprofit organization aimed to bring 250 nurses over from different countries since June 2021.

Meanwhile, there is some legislative action on immigration at the federal level that could bring more health care workers to US shores, but the fate of these bills remains uncertain — while other countries are way out ahead in attracting workers from other countries.

Unworkable math

Immigration does fall outside of the purview of CMS, which means immigration policy as a long-term solution to staffing shortages would have to be a cross-agency lift, ATI Founder and CEO Anne Tumlinson told Skilled Nursing News.

The Biden administration’s sweeping nursing home reform initiatives revealed in February don’t mention any intersection of immigration policy and long-term care either, but Congress has introduced a number of bills to address workforce shortages through immigration — most recently a trio of legislative initiatives in June.

One such bill, the Immigrants and Allied Health Act (HR 8021), would help immigrants get financial support to enter nursing school or another health career. A second bill, the International Medical Graduate Assistance Act (HR 8022), would reduce barriers to immigrants looking to receive their US medical license.

The third offers training and counseling to internationally trained health professionals who are US citizens or immigrants legally residing in the US while also educating employers on the abilities of health care workers that have been educated overseas – the Professional’s Access to Health (PATH) Workforce Integration Act (HR 8019).

“Their staff on the Hill are connecting the dots. I think that is really encouraging,” Tumlinson said. “[The latest bills] are great, but they don’t change immigration law. I don’t know that they addressed the underlying issue, which is that we have to make it easier for people to get here in the first place, legally, to do these jobs. And we have to make it really attractive for them to want to do that.”

The bills join several other proposed legislative efforts that frame immigration as part of the workforce solution.

“We’ve been having, at least within this long-term care policy echo chamber, this very robust conversation about staffing, minimum staffing standards and staffing challenges,” Tumlinson said. “There’s a lot of really great policy experts working in immigration, a lot of great people working on the direct care workforce – it’s really hard to find people who are working across these disciplines because that requires an enormous amount of expertise. That’s part of the challenge.”

Still, there’s “almost no way” to talk about staffing without talking about immigration, she said, because currently the math just doesn’t work. In a webinar earlier this year hosted by the Brookings Institution, a nonprofit public policy organization based in DC, thought leaders including Tumlinson said incentivizing domestic workers won’t come anywhere close to solving the sector’s labor crisis.

The sector has lost nearly 229,000 caregivers since February 2020, according to the Bureau of Labor Statistics.

A June report published by ATI revealed a “long-standing reliance” on domestic talent ultimately limits nursing supply. Immigrants make up nearly one in four direct care workers – about 225,000 undocumented individuals are working as doctors, nurses and home health aides, and 190,000 serve in custodial or administrative roles.

Laura Benzing, an analyst with ATI and co-author for the report, said findings reinforce the idea that the sector and policymakers can’t ignore immigration when considering solutions to the direct care workforce shortage.

Operator efforts in immigration fizzle

Operators, meanwhile, have on their own brought up immigration as a solution to work on in tandem with other short-term staffing stopgaps, but results have been disappointing and slow.

Brickyard Healthcare is working with health care staffing company PRS Global to recruit registered nurses (RNs) from the Philippines. The process is long, taking about 18 months to get nurses from other countries in facilities providing care.

Indiana-based Brickyard has been working to get RNs for a couple of months now, Prince said, making this a fairly recent endeavor. So far, the team has hired 40 international nurses and would like to hire 75, according to Prince.


International efforts were ramped up in light of the temporary nurse aide (TNA) program set to expire in October, and looming staffing measures as part of the five-star rating system.

The TNA program was borne from a waiver tied to the public health emergency (PHE). The waiver allowed certified nursing assistant trainees, or temporary nurse aides (TNAs) to work on the front lines longer than the federally mandated four months before taking a state exam.

As of June 7, that four-month cutoff will be restored. Anyone hired prior to June 7 will have until Oct. 7 to meet testing requirements.

