Written by:
3/4/2010 12:10 PM 

At the heart of any long-term care facility is its caregiving staff. Nothing else matters as much in determining the quality of a resident’s stay — not the food, not the laundry, not the environment, not even the programming. Long-term care nursing is unique in that it attends not only to the physical well-being of the patient (or resident), but pays as much attention to the person’s psychological and spiritual well-being. So, if you understand nothing else about the facility where you are placing your loved one, you should try to understand its staffing situation.

For starters, staffing is the most difficult issue that long-term care managers face. Hands-on nursing home/assisted living staff — usually called nursing assistants, but going by other titles as well - carry a heavy burden in caring for people who are at their most helpless and vulnerable. They also happen to be among the poorest paid workers in the United States, many making barely above minimum wage. This is for three reasons: newcomers are hired having no particular experience with the work; nursing assistants also tend to turn over, i.e. leave their positions, rapidly — 70-100% annual turnover is not uncommon — mainly because of the poor pay and tough challenges. The final reason pay is so poor is that long-term care financing is a mess. This large issue can and will be elaborated upon elsewhere, but for now it suffices to say that nursing homes’ heavy reliance on public financing — from Medicaid, a proven money-loser in most states, and Medicare, growing increasingly stingy — places them in perpetual financial distress. (Relying on private pay at personal outlays of upwards of $40,000 a year, as most assisted living does, is no godsend either.) Although long-term care remains largely a for-profit enterprise, conscientious providers don’t expect to profit much because of the fine line between cost-efficiency and damaging quality of care.

How do you relate staffing to quality of care? Government agencies and other organizations over the years have sought to develop a ratio of nursing assistance hours provided per resident per day — a generalized ideal of about 3.2 hours. Facilities in my experience have been more comfortable with a straight staffer-per-resident ratio — a preferred daytime ratio of, say, 1 nursing assistant to 6 or 8 residents, a nighttime ratio of up to 1 to 12. Needless to say, these can pose heavy burdens on staff, depending on residents’ needs, because the smaller the ratio, the better.

One way staff has tried to make up for these pressures is to organize their work as one would a manufacturing or military enterprise — grouping residents for baths, showers and meals at fixed times of day, and running them through a sort of production line process. It’s the sort of thing that has given nursing homes a bad name, and the “culture change” movement that you may hear about now and then has as its focus a move toward more individualized care. As desirable as this is, it only intensifies the pressure on staffing quantity and competence.

The ideal answer under today’s circumstances is the staffer who accepts the burdens, the low pay and the lack of social recognition and provides warm, supportive care anyway. These people do exist, often remaining on the job for many years and even decades. Indeed, if one were to rank America’s citizens on the basis of human value rather than entertainment value, these people would rank at or near the top. You should feel blessed should you ever encounter such people.

But you shouldn’t depend on that happening. More likely you will encounter people barely making ends meet, possibly doing this as a second or even third job, and very often coming from different countries and cultures and experiencing significant language barriers. Not ideal, but that’s just the way it is in long-term care. On your visits to facilities, pay close attention to what nursing assistants do and how they comport themselves — but do so with an open mind and a supportive attitude. See if there is anything you can do to make their work more effective. In so doing, you can be certain that you’re working in the wheelhouse of long-term care quality.

Download the SNAPforSeniors checklists for other points to consider when choosing a facility:

Skilled Nursing Tour Checklist
Skilled Nursing Administrative Checklist

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Location: Blogs Caregiving by Richard Peck

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