vv
Donald J. Smith Jr.
Christopher W. Dula
Claire M. Fite
Nova E. Gattman
Eleni Papadakis
Lori A. Hinton
Workforce Board
Workforce Board
Workforce Board
Workforce Board
Workforce Board
Hinton Creative
Washington Long-Term Care
Workforce Initiative
Legislative Report
Fall 2023
Report Authors
acknowledgements
The Workforce Training and Educaon Coordinang Board (Workforce Board) would like to thank the many
parcipants and key informants, including long-term care organizaon representaves, healthcare
praconers, direct care providers, educators, and government agencies who dedicated signicant me to
share their experience and insights for this report. Many thanks go to the University of Washington Center for
Health Workforce Studies team members who provided assistance with research contribuons, listed below.
We would also like to thank Bea Rector from the Department of Social and Health Services,
Patricia Hunter from the Oce of the State LTC Ombudsman Program, Kezia Scales and Lina Stepick
from PHI, and Robyn Stone from LeadingAge for their valuable insights to the research included in this
report. Thank you to the Washington State Board of Nursing, with special recognion for Kathy Moisio, for both
the current work and previous eorts we have built in developing this iniave. Thank you to Katherine Boyd of
Halcyon Northwest for providing meeng facilitaon in the recommendaon development process.
Katherine Maggio from the Workforce Board also provided valuable assistance with meeng planning and
administrave support. And nally, thanks to Lori Hinton of Hinton Creave for wring and eding support.
project team
funding
This assessment was funded by the 2022 Washington State Budget, with ongoing funding through 2025.
suggested citation
Smith, D.J., Dula, C.W., Fite, C.M., Gattman, N.E., Hinton, L.A. (2023) Washington Long-Term Care Workforce
Initiative Legislative Report. Olympia, WA: Washington Workforce Training and Education Coordinating Board.
access the report
The full report can be accessed at: hp://www.wtb.wa.gov/long-term-care/
Donald J. Smith Jr.
Christopher W. Dula
Claire M. Fite
Nova E. Gattman
Eleni Papadakis
Bianca K. Frogner
Susan M. Skillman
Tracy M. Mroz
Danbi Lee
Rachel A. Prusynski
LaTonya J. Trotter
Lori A. Hinton
Workforce Board
Workforce Board
Workforce Board
Workforce Board
Workforce Board
UW Center for Health Workforce Studies
UW Center for Health Workforce Studies
UW Center for Health Workforce Studies
UW Center for Health Workforce Studies
UW Center for Health Workforce Studies
UW Center for Health Workforce Studies
Hinton Creative
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Washington Long-Term Care
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Workforce Board, Fall 2023
TABLE OF CONTENTS
executive summary
introduction
History of Stang Challenges & Responses
Steps to Soluons
Washington Responds to the Challenges
project history and approach
Impacts of COVID-19 on Long-Term Care Seng
Our Charge: The Long-Term Care Iniave and Licensed Praccal Nurse Registered Apprenceship
Occupaons and Distribuon of the Long-Term Care Workforce
Nursing Home and Skilled Nursing Facility Stascs
Projected Workforce Demand
project spotlight
The Long-Term Care Workforce Iniave
Iniave Strategies
The Ideal and Current State of Long-Term Care in Washington
The Ideal State
The Current State
project spotlight
Licensed Praccal Nurse Registered Apprenceship for Long-Term Care Sengs
Project Partners
Navigator Impact
Employer Contribuons
Program Expansion
stakeholder driven policy recommendations
Recommendaons
Items for Further Study
next steps: continuing the initiatives
Future of These Iniaves
Conclusion
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5
10
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18
19
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definitions
references
attachments
A: Leadership Team
B: Addional Parcipants in Stakeholder Meengs and Reviews
C: Research Team
appendices
1: Innovaons: Long-Term Care Program Iniaves Supporng Rebalancing
2: Summary of NCQAC Long-Term Care Workforce Workgroup Accomplishments
3: Public Use Datasets from CMMS on Nursing Homes/Skilled Nursing Facilies
4: Stang Disciplines Included in the Payroll Based Journal Dataset
5: Number of Nursing Homes/Skilled Nursing Facilies in Washington
6: LPN Registered Apprenceship Q & A with Edmonds College, Navigators & Employers
7: Stakeholder-Idened Barriers to the Ideal State of Long-Term Care in Washington
8: Strategy for Ongoing Research Eorts
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eXecutiVe summarY
More than half of Washingtonians over the age of 65 are
expected to need paid long-term care (LTC) for an average of
3.2 years (ASPE, 2019). An esmated 70 percent will need help
with at least one acvity of daily living such as bathing, using
the toilet, or eang, at some point in their remaining lifeme
(FIF, 2016). These services are expensive with monthly costs
ranging from $1,700 to $9,000 per month (AARP) depending
on the types of services needed. However, most care is
provided at home by unpaid caregivers, accounng for one
in ve adults (AARP).
This can put extraordinary nancial strain on Washington
families and their loved ones needing care—draining savings,
investments, and assets. To provide the necessary care for
family members, unpaid caregivers oen leave the labor
force, further reducing family incomes and their ability to
save or plan for the future. This puts signicant drag on the
economy.
The demand for LTC is rapidly growing in step with an aging
populaon. By 2030, the populaon of Washington State is
expected to grow by 5 percent from 2023, and 25 percent by
2050. However, the number of residents over the age of 65
will grow by 30 percent in 2030, and by 64 percent in 2050.
For those over 85, growth is expected to be 58 percent and
246 percent, respecvely (OFM).
Washington’s aging populaon growth highlights the
tremendous challenges to recruit and retain a well-trained,
professional LTC workforce. The available pool of workers
is unable to keep pace with the growing demand for LTC
services and supports. This is further complicated by factors
related to ongoing stang challenges that have persisted for
years.
Although Washington has adjusted Medicaid rates in recent
years – a signicant factor in establishing direct care worker
wages – many direct care workers connue to live at or below 200 percent of the federal poverty level. These
are demanding jobs that require signicant training well beyond the requirements of similarly paid work in
other sectors. The LTC sector has been plagued by high levels of turnover, employee burnout, and a lack of
social recognion and respect for decades (Deloie). Average annual turnover rates for direct care workers
hovers around 50 percent (BLS, 2022). Turnover is also expensive, cosng employers as much as 150 percent of
a direct care worker’s annual salary (FQHC, 2014).
Long-Term Care or LTC
includes services provided in the
home such as personal care and
respite, home delivered meals, skills
acquisition and habilitation, and pro-
vision of equipment and supplies;
services provided in licensed
residential settings; services
provided in a center such as adult
day care and day health; and
services in skilled nursing facilities.
It also includes routine skilled treat-
ments and therapies that can be
provided at home, in licensed
residential settings or nursing home
facilities. In Washington, licensed
residential settings include: adult
family homes, assisted living
facilities, and enhanced services
facilities.
The occupations involved in
delivering LTC services are
frontline care workers including
nursing assistants and home care
aides, nursing staff of all levels,
other licensed healthcare providers
(clinical social workers, physical
therapists and assistants, and
dietitians), in addition to their
managers, supervisors, and other
support staff, such as cooks and
custodians.
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LTC stang challenges were further compounded by the COVID-19 pandemic. Skilled nursing facilies, for
example, saw a near 12 percent loss in hours per resident day (the number of hours of direct care for each
paent per day) for nursing assistants. The vacancies that cause these numbers have not yet recovered, forcing
facilies to rely on more expensive temporary contract sta to meet regulatory stang requirements. Stang
shortages and high turnover are directly linked to reduced quality in care outcomes, delays in receiving essenal
care, and increased hospitalizaon rates (Center for Medicare Advocacy, 2021).
Sta who stayed through the pandemic in LTC sengs (and really, any healthcare occupaon) were overwhelmed
with work schedules that stretched their capacity beyond tolerable levels, resulng in experienced sta leaving
for less strenuous work environments, oen in unrelated professions. The resulng sta shortages put greater
pressure on remaining sta and created addional burdens for providers who were exposed to an increased
risk of sancons, e.g., nes, holds on new admissions, and expanded oversight resulng from violaons of
regulatory policies connected to sta-to-paent raos and quality care outcomes.
The LTC stang crisis is not isolated in its impact. Stang shortages in post-acute and long-term care aect the
enre healthcare system. LTC workforce shortages are a detriment to service delivery across other components
of the healthcare system and contribute to disjointed care. For example, if fully staed beds are unavailable in
long-term care sengs for individuals with complex needs, hospitals somemes must keep these paents in
more expensive acute care sengs unl an appropriate placement can be found.
If the status quo is allowed to remain and the LTC workforce shortage is not adequately addressed,
Washington State will face an even greater healthcare crisis by 2030 when the number of individuals
Thankfully, Washington State
policymakers have a history of migang crises in the healthcare workforce – and are once again up to the task.
In 2022, the Governor and Legislature authorized the Workforce Board to take the lead on iniaves aimed at
developing strategies and policy recommendaons to build on the exceponal eorts of previous workgroups
and develop strategies to address the ongoing challenges associated with establishing a stable LTC workforce
that can ulmately impact the healthcare delivery system in Washington. This report is the rst in a series of
three annual reports planned for policymakers communicang the progress of these iniaves and making
policy recommendaons to impact the state’s LTC stang challenges. Starng with this report, addional
reports will be produced annually through August 2025.
The Long-Term Care Iniave (LTC Iniave) convenes healthcare praconers, LTC provider representaves,
educators, direct care workers, labor organizaons, and government agencies, collecvely referred to as
stakeholders, to idenfy factors contribung to workforce challenges. These stakeholders helped to develop
the recommended pracces and policies outlined in this report to increase and stabilize the number of direct
care workers.
This LTC Iniave has engaged a team of talented health and labor researchers to collect and analyze data
needed to help inform the iniave’s recommendaons. The Workforce Board is partnering with the University of
Washington’s Center for Health Workforce Studies (UW CHWS) to invesgate the underlying causes of workforce
shortages and other challenges, including linkages between stang and quality care outcomes. This research will
create the foundaon for idenfying metrics to be used for establishing the needs of LTC and their ability to provide
quality care for Washingtonians. Further, the researchers in this eort will be called upon to monitor and evaluate
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the impact of current and future policies
and programs on alleviang shortages and
improving quality care outcomes.
The LTC Iniave used a strategic approach
to engage stakeholders and provide a guiding
vision for this work. The group rst dened
what the “Ideal State” of LTC would look like
in Washington. Stakeholders then worked
together to dene the “Current State” of the
LTC workforce in Washington through a series
of facilitated exercises that included strategic
planning frameworks, root-cause analysis,
senment analysis, surveys to idenfy broad
problem areas, an exploraon of publicly
available data, and the sharing of direct, lived-
experiences of those working in the LTC sector.
The research ndings, along with the barriers
and challenges idened by stakeholders
to achieving the Ideal State, were dislled,
and priorized into the aconable policy
recommendaons presented in this report.
Included in this report are preliminary
recommendaons that generated broad
agreement among stakeholders. A more
extensive list of barriers and potenal
soluons has been created that requires
further exploraon for consideraon and
inclusion in subsequent reports.
Ideal State of LTC
A high-quality system of coordinated long-term
care support services that provide accessible
choices in care settings.
A regulatory environment that encourages
collaboration and support while still maintaining
the focus on patient safety.
A well-trained, equipped, and respected staff
who provide quality, empathetic, care in a stable,
nurturing work environment, supported by access
to comprehensive career pathways, lifelong
learning opportunities, and recognition of the value
and skills provided by the direct care workforce.
Current State of LTC
LTC providers in Washington are struggling.
Current caregivers are emotionally and
physically taxed. While Washington has specic
training regulations in place, the industry faces
continued challenges with training and testing
delivery. Existing staff shortages, inflexible
work environments, insufcient Medicaid
reimbursement rates, low pay and benets, a lack
of acknowledgement of direct care workers as a
critical part of the healthcare delivery system, and
the impacts of regulatory oversight that can feel
punitive rather than solutions-focused all contribute
to the issues impacting the LTC workforce.
Services are often delayed and/or are not
available in a customer’s chosen form (e.g., home
care vs. facility care). Yet, when and where care
services are available, Washington’s LTC provider
community continues to offer a range of care
options supported by a professional workforce that
is engaged and committed to providing quality
services. Facilities, agencies, and caregivers
provide compassionate, skilled care, often through
innovative programs for their staff as well as those
receiving care.
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The idened barriers / challenges to stabilizing the LTC services and supports for the workforce include:
• Insucient career development and training opportunies
• Credenaling barriers
• Challenges related to regulatory oversight
• Percepons of LTC and lack of recognion of the direct care workforce
• Compeon between healthcare sectors
• Recruitment and retenon
• Inadequate pay and benets
• LTC worker expectaons of care and burnout
This report also contains an update on the Licensed Praccal Nurse (LPN) Registered Apprenceship Iniave.
Led by a three-agency partnership between the Workforce Board, WABON, and the Apprenceship Secon of
Labor and Industries (LNI), with the Washington Health Care Associaon (WHCA) serving as the sponsor, this LPN
pilot apprenceship program is developing a pathway for current nursing assistants-cered (NACs) and home
care aides (HCAs) to become LPNs by implemenng an LPN Registered Apprenceship Program. Representaves
from community colleges, employers, and government agencies are collaborang to support future LPNs with
college educaon, nancial aid, hands-on training in the workplace, program navigaon, and wraparound
support. To date, 37 NACs and HCAs from three employer groups are enrolled in prerequisite coursework at two
partnered community colleges. See page 39 for more informaon about the apprenceship pilot.
Initial Policy Recommendations*
Recognizing the complex challenges within the LTC workforce, a broad range of ideas were proposed by three LTC
Iniave subcommiees. Each subcommiee idened specic policies for consideraon. The recommendaons
below align with the goals of Washington State’s workforce development plan, Talent and Prosperity for All (TAP).
TAP is a four-year strategy for a strong and successful workforce development system oering opportunies for
employers, workers, and communies alike. The inial policy recommendaons to address workforce challenges
in LTC are as follows:
(current funding
expires in 2025)Policymakers funded the development of a Registered Apprenceship Program for
LPNs beginning in 2021 with a planning year. Funding for implementaon is guaranteed through June
30, 2025. This request is for connuaon through June 30, 2027, to ensure the program has the me
needed to become sustainable, the apprences and their employers have certainty that the program
will connue, and all the details of program administraon are in place.
