Paid training, tuition assistance may be key to solving New York’s nursing home staffing crisis
Tea Mickles, 23, wanted to become a nurse because of her late grandmother’s experience in a long-term care facility.
“I always wanted to learn to be the aide that I wanted her to have,” she said.
Already balancing working as a personal care aide and raising an infant daughter, Mickles found an opportunity that was hard to pass up: train for four weeks as a certified nursing assistant — and get paid for it.
She and a dozen others took classes for four weeks earlier this year at D’Youville University in downtown Buffalo, learning things like how to safely get residents out of bed and proper handwashing. If they completed clinical rotations and passed the New York state certification exam, they were guaranteed a CNA job at one of Catholic Health or the McGuire Group’s nine Western New York nursing homes.
“I have a baby at home and I’m doing this,” Mickles said. “They've made it to where we can still make a little bit of income, I have a job promised to me, and I'm getting educated in something I want to do to better myself. So it's all bonuses.”
Most prospective and active care workers are low-income women of color balancing family commitments and multiple jobs, according to a report last year by the Paraprofessional Healthcare Institute (PHI). So unpaid training can be a barrier for them to join the field, while tuition costs can be a barrier to eventually advancing to higher-paid care positions.
That means educational benefits like paid training and tuition assistance may be crucial to rebuilding New York’s nursing home workforce, which data from the U.S. Bureau of Labor Statistics shows has shrunk by nearly 12% since the start of the COVID-19 pandemic.
“In this day and age, we just have to be creative with what we're offering,” said Catholic Health Vice President of Long Term Care Operations Patricia O’Connor.
The New York State Health Facilities Association does not have any data on how many of its 400 nursing homes and assisted living facilities currently offer such educational benefits like those being offered by Catholic Health and the McGuire Group.
But NYSHFA President and CEO Stephen Hanse said they might become more common as the state’s staffing shortages worsen. Over 90% of NYSHFA members reported severe staffing shortages last year.
“What we're seeing throughout New York are providers really thinking outside of the box about what they can do to recruit and retain those workers,” he said.
However, there are roadblocks. Nursing homes’ capacity to offer educational benefits vary, and the taxpayer-funded Medicaid system generally does not reimburse them for such costs.
Still, nursing homes are increasingly facing pressure to attract and retain workers. New York’s safe staffing law, which mandates nursing home residents get at least 3.5 hours of direct care a day, went into effect last month after a three-month delay.
“Historically, healthcare providers may have been in the position of catching applicants,” O’Connor said. “We need to go out now and pitch to applicants and encourage people to consider careers in healthcare, and help them to recognize the important work that can be done.”
Paid training meets CNAs where they are
For 28-year-old Kamera McClain, the CNA training at D’Youville felt like “going back to college.”
She and other trainees were on campus from 7:30 a.m. to 3:30 p.m. for class and given D’Youville ID badges. Some of them even started a study group chat.
“No matter how old you are, you can do what you got to do and do what you want to do,” McClain said.
Catholic Health and the McGuire Group, which have hired a combined 29 CNAs so far this year via the paid training programs, say the college setting was intentional.
“We wanted to create a college atmosphere where people will come in and get a feel for the educational process at a college level,” said McGuire Administrator Aaron Polanski.
In addition to the college setting, Catholic Health and McGuire say they realize that compensating trainees is critical.
“One of the barriers that we've seen over the years for CNA trainees is that people can't afford to not work for three to four weeks while they're in training,” O’Connor said. “And so people just aren't pursuing it.”
Almost one-third of CNAs pay out of pocket for their initial training, which can be a barrier to joining the health care field, according to the U.S. Department of Health and Human Services.
The PHI report recommends providers make training accessible to prospective direct care workers.
“It's certainly the right thing to do when you're asking somebody to embark on a new career change, especially when it's an entry-level position,” O’Connor said. “It's very difficult for somebody to go through that training and not be paid, and I think it makes a huge difference in our ability to recruit.”
Free tuition can provide a career ladder to LPNs, RNs
Even after getting certified, CNAs often lack the time and money to earn the degrees and certifications needed to become licensed practical nurses and registered nurses.
This lack of career advancement can eventually cause them to leave the health care field altogether, the PHI report found. Meanwhile, one survey of over 1,300 nurses showed two-thirds would stay with their employer for five or more years if their next degree or certification was paid for.
That’s why the McGuire Group is offering all of their employees free tuition at Trocaire College to get certified as LPNs or RNs. Employees have their student loan forgiven if they complete the certification process and then work at one of their facilities for three years.
Polanski said the program is designed so workers can go to school without reducing their work hours.
“A lot of the challenges are the day-to-day of home life, work life, taking care of kids and getting the opportunity to be able to further their careers,” he said. “We’re trying to answer a lot of those challenges by creating programs like this for people to be successful within our organization.”
Lakkia Lyons is one of 25 McGuire employees currently taking advantage of the free tuition program. She takes LPN certification classes at Trocaire during the week and then works two 12-hour shifts as a CNA on the weekend.
