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COVID-19 Intensifies Nursing Home Workforce Challenges

Publication Date
Noelle Denny-Brown, Denise Stone, Burke Hays, and Dayna Gallaghe
October 2020

Link to HTML Version (45 PDF pages)


Both long-stay nursing facilities and short stay post-acute skilled nursing facilities rely on the labor of 1.2 million health care personnel and support workers. Direct care workers such as licensed practical nurses, certified nursing assistants (CNAs), and personal care aides, typically provide most of the hands-on care in nursing homes, including assistance with bathing, dressing, and eating. Recruiting and retaining quality direct care staff has long been a challenge in nursing homes, and these problems have only been amplified by the pandemic. The purpose of this project was to study the impact of the COVID-19 pandemic on nursing homes with respect to these long-standing workforce challenges and to identify new federal, state, and facility-level policies and practices that have been implemented to address these challenges.

We found that nursing homes have grappled with how to retain adequate staffing while rapidly making operational changes to ensure the safety of workers and residents. At the same time, direct care workers are balancing concerns about their own safety, the well-being of the residents they care for, and their financial stability during the pandemic. The pandemic imposed greater demands on nursing home staff, such as new infection-prevention and control measures like screening, testing, and cohorting instituted to minimize transmission and contain the spread of the virus.

To maintain adequate staffing levels, federal and state government agencies, as well as nursing homes, altered their standard policies and practices to mitigate the impact of COVID-19 on the nursing home workforce. Licensing, credentialing, and training requirements were relaxed by federal and state agencies to facilitate the entry of new direct care staff into nursing homes and other health care facilities responding to increased needs. Human resources policies were revised by nursing homes to support workers who may be personally and financially impacted by COVID-19. Wages were increasing by nursing homes, state and local governments through hazard pay or weekly stipends; augmented non-wage benefits such as childcare, housing, transportation assistance, and food supports; and/or provided mental health support to help nursing home staff cope with the anxiety, grief, and fatigue they experience on the job as a result of COVID-19. Several federal initiatives were also designed to address the workforce challenges including: (1) an additional $5 billion in funding through the CARES Act to address critical needs in nursing homes; (2) rapid point-of-care diagnostic testing devices that will be distributed to nursing homes to enhance efforts to keep the virus from entering and spreading throughout nursing homes; and (3) onsite education and support to nursing homes experiencing outbreaks to help reduce transmission of COVID-19 spread among residents and staff.

This report was prepared under contract #HHSP233201500035I between HHS's ASPE/BHDAP and Mathematica. For additional information about this subject, you can visit the BHDAP home page at or contact the ASPE Project Officers, at HHS/ASPE/BHDAP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C., 20201;,,,

DISCLAIMER: The opinions and views expressed in this report are those of the authors. They do not reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. This report was completed and submitted on September 24, 2020.