Administrator licensure crisis on hold.

Since the 1970s, the federal government has required that every Administrator of Record (AOR) responsible for a SNF receive a recognized state license as a professional nursing home administrator. This licensure requirement is one of the oldest unfunded mandates imposed on the states by the Medicare program (which initiated it). It traditionally has not been an especially difficult requirement to meet; there always have been more than enough licensed nursing home administrators to meet the needs of the long-term care community.

That is, until 2001, when healthcare researchers released several studies documenting that the long-term care industry was losing significant numbers of experienced licensed administrators. This was coupled with a decline in the number of new individuals entering the profession. Randy L. Lindner, CAE, executive director of the National Association of Boards of Examiners of Long Term Care Administrators (NAB), reports that the number of applicants for the state examinations had dropped by more than a third during the late 1990s. Between 2001 and 2003, the number of applicants continued to decline, but at a slower pace.

Both the Government Accountability Office (GAO) and a broad coalition of associations in long-term care expressed concern that the combination of licensed administrators leaving the field and fewer new applicants for licensure could cause long-term disruption in recruitment of qualified administrators for the number of SNFs required to serve the baby boom generation. Some states reportedly have already experienced problems in attracting licensed administrators to nursing homes in rural areas. The potential crisis is compounded by the fact that licensure technically is a state rather than a national requirement and would therefore embrace a variety of approaches. Despite these ominous signs, none of the financially-strapped federal healthcare agencies placed a priority on research on the causes of the consequences of the decline in applications for nursing home administration licensure.

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In 2004, the number of new applicants for state licensure examinations unexpectedly increased for the first time since 1998. A total of 2,448 candidates (roughly 50 per state) underwent examination--an increase of more than 200 from 2003. NAB believes that 2005 is thus far holding pace with 2004.

No one has a convincing explanation for the apparent end to the decline in new applicants for licensure. While a few states, such as Alabama, have recently modified their criteria to permit applicants with fewer than four years of college, most experts in the field believe that educational requirements have not been a significant barrier for applicants. A more likely difficulty might be the widespread demand for months of full-time service as an unpaid Administrator-in-Training before completion of licensure. Approximately 70% of would-be licensed administrators are already employed in nursing homes or other long-term care facilities, and most understandably resent any requirement that they leave their existing positions to accept unpaid servitude as administrator trainees. States have nevertheless been reluctant to part with this burdensome demand.

Regarding the unexpected good news of increasing applications, Lindner tells Nursing Homes/Long Term Care Management that he can't explain it: "I don't know what we've done, other than our efforts to make the field appear to be a more attractive career choice." One of the most important efforts has been moving states toward license reciprocity. This month, the directors of the NAB will consider a proposal that will allow licensed nursing home administrators to transfer their licensed status among as many as 20 states. If approved, as expected, the multistate reciprocity agreement will go a long way toward transforming nursing home administrators into mobile professionals, able to follow employment opportunities across state lines.

Lindner also notes that the University of Wisconsin-Eau Claire has shown unusual success in expanding student enrollment in its program to prepare students for the state licensure examination at a time when other state educational programs are suffering from an enrollment drought. The university's graduate certificate in Health and Aging Services Administration (HASA) is a strongly marketed collaboration with private businesses involved in long-term care. The program combines coursework on quality management and health services leadership with traditional topics on resource and personnel management. The HASA certificate was designed as part of the university's continuing education extension services and therefore has appeal targeted at older students interested in career transitions.

Above all, according to Lindner, the perception of recently improved employment and financial conditions in the long-term care field may be the most important factor ending the decline in applications for the examination: "Reports of the industry stabilizing over the past couple of years have made the position of nursing home administrator more attractive--but this is not something that we should think of as permanent." More attention to the continuing stability of the field may be needed to ensure that sufficient new applicants are recruited to take the helm of skilled nursing and assisted living facilities that will care for the largest over-80-year-old population in history.

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