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Quality nursing home care requires quality jobs

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The United States is getting older. By 2030 — for the first time in this country’s history — there will be as many Americans aged 65 or older as there are under 18.

Massachusetts is aging even more quickly. By 2030, the group comprising people aged 85 and older is projected to grow by 21 percent, while those aged 75-84 will grow a staggering 70 percent.

This unprecedented boom means more Americans will require some assistance to help them maintain their quality of life. Who will provide that care, and in what setting?

For some people, hiring home care aides is sufficient, particularly if family members are nearby to help out. But the number of family caregivers — typically, adults between the ages of 45 and 64 — is shrinking in comparison to the surge in older Americans. For elders who do not have family nearby and cannot remain safely at home without round-the-clock support, nursing homes remain an important option for long-term care.

Unfortunately, Massachusetts nursing homes are not prepared to meet the growing need for long-term services and supports — they cannot recruit and retain sufficient numbers of certified nursing assistants, the front-line workers who provide the vast majority of hands-on care. Across the state, one in 10 CNA positions remain vacant, and in the rural Western part of the state that number is significantly higher.


Why is it so tough to fill these jobs? Because CNAs do physically demanding, emotionally draining work for very little pay. Their wages are directly tied to the number of residents whose care is paid for by MassHealth — about 70 percent of the nursing home population. But Medicaid reimbursements have been flat for 8 years, meaning wages have remained stagnant while the cost of living has increased. In reality, that translates into a pay cut.


Being a CNA takes skill, compassion, and commitment. They help residents with a variety of intimate tasks, from showering and dressing to using the bathroom. They lift and carry individuals from beds to wheelchairs, turn people in their beds, catch them before they fall. CNAs also provide emotional support for residents who may be lonely, depressed, or confused.

In Massachusetts, the starting pay is $11 per hour — not even a living wage. The meager pay doesn’t match the intensity of the work, and CNAs vote with their feet: 30 percent leave within the first year of employment, either for a similar but better paying job in a hospital, or for a less taxing job in retail or food service. This constant turnover is costly for employers and undermines the continuity and quality of care for residents.

To ensure quality care in Massachusetts’s 400 nursing facilities, the state needs to invest in quality jobs for CNAs. Higher-paying CNA jobs — along with better training, on-the-job support, and opportunities to learn and grow — would attract more workers to nursing homes, help reduce the industry’s chronically high turnover rates, and enable CNAs to provide care to the best of their abilities.

Massachusetts has taken bold steps toward improving nursing home care in the past. About 15 years ago, in response to high turnover and vacancies, the Nursing Home Quality Initiative raised CNA wages and established the Extended Care Career Ladder Initiative (ECCLI), an advanced-training program that helped make caregiving a viable career choice in Massachusetts.


The initiative got results: An independent evaluation showed that facilities offering meaningful advancement opportunities to CNAs were more able to attract potential new employees, and that CNAs provided better care for residents when they knew they had the chance to move forward in their careers.

The triumph of ECCLI — which is now used as a national model for nursing home career paths — and the Nursing Home Quality Initiative shows that Massachusetts has, in the past, developed innovative ways of improving nursing home jobs. Unfortunately, much of those gains have been undercut in recent years because of frozen Medicaid reimbursement rates.

We think it’s long past time for Massachusetts to make another big investment in its nursing home workforce. The House FY ’17 budget contains an $35.5 million for nursing homes, but to truly make a significant impact, that figure needs to be higher — around $90 million, targeted specifically to improving compensation and support for front-line workers. It is up to the legislature to allocate these funds — and ensure that nursing homes are held accountable for providing quality, well-paying jobs to their 40,000 front-line caregivers.

Jodi M. Sturgeon is the president of PHI, a national nonprofit dedicated to improving the quality of care for elders and people with disabilities through better jobs for direct-care workers. PHI’s most recent report is “Raise the Floor: Poor Quality Jobs Undermine Care in America’s Nursing Homes.”