by Anthony Schaffhauser
December 2024
Special thanks to Anna Mowry and the LeadingAge team for their contributions to this article.
Note to readers: This research and analysis was completed during the summer of 2024. Since then, there is increased uncertainty on the future implementation of these regulations.
The Centers for Medicare & Medicaid Services (CMS) at the U.S. Department of Health and Human Services published minimum staffing rules for nursing homes on May 10, 2024 to be implemented in stages through spring 2029. These rules pose an additional workforce challenge to Minnesota's nursing homes, which have seen declines in the number of facilities and staff, and as a result have been able to serve fewer residents since the COVID-19 pandemic. With unalterable demographic trends increasing the need for nursing home care, it is imperative that we address this challenge.
This article quantifies the impact of the CMS staffing rules for Minnesota's nursing homes by identifying the additional staff that will be needed to comply with the new rules, or alternatively the reduction in nursing home residents to meet the new regulations with current staffing levels. We then project how Minnesota's aging population will impact staffing needs into the future.
CMS will require facilities to provide a minimum of 3.48 hours per resident day (HPRD) of total direct nursing care to residents, of which at least 0.55 HPRD of care must be provided by Registered Nurses and 2.45 HPRD of care provided by nurse aides (often called nursing assistants or CNAs in Minnesota). The additional 0.48 HPRD total nurse staffing may be met with any combination of nurse staff: RNs, Licensed Practical Nurses (LPNs), or NAs. The rules also require an RN to be onsite 24 hours a day, seven days a week, and available to provide direct resident care.
For urban facilities, the 3.48 HPRD total nurse staffing and the 24/7 RN requirements go into effect May 11, 2026, and the 0.55 RN and 2.45 NA HPRD requirements go into effect in May 2027. Rural facilities have an additional year for the 3.48 HPRD total nurse staffing and the 24/7 RN requirements (until May 10, 2027), and an additional two years for the 0.55 RN and 2.45 NA HPRD requirements (until May 10, 2029).
CMS collects staffing data to answer this question. LeadingAge Minnesota, one of the two major industry associations supporting long-term care employers in Minnesota, supplied us with an analysis of these data performed by LeadingAge New York. With calculations on the data provided, Table 1 shows the additional full-time equivalent (FTE) staffing required.
| Table 1: Additional FTE to Meet New CMS Minimum Staffing Rules, and Facilities Already Meeting the New CMS Requirements, Fourth Quarter 2023 | ||||
|---|---|---|---|---|
| Area | RN Minimum Staffing per Resident | RN 24 hours/7 days* | NA Minimum Staffing per Resident | Total Nurse Minimum Staffing per Resident** |
| Minnesota | ||||
| Additional FTE to Meet Requirement | 542.57 | 196.00 | 3,341.66 | 198.36 |
| Average Additional FTE Per Facility Not Meeting Requirement | 1.84 | 1.32 | 10.78 | 1.08 |
| Facilities Meeting Requirement (of the 333 that reported staffing of 343 total licensed) | 43 | 190 | 28 | 155 |
| Percent of Facilities Meeting Requirement | 12.7% | 56.2% | 8.3% | 45.9% |
| U. S. | ||||
| Average Additional FTE Per Facility Not Meeting Requirement | 7.49 | 1.55 | 22.23 | 0.99 |
| Percent of Facilities Meeting Requirement | 5.9% | 79.5% | 5.3% | 57.9% |
| * Based on additional hours needed after meeting RN Minimum Staffing
** Based on additional hours needed after meeting RN and NA Minimum Staffing Source: CMS Payroll Based Journal Daily Nurse Staffing, 4th Quarter 2023, analysis by Leading Age New York, and calculations by author. |
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Here are the implications: Minnesota would need an additional 739 full-time RNs and 3,540 NAs, assuming the total nurse minimum staffing requirements were met by additional NAs rather than higher-wage LPNs or RNs. Given part-time workers, we will need quite a few more RNs and NAs than the FTE staffing required. For example, front-line workers in Minnesota's Nursing & Residential Care subsector (which includes nursing homes as well as assisted living and other residential care facilities) worked an average 29.5 hours per week during fourth quarter 2023, according to DEED's Current Employment Statistics.