A 46-year-old mother of two, Lyons said she would have pursued becoming an LPN even without the free tuition program, but said the benefit does give her “peace of mind.”
“I don't have to get up and worry about ‘OK, well, I have to put this on a payment plan or put that on the payment plan,” she said. “It does make it a lot easier.”
Catholic Health also offers some tuition assistance to employees at various levels, O’Connor said, particularly if the degree will advance the employee’s career with Catholic Health.
“We're trying to be creative with retention incentives and rewarding people that stay on with us,” she said. “We just always have to stay ahead of the guy down the street who’s offering something a little bit more.”
Organized labor has a role
Nursing homes aren’t the only ones offering educational benefits.
1199 SEIU, the union representing about 75,000 nursing home workers in New York, has operated its Training and Employment Funds for over 50 years.
“I certainly think that the work of our labor and partner employers and our fund certainly helps grow the healthcare workforce,” said the fund’s upstate region director, Don Fiorilli.
The fund’s benefits, made possible through negotiated contracts with facilities, include everything from tuition vouchers to mentorship programs. One benefit allows union members to receive a monthly stipend to offset any reduction in work hours as a result of going to school.
From 2009 to 2019, the fund helped union members earn over 9,000 associate and bachelor degrees, as well as nearly 3,000 graduate degrees.
“I certainly think that providing training and clearly defined career pathways within the healthcare industry can both help retain current healthcare workers and keep people in the industry,” Fiorilli said.
1199 SEIU has also been trying to grow the state’s health care workforce through wage increases. In Western New York, the union has been pushing for a $16.50 minimum wage for CNAs.
Low wages and part-time status keep roughly half of CNAs living in or near poverty, with a median annual income under $30,000, according to the Brookings Institution.
Richard Mollot, executive director of the Long Term Care Community Coalition, a New York City-based group that advocates better nursing home care, said while wages are crucial, so are overall working conditions. Research has shown nursing home workers’ biggest issues with their jobs are often short staffing and an unsafe environment.
“So, yes, money is critically important, especially for people who are being remunerated on the edge of poverty,” he said. “But working conditions are really the biggest complaint that we hear.”
Should the state reimburse for educational benefits?
Offering educational benefits comes at a cost.
McGuire officials said they pay about $15,000 per CNA training program, while splitting the approximately $22,000 LPN tuition and approximately $30,000 RN tuition with Trocaire.
McGuire is a for-profit chain with at least one of its facilities earning multi-million-dollar profits, but other nursing homes may not have the same resources to offer benefits.
Care training is underfunded and often not reimbursed through the Medicaid system, according to the PHI report. Medicaid dollars account for nearly 80% of New York nursing homes’ revenue.
The report recommends states account for training-related costs in their Medicaid reimbursement rates, with specific funding marked for delivery, enforcement and evaluation. States can also create funds to support facilities in creating training programs, the report recommended.
Hanse agreed it will ultimately take a partnership between the state and nursing homes to properly fund training opportunities.
“Recruiting and retaining workers into long term care requires, first and foremost, additional Medicaid funds, and it requires creativity,” he said. “The crisis won't be solved overnight. It's going to take time, it's going to take resources, it's going to take a partnership.”
Gov. Kathy Hochul’s 2023 executive budget proposal said her spending plan would “expand access to healthcare training and education.” However, her office did not respond to a request for more details.
State Sen. Sean Ryan, a Buffalo Democrat and member of the Health Committee, said he didn’t hear much discussion of reimbursing nursing homes for offering educational benefits during the recent budget season.
However, he notes the $220 billion budget passed by lawmakers last month does include up-to-$3,000 retention bonuses for health care workers. Altogether, the budget invests $20 billion in health care, with the goal of growing the health care workforce by 20% over the next five years.
“Should we look at things down the road? Sure. But we shouldn't look past the largest investment that any state has ever made in this industry,” Ryan said. “It's really extraordinary investment this year into the health care industry.”
Polanski, with McGuire, said any help would be appreciated.
“We could easily have development funds set aside that would help us for the upfront costs associated with running these programs,” he said.
As for their goals, Catholic Health officials said they hope the paid CNA training program will increase their retention rates by 5% over last year, while McGuire officials hope more than half of their CNA trainees will eventually become LPNs or RNs.
For Mickles, she appreciated that a majority of her CNA training took place in a classroom setting. She said the college atmosphere had her considering going back to school.
“I feel like I already got my foot in the door and I could just keep going now that I'm used to studying again and taking quizzes and interacting with a teacher again,” she said. “When thinking about colleges, it seems discouraging, but this is a great way to get us back in.”
This story was produced through the New York & Michigan Solutions Journalism Collaborative, a partnership of news organizations and universities dedicated to rigorous and compelling reporting about successful responses to social problems. The group is supported by the Solutions Journalism Network.
The collaborative’s first series, Invisible Army: Caregivers on the Front Lines, focuses on potential solutions to challenges facing caregivers of older adults.