Edmonds College’s hybrid curriculum
has been approved by WABON and the nal details for implemenng the curriculum component of
the LPN Registered Apprenceship Program are currently under review by WABON. Pending approval
of the LPN apprenceship program, this curriculum will be ulized to train LPN apprences. Edmonds
College’s pioneering work with nursing apprenceships is paving the way for program expansion to
other instuons across the state.
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*Note: More details on each of these recommendaons may be found on page 46
Washington Long-Term Care
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3.
Funding would support a dedicated cohort of apprentices in this competitive
LPN Registered Apprenticeship Program.
4.
, to the extent possible.This will ensure workers are adequately
compensated, which will support greater recruitment, retention, and workforce stability.
5.
Expansion of
this popular program would improve the care of LTC residents and reduce the number of
provider citations.
6.
Flexibility of employment sites for nursing
technicians is critical and should be expanded to include assisted living, adult family homes, and
community care that meet the conditions of position and supervision requirements.
7.
Support continuation of the Initiative and implementation of the full original request,
which proposed funding for small transformation grants for LTC providers to test promising
practices for improving care outcomes, with the goal of increasing workforce retention. This
may include supporting LTC workers in training and education to advance skills and achieve
higher wages within the field.
Shortages of LTC direct care workers are not a new phenomenon, as evidenced by decades of research
presented in this report.
Washington State and the country at large have a severe shortage of people entering—and
remaining in–these important jobs. The recent COVID-19 pandemic, economic and societal shis, along with
changing labor market paerns have taken the LTC workforce situaon from a dire state to one of absolute crisis.
The diverse group of stakeholders who developed and strongly support the ndings and recommendaons
of this report has recognized the challenges underlying the LTC workforce in Washington and concur on the
complexity and scope of the crisis.
Progress will require policymakers, providers, educators, and
business leaders to work together. The seamless connuity of these Iniaves, supported by evidence-based
pracces, is the key to success.
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introduction
History of Stafng Challenges & Responses
The challenges associated with stang in the Long-Term Care (LTC) industry are not new. For decades, the alarm
has been sounding about the impacts that stang shortages, impacted by turnover and low recruitment into
healthcare, will have on LTC services and supports in Washington and beyond. The challenges the industry has
faced, and connues to suer through, have directly contributed to the Current State of LTC in Washington and
across the naon. For decades, insucient resources and inconsistent approaches to problems, in Washington
and naonally, addressed in a host of reports have been ineecve and rounely “kicked down the street.” We
are now, ocially, “down the street.”
Across the board in healthcare, stang shortages impact the ability of LTC providers to support persons in need
of care. This aects the ability of acute care providers to transfer paents to post-acute and community long-
term care sengs. For example, if fully staed beds are unavailable in long-term care sengs for individuals
with complex needs, hospitals somemes must keep these paents in more expensive acute care sengs unl
an appropriate placement can be found.
In post-acute and other LTC sengs, extensive and prolonged sta vacancies
leave beds empty and result in delays
for needed services due to an inability to safely and eecvely care for a populaon that is highly vulnerable.
Providers across the connuum of care, including home care providers, must turn away opportunies for care
because they lack the skilled sta needed to properly care for those in need. LTC providers who struggle with
reimbursement rates that fall short of covering the actual costs of labor-intensive care face signicant nancial
losses and, in some cases, permanent closure of services that reduces the availability of needed services and
supports. The loss of post-acute care further exacerbates a situaon that is already crical. The state, and the
naon, cannot aord the reducon in capacity of LTC providers. The lack of an adequately staed, well-trained,
and well-respected workforce is the primary dilemma facing LTC providers. Current eorts by the state are
inadequate to meet demands that are signicantly outpacing caregiver supply at all levels, a problem that has
long been ancipated.
When considering the challenges that have contributed to the stang crisis in LTC, several factors play a role in the
ability to recruit and retain workers. The number of new sta posions that are needed now, and that connues
to grow, pales in comparison to the number of positions that are currently available due to staff
terminations (voluntary and involuntary). Studies in the state looking at frontline caregivers, namely home care
aides (HCAs) and nursing assistants-certified (NACs), have indicated that turnover contributes most to the
projected need for these entry-level staff. Greater than 75 percent of the projected job openings among
the lowest paid LTC workers are the result of separations from LTC providers (Charts U and V, page 32).
High turnover is a serious impediment to providing high-quality LTC services. The Centers for Medicare &
Medicaid Services (CMS) found an annual turnover rate of 52 percent for direct care nursing sta at skilled
nursing facilies (The Naonal Consumer Voice for Quality Long-Term Care, 2022). A study published in the
Journal of the American Geriatric Society found “higher turnover was consistently associated with lower quality
of care,” (Zheng, 2022).
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In addion to direct care workers experiencing high turnover, leadership professionals, such as nursing home
administrators, also leave aer a lile more than a year on average. Burnout, a lack of resources, and diculty
with corporate management were all cited as factors contribung to turnover (The Naonal Consumer Voice for
Quality Long-Term Care, 2022). With high rates of turnover, instuonal knowledge and exisng relaonships
with those receiving care is connually lost, with workers and providers ulmately dedicang more and more
resources on training of new sta.
The queson at hand is this: How does one reduce the turnover rate and recruit new sta? Prevenng turnover
presents a much greater challenge. Turnover is inevitable; family emergencies, beer job opportunies, career
changes, and burnout are only a few of the factors involved. However, turnover can be reduced. There are a
broad range of studies oering evidence of targeted eorts to reduce turnover. Pay and benets, educaon
leading to career growth and advancement, management engagement and interacons, and feelings of job
sasfacon and engagement are contribung factors in the reducon of turnover rates in LTC.
Another factor, inadequate training, not only leads to poor resident outcomes but can contribute to sta
turnover as well. Research conducted by the University Red Cross College of Nursing in Seoul, South Korea in
collaboraon with the University of Maryland School of Nursing in Balmore found that high-quality training
not only reduces sta turnover but leads to higher levels of job sasfacon (Kihye, 2015).
Reducing the turnover rates is crical and requires that employers be able to recognize the workplace signs that
may indicate whether sta will stay or move to other opportunies. A 2016 study published in the Gerontological
Society of America found that certain workplace characteriscs and agency policies were predicve of home
care aide workers employed by licensed/cered agencies leaving their jobs. In contrast, perceived workplace
characteriscs, such as “feeling valued by one’s organizaon,” were highly predicve of intent to stay:
“Job sasfacon, consistent paent assignment, and provision of health insurance were associated
with lower intent to leave the job. By contrast, being assigned insucient work hours and on-the-
job injuries were associated with greater intent to leave the job aer controlling for xed worker,
agency, and labor market characteriscs.” (Stone, 2016).
A qualitave study published in the Journal of Post-Acute and
Long-Term Care Medicine invesgated factors contribung
to turnover. It found that, although wages are important, a
primary factor to reduce turnover is for direct care sta to
feel appreciated, respected, and listened to (Krein, 2022).
This is supported by the lived experience of direct care
workers in Washington.
“You have to talk about wages.
You cannot put food on the table
without it. But it’s also about the
environment. Give us dignity.
We are not ‘just’ CNAs.”
- Narcisa Gacek, Nursing Assistant
(LTC Iniave stakeholder)
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When considering compensaon, esmates suggest that providing direct care workers a 15.5 percent wage increase
towards a ‘living wage’
1
would boost employment in LTC services by 9.1 percent and reduce turnover by 0.7 to
1.7 percentage points on average in the country (Weller, 2020). Although modest, such a reducon in turnover
was projected to increase total producvity by $5.5 billion,
oseng most of the costs of higher pay. Increasing pay in LTC
facilies would also put these venues on a more compeve
foong with other occupaons in allied health.
A unique challenge faced by Washington State is that it boasts
the highest minimum wage in the country. The minimum
wage in the state is also ed to inaon and increases each
year. This makes it dicult for LTC providers to deliver a
compeve wage given current Medicaid reimbursement
rates, for jobs that also require more training than similarly
paid work in other sectors.
Career engagement is also a recurring retenon theme in the professional literature, which stresses the
importance of sta geng to know the resident as a person, including understanding their likes, dislikes, and
preferences, oen referred to as person-centered care. "Consistently communicang resident preferences and
rounes should be a crical component of person-centered care,” (Krein, et al., 2022). However, high levels of
turnover, leading to increased workloads and burnout for incumbent sta, hinder such pracces.
Last, a 2022 Naonal Academies of Sciences, Engineering, and Medicine (NASEM) report found that NAC
empowerment and increased career opportunies also reduce turnover. Research from the University of
California San Francisco found that 59 percent of NACs are people of color, yet the number of people of color
decreases as educaonal requirements increase, such as LPN and RN posions (Bates, 2018). This nding
strongly suggests that addressing recruitment and retenon issues in LTC stang is also an issue of equity.
Steps to Solutions
The professionals that have examined LTC workforce challenges for decades oer a range of potenal soluons.
None of them provide a “magic pill” that will miraculously solve the crisis. They do, however, oer sound
suggesons that may provide some relief to the workforce challenges.
A 2007 report (IFAS, 2007) authored by the Instute for the Future of Aging Services (IFAS) described
the ndings of a coalion of federal, state, and local agencies that examined the LTC workforce and
the challenges facing the industry’s future needs. Much of the informaon in this report is sll very
relevant today. The IFAS report was largely supported by an independent report released by the
Naonal Commission for Quality Long-Term Care (Naonal Commission for Quality Long-Term Care,
“Out of Isolaon: A Vision for Long Term Care in America,” 2006). The IFAS and Naonal Commission
reports largely agreed on three key issues related to the workforce challenges facing the LTC industry:
1
A ‘living wage’ for a single adult in Washington State without children is $19.58 per hour full-me as dened by the MIT Living Wage Calculator.
The Self-Suciency Standard Calculator developed by the University of Washington can be used to calculate a living wage at the county level.
“We need to learn to empower
those doing the actual work. This
industry is carried by those doing
the care work.”
- Misrak Mellsie, Brookdale Senior Living
(LTC Iniave stakeholder)
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1. There is a well-documented shortage of competent professional and parapro-
fessional personnel to manage, supervise, and provide long-term care services in
facility-based and home care sengs—the result of high turnover, large numbers
of vacancies, and diculty aracng new employees.
2. The instability of today’s long-term care workforce has contributed to:
• Service access problems and, in many cases, seriously compromised safety
quality of care, and quality of life for consumers.
• Excessive provider costs due to the need to connuously recruit and train new
personnel and use temporary, higher-cost contract sta.
• Extreme workloads for both nurses and paraprofessional sta, inadequate
supervision, less me for new sta to learn their jobs, and high accident and
injury rates exceeding those in the construcon and mining industries.
3. As a result of growing demand from aging baby boomers and a shrinking of the
tradional caregiver labor pool, the future will be immeasurably worse without
decisive acon by both the public and private sectors (IFAS).
Since the publicaon of the IFAS report, addional unrelated eorts have produced reports drawing similar
conclusions. A 2013 Report to Congress found:
“The issues of service delivery, workforce, and nancing long-term care services and supports
(LTSS) have challenged policymakers for decades. Most individuals who need LTSS receive the
assistance from a family caregiver. Those who need paid LTSS in a nursing home or in their
own home must negoate a complex, patchwork of expensive services. Most individuals and
their families do not have the personal nancial resources needed to pay for an extended
period of assistance and many end up on Medicaid. As a result, federal and state govern-
ments today pay for 62 percent of paid LTSS—over $130 billion a year. The need for LTSS and
the cost to governments will grow drascally over the next two decades with populaon
aging, increasing the already underfunded government health care programs,” (CMS, 2013).
In March 2018, the U.S. Health Resources and Services Administraon published a report focused on the
“direct care” worker, which included NACs, HCAs, personal care aides, and psychiatric assistants. These
occupaons account for 71 percent of the LTC workforce. This report modeled the demand for direct care
workers in the United States through 2030 (using 2015 as a baseline year) and found that demand would
increase by 47.8 percent. However, the report did not aempt to model supply of the direct care workforce
due to the complexity and challenge of forecasng “seng-specic workforce supplies [that are] dependent
on the compeveness of wages, benets, and workplace characteriscs in LTSS sengs, as well as on
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fundamental workforce supply determinants (e.g., number of new entrants to the direct care workforce),”
(U.S. Health Resources and Sevices Administraon, 2018). The conclusion that can be drawn as a result is
that while demand is projected to increase by nearly 50 percent, and an extremely high number of vacancies
and turnover rates connue to plague LTC, if a projecon of the workforce supply were possible there is no
indicaon that it could in any way approach this escalang demand.
Washington Responds to the Challenges
LTC workforce challenges, though much more crical today, are not new. In the early 1980s, faced with a
demographic projecon that the number of Washingtonians over age 65 was poised to double, the state
became an early adopter of new federal opportunies to support people with signicant disabilies in their
homes and other home-like environments. The formula was simple.
People with disabilies, older adults, and their families preferred to receive services in their own homes where
they were close to family, friends, and pets—and where they could live meaningful lives by parcipang in their
communies and in family events. They would be able to maximize their self-determinaon and keep as much
control as possible over the daily decisions that impacted them.
State policymakers and budget writers thus made changes to the law with new budget appropriaons aligned
with what Washingtonians and their families wanted. On average, in-home LTC services and supports were far
less expensive, only requiring intermient support on an “as-needed” basis rather than assuming the cost and
responsibility for around-the-clock care in an instuon when that level of care was not always necessary. This
approach addressed one aspect of the LTC dilemma, but fell short of an adequate soluon over me, especially
as the proporon of those not in the labor force has grown.
In addion to a dwindling workforce, healthcare needs have evolved and expanded. The complexity of the care
and the cost of those services and supports has grown. Home care is typically preferred, but not always feasible
for a variety of reasons. The acuity of care needs, availability of family resources to meet the needs of family
members, access to transportaon to and from care resources, and the ability to care for their loved ones
safely and eecvely must all be considered.
In 1995, Washington’s Legislature recognized the importance of community-based services in a statute that
directed further development of a system of supports that provides choice and exibility paired with reducons
in Medicaid and overall nursing home beds. At that me roughly 53 percent of all individuals receiving Medicaid
funded long-term services and supports received their services in a skilled nursing facility.