The Evangelical Lutheran Good Samaritan Society has been advocating for immigration as a workforce solution for years, CEO Nate Schema said, but so far efforts have fizzled. In June 2021, the nonprofit organization sought to bring 250 nurses over from various countries – they have currently been successful getting one international nurse at their facilities.

Schema attributes the slow approvals to the bureaucracy that exists in bringing international nurses in, including visa delays and ensuring that all paperwork is being processed. Such red tape impedes that race to the finish line.

“It’s frustrating. Frankly, very frustrating. We’ve got over 1,500 open positions, 2,000 open positions, and we just can’t get these people here fast enough,” Schema said. “They’re excited and anxious to enter the United States and … enter the sector, and we just can’t get them here fast enough.”

Meanwhile, Good Samaritan has had to increase resident referral restrictions as a result of the workforce shortage. The organization was denying 5% of prospective residents in March – that statistic has jumped to more than 20% as of July.

Schema said he’s not overly optimistic that the team will meet their goal of bringing 250 nurses in by the end of 2023, but still acknowledges international nursing and immigration reform as “absolutely critical” and “paramount” to staffing strategies in the sector.

Brickyard and Good Samaritan aren’t the only operators seeking to work with companies to bring international workers through their doors. Pruitt Health and SALMON Health and Retirement are among other nursing home chains in the same situation, leaders have previously told Skilled Nursing News.

Pruitt, for one, in March said the organization plans to hire as many as 1,000 international nurses and certified nursing assistants (CNAs).

Once international nurses are in the country, operators can take it from there to create a warm, culturally sensitive environment.

“I’ve had the unique opportunity to work with international nurses over my career, and I’ve found it to be a very rewarding experience as long as we take the proper care to ensure that we are welcoming them, and culturally that we are very cognizant of the needs of our international nurses,” Prince said.

Staffing solution in a lightning rod topic

In the summer of 2020, the Biden campaign did propose immigration as one solution to the health care workforce shortage, but recent initiatives have left this cross-departmental solution by the wayside.

Instead, CMS is focusing on appropriate staffing levels, while Congress and the Biden administration incorporate immigration policy as part of initiatives like the Build Back Better Act.

A bill gaining the most traction was originally part of the act, and has been reintroduced on its own with bipartisan support: The Citizenship for Essential Workers Act (S. 747, HR 1909).

The legislation, introduced in Congress last May, would allow a pathway to citizenship for immigrants that have been deemed essential during the Covid-19 pandemic.

“I would say that is a proposal that is less controversial, because it is really a pathway to citizenship, permanent resident status,” said Andrea Price-Carter, director of workforce and technology policy for LeadingAge.

Another existing bill with bipartisan support, the Health Care Workforce Resilience Act (S. 1024), would allow unused immigrant visas to be recaptured and used to bring in more nurses and physicians. Price-Carter said there are approximately 40,000 visas that went unused in previous fiscal years.

Price-Carter said the Resilience Act, introduced in March, is also considered relatively uncontroversial and also more likely to be supported across the aisle.

“Every time you try to have consideration of a broader immigration bill … there needs to be discussion on the border, border control issues, and so that’s a lot more controversial,” said Price-Carter. “It’s really hard. It’s hard to move.”

The trio of bills introduced in June do not have bipartisan support or additional sponsors as of yet: Democratic Reps. Adam Smith of Washington and Lucille Roybal-Allard of California are the original sponsors of these bills.

“Sometimes a proposal will be introduced, but then there are other strategies that the sponsors may use to actually try to get the intent of the legislation moving,” said Price-Carter.

Slow immigration policy reform will ultimately come back to bite us, Tumlinson said, as other countries like the United Kingdom already have a robust nurse recruiting program.

“As a country, we’re way behind. Five years from now, we’re going to be competing with other countries to offer attractive packages to a whole bunch of workers from other countries to come here and do this work,” Tumlinson said.


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