Staffing During the COVID-19 Pandemic: A Guide for Nursing Home Leaders

This resource guide from the Project ECHO and IHI Teams was written by and for directors of nursing, administrators, and other nursing home leaders. It outlines steps to reduce or eliminate urgent staff shortages, particularly shortages of direct care workers.

The actual order to these steps may vary depending on each organization’s situation or experience, and nursing homes may have gone through many of these steps already. However, your organization may benefit from at least one or two of the recommendations here.

Each category includes recommendations with an estimated amount of time or effort (this may vary, depending on other programs or services that are already in place):

Key
= easy or relatively short amount of time to implement	= easy / moderate amount of time to implement
= moderate time to implement	= longer amount of time to implement

Required COVID-19 Emergency Staffing Plans outline processes for accessing contingency staff if the need arises. The information below contains additional practical approaches and resources that may be considered to support or enhance your current Plan.

Assess Resident Population and Staffing Model

Identify staffing needs with a review of your current workforce and resident population during the COVID-19 pandemic. Below are two practical approaches.

Conduct a brief review of census, occupancy, and resident location.

Think about where you locate residents within the center.
Align current staffing model with occupancy and resident needs to determine efficiency of staff assignments.
If staff is represented by a collective bargaining agreement (CBA), meet with CBA representatives to review critical needs and labor management input. Review communication processes and potential need to cross-train staff.
Consider flexible scheduling, self-scheduling, change of shift hours, change of shift start times, change of days worked, as well as accommodation of staff’s family needs and life situation (e.g., virtual school needs, day care needs, transportation availability).
Refer to Use of Current Nursing Home Staff Quick Tip (PDF) for further recommendations.

Review care schedules, nursing processes, and resident acuity to determine essential and non-essential tasks during the pandemic.

Include a review of all medications and treatments with clinicians and consulting pharmacist to determine if any can be discontinued. This may reduce nursing staff time, allowing for workflow flexibility during the pandemic.
Include a review of other clinical considerations, such as individuals who may qualify for hospice. Work with your hospice partner to provide services related to direct care needs.

Use Current Nursing Home Staff

Identify current staff who could serve in alternate roles during the COVID-19 pandemic. Below are approaches to consider for how to use and support staff during the pandemic.

Determine strategies for the most efficient and effective use of staff resources.

Determine non-direct care tasks and procedures that may be assigned to non-nursing staff. These tasks may be performed by other trained individuals within your organization.
- Review the Use of Current Nursing Home Staff Quick Tip (PDF)
Identify additional professional staff who may assist with care within their scope of practice. For example:
- Occupational therapists and certified occupational therapy assistants can provide activities of daily living (ADL) care. Physical therapists and physical therapy assistants can assist with some direct care functions such as transfers, using the toilet, etc.
- Licensed physical therapists can conduct accident investigations, implement care plan updates, and lead teams in fall/injury prevention.
- Encourage department heads to have a visible presence on the units, assisting with support functions, coordinating staff, and completing their own assignments while on the floor.
- Use medication assistants/technicians to support licensed nursing in states that permit medication assistants/technicians. Check state requirements.

“My team and I worked together to identify tasks that were not “hands-on care” for both CNAs and licensed nurses. We wrote them down and compiled our lists. We found many tasks that could be completed by other staff. We created a new job for which we were able to recruit individuals from local businesses, who help on the nursing units. This has truly helped my nursing team.”

- Director of Nursing, SC

Optimize External Staffing Resources

Organizations may need to increase access to external staff during the pandemic. Below are practical approaches to consider.

Review external staffing resources available.