This rebalancing of Medicaid-supported care helped the state adopt a primarily “aging at home” model. It was
designed to be a non-medical model, focused rst on the customer’s quality of daily life. The state created
the home care aide posion with a training program and funded the SEIU 775 Training Fund to support the
40,000 independent providers the state would be paying for with home care services. A network of community
trainers was also developed to support training of LTC workers not covered under labor agreements with SEIU
775. Washington was lauded naonally for its model, which proved to lower the cost of LTC, making services
more accessible, with increased sasfacon rangs from customers and family members. Costs were reduced
because the need for skilled nursing care was greatly reduced.
Since that me, mulple governors and many state legislators have supported connual innovaons in law with
appropriaons to create a responsive service delivery system. These responses include a statewide training and
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cercaon for home care aides that is portable across sengs and funding sources. It is the only cercaon
of its kind in the naon (refer to Appendix 1 for a list of innovaons). This program allows workers to begin
work with ve hours of training and then complete the remaining 70 hours of training while they are working.
Most employers pay for the training and the cercaon exam, which is available in 12 languages to reect the
diversity of individuals who make up the direct care workforce.
Washington’s success in this arena has made the state a naonal leader. The Public Health Instute (PHI) has
ranked Washington as #1 in its Direct Care Workforce State Index for its public policies that support direct care
workers and how these workers fare nancially (PHI Internaonal, 2023). A majority, 91 percent of individuals
receiving Medicaid-funded Long-term Services and Supports (LTSS), are served in their own home or community
residenal sengs such as adult family homes, assisted living facilies, and enhanced services facilies (ALTSA,
2023). Three quarters of these individuals live in their own homes. Further, Washington State is consistently
ranked in the top two states by AARP in its scorecard due to its high-performing system of long-term services
and supports (Long-Term Services and Supports State Scorecard).
While the state has a lot to celebrate, in terms of its acons to address issues in LTC workforce recruitment and
retenon, there is sll a long way to go to move Washington from the Current State of LTC (see p. 7) to the Ideal
State visualized by stakeholders.
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project historY and approach
A 2002 report, “Exploring Pathways to Long Term Care Stang Soluons,” prepared by the Alzheimer’s
Associaon in response to the healthcare stang crisis, delivered recommendaons that sll ring true. A similar
stakeholder approach was adopted for previous and current LTC iniaves:
1. Advocates must be informed, smart, and sophiscated.
2. This requires a long-term commitment.
3. The approach must be comprehensive, mul-faceted, and strategic.
4. Advocates must be exible and opportunisc.
5. Coalions are essenal.
6. Workers must be out front and visible.
7. Successful advocacy requires ocial champions.
In Washington State, a 2017 budget proviso directed the Nursing Care Quality Assurance Commission (NCQAC, now
Washington State Board of Nursing or WABON) to convene a LTC Workforce Development Steering Commiee to:
“Assess the need for nurses, including nursing assistants, in LTC sengs, and to make
recommendaons regarding worker recruitment, training, and retenon challenges for long-
term care providers in the sectors of skilled nursing facilies, assisted-living facilies, and adult
family homes,” (Nursing Care Quality Assurance Commission, 2018).
Expanding the LTC workforce is crical to sasfying rising demand for services and supports from a rapidly
aging populaon, but also to sasfy rising demand resulng from policies aimed at addressing the nancial
impact of aging and disabilies on Washington families.
The formaon of the LTC Workforce Development Steering Commiee was in response to strong anecdotal
evidence that LTC sengs were struggling to ll vacancies and retain workers. Career progression within these
sengs was “problemac” and training requirements and regulatory oversight needed an overhaul. The work
of the current LTC Iniave draws heavily from the lessons of this Commiee and those before it.
The NCQAC workgroup succeeded in developing a data catalog encompassing resources from numerous
repositories including workforce data as well as training and tesng data. A preliminary dashboard was also
developed as proof of concept to capture known workforce shortages and ongoing demand for LTC direct care
workers to inform policy decisions. The workgroup acknowledged that gaps in the data exist and that, “Full
integraon of data sources and other work, such as the establishment of data agreements and sustainable
infrastructure for ongoing use, is beyond the scope of the workgroup.”
The workgroup thus recommended that ongoing research is needed to “integrate and validate disparate
data from mulple sources; assure accurate, meaningful interpretaon; and sustain ongoing data collecon
and monitoring of trends over me.” One of the recommendaons of the workgroup was for a dedicated
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posion focused on LTC research. 2022 State funding for the LTC Iniave allowed the hiring of a full-me
Healthcare Senior Researcher at the Workforce Board through FY25, but this is not a permanent posion. Data
-driven soluons indicate the “need for a long-term commitment” and “ocial champions” and make clear
the persistence of the problem. Sll, it remains a sensive and dicult issue that tends to be passed around.
It is me to act. A permanent iniave is needed to make this eort seamless and not subject to the starts
and stops of mulple eorts. These eorts are admirable and necessary, but interrupons slow these eorts,
creang crical me, experience, and nancial losses.
When considering the challenges to stang, the barriers to a stable workforce begin with what are arguably
the most crical caregivers of the direct care LTC sta: HCAs and NACs. The NCQAC workgroup found mulple
barriers to training, such as program variability leading to inconsistent training, high tesng costs, and inadequate
me to complete core competencies. Training modules were outdated, failing to address current needs such
as increasing levels of paent acuity and needs with acvies of daily living (ADLs), and bridge programs for
HCAs to NACs were “ineecve.” More details about how the workgroup addressed many of the major issues
idened in their work can be found in Appendix 6.
This crical group of caregivers, who are also the lowest compensated of the direct care sta, lack clear
opportunies to career advancement. Tradional career growth pathways are oen unaainable to these
vital sta. Work schedules, loss of income, language barriers, and the high cost of addional educaon are
impediments to pursuit of further educaon among these highly talented paraprofessionals. One soluon
came from the observaon that there are no LPN apprenceship programs in the state and the state’s need for
innovave LPN programs to provide more diverse educaon pathways, such as hybrid, registered apprenceship,
and distance learning opportunies.
Bridge programs from HCAs, to NACs, to LPNs, to registered nurses (RNs) were also idened as mechanisms for
enhancing career progression. Further complicang the expansion of educaon pathways and the development
of more innovave training programs are potenal regulatory and oversight barriers, such as approving training
programs, credenals, and instructors.
A 2019 budget proviso (ESHB 1109) reconvened the LTC Workforce Development Steering Commiee to act on
the previous workgroup’s recommendaon from the 2018 report. Priories included:
“Improving the availability and use of workforce-related data; developing a common curriculum for
nursing assistant training; revising tesng for nursing assistants; and recommending requirements to
improve skilled nursing facility stang models and address deciencies in resident care,” (Nursing
Care Quality Assurance Commission, 2020).
The follow-up report, published in October 2020, detailed major outcomes for each legislave charge related to:
Data, Common Curriculum, Tesng, SNF Stang, and an HCA-NAC-LPN Registered Apprenceship Pathway. The
report, prepared by the NCQAC, highlighted the successes of the collaborave; specically accomplishments related
to key challenges that include data collecon and curriculum development. The curriculum accomplishments,
which are signicant and briey described on the next page, are detailed in Appendix 2, along with the group’s
data recommendaons. In addion to idenfying and implemenng soluons related to the data needs of the
eorts, the workgroups made signicant strides in improvements of the curriculum for the caregiver training.
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Impacts of COVID-19 on Long-Term Care Settings
In early 2020, the healthcare industry was taxed to its limits with the rapid spread of COVID-19, with devastang
consequences. Individuals with chronic condions and older adults are especially vulnerable to the virus.
Acute care facilies were overwhelmed and ill-equipped to keep pace with the demands of the pandemic and
experienced signicant losses in sta to resignaons, illness, and death. While acute care experienced horric
condions due to the COVID-19 pandemic, the impact on the LTC workforce was devastang. Pre-exisng
stang challenges would prove to be greatly exacerbated, with catastrophic results. As of October 2020,
“The impact of COVID-19 has been devastang to LTC facilies, their residents, and their
sta. According to a recent report from the Department of Health, approximately 9
percent of total cases and 54 percent of total deaths in Washington have been idened as
associated with a LTC facility (i.e., nursing home, assisted living facility or adult family home),”
(Washington State Board of Nursing, 2020).
In Washington and across the naon, extreme isolaon measures were implemented across LTC facilies, as well
as mandatory quarannes for sta exposed to the virus. Safety protocols and the increased demand for taking
care of sick residents put further stress on direct care workers. According to esmates from the Washington
Department of Health (DOH) and WABON, the state lost nearly 5,000 NACs, or 6.7 percent of the overall NAC
workforce, between January and October 2020 (NCQAC, 2020) . Stang levels sll have not recovered as of the
wring of this report (refer to Chart P: Composion of Nursing Discipline Hours per Paent-Day per Facility in
Washington).
NAC training and tesng processes, which were
conducted in-person, had to be halted as the pandemic
unfolded. At the state level, eorts quickly pivoted to
facilitate a live online model for classroom training
combined with virtual skills pracce and an on-the-job
learning model for clinical training (NCQAC, 2020) to
maintain a steady stream of LTC workers during the
pandemic. However, the tesng process remained
shut down for ve months during the pandemic.
Emergency rules were enacted to extend otherwise
strict cercaon deadlines. As of June 2021, an
esmated 18 months would be needed to test the
5,000 NACs that completed training but had not yet
been tested and cered. In the meanme, NACs that
completed training, but were not yet cered, were
temporarily allowed to work in SNFs past the 120-day
limit for those not yet cered. The Steering Commiee
recommended mass tesng and examinaon events
to tackle the backlog.
Select NCQAC LTC
Workforce Workgroup
Accomplishments
(Curriculum)
Development of a common curriculum
for traditional NAC training programs.
Revamp of the HCA to NAC Bridge
Program.
• Aligns with new NAC training.
• Recommended changes in the bridge
program hours (adopted by the
2021 Legislature).
Testing improvements implemented
from workgroup recommendations.
(for more accomplishments see Appendix 2)
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As the pandemic began to recede, stang across healthcare saw a recovery, except for LTC. Research into pre-
and post-pandemic stang indicated that while most of healthcare had returned to pre-pandemic stang levels,
post-acute care (LTC) is sll struggling to recruit and retain sta needed for direct care and support sta in all
services areas. Further, with the disconnuaon of regulatory waivers and pandemic nancial support from state
and federal sources, LTC providers are forced to cut back services to maintain a quality of care for persons needing
LTC services and supports, which impacts the broader healthcare system through increased hospital ulizaon.
Our Charge:
The Long-Term Care Initiative and Licensed Practical Nurse Registered Apprenticeship
It is abundantly evident that the quality of care provided in LTC sengs
4
is heavily dependent on the workforce.
In Washington State, the LTC workforce is facing signicant challenges related to recruitment, retenon, and job
sasfacon. A study by the Washington State Department of Social and Health Services conrmed that facilies
with higher stang levels had fewer deciencies and beer resident outcomes (Washington State Department
of Social and Health Services, 2019).
To respond to these issues, in a 2021 Long-Term Care Workforce Proposal to the Legislature, Workforce Board
and NCQAC sta wrote:
“The LTC workforce provides essenal services to Washingtonians of all ages, races, and
socio-economic status, and the need for these services connues to rise. Despite this ever-
increasing need for services and the workers who provide them, LTC employers struggle
both to recruit and retain workers, oen cing low wages and stagnant professional growth
opportunies.
There exists an opportunity to make signicant progress in the provision of LTC, as well
increase the recruitment and retenon of quality LTC workers.”
On March 31, 2022, the Washington State Legislature passed ESSB 5693, the state’s operang budget, which
included a budget proviso for the Workforce Board to follow-up and connue the work spearheaded by past steering
commiees. The bill appropriated funding “to conduct health workforce surveys, in collaboraon with WABON, to
collect and analyze data on the long-term care workforce; and manage a stakeholder process to address retenon
and career pathways in long-term care facilies,” (Washington State Legislature, “ESSB 5693,” 2022).
This included funding for the Workforce Board to hire a full-me Health Workforce Senior Researcher through June
30, 2025, in direct response to this need and other research priories, such as monitoring and evaluang programs
and policies designed to address healthcare and LTC stang issues.
In addion, the budget proviso made available funding “for apprenceship grants, in collaboraon with the Washington
State Board of Nursing and the Department of Labor and Industries, to address the long-term care workforce.” The
funding for the apprenceship provided an opportunity to establish alternave pathways to rewarding careers in
nursing, thus opening an addional source of highly trained professional caregivers that are desperately needed now
and for years to come.
2
Long-term care sengs include in-home care, skilled nursing facilies, assisted living facilies, adult family homes, enhanced services facilies
(ESF), and Intermediate Care Facilies for Individuals with Intellectual Disabilies (ICF/IID).
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-Workforce Board and NCQAC
Occupations and Distribution of the Long-Term Care Workforce
As of May 2022, there are an esmated 182,560 direct care workers within the healthcare and social services
sector employed in Washington State according to the Occupaonal Employment and Wage Stascs research
by the US Bureau of Labor Stascs (refer to Charts A and B for the distribuon of direct care workers).
HCAs account for most employment throughout the enre
sector, except for the nursing and residenal facilies sub-
sector—where NACs and HCAs have similar counts.
However, the actual count of direct care workers is much
higher since the available data do not include family and other
caregivers who are providing direct care on an unpaid basis.
According to ALTSA research:
“There are an esmated 850,000 unpaid caregivers
in Washington State. The work of these unpaid care-
givers is valued at $10.6 billion per year. If 1/5 stopped
providing care, [public] LTSS costs would double,”
(Rector and Engels, 2022).
Median earnings for paid LTC work are low. According to the
Washington State’s Oce of Financial Management, per capita
personal income for all Washington adult residents was $67,126
in 2020. The median personal earnings for all direct care workers
in the state was about one-third that, or $24,000 in 2020
(refer to Chart C for Median Earnings of Direct Care Workers
in Washington). For context, at the me of the prinng of this
report, Fall 2023, the minimum wage in Washington State is
$15.74 per hour. This works out to $31,480 in annual earnings
assuming full-me work at 40 hours per week for 50 weeks
per year. It is important to note, as seen in Chart W; page 33,
approximately 30 percent of direct care workers are part-me.
54,420
5,090
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These earnings cause high levels of direct care workers to fall within 200 percent of the Federal Poverty Level
(FPL), (refer to Chart D: Poverty Status of Direct Care Workers in Washington).
