Susie Little Light spends about four hours every day commuting to and from her place of work. That kind of travel time would be a deal-breaker for most, but in rural Montana, it’s not unusual for essential workers to make substantial daily commutes.
Little Light is the director of human resources at Awe Kualawaache Care Center in Crow Agency, one of two nursing homes located on Montana reservations. Her work is largely focused on one of the most challenging and important roles in health care at the moment — recruitment and retention.
Director of Human Resources Susie Little Light is seen outside the Awe Kualawaache Care Center in Crow Agency on Tuesday.
With demand for health care workers at an all-time high, Montana’s long-term care administrators have struggled to compete with urban hospitals for qualified health care providers in the years since the pandemic. In 2022, 11 rural nursing homes in the state closed permanently along with more than 850 long-term care beds largely due to the workforce shortage.
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The remoteness of the Crow care center has always created a barrier to hiring staff. Even Little Light was hesitant to take the job when she got the offer a year ago, saying it would take time away from her family. Little Light has six children, and if it wasn’t for her strong support system and her husband, she wouldn’t be able to work for the facility.
It took a year-and-a-half to hire a director of nursing, but Little Light has finally managed to recruit an experienced registered nurse from Wolf Point to work at the 40-bed facility. He will be living in Billings, about an hour drive from Crow Agency.
The front of the Awe Kualawaache Care Center in Crow Agency is photographed on Tuesday, Sept. 26.
Leadership at the facility worked to increase starting wages to a competitive rate, but still, RNs are hard to come by.
That’s why Little Light has serious concerns about the looming staffing mandates the Biden administration proposed in early September that would create a federal floor for staffing levels in long-term care facilities around the country.
The mandate would be the first of its kind and comes after nursing home residents were the first fatalities of the COVID-19 pandemic, according to Susan Reinhard, senior vice president of AARP Public Policy Institute.
“COVID-19 tested our long-term care systems, and they failed,” Reinhard said.
Numerous studies have shown that quality of care and safety increases with staffing levels in nursing homes and in hospitals, but three of Montana’s four congressmen are pushing back on mandated staffing for long-term care in Montana.
In a bipartisan letter to the CMS administrator, Sen. Steve Daines and Sen. Jon Tester expressed concerns that a “one-size-fits-all” approach to long-term care will further hinder rural access to essential services for seniors and disabled people.
Rep. Matt Rosendale also drafted a letter, calling for CMS leadership to resist the mandate.
When a facility can’t meet the new staffing requirements, nursing home administrators will have to limit the number of residents they can take or close down altogether, said Rose Hughes, executive director for the Montana Health Care Association.
Rose Hughes with the Montana Healthcare Association.
Nursing homes across the state are already limiting the number of Medicaid patients they will accept due to inadequate reimbursement from the State of Montana. Instead, they're favoring private payers. As a result, more seniors are experiencing homelessness in Montana than ever before or they're relying on family to provide caregiving support.
“You can’t mandate staffing without addressing the workforce,” Hughes said. “There are shortages up and down the line.”
The new requirements
The new standard outlined in the proposal would require an RN onsite 24-hours a day, posing a big problem for a lot of small facilities, said Marie Weasel, the administrator of the Crow care center.
A federally funded tool called Care Compare compiles data from nursing home inspection reports to generate a star-rating for every nursing home in the country. Care Compare draws from three data sources to generate an overall rating — health inspections, staffing and quality measures.
The Crow care center has an overall one-star rating, performing the worst under staffing. The center’s most recent state inspection flagged staffing deficiencies when an RN was not onsite for the required 8-hours a day, Weasel said.
Currently, CMS does not specify the types of staff that must be onsite, although they do require an RN for at least 8-hours a day. Other staffing guidance is vague, asking that administrators staff sufficiently to meet the needs of the residents.
“That part is tough enough. I can’t even imagine what we’ll have to do to have an RN 24-hours a day,” Weasel said, adding that the lack of childcare in the area contributes to their staffing woes as workers call out on days when their care plans fall through.
A hallway at Awe Kualawaache Care Center in Crow Agency is photographed on Tuesday, Sept. 26.
As it stands, nearly every nursing home in the country, 94%, are not currently meeting the new staffing requirements, according to an analysis by the American Healthcare Foundation.
It's estimated that the federal staffing mandate would require 100,000 more nurses and CNAs to enter the workforce full-time. And if nursing homes are unable to increase staffing to meet the requirements, more than 208,000 nursing home residents could be displaced.