Table 1 also has the average FTE per facility that would need to staff up to meet the requirement if implemented in fourth quarter 2023. It is useful to compare Minnesota to the entire U.S. The average additional staffing required by Minnesota facilities is less than the U.S., except for meeting the Total Nurse requirement, which is only slightly more for Minnesota.
Minnesota has a larger share of facilities that would meet the RN minimum and NA minimum than the U.S., but it is still a small minority of facilities. Note that a much smaller share of Minnesota facilities would meet the RN 24/7 requirement than nationwide. One factor is that Minnesota has smaller facilities, with an average 72 certified beds in first quarter 2024, compared to a national average of 107 beds. The RN 24/7 requirement will have a greater impact on smaller facilities. Larger facilities would spread this work among a larger number of RN staff and spread the cost over a larger number of residents. Many of the smaller facilities are also located in rural areas where RN availability is already more limited. Attracting RNs to weekend and night shifts in rural communities is already a challenge; that will be exacerbated by this requirement.
It is worth noting that while Minnesota is not one of the five states where over half of facilities currently meet the staffing requirements, our overall long-term care systems ranked number one in the nation according to the AARP Foundation.
DEED's 2023 Job Vacancy Survey results show 4,382 RN job vacancies and 2,591 NA job vacancies in Minnesota. Vacancy rates are also much higher than for other occupations in Minnesota, at 6.9% for RNs and 10.4% for NAs, compared to a vacancy rate of 5.1% for all occupations. What's more, RN and NA are both in the top ten of DEED's Occupations in Demand in Minnesota. As Oriane Casale's article in a prior Trends issue concludes, ". . . for the foreseeable future, demand for direct care workers will likely continue to outstrip supply."
If implemented in 2023, these staffing requirements would have increased RN job vacancies by 17% (739 additional RN FTE + 4,382 RN job vacancies) and more than doubled NA vacancies by 137% (3,540 additional NA FTE + 2,591 NA job vacancies). And the vacancies would increase even more if any portion of them are part-time. Adding more vacancies on top of so many open positions implies that positions would not be filled, forcing a reduction in the total number of residents that facilities could serve.
In fact, this is already happening in Minnesota. The COVID-19 pandemic created an acute staffing challenge on top of the pre-existing chronic staffing challenge in Nursing & Residential Care Facilities. You can view this article in the prior issue of Trends for graphic illustrations of employment and wages in the Nursing & Residential Care Facilities subsector during and after the pandemic. CMS Provider Information data show that in first quarter 2019, Minnesota's nursing homes had an average of 24,042 residents per day. In first quarter 2024, that figure was down to 19,914. That's more than a 17% reduction in only five years. Considering our rapidly aging population, nursing home resident counts should be trending in the opposite direction.
Likewise, the number of nursing homes dropped from 375 to 343 in this time, resulting in a decrease of 3,619 certified beds, from 28,333 to 24,714, or -4.3%. Thus, with residents down 17.2% and beds dropping 4.3%, staffing difficulties are limiting the ability of nursing homes to utilize a smaller number of certified beds. Certified bed capacity utilization was 84.9% in first quarter 2019, and it dropped to 80.6% in first quarter 2024.
As of earlier in 2024, more than 30% of nursing homes in Minnesota reported that they were unable to staff all their beds due to inadequate staffing, according to a recent industry survey shared with the Legislative Task Force on Aging. The implementation of required staffing levels would exacerbate existing access challenges by forcing more providers to use less than their licensed capacity to meet the staffing ratios.
Thus, it makes sense that these staffing rules could lead to a smaller number of residents receiving care. If the rules went into effect in first quarter 2024, and additional nursing staff were not employed, residents would need to be reduced by 1,753 to comply with the regulations (Table 2). Note that this is about 42% of the 2019 to 2024 reduction in residents. So, it seems likely that there would be reduction in residents to meet the regulations, and fathomable that the regulations would be met entirely by reduced residents because staff increases have not been occurring.