Chart C: Median Personal Earnings of Direct Care Workers
in Washington vs. Naon, 2020
Chart D: Poverty Status of Direct Care Workers in Washington, 2020
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200 percent of the FPL for a single individual —about $29,160 as of 2023—is the individual threshold to qualify
for certain social support services and benets (refer to Chart E for the percent of Direct Care Workers Receiving
Public Assistance).
Moreover, about one-third of all direct care workers have at least one child under the age of 18 at home
(refer to Chart F: Parental Status of Direct Care Workers). This may prevent some workers from being able to
work full me or pursue further educaon and training if aordable access to childcare is unavailable.
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Chart F: Parental Status of Direct Care Workers in Washington, 2020
Chart E: Direct Care Workers Receiving Public Assistance in Washington, 2020
About 90 percent of direct LTC workers in Washington have health insurance. More than half receive health
insurance either through their employer or union, with public benets making up another third (refer to Chart
G: Health Insurance Status of Direct Care Workers in Washington).
Although direct care work is far from ‘un-skilled’ labor that requires lile or no training experience for sasfactory
performance, direct care workers’ wages and educaonal aainment do not reect that denion. For example,
63 percent of all direct care workers in the state have either some college, but no degree, or have an associate
degree or higher (refer to Chart H: Educaonal Aainment of Direct Care Workers in Washington). In addion, a
signicant amount of required training is needed to fulll direct care occupaons despite lile to no training or
experience needed for jobs of comparable wages, such as a general laborer, retail/hospitality worker, or farm hand.
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Chart G: Health Insurance Status of Direct Care Workers in Washington, 2020
Chart H: Educaonal Aainment of Direct Care Workers in Washington, 2020
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Access to aordable housing is another challenge the LTC workforce faces, with about one-third lacking such
necessies (refer to Chart I: Direct Care Workers in Washington with Aordable Housing).
The LTC workforce is racially and ethnically diverse, characterized by employing large percentages of women,
people of color, and immigrants. For example, Black or African Americans make up a disproporonate number
of workers in LTC compared to the composion of all workers (aged 18-65) in the state (refer to Chart J: Race
and Ethnicity of All Direct Care Workers vs.Total Workforce in Washington).
Chart I: Direct Care Workers in Washington with Aordable Housing, 2020
Chart J: Race and Ethnicity of All Direct Care Workers
vs. Total Workforce in Washington, 2020
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Over 85 percent of all direct care workers in Washington are female. This rao is very similar across sengs,
with Residenal Care Homes having a slightly higher share of males (refer to Chart K: Gender of Direct Care
Workers in Washington).
More than one-third are immigrants: 19 percent are U.S. cizens through naturalizaon and 15 percent are
non-cizens (PHI Internaonal, 2020). The age composion of LTC workers in Washington is also diverse (refer
to Chart L: Age Composion of Direct Care Workers in Washington).
Chart K: Gender of Direct Care Workers in Washington, 2020
16%
21%
20%
19%
17%
7%
0%
5%
1 0%
1 5%
2 0%
2 5%
1 6- 24 2 5- 34 3 5- 44 4 5- 54 5 5- 64 6 5+
Chart X: Age Composition of all Direct Care Workers in WA State, 2020
Chart L: Age Composion of Direct Care Workers in Washington, 2020
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Nursing Home and Skilled Nursing Facility Stafng Statistics
American Community Survey (ACS) and Bureau of Labor Stascs (BLS) data, the sources from which PHI derives
their stascs presented in charts A through L, are not up-to-date, typically lagging by a year or more, and lacks
crical details concerning characteriscs and condions within facilies. Alternave public use datasets (SNFs
alone) are available from CMS, including data from Cost Reports, Nursing Home Compare, and the Payroll-
based Journal (PBJ). These datasets contain highly granular data related to stang, facility characteriscs, and
resident metrics related to needs and quality care outcomes that are required to be reported to CMS on a
quarterly or annual basis. These data can be used for in-depth facility-level analysis (refer to Appendix 3: Public
Use Datasets from the Centers for Medicare & Medicaid Services on Nursing Homes/Skilled Nursing Facilies).
Researchers at the UW CHWS used the PBJ data to examine the average number of paents, average sta hours,
and the use of contractor stang in Washington nursing homes between 2018 and 2022 as a supplement to
ACS and BLS data for beer understanding broad workforce condions across the state.
SNFs are dierent from other sengs in that they provide both facility-based LTC as well as short-term post-
acute care; nonetheless, these data can be used to make broad inferences about stang across other LTC
sengs (refer to Appendix 4 for a table with PBJ data).
Across Washington’s 39 counes, there are 218 total nursing homes/SNFs. Yet of Washington’s 29 rural counes,
nine counes do not contain any nursing homes/SNFs (refer to the map of Washington with SNF counts by
county below, and Appendix 5 for the number of nursing homes/skilled nursing facilies in Washington).
Washington’s Nursing Home/SNF Counts by County, 2022
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Between Q1 2018 and Q1 2021, the average total paent census in Washington nursing homes/SNFs,
including both long-stay residents and short-stay post-acute paents, declined from an average of 76 paents
to 62 paents. This decline is most apparent beginning Q1 2020 – the beginning of the COVID-19 pandemic.
Throughout 2021 and into 2022, the average census has uctuated. As of the latest data from Q3 2022, the
average total paent census was 65 paents (refer to Chart M: Nursing Home Census for Washington).
During this same me frame, the total average sta hours per nursing home/SNF for both nursing (RNs, LPNs,
and NACs) and non-nursing disciplines also declined (refer to Chart N: Average Skilled Nursing Facility Stang
Hours per Facility in Washington).
0
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Average Hours per Facility
Chart X: Average Skilled Nursing Facility Staffing Hours per Facility in
Washington
COVID-19 Emergency Order All Nursing Discipline Hours
All Non-Nurse Discipline Hours
Chart N: Average Skilled Nursing Facility
Stang Hours per Facility in Washington
Chart M: Nursing Home Census for Washington State, 2020
0
10
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Chart X: Nursing Home Census for Washington State, 2022
COVID-19 Emergency Order Washington State
Urban Washington Rural Washington
Chart M: Nursing Home Census for Washington
Q1 Q2 Q3 Q4
Q1 Q2 Q3 Q4
Addionally, average per-paent stang hours of non-nursing disciplines (e.g., administrave sta, nursing home/
SNF leadership, acvites sta, social works, etc.) remained stable unl Q1 2021, aer which the average hours
declined (refer to Chart O: Average Skilled Nursing Facility Stang Hours per Paent-Day per Facility in Washington).
When accounng for the average total paent census, the per-paent nursing discipline sta hours have
remained stable. Even if overall nursing discipline sta numbers have declined, the number of hours nursing
sta have worked with paents has not declined due to a decreased average total paent census.
This presentaon of the aggregate data (for nursing) hides a key fact–the composion of nursing sta has
changed.
These counts should hopefully return to pre-pandemic levels assuming increased
numbers of nursing aides in training
5
are enough to eventually oset the decline. Current hours per paent
day for nursing aides in training is 0.11 hours below the necessary hours to replace separated NACs, which is
equivalent to a 12 percent reducon in sta hours. Moreover, pre-pandemic levels of NACs were insucient
for Washington to realize its vision for ideal LTC services and supports, and NAC demand is expected to increase
further (refer to Chart P: Composion of Nursing Discipline Hours per Paent-Day per Facility in Washington).
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0
1
2
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Chart X: Average Skilled Nursing Facility Staffing Hours per Patient-
Day in Washington
COVID-19 Emergency Order
All Nurse Discipline Hours per Patient-Day
All Non-Nurse Discipline Hours per Patient-Day
Chart O: Average Skilled Nursing Facility Stang Hours
per Paent-Day in Washington
3
An individual who has not completed an approved nurse aide training course and competency evaluaon and is demonstrang knowledge, while performing
tasks for which they have been found procient by an instructor. These tasks shall be performed under the direct supervision of a registered nurse.
Q1 Q2 Q3 Q4
Page 29
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
When comparing urban and rural nursing homes/SNFs, both nursing and non-nursing sta hours are lower
in rural areas. Rural nursing homes/SNFs were not signicantly more impacted by stang declines during the
COVID-19 pandemic; rather, all facilies experienced similar paerns of stang declines between Q1 2018 and
Q3 2022 (refer to Chart Q: Urban and Rural Average Sta Hours per Facility in Washington).
0
0.5
1
1.5
2
2.5
3
2018
Q1
2018
Q2
2018
Q3
2018
Q4
2019
Q1
2019
Q2
2019
Q3
2019
Q4
2020
Q1
2020
Q2
2020
Q3
2020
Q4
2021
Q1
2021
Q2
2021
Q3
2021
Q4
2022
Q1
2022
Q2 2022
Q3
Average Hours per Patient-Day
Chart X: Composition of Nursing-Disipline Staff Hours per Patient-Day
per Facility in Washington
COVID-19 Emergency Order Registered Nurses Licensed Practical Nurses
Certified Nursing A ssistants Nurse Aides in Trai ni ng
0
50
100
150
200
250
300
350
400
2018
Q1
2018
Q2
2018
Q3
2018
Q4
2019
Q1
2019
Q2
2019
Q3
2019
Q4
2020
Q1
2020
Q2
2020
Q3
2020
Q4
2021
Q1
2021
Q2
2021
Q3
2021
Q4
2022
Q1
2022
Q2 2022
Q3
Average Hours per Facility
Chart X: Urban and Rural Average Staff Hours per Facility in
Washington
COVID-19 Emergency Order All Nursi ng Dis cip li ne Ho urs (Urban)
All Non-Nurse Discipline Hours (Urban) All Nursi ng Dis cipline Hours (Rural)
All Non-Nurse Discipline Hours (Rural)
Chart Q: Urban and Rural Average Sta Hours per Facility in Washington
Q1 Q2 Q3 Q4
Q1 Q2 Q3 Q4
Chart P: Composion of Nursing-Disipline Sta Hours
per Paent-Day per Facility in Washington
There was a large increase in contractor stang starng in Q3 2020, likely because of nursing homes/SNFs
using contractors to oset NAC declines to maintain compliance with direct care hours per paent regulaons.
Contractors were also used to supplement non-nursing sta hours. The average contractor hours per facility for
nursing disciplines increased from 8.9 hours per day in Q1 2018 to 27 hours per day in Q3 2022. In comparison,
non-nurse contractor sta hours declined from an average of 22.8 hours per facility per day in Q1 2018 to
12.8 hours per facility per day in Q3 2022. Filling stang gaps with temporary employees, such as contractors,
is typically far more expensive, pung further upward pressure on facility costs (refer to Chart S: Average
Contractor Stang Hours per Facility in Washington).
Per-paent stang is sll lower in rural facilies, but stang disparies between urban and rural facilies are
smaller when accounng for the average total paent census (refer to Chart R: Urban and Rural Sta Hours per
Paent-Day per Facility in Washington).
0
1
2
3
4
5
2018
Q1
2018
Q2
2018
Q3
2018
Q4
2019
Q1
2019
Q2
2019
Q3
2019
Q4
2020
Q1
2020
Q2
2020
Q3
2020
Q4
2021
Q1
2021
Q2
2021
Q3
2021
Q4
2022
Q1
2022
Q2
2022
Q3
Average Hours per Patient Day
Chart X: Urban and Rural Average Staff Hours per Patient-Day per
Facility in Washington
COVID-19 Emergency Order
All Nurse Discipline Hours per Patient-Day (Urban)
All Non-Nurse Discipline Hours per Patient- Day (Urban)
All Nurse Discipline Hours per Patient-Day (Rural)
All Non-Nurse Discipline Hours per Patient- Day (Rural)
Chart R: Urban and Rural Sta Hours per Paent-Day per Facility in Washington
Q1 Q2 Q3 Q4
Page 30
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
Page 31
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
These contractor stang trends were similar in rural and urban nursing homes/SNFs, with increases in
contract hours for nursing disciplines and decreases for non-nursing disciplines. Compared to in-house sta,
the percentage of hours paid to contractors was similar for urban and rural nursing homes/SNFs, and both
urban and rural nursing homes/SNFs had similar paerns of increasing percentages of nursing contractors and
decreasing percentages of non-nursing contractors (refer to Chart T: Urban and Rural Percent of Sta Hours
Paid to Contractors per Facility in Washington).
0
5
10
15
20
25
30
35
2018
Q1
2018
Q2
2018
Q3
2018
Q4
2019
Q1
2019
Q2
2019
Q3
2019
Q4
2020
Q1
2020
Q2
2020
Q3
2020
Q4
2021
Q1
2021
Q2
2021
Q3
2021
Q4
2022
Q1
2022
Q2
2022
Q3
Average Hours per Facility
Chart X: Average Contractor Staffing Hours per Facility in Washington
COVID-19 Emergency Order Total Staffing Hours - All Nursing Disciplines
Total Staffing Hours - Non-Nursing Disciplines
Chart S: Average Contractor Stang Hours per Facility in Washington
0%
5%
10%
15%
20%
25%
30%
35%
40%
2018
Q1
2018
Q2
2018
Q3
2018
Q4
2019
Q1
2019
Q2
2019
Q3
2019
Q4
2020
Q1
2020
Q2
2020
Q3
2020
Q4
2021
Q1
2021
Q2
2021
Q3
2021
Q4
2022
Q1
2022
Q2
2022
Q3
Percent of Staff Hours
Chart X: Urban and Rural Percent of Staff Hours Paid to Contractors
per Facility in Washington
COVID-19 Emergency Order
Pe rcent Contrac tors - A ll Nur sin g Di sci pl ines ( Urb an)
Pe rcent Co ntractors - No n- Nurs ing Di sci pl ine s (Ur ban)
Pe rcent Co nt rac tors - A ll Nursin g Di sci pl in es ( Rural )
Pe rcent Co ntractors - No n- Nurs ing Di sci pl ine s (Rural )
Chart T: Urban and Rural Percent of Sta Hours
Paid to Contractors per Facility in Washington
Q1 Q2 Q3 Q4
Q1 Q2 Q3 Q4
Page 32
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
Average sta hours per nursing home/SNF for NACs declined during the COVID-19 pandemic while hours for
LPNs and RNs were stable and hours for nursing aides in training increased slightly. When examining these
three primary nursing disciplines by urban versus rural counes, sta hours were lower for all disciplines except
for nursing aides in training in rural nursing homes/SNFs compared to urban nursing homes/SNFs.
The impact of the pandemic thus put further stress on LTC workforce hours, which is simultaneously facing
increased levels of demand given an aging populaon.
