Recent calls for nursing home reform and actions from regulators and lawmakers have drawn renewed attention to the role that certified nursing assistants currently play in care centers – and how their role could evolve.
Some skilled nursing operators have responded to calls for expanding the CNA role by creating more specialized positions, and legislatures in some states are supporting these moves.
Expanding this role also means aligning more closely with value-based care, industry leaders say, as the pandemic and staffing crisis has forced SNFs to think about the division of labor from the top-down.
“Ninety percent of the care provided in nursing homes is given by CNAs. That means that is one of the most significant roles in a care center,” Lori Porter, co-founder and CEO for the National Association of Health Care Assistants (NAHCA), told Skilled Nursing News. “I do think that if we expanded the role to be more like the other settings where CNAs are utilized, we would see a greater number of people embracing that career opportunity.”
NAHCA represents more than 26,000 caregivers in 500-plus nursing homes across 49 states.
The recently released National Academies of Sciences, Engineering, and Medicine (NASEM) report discussed role expansion as a crucial step toward empowerment among CNAs, as demand for the position is increasing. Simultaneously, operators are having a hard time recruiting and retaining such workers, and now they face added pressure as CMS recently announced the expiration of temporary nurse aide waivers.
About 420,000 nursing home workers have left the industry since the start of the pandemic, according to the U.S. Bureau of Labor Statistics.
In addition to role expansion, NASEM authors call for career advancement opportunities and peer mentoring, free entry-level training and continuing education, coverage of time for completing education and training programs, and new models of care that include the CNA as part of an interdisciplinary team.
“A few states have advanced CNA positions, and I think that we’ll see more of that, really trying to create career paths for those who wish to advance,” said Katie Smith Sloan, president and CEO of LeadingAge. “We need to professionalize that [role] by paying them well, by giving them career opportunities … elevate the role that they play.”
CNA specializations
Currently, CNA training is “pretty generic,” Porter said. The organization is working toward a CNA career that offers workers multiple pathways to advance and gain education.
Some of those specializations involve medtech training, or education to become a certified medication aide (CMA). These specialized CNAs have the authorization to do “med pass,” or hand out medications to residents.
“Nurses look at pushing the pill cart, as they call it, as a punishment. A CNA who becomes a CMA pushes that cart like it’s the American flag,” added Porter.
Another specialization leans into family communication, with a CNA becoming a liaison between the nursing home and the resident’s family.
“CNAs are the families’ experts,” said Porter. “Yet, facilities never want CNAs talking to families … trust has been a big issue, a big talking point throughout the pandemic. This is one of those reasons, one of those things that chips away from trust. Don’t talk to the surveyors. Don’t talk to the ombudsmen. Don’t talk to the families. Well, why not? They’re where we get our recognition.”
Every role at Tabitha Health Senior Care has changed because of the pandemic, according to Tabitha President and CEO Christie Hinrichs. CNAs, for one, took on the role of connector and companion when families weren’t able to enter the building.
Tabitha, a nonprofit operator in Nebraska, added another position called a personal care assistant to the roster. This position consists of taking responsibility for time consuming activities that don’t require clinical certification.
“There simply aren’t enough bodies for us to ever have the same kind of workforce that we’ve always had,” said Hinrichs.
Tabitha’s leaders are reviewing every job description and asking themselves what the demands of each position are and whether the role truly requires a worker with certification.
Specializations and state legislation
Recent Florida legislation expanded positions that count toward staffing minimum requirements – the personal care assistant would be a prime example.
The state currently requires 3.6 hours of direct care per resident per day, but the Florida legislature in March passed a bill that reduced the minimum hours of care provided by certified nursing assistants, from 2.5 to 2.0.
The new law allows other health care professionals, such as mental health workers and physical therapists, to help meet the required hours.
The bill alleviates some of the pressures related to hiring CNAs when the pickings are slim but without sacrificing patient care, according to Florida Health Care Association (FHCA) Director of Communications Kristen Knapp.
Allison Salopeck, president and CEO of Jennings Center for Older Adults in Ohio, said she’d love to see such legislation in her state.
“I love that in Florida, and we need to be louder about that,” said Salopeck. “The background and the skill level of the people that are serving the residents are not all nurses and nursing assistants.”
Nursing homes have shifted roles and created new positions out of “pure survival,” Salopeck added; she hopes state and federal entities recognize and accommodate the industry’s ability to adapt.
Another specialization can be achieved through a course offered by NAHCA, to become a geriatric care specialist, which more than 10,000 members paid to participate in. Porter said she’d like to see a career pathway that links CNAs to the infection control specialist role too.
Other experts in the sector also believe CNAs have more to offer than they have been given a chance to contribute.
“When this job was initially conceived, it was relatively narrow, and I think a lot of CNAs around the country can and want to do so much more,” said David Grabowski, a professor at Harvard University and a member of NASEM’s committee focused on nursing homes. “Nobody knows the resident better than these individuals. They could be that liaison with the family.”
Empowering CNAs also means allowing them to work at the top of their license, added Grabowski, and potentially having other unlicensed positions created to free up CNAs to provide services only they can provide.
Operational blueprints and the enclave model
One staffing pilot program gaining traction in the nursing home space is the Enclave Principle model, Porter said. In this approach, a CNA department is created, with individuals in that department reporting to the full-time director of CNAs.
That department head would then report clinically to the director of nursing (DON) and operationally to the administrator. NAHCA is working to launch the model on a national scale, Porter said, with more announcements on the way in a matter of weeks.
“The enclave [model] has been around, it’s no secret. This will just be our first major player to really make national news with it,” she added. NAHCA has rolled out the model in Michigan, Arizona and Missouri so far.
The model would expand the CNA role and empower those in the position, especially if a facility is experiencing high turnover in other leadership positions such as administrators and DONs.
“We have to stop beating on leadership to be better and empower people to be great themselves, no matter who the leader is. That’s what the enclave model does, creates a distinct CNA department run by CNAs,” said Porter.
Such a model adds to career pathways for a CNA and encourages higher education without boxing a CNA into RN or LPN training.
Historically, the nursing home workforce has been very hierarchical, Grabowski said. There was a lot of discussion from NASEM committee members around how to make the CNA role a long-term position..
“There hasn’t been a lot of investment or empowerment of direct care workers. I think the idea here was to try to reimagine not just CNAs but all these roles,” he added. “Let’s not make this a job somebody does as a last resort, but rather something somebody invests in and can use … as a career ladder towards a broader set of positions.”
Companies featured in this article:
FHCA, Jennings, Jennings Center for Older Adults, LeadingAge, NAHCA, NASEM, Tabitha Health Senior Care