Contact your provider association(s) for support and assistance related to staffing resources.
Contact your state’s Department of Public Health for crisis staffing, including National Guard and state response (strike) teams if available.
Contact your state’s Department of Public Health or your city/town’s local board of health or health department about candidates who have asked to work at vaccination clinics but were turned away for lack of open positions. Some of those individuals might consider nursing home positions.
Contact your local Medical Reserve Corps (MRC) unit for additional staffing assistance, if available.
Access ConnectToCareJobs.com.
Work with staffing agencies to identify non-traditional options, including longer-term contracts and block-booking of consistent staff. Consider staff without prior nursing home experience (but with orientation and mentoring). Refer to Use of External Staffing Quick Tip (PDF) for further recommendations.
Collaborate with partners—including contract therapy providers, home care, hospice, acute care, ambulatory care clinics, and others—for staffing resource availability. Refer to Recruitment Quick Tip (PDF) for additional partner collaboration.
Consider working with peer organizations, such as other health systems or nursing centers, to develop a shared staff program (following careful screening and other guidelines to prevent spread of COVID-19).

Leverage Non-Certified or Non-Licensed Staff

Public Health Emergency (PHE) Waiver 1135 may allow facilities to employ nursing staff who are not certified or licensed within their state. Access the State-by-State PHE Resource Links Tool (PDF) to learn more about your state’s requirements. Below are strategies to consider in addition to your Emergency Staffing Plan.

Determine options for use of non-certified or non-licensed staff in your organization.

Identify current staff who could be cross-trained for direct care or non-direct care roles.
Work with local Chamber of Commerce or Small Business Association to identify displaced or furloughed workers as an option to supplement ancillary staff.
Access resources targeted at the mature workforce for support positions and potential non-certified direct caregiver roles. Refer to Recruitment Quick Tip (PDF) for further recommendations.
Network with family members or care partners who may consider a role as a non-certified direct caregiver within your organization.
Provide required training and competency evaluation, in accordance with state guidance. Provider association training resources are in the Additional Resources section.

“We hired 6 individuals for non-certified caregiver roles a few months back. We worked with our provider association for training modules and resources to support the new staff members, following waiver and state guidelines. Three of the individuals want to become CNAs and they have been accepted into a local program.”

– Administrator, MN

Strengthen Partnerships

Collaborate with partners and peers to review potential staffing solutions during the COVID-19 pandemic.

Identify your organization’s partners for collaboration on staffing resources that are available.

Identify and reach out to partners to discuss staffing needs and opportunities for creative collaboration. There are a variety of health care partners that have redesigned how they work with direct care staff (or are in the process of doing so). Refer to Recruitment Quip Tip (PDF) for examples of potential partners.
The Partnership Quick Tip (PDF) provides additional practical recommendations on how to build and sustain local partnerships.

Enhance Recruitment Strategies

Recruitment has become increasingly challenging during the pandemic.

Consider the following ways to implement recruitment strategies.

Engage all staff.
Review and refresh recruitment messaging on job boards, advertisements, website and social media channels.
Enhance the use of social media platforms to increase exposure.
Contact local partners for creative collaboration, including local colleges, universities, and technical high schools.
The Recruitment Quick Tip (PDF) and Social Media Quick Tip (PDF) provide additional practical recommendations.

“Recruitment has been a struggle for our campus. We decided to extend our recruitment efforts to a full team approach, bringing together staff from various departments for their input. The team came up with three quick ideas on where to find candidates. They were very creative and took on most of the tasks. We are starting to see some traction on applications. One thing I learned through this process, my team has great ideas and wanted to help.”

– Director of Nursing, TX

Optimize Technology

Technology may play a key role in efficiency and effectiveness in both recruitment and direct care processes.

Assess current technology platforms used for recruitment and direct care processes. Examples may include:
- Electronic health record (EHR): Work with vendor to optimize EHR. The Leveraging Technology Quick Tip (PDF) provides additional recommendations.
- Application process: Review current employee application process for ease of use and quick response. Refer to Recruitment Quick Tip (PDF) for recommendations.

Additional Resources

AHRQ ECHO National Nursing Home COVID-19 Action Network

Nursing Home COVID-19 Network

Workforce Solutions – National

Training for Non-Certified Caregivers

Centers for Medicare and Medicaid Services (COVID-19 Resources)

The Centers for Disease Control and Prevention (COVID-19 Resources)

The Institute for Healthcare Improvement developed this resource in collaboration with Project ECHO at the University of New Mexico Health Science Center in support of the AHRQ ECHO National Nursing Home COVID-19 Action Network.

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