Projected Workforce Demand
Occupaon projecons of LTC openings are developed by the U.S Department of Labor (DOL) at the naonal
level, and by the Washington State Employment Security Department (ESD) at the state level. These projecons
are dened by the Standard Occupaon System and based on industry employment esmates within the North
American Industry Classicaon System (NAICS) taxonomy.
The LTC sector is expected to experience substanal demand growth between 2025 and 2030. For all direct
care workers, the total number of expected openings during this period is 176,000—a 23 percent increase.
However, only 13 percent of total openings are expected to be from growth. The remaining 87 percent of
openings are predicted to be from turnover.
The fastest growing occupaons are esmated to be HCAs, reecng a trend towards community health and
aging in place. The need for NACs will grow substanally as well (refer to Charts U and V for projected job
openings in Washington).
Between 20 percent and 30 percent of the LTC workforce are unable to work full-me due to economic reasons,
dened as business condions at individual workplaces or condions within the broader labor market. Non-
economic reasons include personal or family obligaons and health problems (refer to Chart X: for Employment
Status by LTC Occupaon). These issues could be improved with investments into Medicaid reimbursement
rates or programs for employers to beer support their sta as referenced in Recommendaon 7.
17,460
103,340
Projected Job Openings in WA
State: Home Health and Personal
Care Aides, 2020 - 2030
Job Openings Due to Growth
Job Openings Due to Separations
4,860
50,340
Projected Job Openings in WA
State: Nursing Assistants, 2020 -
2030
Job Openings Due to Growth
Job Openings Due to Separations
Chart U: Projected Job Openings in Washington;
Home Health and Personal Care Aides, 2020-2030
Chart V: Projected Job Openings in Washington;
Nursing Assistants, 2020-2030
Page 33
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
WABON provides a comprehensive data dashboard that tracks training, licensing, and credenaling outcomes
for nursing educaon across 79 programs at 41 colleges or universies in Washington State. The 2021-2022
academic year produced 4,578 graduates in various nursing disciplines with a student body of 10,186 pupils
instructed by 1,670 faculty members (Washington State Board of Nursing, 2023).
WABON has not historically tracked the number of graduates from NAC training programs but has tracked the
number of test-takers as a proxy. Beginning in 2024, WABON will begin collecng data regarding the number
of graduates from nursing assistant training programs and include them in the data dashboard. The Workforce
Board collects data on graduates of many NAC training programs through its oversight of private career
schools and Workforce Innovaon and Opportunity Act (WIOA) monitoring of community and technical college
programs; however, these data do not capture graduates from other types of NAC training programs oered in
facilies for their employees. In 2022, the Washington State Department of Health (DOH) granted 6,146 nursing
assistant cercaons. Of these, the Bureau of Labor Stascs (BLS) esmates 50.5 percent work in nursing
and residenal care facilies, while the other half mostly work in hospitals and ambulatory health care services
– sectors that tradionally pay higher wages. Between 2019 and 2022, there were 22,325 nursing assistant
cercaons, or about 5,581 per year on average, with 2,818 esmated to work in LTC sengs. However, with
the high rates of turnover, among a workforce with many who cannot work full me (because of disabilies,
family obligaons, etc.), simply training to the gap number is not sucient to stabilize the stang crisis.
A signicant poron of the LTC workforce—between 20 percent and 30 percent—are unable to work full-
me due to economic reasons, dened as business condions at individual workplaces or condions within
the broader labor market. Non-economic reasons include personal or family obligaons and health problems,
presenng yet another boleneck to adequate stang (refer to Chart W: Employment Status for Direct Care
Workers in Washington). These issues could be improved with investments into Medicaid reimbursement rates
or programs for employers to beer support their sta as referenced in Recommendaon 7.
64%
78%
76%
69%
5%
4%
3%
4%
31%
17%
21%
27%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Home Care Residential Care Homes Nursing Homes All Direct Care Workers
Chart X: Employment Status for Direct Care Workers in WA State,
2021
Full-time Par t-ti me, Non-e co nomic Reasons Par t-ti me, E cono mic Reasons
Chart W: Employment Status for Direct Care Workers in Washington, 2021
Page 34
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
project spotlight
The Long-Term Care Workforce Initiative
The LTC Iniave is idenfying the root causes of the LTC workforce shortage in the state and is developing
collaborave strategies to overcome these shortages. The Iniave’s mulpronged strategy for addressing
the challenges in LTC includes establishing a Leadership Team to guide the complex eorts of this iniave.
The convened Leadership Team includes representaon of state agencies, direct care providers, educaon
professionals, labor organizaons, LTC advocates and providers, and the business community.
Beyond the Leadership Team, a broad range of professionals have parcipated as stakeholders in larger group
meengs. These stakeholders include LTC sta, facility owners, WABON, hospital groups, labor unions, educators
(secondary, postsecondary, private training facilies), and researchers. The purpose of LTC Iniave meengs is
for stakeholders to idenfy ongoing strategies, recognize opportunies for collaboraon that have potenal for
success, and cra policy recommendaons to be presented to policymakers in this, the rst of three annual reports.
This preliminary report will serve as a ‘roadmap’ for the next two reports and includes a synthesis of stakeholder
feedback on LTC workforce priories, inial research ndings, and next steps for follow-up research, such as
quantave analysis and key informant interviews performed by the UW CHWS. In addion, the LTC Iniave,
in collaboraon with stakeholders, will idenfy key performance metrics to monitor and evaluate programs and
policies designed to address the LTC workforce crisis.
Initiative Strategies
The inial eort of this Iniave is built around a series of stakeholder engagement meengs that began in
October 2022 on a recurring monthly basis. The meengs served to gather input regarding the history and
current state of the LTC workforce from those with the most experience and interest in the issue across the
state (refer to Aachment B for a list of stakeholders and organizaons parcipang in these meengs). A total
of 14 meengs have been held as of the wring of this report, including six subcommiee meengs focused on
three specic, yet interrelated, topics within the LTC workforce: 1) Educaon and Career Pathways; 2) the LTC
Ecosystem; and 3) Human Resources and Worker Support.
These three topic areas were priorized through two surveys and the results reported in this document.
The rst of the two surveys asked the LTC Iniave’s Leadership Team to idenfy the ’Ideal State’ of LTC in
Washington, the ‘Current State’ (prevenng Washington from realizing its vision of the ‘Ideal State’) and known
LTC workforce issues. The results, while not unexpected, clearly idenfy the challenges.
There is a wide gap when one considers where LTC services are—the Current State—and where they want to be,
the Ideal State, in Washington. Stakeholders worked to dene these two states, along with problem statements
and barriers that constute the gap between vision and reality, and to develop policy recommendaons meant
to help move us from the Current to the Ideal. Survey responses from LTC professionals revealed their views of
the two states and the exisng gap.
Page 35
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
The Ideal and Current State of Long-Term Care in Washington
The Ideal State
Stakeholders dened the Ideal State aer a series of meengs and a survey distributed to LTC Iniave
leadership, resulng in the following vision statement:
“A high-quality system of coordinated long-term care support services that provide accessible
choices in care sengs. A regulatory environment that encourages collaboraon and support
while sll maintaining the focus on paent safety. A well-trained, equipped, and respected
sta who provide quality, empathic care in a stable, nurturing work environment, supported
by access to comprehensive career pathways, lifelong learning opportunies, and recognion
of the value and skills provided by the direct care workforce.”
Career
Pathways
Sufficient
Staffing
Nurturing
Work
Environment
Trained and
Well
Equipped
Caregivers
Regulatory Framework
Improve Public Percepon of Aging & Long-Term Care
Page 36
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
Limited choice of
nearby, quality &
affordable settings
Insufficient
Funding
Non-Competitive
Wages & Benefits
Staffing &
Caregiver
Shortages
Rapidly Aging &
Increasingly
Morbid Population
Overworked Staff
& Caregiver
Burnout
Difficult to
Navigate System
THE CURRENT STATE
Negative Stigma of
Long-Term Care
The Current State
Through the same approach, the group also worked on idenfying numerous and interrelated challenges
prevenng the Ideal State from being realized. These challenges can be expressed in the following conceptual
framework:
Given the challenges facing LTC services in the state, the
LTC Iniave began a systemac priorizaon of the needs
of the industry and started exploring ways to alleviate the
crisis projected to present signicant ongoing problems
into the foreseeable future.
A second follow-up survey was sent to a broader audience
of parcipants, asking them to weigh in on the vision
statement of the Ideal State and the Current State of
LTC, to triage priority issues prevenng Washington from
realizing its vision of LTC, and to idenfy any other maers
not idened by the Leadership Team.
The follow-up survey had 246 respondents, 42 percent of
whom worked in LTC sengs. The composion of respondents working in LTC sengs is contained in Table 1.
Respondents not working in LTC sengs were predominantly in government (65 percent), healthcare (10
percent), educaon (7 percent), and other (18 percent).
Other occupaons included legal services, community-based organizaons, and social services. The follow-up
survey also asked respondents to idenfy how many years of experience they’ve had in their respecve elds.
Please refer to Table 2.
Page 37
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
Overall, the second survey captures a diverse view of the
respondents in terms of occupaonal roles, sengs, and
years of experience.
A 4-point Likert scale was used to gauge the respondents’
senment on the Ideal State developed by the Iniave’s
Leadership Team (strongly agree, agree, disagree, and
strongly disagree).
In the survey, 91 percent of the respondents either strongly
agreed or agreed, with 50 percent strongly agreeing.
Respondents from LTC sengs mirrored the senment of
total respondents.
Similar senment was observed for the Current State, in
which 88 percent of respondents either strongly agreed or
agreed (56 percent strongly agreed). Respondents from LTC
sengs were more in agreement, with 63 percent strongly
agreeing and 28 percent agreeing with the Current State.
Finally, respondents were asked to select the top three barriers to a stable LTC workforce. These barriers were
inially idened in earlier stakeholder meengs as well as the rst survey (in no parcular order):
• Negave percepons of LTC
• Insucient qualied sta
• Insucient career development
• Insucient training opportunies
• Inadequate pay and benets
• Recruitment and retenon
• Burnout
• Challenges related to regulatory oversight
• Compeon between facilies
• Credenaling failures
• Other
Total response count for the respondents selecng the top three barriers was 199 and accounted for 74 percent
of all selecons (refer to Chart X for Top Three Barriers to a Stable LTC Workforce, all respondents).
Inadequate
pay and
and
Responses to selecng the top three barriers somewhat dier depending on whether respondents work in LTC
sengs (refer to Charts Y and Z for Top Three Barriers to a Stable LTC Workforce, LTC vs non-LTC respondents).
Although the top two barriers are the same between LTC and non-LTC respondents, LTC respondents idened
recruitment and retenon as a higher priority barrier than negave percepons of LTC (refer to Charts Y and Z
for survey responses).
Stakeholders then rened the denion of the Current State into the following statements:
“LTC providers in Washington are struggling. Current caregivers are emoonally and physi-
cally taxed. While Washington has specic training regulaons in place, the industry faces
connued challenges with training and tesng delivery. Exisng sta shortages, inexible work
environments, insucient Medicaid reimbursement rates, low pay and benets, a lack of
acknowledgement of direct care workers as a crical part of the healthcare delivery system
and the impacts of regulatory oversight that can feel punive rather than soluons-focused all
contribute to the issues impacng the LTC workforce.
Services are oen delayed and/or are not available in a customer’s chosen form (e.g., home care
vs. facility care). Yet, when and where care services are available, Washington’s LTC provider
community connues to oer a range of care opons supported by a professional workforce
that is engaged and commied to providing quality services. Facilies, agencies, and caregivers
provide compassionate, skilled care, oen through innovave programs for their sta as well as
those receiving care.”
The ndings concerning the Current State from these stakeholder surveys are aligned with the ndings of past
research eorts and are further supported by empirical evidence.
Page 38
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
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Page 39
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
project spotlight
Licensed Practical Nurse Registered Apprenticeship for Long-Term-Care Settings
The second LTC iniave is a connuaon of the development and implementaon of the HCA/NAC to LPN
Registered Apprenceship Program. This eort builds on the previous work of WABON in 2021-22 that created
a coalion, idened early adopters and program testers, and provided a dra plan for the development of the
program. There has been signicant progress on this project. One of the most tangible indicators of progress
are the NACs and HCAs currently working on their prerequisite courses in ancipaon of subming their
applicaon to the LPN Registered Apprenceship Program for Fall 2024.
The program has shown signicant progress as the rst year of the Workforce Board’s management of state
funding ends. Under the guidance of the Workforce Board, WABON, and LNI, the stakeholders in the program’s
development connue to push towards a Fall 2024 launch date for the rst apprences. In addion to the three
state agencies, three employers (Pennant, Hya Family Facilies, and Brookdale), and two community colleges
(Edmonds College and Yakima Valley College) have commied signicant me and resources to this project.
A high-level view of the key features of the pilot model includes:
• The pilot model requires students to complete the required prerequisite coursework before
applying to enter into the apprenceship pilot.
• Students must successfully complete the prerequisite coursework and be accepted into the
praccal nursing program prior to acceptance into the pilot as an apprence.
• Prospecve apprences meet the same standards for acceptance into the praccal nursing
program as other students.
• Once they are accepted into the praccal nursing program and the apprenceship pilot, they can
begin their journey to “earn while they learn.”
• The pilot is based on a part-me LPN program model and provides nancial support with tuion,
books, and other needs—all of which are intended to support a reasonable balance of school and
work hours for students. This means students work part-me and go to school part-me as they
complete their nursing educaon program. They do work full-me in the summer months when
classes are out.
• When students begin the praccal nursing program, their work role is that of a nursing assistant.
Aer they successfully complete their rst term that includes a clinical rotaon, students in good
standing in the nursing educaon program may apply to work in the role of a praccal nursing
technician in the nursing home where they are employed. The praccal nursing technician works
under the direct supervision of an RN who is immediately available, in accordance with RCW
18.79.350.
• While the pilot allows students to complete a poron of their clinical hours in the nursing home
where they are employed, students in the pilot sll need to complete addional clinical hours in
other clinical sengs, just like all students in the praccal nursing program. This plan is crical
Page 40
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
for meeng the requirements of WAC 246-840-537 (Curriculum for approved nursing educaon
programs) and WAC 246-840-539 (Curriculum for praccal nurse nursing educaon programs),
which supports our vision for graduates of the pilot meeng all the same standards for nursing
educaon and nursing pracce as other praccal nursing graduates.
