TEWKSBURY — Frank Romano spends $10,000 a month advertising nursing home jobs at Blaire House of Tewksbury. He offers registered nurses $4,000 signing bonuses and takes over their student loan payments when they come onboard.
Every day he’s on the hunt for workers. Still, more than a third of 180 staff positions are vacant.
In his 50 years in business, Romano has never faced anything like it.
To fill the gaps, he brings in temporary nurses and increases overtime — and has closed more than 20 beds. Limiting admissions significantly curtails revenue, at the same time the facility is shelling out an extra $1.5 million a year to nursing agencies to address chronic staff vacancies. The long hours being asked of existing employees are driving even more out the door.
All six of Romano’s Essex Group Management nursing homes in Massachusetts, in addition to two assisted living facilities and other senior services, are facing similar workforce challenges. He’s raised wages repeatedly, but it hasn’t stopped the bleeding. Requests are coming in nonstop from hospitals seeking placements for elderly patients, but Romano’s centers often can’t take them.
“It’s a death spiral,” he said. “If we don’t get help, we’re going to implode.”
At a time when people have been quitting their jobs at record rates, nursing homes have been dealt a particularly devastating blow. The labor shortage was an issue well before the pandemic, and now it’s ballooned to historic highs, with 6,900 open nursing staff positions in long-term care facilities across the state — a 22 percent vacancy rate, according to the Massachusetts Senior Care Association, an industry trade group. Most of these skilled nursing facilities are heavily dependent on Medicaid reimbursements, which means pay is typically less competitive than in hospitals or other health care facilities. The number of immigrants, many of whom work in nursing homes, has also fallen sharply.
And the problem is only going to intensify as the population ages.
“There is no greater purpose than taking care of our elderly and frail,” said Tara Gregorio, president of the Massachusetts Senior Care Association.
But with wages limited and job demands high, a sense of purpose only goes so far. And the appreciation for health care workers that swelled at the beginning of the pandemic quickly faded. As one nurse told Gregorio in the summer of 2020: “We’ve gone from heroes to zeroes in the snap of a finger.”
Romano got into the nursing home business after coming home from the Vietnam War and deciding he didn’t want to be an IBM salesman for the rest of his life. His father, who was a doctor, had converted several old estates into rest homes, and Romano knew there was a need for elder care. Soon Romano’s wife was working in the IT department, and three of his grown children joined the family business, too.
When the pandemic hit, COVID ravaged senior care facilities, spurring lockdowns and putting serious stress on those caring for sick and isolated residents. At Blaire House of Tewksbury, workers stayed overnight on cots during outbreaks. In 2020, COVID killed 23 residents and one employee; just one resident has died of it since.
The pandemic also exposed staffing shortages that have plagued nursing homes for years. More than half of US facilities had staffing levels below those recommended by experts in 2014, according to a University of California, San Francisco study, and a recent USA Today investigation found significant shortages continue.
At the Blaire House of Tewksbury, which must provide an average of 3.58 hours of care per resident per day to receive full reimbursement from Medicaid, the average number of daily patient care hours in the third quarter was 3.42. This resulted in a shortfall of more than $18,000, which Romano largely attributes to temp agency nurses failing to show up. About 45 percent of nursing facilities in the state don’t meet the 3.58 requirement, according to industry estimates.
Burnout is just as high now, if not higher, than at the peak of the pandemic, health care workers say. At Blaire House, nurses have retired early or jumped ship to hospitals, temporary agencies, and insurance companies, where pay is higher, and, in many cases, pressure is lower. Food service workers, housekeepers, and nursing assistants are going to Amazon, local colleges — pretty much anywhere — to find higher wages.
State-mandated COVID vaccination requirements for all nursing home workers are also driving people away, as are shortages of nursing school teachers and immigration policies that make it difficult to bring in foreign-trained nurses. (Romano contracted 40 registered nurses from the Philippines 14 months ago, all of whom have green cards and passed licensing exams, but none have cleared immigration). Some employees are tired of being required to wear a mask; others who worked throughout the pandemic simply needed a change.
Over the past year, 75 workers have left Blaire House, and some positions have remained vacant for months.
Housekeeping, laundry, and maintenance is down five workers; food service has seven vacancies; and the nursing department needs 10 full-time nurses and 13 nursing assistants. The director of nursing left for a health care company in June, and the position has been vacant ever since.
Some people are quitting with no job lined up, said human resources staffer Julissa Rivera. And filling open jobs is a scramble. Rivera reaches out to applicants who never call back and sets up interviews for people who never show.
“It’s just been a battle,” she said.
The director of a residential care facility in the Worcester area owned by another company, who asked not to be identified by name, said in an interview that job applicants have an “entitlement mentality” that didn’t exist 10 years ago: They don’t want to work hard, don’t want to get vaccinated, and refuse to give up their cellphones while they’re on duty. Some new college grads are going straight to temporary or travel nursing agencies because of the flexibility they provide.
