Documenting the Disappearing Administrator. (View on Washington).

An administrator can be hired to run a 500-bed hospital in the United States without a specialized license or certification. No special training or background is legally required nationally for people in charge of home healthcare, hospices or assisted living.

Since the 1970s, however, the federal government has required that no one may administer a skilled nursing facility (SNF) unless he/she receives a recognized state license as a professional nursing home administrator (NHA). The requirement is one of many burdens uniquely placed by Medicaid and Medicare legislation on the operation of nursing homes. It has not been an especially difficult requirement to meet; there have always been more than enough licensed NHAs to meet the needs of the long-term care community.

That is changing. A research and policy panel at the 2001 annual meeting of the American Public Health Association last October revealed that the long-term care industry is slowly losing increasingly significant numbers of licensed administrators. Part of the evidence for the leadership drain was uncovered by Paul Wing and Edward S. Salsberg of the Center for Health Workforce Studies at the State University of New York--Albany. Wing and Salsberg surveyed all active licensed NHAs in New York State, as well as a sample of 100 inactive licensees. They discovered that nearly one-third of all active nursing home administrators in New York plan to leave the field within the next five years. Moreover, more than 40% of those who plan to remain in the field are more than 50 years old.

The graying of nursing home administration is a potential problem because fewer candidates are applying for licensure. Randy L. Linder, executive director of the National Association of Boards of Examiners of Long Term Care Administrators, reported that the number of applicants for state examinations dropped by more than one-third during the late 1990s. Although the decline appears to have leveled during the past two years, there still might not be enough new license recipients to replace the administrators who are retiring or leaving the field.

Research to date has not pinned down the causes of this. Wing and Salsberg report in their survey that retirement was the most commonly offered explanation for leaving the field, but the search for positions with better career opportunities and salaries also continued to be important. Increasingly, "burnout" and differences with SNF owner/operators are cited by inactive licensees as reasons for ending careers as NHAs. Very few of the survey respondents reported that they did not enjoy being an NHA. However, the New York State licensees are not typical of nursing home administrators throughout the United States, in part because New York does not permit private chain ownership of SNFs. The reasons for leaving the field might differ in other states where Medicaid reimbursements are less generous and private chains are major owners.

Lindner and the New York State researchers agree that many barriers have emerged to discourage new applicants from pursuing licensure. One of the most important is the absence of paid internships to meet the Administrator-in-Training (AIT) program hours that states require as a prerequisite for licensure. Instead, would-be applicants often must consider months of work without pay to fulfill their AIT requirements. Few educational institutions offer academic programs that lead to completion of the licensing requirements. In fact, relatively few potential applicants are even aware that licensed nursing home administrator could be a career choice.

The researchers also agree that the challenges confronting nursing home administrators have grown increasingly more difficult. Unlike hospital administrators, SNF administrators have small support staffs and very limited reimbursement for overhead expenses. The researchers report that licensed NHAs are increasingly stressed by difficulties in recruiting direct care workers and by a hostile regulatory environment. The growing perception of nursing homes as institutions to be avoided by all but the most incapacitated patients also affects both the willingness of students to consider licensure and the willingness of administrators to stay in the field.

There is no shortage of potential solutions to the problem of the vanishing administrator. Some states have expressed interest in loosening the requirements for licensure by demanding fewer years of formal education. Other groups, including the Archstone Foundation, are attempting to develop training curricula that more accurately reflect the challenges facing nursing home administrators in the 21st century. Many organizations--including the American Health Care Association and the American Association of Homes and Services for the Aging--support a comprehensive public relations campaign to improve the image of both nursing homes and nursing home administrators.

There is no guarantee that any of this will produce the desired result of increasing the number of people who want to become and remain licensed nursing home administrators. There are no hard data on whether or where shortages of available licensees already exist or whether some states have succeeded by now in reducing the exodus from the profession. In general, no one has systematically collected information on the "typical" career pattern of NHAs and on the factors that cause those careers to be extended or aborted. All that we can be certain of for the moment is that a lot of people who received a state NHA license never became the administrator of record for a nursing home.

As the postwar generation nears retirement age, both the numbers and quality of licensed administrators bears watching. It's likely that the loss of active licensed nursing home administrators from the long-term care field will cause a crisis at least as severe as the loss of nurses from the profession. Providers, residents and their families will be in trouble if SNFs are unable to attract bright young administrators to the field or retain them until they gain the practical experience needed to manage these facilities.