Table 2 displays the results of identifying whether the RN, NA, or total nurse HPRD minimum staffing rules would require the largest resident reduction for each Minnesota facility that does not meet these staffing minimums, based on current staff availability. For example, the NA minimum staffing rule would have the biggest impact on the number of residents served at 169 facilities. Each of these 169 facilities would meet the RN and total nurse staffing without having to reduce residents as substantially. However, the RN minimum staffing rule would require the biggest resident reductions at 16 facilities. Only two facilities would be most constrained by the total nurse staffing requirement. Thus, Table 2 shows the hypothetical impact of these rules if implemented as of first quarter 2024 and if no additional staffing were possible.
| Table 2: Hypothetical Resident Reductions Required to Meet Minimum Staffing Rules if Implemented First Quarter 2024 and No Additional Staff Were Available | ||||
|---|---|---|---|---|
| Largest Resident Reductions Required to Meet | Facilities | Average Residents per Day Reduction to Comply | ||
| Number | Percent | Number | Percent | |
| RN Minimum Staffing | 16 | 4.8% | -192 | -1.0% |
| NA Minimum Staffing | 169 | 50.8% | -1,558 | -7.8% |
| Total Nurse Minimum Staffing | 2 | 0.6% | -3 | 0.0% |
| Sum, Do Not Meet Minimum Staffing | 187 | 56.2% | -1,753 | -8.8% |
| Meet Staffing Minimums | 146 | 43.8% | - | - |
| Source: CMS Provider Information, First Quarter 2024, released July 31, 2024, and author's calculations. | ||||
Of course, additional staffing is possible over the next few years, and this analysis shows that NA staffing is the primary constraint for the largest number of facilities. Thus, the greatest number of residents could be maintained if additional NA staff were employed.
Note that we do not similarly analyze the RN 24/7 rule because a reduction in residents would not bring a facility into compliance. If a facility cannot meet this rule, it will have to get a waiver or close. Note that the rules acknowledge both waivers and hardship exemptions. KFF reports that "The federal government estimates that a quarter of all 15,000 nursing facilities could end up obtaining an exemption." However, per LeadingAge Minnesota's initial analysis of the waiver concept, fewer than 20 facilities in Minnesota would qualify for the waiver concept as introduced.
With the oldest of the massive Baby Boom generation turning age 80 in 2026, the need for long-term care will increase over the next 20 years. The total number of older adults aged 65 years and over in the state was anticipated to double between 2010 and 2030 according to the Minnesota State Demographic Center. By then, more than 1 in 5 Minnesotans will be 65 or older, including all the Baby Boomers.
Table 3 applies statistics from the Profile of Older Americans on the percent of the U.S. population in nursing homes by age to Minnesota's population projections to estimate the increased need for nursing home care. The estimated increase is 4,656 people, or 21.6%. That is 528 more residents, or 4.4%, more than the decrease in residents from 2019 to 2024 identified above.
| Table 3: Projected Minnesota Senior Population and Estimated Number in Nursing Homes | |||||||
|---|---|---|---|---|---|---|---|
| Age Group | Estimated Percent in Nursing Homes | 2025 Projected Population | 2025 Estimated Number in Nursing Homes | 2035 Projected Population | 2035 Estimated Number in Nursing Homes | 2025 to 2035 Change | |
| Estimated Number in Nursing Homes | Estimated Growth in Nursing Homes | ||||||
| 65-74 years | 1% | 628,305 | 6,283 | 604,498 | 6,045 | -238 | -3.8% |
| 75-84 years | 2% | 323,878 | 6,478 | 448,268 | 8,965 | 2,488 | 38.4% |
| 85 years & over | 8% | 110,005 | 8,800 | 140,086 | 11,207 | 2,406 | 27.3% |
| Total, Age 65 & over | 2.0% in 2025
2.2% in 2035 |
1,062,188 | 21,561 | 1,192,852 | 26,217 | 4,656 | 21.6% |
| Sources
Estimated percent in nursing homes from U.S. Census Bureau Annual Social and Economic Supplement of the Current Population Survey, tabulated by U.S. Department of Health and Human Services, Administration for Community Living Profile of Older Americans. Population Projections from Minnesota State Demographic Center. |
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CMS staffing rules would be fully in place by 2029. So, what would the projected increase in nursing home residents of Table 3 mean for needed RNs and NAs by 2035? Table 4 uses the information we have now to venture an answer.