With only two nursing homes located on Montana reservations, one in Crow Agency and one in Browning, the facility provides important access to culturally safe health care for Native Americans in the state.
While the center welcomes all residents who need care, preference is given to those of Native American descent.
“We have traditions and cultures, different ways of thinking about things, and it affects how we do things here,” Little Light said.
Little Light also strives to hire Native Americans to work at the care center. Shared cultural knowledge and experiences helps breakdown barriers that exist when people of different cultures access Western health care systems, according to previous reporting by the Missoulian.
Gwen Heser, a registered nurse is seen outside the Awe Kualawaache Care Center in Crow Agency on Tuesday. Heser says the value of providing health care to Native Americans near their homes is that it keeps the patients in touch with cultural traditions.
Gwen Heser, an RN who worked at the facility through COVID, is non-Native, and has seen firsthand how some patients respond differently when they receive care in their native Apsáalooke language.
“There are some people who may not take medications from me as much, but a nurse who can speak to them in their own language they just have a better connection. Just because of that connection it can improve the quality of care,” Heser said.
Having a long-term care facility on the reservation also keeps residents participating in cultural traditions, Heser said, including the Crow Nation buffalo hunt. Nursing staff members facilitate transportation, which is provided by the tribe, and support the residents in the community.
In order to hire locally, Little Light started a program where certified nursing assistants can get their training and certification while working at the care center, but turnover continues to be high.
Across the state, long-term care facilities struggle to retain their employees. The nursing staff turnover rate in Montana is 63.2%, higher than the national average of 53.9%.
The gaps that are left behind contribute to persistent problems in delivering care, according to the most recent AARP Scorecard.
A balancing act
For years, Montana nursing home administrators have used an array of different provider types to deliver care to residents, said Hughes with the Montana Healthcare Association. Licensed practical nurses (LPN), for example, are extremely important to long-term care operations.
LPNs provide basic clinical care and are responsible for keeping patients comfortable. They also assist in passing medications, a job that could take an RN all day to do. LPNs aren’t mentioned in the federal proposal for staffing mandates, and with the increase in RNs, these roles would become obsolete.
Director of Rehabilitation and Physical Therapy Assistant Michael Farotto works with a resident at the Awe Kualawaache Care Center in Crow Agency on Tuesday.
Nurse aides or CNAs provide support for activities of daily living such as getting dressed, toileting and washing. This provider type typically spends the most time with residents.
Staffing levels of each provider type also vary by nursing home characteristics.
“It matters how your facility is laid out, how big it is, how many residents there are, the acuity level of the patients is huge. Staffing is a real balancing act and I think we need to let them do it,” Hughes said. “We use all sorts of layers and all the people we can get to get the job done.”
And Hughes isn’t convinced that the increased staffing will result in enhanced care.
One study commissioned by CMS to identify ideal staffing levels, found there is no staffing level that assures quality care.
Proponents
Representatives from AARP and Montana’s Nurse Association have spoken out as strong proponents for established staffing requirements, saying that it would create a safer workplace for employees and patients.
Last year, CMS issued a survey to long-term care leaders across the country, seeking feedback on proposed rules.
Excellence awards hang on the wall at the Awe Kualawaache Care Center in Crow Agency on Tuesday, Sept. 26.
In a June 2022 response from AARP, David Certner, legislative counsel and legislative policy director, encouraged CMS to hold nursing homes accountable for staffing, saying that AARP has been disappointed with the department’s inaction in the past.
“Nursing homes lead with ‘nursing’ in their nomenclature because they depend on RNs and nursing care teams to deliver safe care to their residents. Without an adequate nursing staff, including licensed practical nurses, and certified nursing assistants led by a registered professional nurse around the clock, safe care is not possible,” Certner wrote.
Vicky Byrd, CEO of the Montana Nurses Association, implores state and federal leadership to include frontline nurses in the conversations about mandated staffing.
Byrd deals mostly in hospital level nursing, but supports the CMS proposal, saying that health systems should be held accountable, putting patients over profits.
The nursing profession needs greater investment across the board, from expanding faculty to teach at universities to developing high school programs to get kids interested in health care to pay and benefits, Byrd said.
“Knowing that it’s not the magic wand, why not try some staffing ratios and then re-evaluate. When we don’t invest in nurses who are at the table, how can we expect young people to be interested in the profession,” Byrd said.