Program accomplishments include:
1. A total of 37 HCAs/NACs are currently enrolled in prerequisite coursework.
2. Edmonds College has successfully led a group of nursing educators in the development of a hybrid
LPN curriculum. This hybrid program will serve as the nursing curriculum ulized for the LPN
Registered Apprenceship Program. This hybrid curriculum will serve as the nursing curriculum
for the apprenceship coursework in 2024.
3. Three employer partners, represenng facilies all over the state, are acvely engaged in the
program development and are supporng their sta as they pursue addional educaon with
the goal of entering the LPN hybrid program.
4. The Workforce Board hired and trained two Apprenceship Navigators who support the HCA/
NACs currently enrolled in prerequisite coursework at the community colleges.
5. As part of the federal HRSA grant, (more on page 41) the Merit Group is working with the partners
on customizaon for a digital wallet. The wallet will oer a process for the parcipants to track
their progress and credenals.
6. A solicitaon process has selected the Washington Health Care Associaon, a nonprot LTC
industry associaon, to act as the apprenceship sponsor. The sponsor will manage the daily
operaon of the apprenceship program.
While an extensive amount of progress has been made, much remains to be completed before the rst
apprences begin the formal nursing program educaon and on-the-job training component in Fall 2024, as
well as building enough capacity across the program aspects to ensure sustainability aer the state funding
ends (see Recommendaon 1, on page 46). A great deal of interest in the program has been expressed across
the state from employers, educators, and potenal apprences alike. The program developers have received
inquiries from HCAs and NACs regarding the general availability of opportunies for enrollment as apprences.
One such inquiry led to conversaons between the Washington Department of Veterans Aairs (DVA) and the
Workforce Board regarding a potenal partnership in the development of an LPN Registered Apprenceship in
the four DVA nursing homes in the state. In January 2023, the Workforce Board entered into discussions with DVA
leadership to explore an opportunity to pilot a registered apprenceship program within one of the four homes.
Although the DVA registered apprenceship and the private employer registered apprenceship may develop
along similar lines, it was determined that public and private employers were structured dierently enough to
require separate programs. The DVA program will be disnct from the eorts with the private employers but
Page 41
Washington Long-Term Care
Workforce Iniave Legislave Report
Workforce Board, Fall 2023
will draw from the experiences of that eort. Having two LPN
apprenceship models will broaden the applicability of the
programs to a variety of potenal employers.
With guidance and funding support of the Workforce Board,
WABON, and LNI, DVA has recruited and hired a Program
Navigator to lead an exploratory eort to examine the
potenal for establishment of an independent, yet parallel,
Registered Apprenceship Program. DVA is working to
develop a new job classicaon for their facilies – nursing
technician. This classicaon already exists within the private
facilies. The nursing technician classicaon is a key step
in the transion into LPN and ensuring wage growth for
apprences.
DVA received nancial support for the exploratory poron
of this project from the Workforce Board. Students will start
prerequisites at Olympic College in the Fall of 2023. DVA has
already begun receiving inquiries from their sta about the
program and are enthusiasc about this opportunity. These
eorts were further recognized when DVA was awarded a
federal Department of Labor grant administered by LNI in
August of 2023 for the development of the LPN registered
apprenceship, complemenng the work already done in the
exploratory eort.
Project Partners
The success of this program will depend upon the partners
and their diverse contribuons. In addion to the support
and guidance of the state agency partners and sta, the
program’s development depends upon the contribuons of
educaon instuons, the employers in the development
partnership, and the apprenceship sponsor.
: In 2022, Congressional funding was secured by U.S. Senator Pay Murray and U.S.
Representave Dan Newhouse for the development of an NAC/HCA to LPN Registered Apprenceship in the
state. The Health Resources Service Administraon (HRSA) disbursed the funds to Yakima Valley College (YVC)
as the Administrator of the funds. Working with Edmonds College, the employers, and state agencies, Yakima
Valley College, in their role as grant administrator, play a key support role in the connuing development of the
apprenceship program.
From the onset, YVC’s role provided vital contribuons to program’s growth and development. YVC’s primary
contribuon has been the management of the federal funding, establishing parameters for the disbursement
of funds to partner agencies and HCA/NAC students who are acvely engaged in prerequisite coursework, and
enrolling students in prerequisites. The support provided by YVC came despite challenges to stang that arose
as the grant was inially awarded. YVC’s management of the $1.7 million federal funding provided key nancial
The Path to Registered
Apprenticeship
Working with an LNI
Apprenticeship Consultant, the
program sponsor and the
Apprenticeship Committee will
develop a set of Apprenticeship
Standards to govern the program.
These Standards and the
educational curriculum must be
approved by the Washington State
Apprenticeship and Training
Council (WSATC) in order for the
program to become a Washington
State Registered Apprenticeship.
The rst year of the program is a
provisional year, after which LNI
Apprenticeship will conduct a
compliance review and WSATC will
determine whether or not to grant
permanent registration status to the
program.
The anticipated timeline is to apply
for provisional WSATC approval
in April 2024 and to start the ap-
prenticeship, including the hybrid
nursing program through Edmonds
College, in Fall 2024.
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support to the program components contributed by YVC and the partners. The college’s support of the program
and grant administraon will allow other NACs and HCAs to enter the career pathway into the future.
: Edmonds oers a well-established nursing program designed for working healthcare
professionals to connue their educaon. Utlilizing a hybrid curriculum allows students to aend online lectures
while sll maintaining their employment as LTC workers.
The proposed LPN Registered Apprenceship curriculum through Edmonds College follows the same successful
hybrid model as Edmonds’ exisng nursing program, but the key dierence is that some of their clinicals will
be done in the same LTC facilies where student apprences currently work. Student apprences can connue
their jobs, but as they progress through the program and become a nursing technician, they can expand their
scope of pracce, applying skills as they learn, with appropriate clinical supervision and preceptorship.
The apprenceship model opens the door to employees with the potenal to be excellent LPNs who would not
otherwise have the resources to aend a tradional nursing program. Many of these employees have never
parcipated in a tradional college program. Many migrated
to this country and speak English as a second language. A large
percentage have young children to care for, and some are
already working over 60 hours per week to make ends meet.
However, the apprenceship program’s employment and
educaonal standards are high. Potenal apprences must be
nominated by their LTC employers and apply to the program
to be considered for the LPN Registered Apprenceship. An
Apprenceship Commiee, composed of equal numbers of
employer and employee representaves will select the HCAs
and NACs from sta who meet program qualicaons.
Edmonds sta have taken the lead to develop plans for the
apprenceship curriculum, skills labs and simulaons, and
prerequisite navigaon, with a goal of formal admission to
a pilot program beginning in Fall 2024. As part of the HRSA
grant, the faculty developed a hybrid curriculum with an
online didacc component, which has been approved by WABON. The development of the online didacc
curriculum—combined with the development of four simulaon skills labs in LTC facilies in the state—will
allow apprences to complete their educaon “in place” from mulple areas across the state with strong
support from on-site preceptors and college faculty via live-streaming video. The online curriculum will be
available as an open educaonal resource through the State Board for Community and Technical Colleges,
which could support scaling of the program to other colleges in the state.
The rst group of students admied to the pilot LPN Registered Apprenceship Program are projected to begin
in Fall 2024. Workforce Board sta, agency partners, the sponsor, researchers, and the college faculty will
analyze the success of the program.
The goal of the Apprenceship Program is for LTC employers to have beer access to increase the number
of qualied nurses and incenves for recruing direct care workers. This will help save on turnover costs
and generate improved quality care outcomes. Employees will receive higher wages, career progression, and
recognion. Ulmately, the program oers job choices to a group of caregivers who might not otherwise get
“It’s a real win-win. Students win
with on-the-job training hours
and higher pay as they progress
to become nurses. Facilities
win because they get to retain
their employees who continue
to increase their skill levels with
what they’ve learned in school.”
- Kyra McCoy
Director of Nursing, Edmonds College
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the chance to move forward in their career. The signicance of this program is summed up nicely by the Director
of Nursing at Edmonds College, Kyra McCoy:
“Our students are rst generaon—the rst people in their enre family to ever go to college.
These are people who have been told ‘no’ all of their lives. Either their English was not good
enough, or they didn’t have the right credenals, etc., etc. But with this program, we are able to
tell them ‘yes, you CAN do this—and we will help.’
We’re diversifying our workforce and improving our stang shortages while liing everybody up.”
Navigator Impact
The success of the apprenceship is directly linked to the success of the students. Providing connecons
to support services and guidance throughout the program (prerequisites and Apprenceship) is the
responsibility of Apprenceship Navigators. The Navigators
are Workforce Board sta members Rebecca Adams and
Erica Wollen. Both Navigators bring passion, enthusiasm, and
experience as they provide guidance to the HCAs and NACs.
Navigators are an integral part of the LPN Registered
Apprenceship Program. This direct support can make a profound
impact on students. Aer a relavely short me in the program,
they are already seeing the posive results.
Wollen admits that somemes something as simple as forwarding
an email to the right person can go a long way. But others need
considerably more help.
Both Navigators point out that the job is a series of ongoing
challenges —some mundane, others extraordinary. The challenges
range from conducng an orientaon to the acvies related to
enrollment and course selecon. However, as evidenced below,
the navigators and students have worked hard to overcome
these challenges.
In March, one of the students enrolled in prerequisite coursework
shared her story with Governor Inslee on TVW. See how Dulce
Brambila, a NAC at Pennant Healthcare Washington and a student
going through prerequisites at Edmonds College, represents the
challenges for the state’s NACs struggling to improve their lives
and provide for their families (me code 34:40).
“I want to be able to provide
resources during the application
process, set up placement
tests, ne tune schedules, help
students nd childcare, gure out
transportation—whatever it takes
to get them through school.”
- Rebecca Adams
Workforce Board
“There are a lot of little things
we do to help our students but
keeping them encouraged is
most important to me.”
- Erica Wollen
Workforce Board
-Kyra McCoy, Edmonds College
Employer Contributions
When employers support employees furthering their
educaon, both pares’ benet. Not only do employees get
opportunies they would not have otherwise, but they build
condence and skills that they can use to level up their careers
and give back to their employers for believing in them. The
employer contributors to the LPN Registered Apprenceship
have done just that. By taking the innovave step of adopng
a registered apprenceship in their workplace, a world of
opportunity opens for direct care workers, and they feel
supported and encouraged to do something they never
thought possible.
Key partners in the LPN Registered Apprenceship Program
are the LTC employers who are dedicang their me, eorts,
experience, and their valuable employees as students to
build a rst-of-its-kind program from square one. Three
employer groups in LTC have taken charge to pave the way for this Apprenceship and change the state of LTC
in Washington—for the beer. These employers are making an impact on the lives of employees, the outlook of
their own facilies, and the future of the state through expansion of the program. They have steadfastly worked
to create this program and remain commied to the LPN Registered Apprenceship.
Mindy Schaner, employer with Pennant Healthcare Washington, explains how this program is not only
helping employees and their employers, but is also bringing providers together (who would tradionally be in
compeon with each other) to work for the greater good.
“It’s important that we’ve all come together for a common goal—working closely with each
other and being supporve of one another. Everyone recognizes the need for the good of the
whole LTC system, not just skilled facilies but assisted living, and home care too.”
Schaner’s current employees who are compleng prerequisites for hopeful admission to the apprenceship
program are thankful for the program and see it as a privilege and opportunity. When they succeed, their
employer succeeds.
Program Expansion
With three statewide employers helping get this program o the ground (and many more needed to sustain
it), others are intrigued and are following closely. The current employers involved recommend addional
organizaons coming on board as soon as they are able — for the sake of their own facilies and for the future
of the enre state. Jane Davis, Administrator at Hya Family Facilies - Landmark Care and Rehab, explains that
she has already been approached numerous mes with interest from potenal parcipants in the program,
especially aer the three employers received the 2023 For the Good of the Order Award for their work on the
Apprenceship pilot at the Washington Health Care Associaon’s annual convenon:
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“This program is made for HCAs/
NACs. The fact that we are able to
give so much support is why we’re
going to get more LPNs. If it wasn’t
for this Apprenticeship, these
HCAs/NACs would be struggling.
Participants just need a little bit
more support to make things run
smoothly.”
- Rebecca Adams
Workforce Board
-Mindy Schaner, Pennant Healthcare Washington
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“Being recognized for what we’re doing is a real honor. We’re going to be able to set a precedent
in this state—to be a leader in making change. In fact, other states like Idaho are already looking
to us as an example of how they could follow suit.”
Misrak Mellsie of Brookdale Senior Living encourages other employers to join the program:
“Given the opportunity, any organizaon should be happy to join because there is literally no
downside—every way you look at it, there is a benet to join forces.”
For full interviews with Edmonds College, Employers, and Navigators, see Appendix 6.
-Jane Davis, Hya Family Facilies
-Misrak Mellsie, Brookdale Senior Living
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stakeholder driVen policY recommendatons
Recommendations
In response to the crical needs of long-term care and its workforce, the coalion of stakeholders developed
this inial list of policy recommendaons. The development of these policy recommendaons was the result
of a methodical process that involved the Leadership Team and stakeholders in the LTC Iniave. Working in
collaboraon with the Workforce Board research team, two separate surveys were conducted to dene the
Current and Ideal States of the LTC workforce in Washington. The survey results subsequently drove the creaon
of three subcommiees including: 1) Educaon and Career Pathways, 2) Human Resources and Worker Support,
and 3) the LTC Ecosystem. In a series of subcommiee meengs, specic barrier concerns were idened and
used to develop preliminary recommendaons (See the Appendix 7 for the full list of barriers).
In June 2023, the preliminary policy recommendaons were brought in front of stakeholders at two separate
in-person meengs on each side of the state: in Spokane and Port Angeles. The two groups developed this
series of early recommendaons for presentaon to policymakers with items that were not quite ready added
to Items for Further Study (see page 50) for connued stakeholder work in 2024.
The current HCA/NAC to LPN Registered Apprenceship has drawn upon the experse of WABON, LNI, the
Workforce Board, three employers represenng more than 50 facilies across the state, two community
colleges, and mulple other stakeholders. The process has been arduous and fraught with a range of challenges
due to the complexies of creang this nontradional apprenceship. However, this program has also seen
many successes with the development of a hybrid training program at Edmonds College that will be used
for the apprenceship, an employer-led applicaon process for recruing HCAs and NACs into the program,
the development of dra Standards of Apprenceship, and the development of a prototype for a digital
wallet for potenal use by the student/apprences and sponsor group. The procurement process to select an
Apprenceship sponsor organizaon idened a non-prot awardee (Washington Health Care Associaon) in
early August. Currently, 37 direct care workers employed in LTC facilies are enrolled in prerequisite coursework
at Edmonds College and Yakima Valley College.