| Table 4: Actual First Quarter 2024 and Projected 2035 RN and NA Staffing to Meet CMS Regulations and Projected Resident Growth | |||||
|---|---|---|---|---|---|
| Actual First Quarter 2024 | Projected 2035 | 2024 to 2035 Change | |||
| Residents | 19,914 | Residents | 26,217 | 6,303 | 31.7% |
| Total RN FTEs | 2,411 | RN FTEs Needed at 0.55 HPRD + 196 FTE to meet 24/7 RN* | 2,726 | 315 | 13.1% |
| Total LPN and NA FTEs | 9,686 | NA FTEs Needed at 2.45 HPRD + 0.48 HPRD to meet Total Nurse | 13,480 | 3,794 | 39.2% |
| * The daily staffing analysis that generated this 196 FTE estimate for Table 1 is the best information available on the FTE required to meet the 24/7 RN requirement, so it is used here as well.
Source: CMS Provider Information, First Quarter 2024, released July 31, 2024, and author's calculations. |
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Unlike the per facility daily staffing analysis that underlies Table 1, Table 4 projects 2035 staffing based solely on the projected residents and the HPRD staffing minimums. It also employs the 196 FTE estimate for RN 24/7 staffing from Table 1 that was estimated from actual fourth quarter 2023 daily staffing. Note that the staffing to meet the RN 24/7 requirement would increase more with the number of facilities than with the number of residents. So, even with a projected 31.7% increase in residents, the RN FTE to achieve RN 24/7 staffing would not increase commensurately. However, the 196 FTE estimate is low given that more facilities would need to open to meet this more than 30% increase in residents.
Table 4 estimates a whopping 13% increase in demand for RNs and a blistering 39% increase in demand for NAs from 2024 to 2035. By comparison, DEED's Employment Outlook projects 5.3% growth for RNs and 2.4% for NAs from 2022 to 2032, but this is for all industries, not just nursing homes. Nationally, 4% of total RN employment and a bit over a third of total NA employment is in nursing homes.
This analysis raises the question of how nursing home employment will grow relative to other Nursing & Residential Care subsectors. Based on the current trends, DEED's Employment Outlook projects a 2.5% employment decline in Nursing Care Facilities (commonly called nursing homes) from 2022 to 2032, while Community Care Facilities for the Elderly (commonly called assisted living) is projected to grow 13.2%.
Perhaps less than 2% of 75-to-84-year-olds and less than 8% of those over 85 years will be in nursing homes in the future. Or perhaps nursing homes will pull employees away from assisted living to provide the more intensive care that is needed.
The potential adverse impacts of the regulations stem from the fact that the RN and NA workforce is simply not available to meet these requirements, and the state's aging population is a compounding factor. The over 30% projected growth in nursing home residents is a monumental challenge on its own. Perhaps the additional attention from the new CMS rules will paradoxically help meet this challenge.
Given the workforce situation, it seems likely that the regulations will be met to some extent by having fewer residents. As discussed, this has already happened. CMS officials have acknowledged that some facilities will likely close because of these regulations. This will force older adults to seek care further from their chosen communities and live further away from vital support systems, including their family, friends, churches and other social groups. While better staffing for better care makes intuitive sense, health and wellbeing is adversely impacted by being far away from family and support systems. This is particularly an issue for rural areas where the RN staffing rules could prove most difficult. Only 9.6% of Minnesota's RNs practice in small towns and rural communities.
A related issue is keeping someone at home or in a retirement community who needs nursing home level of care. This happens if there is not a local nursing home bed available, and these staffing regulations place a new constraint on admitting a resident to an available bed. Family members often lack the strength, skill and equipment to care for someone with limited mobility or other issues.
In addition to serious quality of care concerns with family members compelled to provide nursing home level care, there is also a decline in the overall workforce from people quitting their jobs to care for family. A previous Trends article notes that ...a significant portion of care for the elderly shifted to family.... This adds to the workforce challenges in health care and other sectors of the economy.