This inability to fill nursing home jobs has a distressing ripple effect. About 62 percent of the state’s skilled nursing facilities had to freeze new admissions in October due to staffing shortages, according to industry data, which means hospital patients ready to be discharged can spend weeks or months in the hospital waiting for space at a nursing home to open up. And with some hospitals at capacity and facing worker shortages of their own, this creates a serious backlog. Admitted patients at UMass Memorial Medical Center in Worcester, for example, are waiting an average of 17 hours in the emergency department for a bed.
The mass exodus from the workforce has stunned nursing home administrators.
“It’s like a tsunami,” said Damian Dell’Anno, chief executive of Next Step Healthcare, which is shutting several of its nursing homes in Massachusetts due to rising costs, insufficient state funding, and temp agencies luring nurses away with higher pay.
And it’s only expected to get worse. With nearly one-third of registered nurses in the United States saying they’re likely to leave direct patient care in the next year, according to a McKinsey & Co. survey, the health care system could have a shortfall of as many as 450,000 nurses within the next three years.
“If we’re at the breaking point right now, what is going to happen in 2025?,” Romano said.
In Massachusetts, the shrinking workforce is being compounded by a declining birth rate, aging population, a drop in international immigration, and people leaving the state at the fourth-highest rate in the country last year, according to the Massachusetts Taxpayers Association.
In Tewksbury, registered nurse Maura Ratchford remembers a time when in-service training was a pleasant experience, with refreshers about policies conducted over lunch. Now, Ratchford has to pull people aside at the nurses’ station and go over procedures on the fly.
“They can’t leave the floor that long,” she said. “They’re lucky to eat.”
Ratchford, who also helps out the acting director of nursing — who is sometimes called in to cover weekend shifts — only recently returned to Blaire House of Tewksbury. For seven months, Ratchford was filling in part time as the nursing director at Blaire House of Worcester, which has been piecing together temporary directors for more than a year.
“There’s a lot of robbing Peter to pay Paul,” Ratchford said.
Plant manager Rafael Torres, who oversees the housekeeping, maintenance, and laundry staffs in Tewksbury, shut down the laundry room at night and pitches in to assist his overwhelmed workers. Last winter, Torres did all the snow removal himself, putting in 16-hour days and telling his three kids not to wait up.
An assistant left a year and a half ago to drive for Amazon, and the man Torres hired to replace him quit after a few months. Finally, in July, Torres hired a new assistant, at $19 an hour, instead of having two at $13.50 each: “I’m hoping he stays through the snow at least,” he said.
To make up for the shortfall of nurses, long-term care facilities have been relying heavily on temporary nursing agencies, whose numbers skyrocketed during the pandemic, from 43 in 2020 to 205 in 2022, according to Massachusetts Department of Public Health estimates. But these agencies are also adding to the problem, nursing home executives say, luring full-time nurses away with higher pay and greater flexibility. Last year, the state raised the cap on what agencies can charge nursing homes, and, in turn, pay nurses, by 25 percent on average.
At Blaire House, which brings in twice as many temps as it did a year ago, staff RNs making $34 an hour could be working side by side with an agency nurse making $50 to $55 an hour, who, unlike employees, can choose not to work nights or weekends. This inequity can cause tension, said Lilybeth Solis, the 24-year-old executive director in Tewksbury, who took over a year ago, with the help of a mentor. It’s her first job after graduating from college.
At Next Step Healthcare, one staff nurse called in sick and tried to cover her own shift by working through an agency in order to make $10-plus more an hour, Dell’Anno said.
IntelyCare, a temporary nursing agency in Quincy, considers itself a “strategic partner” with long-term care facilities that can give staffers more flexibility and therefore help with retention, said president John Shagoury. And when the cost of benefits and vacation pay are factored in, according to a report commissioned by the company, the hourly cost of full-time nurses is roughly the same amount facilities pay for temporary nurses.
Romano dismisses the finding as “hogwash.”
The state has taken steps to alleviate the nursing home workforce crisis, recently designating $165 million for wages and deploying state-funded nursing teams to senior care facilities.
Along with funding, what’s really needed, nursing home administrators and advocates say, is structural change: more instructors to increase capacities at nursing schools; career ladders that pay for and support workers attending nursing programs; immigration policies that speed up the process of licensing foreign-trained nurses.
At Essex Group Management, the Romano family itself has been buffeted by the staffing crisis. A son who served as executive director in Milford recently resigned, citing the stress of dealing with the labor shortage. Romano’s wife, who is retired, has been helping another son at the Milford assisted living facility, volunteering three days a week in the kitchen and helping with admissions and hiring.
Romano, 80, works full time, and tries to make site visits every Saturday. He takes pride in his work, which he compares to running a country inn — right down to the garnishes on guests’ dinner plates.
Romano likes to joke with his employees and laughs easily, despite the stress he’s under. But his company is “hemorrhaging money,” he said. The only time in his life he can remember being more difficult was the year he spent fighting in Vietnam, when he never knew which day could be his last.
He has a similar feeling about his business. If things continue as they are now, he said: “We’re dead in the water.”
Katie Johnston can be reached at firstname.lastname@example.org. Follow her on Twitter @ktkjohnston.