The program has had great success in its early stages, with a commied employer base, support from mulple
stakeholders, and an engaged, excited group of frontline sta in the program. More work is needed to ensure
that this budding program can become fully registered, scaled up to include more employers, and that the
employer business model is established to ensure the program is self-sustaining. The Iniave members
calculated that another two years beyond the current end date of state funds is required to meet these
objecves (current sunset date is June 30, 2025). The early expiraon of the funding could signicantly hamper
enrolled apprences’ ability to complete the program, as well as the program’s expansion and stability, which
go hand-in-hand.
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Edmonds College has taken the lead in the development of a hybrid curriculum that will serve as the the
required supplemental component of the HCA/NAC to LPN Registered Apprenceship Program. Their work is
crical to the connued success of the apprenceship, and the College’s connued leadership and guidance will
be necessary for the establishment of addional programs as other colleges commit to the support and training
of apprences. Edmonds College will need addional sta capacity—including addional FTEs for instrucon,
administraon, and support—to connue their work and provide educaon to the hybrid parcipants across
the state while addional capacity is being developed in other instuons oering LPN training. Other resources
needed may include equipment and infrastructure for curriculum delivery.
Funding would support a dedicated cohort of apprences in this compeve LPN Registered Apprenceship
Program. LPN educaon programs are highly compeve. The LPN Registered Apprenceship Program is
meant to be a grow-your-own strategy, where partner employers support those individuals with a passion
for caring for LTC paents to achieve LPN cercaon through a registered apprenceship training modality.
This program has a signicant support structure for the parcipants, including navigaon services for tutoring,
childcare, housing, and more. If an apprenceship candidate has met all of their prerequisite requirements,
it is important to ensure that they can connue their educaon to nish their LPN credenal. Therefore, this
group proposes that policymakers expand enrollment capacity for registered apprenceship cohorts in the LPN
programs, beginning at Edmonds College and expanding as more colleges come on board, to ensure that these
NACs and HCAs who have met the requirements of LPN programs can nish their studies.
, to the extent possible.
As evidenced by this report, the greatest impact on stang is aributed to sta leaving the LTC workforce.
Compensaon and benets have a signicant impact on retenon and recruitment across the direct care
workforce. LTC workers tend to have lower average annual wages, which fail to provide stability to the LTC
workforce. The annual salary for many LTC workers falls below the 200 percent poverty level. Increasing
demands for workers across all sectors have created a salary compeon with various other non-direct care
posions. As a result, LTC workers have opportunies to make the same or more in terms of salary and benets
in retail, food service, and other places of work that do not require as much training.
Although not the only payer source in LTC, Medicaid clients make up a large poron of all LTC consumers.
Medicaid reimbursement rates for LTC services have been below what LTC providers have indicated they need
to maintain quality of care and a stable service sector. The connued funding levels, coupled with the inevitable
labor costs, is not economically feasible and is only expected to worsen into the future. An example would
be the funding associated with assisted living facility (ALF) rate methodology, where rates starng on July 1,
2023, are only funded at 79 percent of the labor component that is calculated in the rate methodology. For
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SNFs, the esmated Medicaid costs that providers have reported exceeded the Medicaid reimbursement rate
by 15-18 percent (Calendar year 2020, with the emergence of COVID-19, showed a 22 percent gap between
reported Medicaid costs and reimbursement). Although the rates for adult family homes, which are collecvely
bargained, are beer funded than ALFs, it is sll funded below what is needed to fully cover labor costs. In-
home workers, which make up 75 percent of the Medicaid provider network, also do not receive wages that are
compeve with the private market or employees in other sectors.
As with many LTC Medicaid rate methodologies, the data used to calculate rates or inform rate negoaons do
not account for emergent changes in costs in a mely manner. This makes it dicult for providers to address
wage or inaon growth in real me where other healthcare sectors may have more exibility in their revenue
streams to adapt quicker. SNFs have also seen a signicant increase in reliance on agency stang, which is
only reimbursed up to the in-house wages the provider is paying. Throughout the COVID-19 pandemic, agency
stang costs have increased signicantly, meaning there is a growing gap between in-house sta wages and
agency sta costs, which are not accounted for in the Medicaid reimbursement rate. SB 5547, adopted by the
2023 Legislature, implements registraon and cost reporng requirements for stang services providers in
Washington. This informaon should help inform policy decisions related to reimbursement for labor-related
costs.
Quality Improvement Programs (QIP) run by DSHS are a key support to LTC service providers’ ability to
provide quality care for residents served. Established in 1992, the goal of the highly regarded program was
to strengthen care, improve regulatory compliance, and prevent harm to vulnerable adults. The program by
the regulatory division, Residenal Care Services, oered support to all types of providers in a “non-punive
quality improvement approach.” These services were disconnued in 2012 due to budget cuts. In 2021, the
Washington Legislature authorized funding for six QIP nurses and the reimplementaon of the program. The six
nurses are responsible for providing QIP services to over 4,000 LTC service providers across the state. These six
nurses provide a range of services that include focused reviews and visits, analysis of care systems, idencaon
of provider goals, and provision of resources. These welcome services delivered to LTC providers ulmately
improve the care of the residents, reduce the number of provider citaons, establish a collegial relaonship
with RCS, and improve the ecacious use of public funds. This recommendaon received rousing support from
all stakeholders parcipang in the Iniave. The group would like to see a much larger investment but chose
to recommend doubling the small current number of nurses as a starng place.
In RCW 18.79.340, nursing technicians may work at specic types of employment facilies, spelled out as a
hospital, clinic, or nursing home, with a requirement for RN oversight of this posion. It is believed the original
focus on these care sengs was because they are known to have full-me RN nurses on sta during all opening
hours. However, as the acuity of residents in non-nursing home LTC sengs have evolved, the presence of RNs
in many has increased. For example, many assisted living facilies (ALFs) have residents that require supported
medicaon administraon, diabec care, and wound care. While not every ALF uses RN stang to the level to
accommodate nursing technicians, for those that do, nursing technicians have the potenal to alleviate stang
challenges while employing students who are pursuing healthcare careers.
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Among the stakeholders, there are ALFs who have been working as partners to implement the LPN Registered
Apprenceship Program, and they hope to oer their NAC employees who want to become LPN apprences
expanded roles as nursing technicians as they advance through their nursing program. This would allow the ALFs who
qualify to “grow their own” nurses the opportunity to use the nursing technician role to build in wage progression
opportunies as they advance through their LPN program coursework. Finally, it should be said that while ALFs
are the example we have discussed here, other care sengs such as adult family homes and community-based
sengs could benet from the employment of nursing technicians if the statute were expanded to include them.
LPN Registered Apprenceship Program stakeholders were mostly in agreement with this recommendaon. There
was, however, a minority who expressed concerns with this recommendaon due to quesons regarding whether
the lower levels of paent acuity and medical needs in ALFs would address the full range of skills as oered in a
skilled nursing facility, for example. However, there are potenal opons for the NACs in those facilies that would
allow them to complete training and master all the skill sets required by the apprenceship standards.
This recommendaon emerges from a range of stakeholders willing to be part of a community of pracce to
help the state improve LTC and its accessibility to all Washingtonians who need it, when they need it. The Board
will be bringing forward a formal ask for connuing the focus on LTC workforce policy with a funding request for
the LTC Iniave in the 2025 Legislave Session. A vital component for the success of the LTC Iniave will be the
connuaon of current eorts. Stang in LTC workforce policy, like all healthcare sengs, needs consistency.
The Board is hoping to connue the research and policy development work done in this report (and over the next
couple of years); current funding ends in 2025 and will most certainly interrupt the momentum of this work.
There are a wide range of eorts across the state designed to improve recruitment and retenon in LTC.
Consistent coordinaon and communicaon of these programs are the best opons for success. Connued
funding through 2028 aords an opportunity to implement strategies and evaluate their success. To date, the
LTC Iniave’s eorts have been enthusiascally endorsed by the stakeholders, and the number of parcipants
in the Iniave connues to grow statewide.
The success of this work will further require sound research and innovave strategies to counter the current
crisis. There has been research into what aracts and retains workers in LTC sengs, as well as what impacts
the percepons of paents, residents, and their families about quality of care. However, LTC employers
rarely have the expendable resources needed to test new methods of operaon while connuing to meet
all reimbursement criteria of the public payers. Currently, public reimbursement rates do not even include
allowances for sta training and professional development at the frontline level.
Under this recommendaon, as part of the extension of funding for the LTC Iniave the Workforce Board will be
seeking funding to operate a compeve grant process to idenfy pilot projects to address these issues. Iniave
stakeholders will help develop the criteria for selecon. One absolute criterion is that projects will be developed
with and overseen by a collaborave of administrators, frontline workers, and care recipients, at a minimum. An
external evaluator will help assess the projects and support the shared learning of the community of pracce.
The following gives an idea of early thinking from stakeholders about these projects:
• Have Workforce Development Councils/WorkSource oer services tailored to LTC workers.
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• Create a nancial aid pool including funds for supporve services (e.g., family needs) to keep
workers in the workforce while accessing educaon/training opportunies.
• Fund enhanced childcare subsidies for LTC workers who have complex childcare needs.
• Use a public-private partnership to promote a feasibility study and pilot an LTC leadership
cercaon program, which would oer mentor training and opportunies for higher wages.
An addional component to the novel research eorts will be the idencaon of published literature related
to successful programs across the globe for consideraon as demonstraon projects in the state. Providing
funding for demonstraon projects to improve retenon and job sasfacon for LTC workers is one proposal
this group has explored to test promising pracces, such as funding for predicve scheduling or providing
consumer-directed care for daily acvies.
Items for Further Study
This work generated a broad list of ideas on ways to address recruitment and retenon issues and how to
improve care. Areas of early consensus in the commiees and stakeholder discussions are reected in the
recommendaons. However, several ideas were oered that may sll be potenal items for future reports. A
selecon of these potenal policy items is listed below, and these items may be considered by the group for
inclusion in the next report in 2024.
• Provide nancial incenves to encourage more LTC facilies to parcipate in the apprenceship
program as the program expands.
• Support increased access to evening, weekend, and instructor-led online courses to maximize
exibility for training opons for providers.
• Review opportunies and requirements for LTC preceptors to potenally expand access.
• Explore more frequent reviews of the rules and policies governing state administraon of LTC
sengs to idenfy duplicaon, unneeded requirements, and areas for improvement.
• Review the weighng of complaint reports to the Complaint Resoluon Unit at DSHS for
facility-reported and public-reported incidents.
• Develop a campaign to improve the percepon of LTC, both from a recruitment and retenon
perspecve as well as public understanding of the value of LTC services. Fund a dedicated FTE
communicaons manager and a contractor to develop content and implement the
communicaons plan over two years, including a dedicated website.
• Review available technology for recommendaons on how to augment individual support
– medicaon and care reminders, for example. Oer virtual service and/or mentorship opons
through phone and video.
• Increase opportunies for mentorship, skills improvement, and support for direct care workers
in their rst LTC role.
• Explore opportunies for retraining for older workers, or post-COVID workers, into less-
strenuous roles. This would ll some needed posions and keep experienced sta in the eld.
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neXt steps: continuing the initiatiVes
Future of These Initiatives
The expansion of this eort to increase representaon from federal, state, and local agencies, educaon,
providers, direct caregivers, business communies, tribal leaders, and rural/underserved communies
is currently underway. Year two of this project will build upon the inial year’s work with connuing input
from the stakeholders and commiees. Further, an expansion of the subcommiees is already planned with
establishment of a Rural and Underserved Communies subcommiee.
The ongoing work of both iniaves will be research-driven, drawing upon proven eorts or those eorts
with strong potenal for success. The research will be led by the Research Team at the Workforce Board. The
team will be partnering with UW CHWS. The researchers will provide mely, state-specic informaon on key
health professions and quality metrics to inform guidance and policy recommendaons. This study will include
a blend of quantave and qualitave components, (see Appendix 8 for details on the research strategy). This
informaon will drive the work of the leadership and subcommiees.
The LTC Iniave will build upon the work of the rst year. An emphasis will be placed upon collaboraon
and eliminaon of silos, a message that has been voiced me and me again from partners in this eort. As
the collaborave grows, the partners will look towards developing a long-term strategy, recognizing that this
work is not a “quick x” and will require eorts working well into the future. Subcommiee members will be
encouraged to look toward innovave ways to approach the challenges of the workforce and consider potenal
opportunies that are supported by the exisng and novel research eorts from the Research Team.
The further development and implementaon of the LPN Registered Apprenceship Program will be a priority
as the eort moves toward a Fall 2024 launch date for enrollment in the LPN program. The team will connue
monitoring and making needed changes, supported by the evaluaon processes overseen by the research
teams. As the pilot engages HCAs and NACs in Apprenceship, expansion of the program across the state will
be a priority to meet the direcves established by the Legislature.
Conclusion
The road to a stable workforce, challenging and rife with obstrucons, has been a state priority for over two
decades, yet the problem has only become increasingly dicult to resolve. Dedicated and professional stakeholders
recognize the workforce’s immediate and long-term needs and are gaining a beer picture of the crisis.
The eorts and commitment that are required to solve this challenge are signicant, yet success is aainable.
The policy recommendaons presented in this report were developed as a starng place to help move
Washington from the Current State to the Ideal State. With research dang back as far as 20 years in hand,
now is the opportunity to make an impact with collaborave eorts supported by state funding. These eorts
will improve the future of LTC in Washington to ensure that our family, friends, and loved ones receive quality,
accessible care.
The need for connuity and stability in these eorts is crical to the success of these iniaves. Dedicated me
and resources are required, especially for training and educaon programs like apprenceships, which can take
years to complete, and even longer for posive outcomes to emerge. Other similar eorts across the country
have proven successful because of a long-standing commitment to the eort.
The task ahead of us is formidable. Resources are limited and must be ulized wisely and prudently. The
unwavering commitment of all contributors involved in this endeavor is unquesonable. The partners’ vast
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Washington Long-Term Care
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Workforce Board, Fall 2023
experience demonstrates their dedicaon not just to this cause, but to the well-being of individuals who cur-
rently or will eventually require LTC services.