Ideally, implementation of these rules will include adjustments to strike a balance between improving staffing levels and maintaining access to care, especially in underserved areas. Kari Thurlow, President and CEO of LeadingAge Minnesota states, "Minnesotans expect that they will be able to access care in their local community—where and when they need it. That is why it is imperative that policymakers, families and providers work together to ensure we can protect that long-held Minnesotan value."
When announced in September 2023, the CMS rule "was accompanied by an initiative that would invest over $75 million as part of a nursing home staffing campaign, introducing incentives for workers to pursue careers as nursing home staff." CMS communications mention financial incentives such as tuition reimbursement and scholarships to begin in 2025. Workforce development is clearly needed with or without the regulations.
Teri Fritsma's article in a prior Trends issue explains that "Minnesota is undersupplying our estimated demand for new nurses." It also identifies grants or loan forgiveness programs targeted to students in rural areas as a solution to increase rural RN supply. Interestingly, "Having grown up in a rural area" was by far the biggest factor influencing Advanced Practice RNs practicing in rural areas, with more than two-and-a-quarter times greater impact than any other factor.
Intentional international immigration policies, such as work visas for work in long-term care, likely have the greatest potential to increase the supply of NAs. But this also appears to have the lowest political feasibility. Visas are typically only issued for licensed health care workers, but this analysis shows a lack of NAs is the biggest constraint on resident capacity. Expanding the current visa programs to non-licensed health care providers will likely also help build a pipeline for future licensed providers, because NAs often go on to become licensed nurses.
Perhaps there is more feasibility for programs to assist refugees and immigrants already here with free NA training opportunities, improving access to English-literacy resources, and improving pathways to become a licensed nurse in Minnesota.
DEED's Northeast Minnesota Regional Workforce Strategy Consultant Shayla Drake previously worked as an HR manager in long-term care. She also was a key team member on the "Follow Your Heart to a Caring Career" workforce outreach campaign launched by in 2023.
"There is high interest in direct care work among new arrivals to Minnesota, but many New Americans' English language skills don't meet minimum requirements for health care courses. Many people need a paycheck right away, they can't wait to improve their English before preparing for and finding work, so they find work in other sectors," said Drake. "More and more employers are independently implementing different measures for individuals such as image documentation in charting systems to help reduce reliance on written language or pairing new English language learners with fluent English speakers who speak the same first language as the new language learners. Anyone who has worked in health care understands medical terminology is a different language. Imagine you are not learning one new language, but two in order to work in your desired field. That's why programs to teach ESL for health care and 'earn-while-you-learn' design can be highly effective in realizing the existing interest in direct care jobs among refugees and other immigrants arriving in Minnesota."
Minnesota's direct care workforce, including those that work in long-term care settings, is among the most diverse sectors in the state—approximately 38% of the direct care workers in Minnesota are people of color, 26% are immigrants and 81% are women. To that end, LeadingAge Minnesota is helping long-term care employers build capacity and become a more welcoming and inclusive environment for New Americans—for those already in their local communities, as well as making connections with qualified candidates abroad.
In March 2024, the Minnesota Department of Human Services launched a new $28.3 million grant program focused on supporting New Americans in both entering and advancing within the long-term care field. Anna Mowry, Director of Workforce Solutions at LeadingAge Minnesota, added that "Long-term care providers are eager for innovative solutions that lead to a stable, committed workforce to serve Minnesota's aging population. This new investment shows the state's commitment to enriching our diverse workforce and creates paths for new Americans to pursue meaningful roles and leadership within our sector, while ensuring employers foster inclusive, welcoming communities."
Ambitious workforce development initiatives will be critical to these regulations realizing the improved care they strive to achieve. The coming years will reveal whether these ambitious staffing standards can achieve their intended goals of enhancing quality of care while maintaining accessibility and financial sustainability in the long-term care sector.
The path forward will require innovative solutions, sustained investment in workforce development and a willingness to address unintended consequences promptly. While the challenges are significant, these regulations also present an opportunity to reimagine and improve the delivery of care for our nation's most vulnerable older adults.
