Staffing: a multi-faceted challenge.

Many industries list staffing as one of their top challenges. Post-acute care providers are no exception. Today's unstable health care environment, coupled with increasing economic pressures, has led many organizations to identify staffing as indeed their number-one priority. Needless to say, retention and recruitment of quality personnel and adjusting staffing according to acuity needs and census requires continuous attention, skill, flexibility, ingenuity and patience. Nursing Homes asked some professionals who have dealt successfully with staffing issues to share their experiences.

Eli Pick, Executive Director of the Chicago-based Ballard: "Federal and state requirements dictate the number and categories of staff that satisfy minimum standards, based on the assumption that certain staff categories perform specific functions. When we embarked on the process of reviewing who in our organization performs which functions, we identified these licensing prerequisites as the starting point. Additional services that are non-clinical in nature, and who was performing them, were then identified - tasks like bed-making, cleaning wheelchairs, filling water pitchers, replacing bed pans, or even answering call lights. These tasks were primarily being performed by CNAs and the salary level of this position had risen significantly in this market. This led us to develop the Patient Care Assistant position, focused on meeting the non-clinical service needs of residents and thus maintaining the clinical roles of the CNA and RN. And this, in turn, opened up a review of all the positions in our organization.

"Gathering resident/patient satisfaction data, including those from the subacute units, had identified specific areas of possible improvement, including: 1) the dining experience; 2) communication related to a patient's condition; and 3) clinical treatment. We learned that, with the dining experience, the food was fine but the atmosphere and service delivery needed improvement. We had utilized CNAs to fulfill this function, without paying much attention to how this was working from a service orientation. We found an opportunity to change the staffing in much the same fashion as on the nursing units. Also, because the population and food preferences were significantly different on the subacute units, we had to develop processes especially for them, using teams of staff aimed at meeting these customer needs.

"Similar experience led to our examining the delivery of rehabilitation services and provided us another opportunity to adjust skill levels of staff providing non-clinical services."

John Perticone, Corporate Director of Managed Care, Multicare Co., New Jersey: "One of the more difficult tasks for subacute/skilled nursing facilities is differentiating themselves from competitors. That is why marketing and community outreach activities are essential to expand or even maintain market share. This is especially true for subacute care programs, which necessitate a much greater volume of patients to sustain census. This has created a need for marketing staff specific to the program or facility. These marketing staff are charged with relationship-building with hospitals and other key community referral sources, and this staff can often be enhanced by utilizing entrepreneurial nurses. Largely through careful timing, follow-up and overall experience, the skilled nurse can expand the unit's market presence. The field marketers need to be supported by an infrastructure, e.g., admission staff, contract personnel, clerical staff and internal case managers. There must be a system that encourages rapid admission; administration able to motivate thinking beyond the Medicare model; professionals who understand care management within the limits of per diems, case rates and capitation; and clinical pathways that support transitioning the patient along the continuum to the least costly care setting. In short, it is more expensive these days to fill beds than it was in the recent past. Facilities have incurred added costs in order to increase census and compete for managed care dollars. The growing number of Medicare and Medicaid risk patients has added to these pressures."

Nancy West, Vice President of Health Care Dimensions, Colorado: "As integrated delivery systems grow, we're seeing the need for more cross-training of staff, from corporate to regional to the facility level. A working knowledge of a range of areas from managed care contracting, to case management to service delivery is a must if a company is to have the capability of putting together networks to keep people in the continuum. At the corporate and regional levels, operations, marketing, professional services and development executives must be multidimensional. At the facility level, administrators and executive directors must be able to build networks and joint ventures. They must be able to implement higher acuity programs, which involves hiring clinical staff with high-tech skills, working with therapists and case managers, and providing ongoing inservice training to keep staff skills current.

"Administrative and clinical staff must have thorough knowledge and understanding of rules and regulations, documentation and outcomes evaluation in order to keep facilities in good standing with all agencies. An inexperienced administrator or director of nursing services, or one with a less than stellar track record of survey results, can quickly undo what has taken a facility years to achieve in terms of quality and compliance.

"When hiring, create your 'ideal candidate' profile, but don't stop there. For each criterion, decide what qualifications are non-negotiable and which ones can be optional. If you screen too heavily for the 'perfect' candidate, you could miss out on the opportunity to hire a talented individual with potential value. On the other hand, if you go too far outside your own specifications, you will waste an inordinate amount of time interviewing marginal candidates. Worse, you might hire one.

"If these methods fail to generate the caliber of candidate you desire, or if the position is a confidential replacement and therefore too sensitive to publicize, it is time to consider calling in a professional search firm.