Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Staffing


Most concerns about quality related to staffing issues, particularly that fact the providers may not have sufficient staff to care for their residents due to problems with recruitment and retention.

  • The basic quality problem is that the staff do not know and do not recognize signs of need. The state does criminal background checks. The really bad things we find are not system problems. Staff incompetence and neglect are the problems. The best nurse managers go to other settings to work, even though they like the business. They don't' like working with untrained staff who are not contributing to the health and well-being of the residents.

  • The biggest quality problem is the lack of training for staff in residential care facilities. Sometimes I'm appalled at the lack of knowledge of basic common sense things. It makes me wonder if they have received any training.

  • There are major issues with the workforce. Huge turnover due to low pay, no benefits. Managers don't know how to manage people with low skills. It will get worse with less money. Housing is relatively cheap now with low mortgage rates, but the money squeeze on services will lead to staff cuts and quality will become more of an issue.

  • Recruitment and retention is a major issue. Direct care worker turnover rates are very high. They work in a traditionally undervalued field for low pay and do not have benefits or paid time off. Some solutions are simply monetary, but there is a need to identify ways to make care giving a more attractive profession.

There was consensus that lack of pay and benefits, lack of a career ladder, poor management and oversight, and in some cases, an unpleasant work environment were responsible for many of the staffing problems. When asked whether the state should require staff to resident ratios, the response was ambivalent:

  • Mandatory staff to resident ratios can help to assure adequate staff, but it's so hard to find staff--some facilities may just not be able to stay within regulatory requirements. For safety reasons and prevention of potential abuse--I'd rather see tighter regulations, but I understand the other side.

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