The Workforce Board is pleased to provide this year’s report for the consideraon of policymakers, but this is
just the beginning of our work in this area. We have provided some early consensus areas from the stakeholders,
as well as some introductory research and updates on the LTC workforce. The Workforce Board has funding for
two more years for this project and will provide addional reports to policymakers in the summer of 2024 and
2025. However, any success in addressing the stang challenges in LTC hinges on the collecve contribuons
of dedicated stakeholders engaged in research and future planning, as well as the support of policy champions.
The state has demonstrated that it possesses the foresight to see the complexity and the willingness to take the
steps needed to guarantee that future LTC services needs of Washington residents will be met.
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definitions
Acronyms are a part of every industry. In healthcare, and specically in LTC, acronyms abound—from the
abbreviaons of clinical posions to agency names. Here is quick guide to the acronyms used in this report.
ACS American Community Survey
Acvies of Daily Living
Adult Family Home
Assisted Living Facility
American Health Care Associaon
ALTSA Aging and Long-Term Support Administraon (DSHS)
Community Health Center
CMS Center for Medicare and Medicaid Services
Cered Nursing Assistant (see NAC)
CTC Complex Transional Care
Director of Nursing Services
Department of Health
Department of Labor
Department of Social and Health Services
Department of Veteran Aairs
Employment Security Department
Engrossed Substute Senate Bill
Home Care Aide
Health Career Fund
Home and Community Services
Home Health Aide
Instute for the Future of Aging Services
Integrated Postsecondary Educaon Data System
Labor and Industries
Licensed Praccal Nurse
LTC Long-Term Care
LTSS Long-Term Services and Supports
MSA Metropolitan Stascal Area
Naonal Academies of Sciences, Engineering, and Medicine
Nursing Assistant-Cered
Nursing Care Quality Assurance Commission (see WABON)
Occupaonal Employment and Wage Stascs
Payroll Based Journal
Personal Care Aide
Public Health Instute
Registered Nurse
Skilled Nursing Facility
University of Washington Center for Health Workforce Studies
Washington State Board of Nursing (formerly NCQAC)
Washington Health Care Associaon
Washington State Hospital Associaon
Workf
orce Board (Workforce Training and Educaon Coordinang Board)
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references
AARP. “1 in 5 Americans Now Provide Unpaid Family Care.”
Study Shows 1 in 5 Americans Provide Unpaid Family Care (aarp.org)
American Council on Aging. (2023). What denes Long Term Care? Which Types of Care are Included.
Retrieved from MedicaidPlanningAssistance.org:
hps://www.medicaidplanningassistance.org/what-denes-long-term-care/
Oce of the Assistant Secretary for Planning and Evaluaon (ASPE). “Most Older Adults Are Likely to Need
and Use Long-Term Services and Supports Issue Brief.”
Most Older Adults Are Likely to Need and Use Long-Term Services and Supports Issue Brief | ASPE (hhs.gov)
Oce of the Assistant Secretary for Planning and Evaluaon (ASPE). “What Is the Lifeme Risk of Needing
and Receiving Long-Term Services and Supports?” April 3, 2019.
What Is the Lifeme Risk of Needing and Receiving Long-Term Services and Supports? | ASPE (hhs.gov)
Bates, T et al. (2018). Racial/Ethnic Diversity in the Long-term Care Workforce. Retrieved from the University
of California San Francisco:
hps://healthworkforce.ucsf.edu/sites/healthworkforce.ucsf.edu/les/REPORT-2018.HWRC_diversity_.4-18.pdf.
BlueCross BlueShield (BCBS). “The Economic Cost of Caregiving.”
The Economic Impact of Caregiving | Blue Cross Blue Shield (bcbs.com)
Bureau of Labor Stascs (BLS). Occupaonal Employment and Wage Stascs.
May 2022 OEWS Naonal Industry-Specic Occupaonal Employment and Wage Esmates (bls.gov)
Center for Medicare Advocacy. (2021). New Study: High Nursing Home Sta Turnover Impacts Quality of
Care. New Study: High Nursing Home Sta Turnover Impacts Quality of Care. (medicareadvocacy.org)
Centers for Medicare & Medicaid Services. (2023). Long-term care denion. Retrieved from HealthCare.gov:
hps://www.healthcare.gov/glossary/long-term-care/.
Centers for Medicare & Medicaid Services. (2001). Appropriateness of Minimum Nurse Stang Raos in
Nursing Homes. Retrieved from:
hps://theconsumervoice.org/uploads/les/issues/CMS-Stang-Study-Phase-II.pdf.
Commission on Long-Term Care. (2013). Report to the Congress. Retrieved from:
hps://www.govinfo.gov/content/pkg/GPO-LTCCOMMISSION/pdf/GPO-LTCCOMMISSION.pdf.
Deloie. “Addressing health care’s talent emergency.”
Health care’s worker shortage | Deloie Insights
U.S. Department of Health and Human Services (DHHS). “Caregiver Resources and Long-Term Care."
Caregiver Resources & Long-Term Care | HHS.gov
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Engrossed Substute Bill 5693. (2022). 67
th
Legislature, 2022 Regular Session, Supplemental Operang
Budget, Chapter 297, page 751. Retrieved from:
hps://lawlesext.leg.wa.gov/biennium/2021-22/Pdf/Bills/Session%20Laws/Senate/5693-S.SL.pdf.
Federal Interagency Forum (FIF) on Aging-Related Stascs. (2016). Older Americans: Key Indicators of Well-
Being. Older Americans 2016: Key Indicators of Well-Being (agingstats.gov)
FQHC Associates (FQHC). (2014). “The True Cost of Employee Turnover.”
The True Cost of Employee Turnover — FQHC Associates
Instute for the Future of Aging Services. The Long-Term Care Workforce: Can the Crisis be Fixed.
hps://leadingage.org/wp-content/uploads/drupal/LTC_Workforce_Commission_Report.pdf.
Kihye Han, et al. (2014). Associaons between state regulaons, training length, perceived quality, and job
sasfacon among cered nursing assistants: Cross-seconal secondary data analysis. Internaonal Journal
of Nursing Studies, Volume 51, Issue 8, 2014, 1135-1141. Retrieved from:
hps://pubmed.ncbi.nlm.nih.gov/24468194/.
Kihye, Han, et al. (2015). Work-related factors, job sasfacon and intent to leave the current job among
United States nurses. J. Clin. Nursing vol 24 (21-22).
hps://doi.org/10.1111/jocn.12987
Krein, Sarah, L. (2022). Somemes it’s not about the money… it’s the way you treat people... A Qualitave
Study of Nursing Home Sta Turnover. Retrieved from the Journal of Post-Acute and Long-Term Care
Medicine: hps://pubmed.ncbi.nlm.nih.gov/34990586/.
Long-Term Services and Supports State Scorecard.
Long-Term Services and Supports State Scorecard (longtermscorecard.org)
Naonal Academies of Sciences, Engineering, and Medicine. (2022). The Naonal Imperave to Improve
Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Sta. Retrieved from The
Naonal Academies Press:
hps://nap.naonalacademies.org/catalog/26526/the-naonal-imperave-to-improve-nursing-home-
quality-honoring-our.
Naonal Commission For Quality Long-Term Care. (2006). Out of Isolaon: A Vision for Long Term Care in
America. Retrieved from:
hps://www.commonwealthfund.org/sites/default/les/documents/_usr_doc_out_of_isolaon.pdf.
The Naonal Consumer Voice for Quality Long-Term Care. (2022). High Sta Turnover: A Job Quality Crisis in
Nursing Homes. Retrieved from:
hps://theconsumervoice.org/news/detail/all/nh-sta-turnover-report.
Nursing Care Quality Assurance Commission. (2018). Long-Term Care Workforce Development, ESSB 6032
Budget Proviso. Retrieved from:
hps://app.leg.wa.gov/ReportsToTheLegislature/Home/GetPDF?leName=Long%20Term%20Care%20
Workforce%20Development_eeedb0a4-44a5-431f-a725-046609881db1.pdf.
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Nursing Care Quality Assurance Commission. (2020). Long-Term Care Workforce Development Progress
Report, ESHB 1109 Budget Proviso. Retrieved from:
hps://app.leg.wa.gov/ReportsToTheLegislature/Home/GetPDF?leName=2020%20LTC%20Workforce%20
Report_4f99fcb1-e8f6-4334-a1bf-4927fab77d14.pdf.
Nursing Care Quality Assurance Commission. (2021). Long-term Care Workforce Development Final Report,
ESHB 1109 Budget Proviso. Retrieved from:
hps://nursing.wa.gov/sites/default/les/2022-06/2021LTCWorkforceDevelopmentReport.pdf.
Oce of Financial Management (OFM). “Populaon forecasts and projecons.”
Populaon forecasts and projecons | Oce of Financial Management (wa.gov)
Papadakis, E., Gaman, N.E., & and O'Connor, J. (2021). Long-Term Care Workforce Proposal to the
Washington State Senate. Retrieved from:
hps://nursing.wa.gov/sites/default/les/2022-06/2021LTCWorkforceDevelopmentReport.pdf.
PHI. (2020). It’s Time to Care: A Detailed Prole of America’s Direct Care Workforce. New York, NY: PHI Internaonal.
hps://www.phinaonal.org/resource/its-me-to-care-a-detailed-prole-of-americas-direct-care-
workforce/#:~:text=January%2021%2C%202020-,It%27s%20Time%20to%20Care%3A%20A%20Detailed%20
Prole%20of%20America%27s%20Direct,%2C%20socio%2Deconomic%20characteriscs%2C%20and
PHI Internaonal. (2021). Workforce Data Center. Retrieved from:
hps://www.phinaonal.org/policy-research/workforce-data-center/.
PHI. (2022). Direct Care Workers in the United States: Key Facts. Retrieved from:
hps://www.phinaonal.org/resource/direct-care-workers-in-the-united-states-key-facts-3/.
Rector, B. and Engels, S. (2022). Family Caregivers and Workforce Development. Naonal Academy for State
Health Policy, Department of Social and Health Services, Aging and Long-Term Support Administraon.
Riggs, J.A. (2002). Exploring Pathways to Long Term Care Stang Soluons. Retrieved from the Alzheimer’s
Associaon:
hps://www.alz.org/naonal/documents/workforcepaperjriggs02.pdf.
Stone, R. et al. (2016). Predictors of Intent to Leave the Job Among Home Health Workers: Analysis of the
Naonal Home Health Aide Survey. Retrieved from The Gerontological Society of America:
hps://pubmed.ncbi.nlm.nih.gov/27106825/.
U.S. Bureau of Labor Stascs. (2022). Occupaonal Employment and Wage Stascs. Retrieved from:
hps://www.bls.gov/oes/current/oessrcst.htm.
U.S. Census. (2020). 1-year American Community Survey. Retrieved from:
hps://www.census.gov/programs-surveys/acs/technical-documentaon/table-and-geography-
changes/2020/1-year.html.
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U.S. Health Resources and Services Administraon. (2018). Long-Term Services and Supports: Direct Care
Worker Demand Projecons 2015-2030. Retrieved from the Naonal Center for Health Workforce Analysis:
hps://bhw.hrsa.gov/sites/default/les/bureau-health-workforce/data-research/hrsa-ls-direct-care-worker-
report.pdf.
U.S. Senate Commission on Long-term Care. (2013). Retrieved from the Report to the Congress:
https://stateofthestates.org/wp-content/uploads/publications/Commission%20on%20Long-Term%20
Care-%20Final%20Report%209-26-13.pdf.
Washington State Legislature. (2022). ESSB 5693, Chapter 297, Laws of 2022 (paral veto), 67
th
Legislature,
2022 Regular Session, Supplemental Operang Budget, March 31, 2022, page 751.
Washington State Board of Nursing. (2023). Research, Data, and Reports.
Weller, C. et al. (2020). Making Care Work Pay: How Paying at Least a Living Wage to Direct Care Workers Could
Benet Care Recipients, Workers, and Communies. Retrieved from Leading Age, LTSS Center:
hps://leadingage.org/making-care-work-pay/.
Zheng, Q. et al. (2022). Associaon between sta turnover and nursing home quality – evidence from payroll-
based journal data. Retrieved from: Journal of the American Geriatrics Society:
hps://pubmed.ncbi.nlm.nih.gov/35524769/.
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attachment a
Leadership Team
Alyssa Odegaard LeadingAge Washington
Bea Rector Department of Social and Health Services
Chris Harter Greater Spokane Chamber of Commerce
Chrisne Morris DSHS/ALTSA/HCS
Christopher Dula Workforce Board
Dan Ferguson WA State Allied Health Center of Excellence
Dave Wallace Workforce Board
David Puente Jr. Washington State Department of Veteran Aairs
Donald Smith Jr. Workforce Training and Educaon Coordinang Board
Eleni Papadakis Workforce Board
Inez Olive Washington Student Achievement Council
Kathy Moisio Washington State Department of Health
Lauri St. Ours Washington Health Care Associaon
Leigh Christopherson Health Career Fund
Mark Beaufait Health Career Fund
Megan McQuade Health Career Fund
Mindy Schaner Pennant Healthcare Washington
Nathan Dikes Sunshine Health Facilies, Inc.
Nova Gaman Workforce Board
Sarah McKiddy University of Washington
Stacy Gra DSHS/ALTSA/HCS
Suzanne Swadener Washington State Health Care Authority
Taana Sadak University of Washington School of Nursing
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attachment b
Additional Participants in Stakeholder Meetings and Reviews
Adora F Brouillard DSHS/ALTSA/HCS
Aimee Hickey Encore Communies
Aimee Runnels Encore Communies
Aschlee Heiny Washington State Department of Veteran Aairs
Aubre Nelson Department of Labor and Industries
Audrey Slade Health Career Fund
Benjamin A. Stubbs UW School of Medicine
Bill Swarens Bates Tech
Chris Nance Sparrow Health
Claire Fite Workforce Board
Claire Horton Department of Health
Cori Morris Washington State Department of Veteran Aairs
David Carter LeadingAge Washington
Deb Murphy LeadingAge Washington
Elena Madrid Washington Health Care Associaon
Eric Erickson CDMLTC
Gena Ahlawat WSHA
Heather Lewis CHCC Lynden
Jac Davies Rural Collaborave
Jacob Schaefer Alumnus
Jason Druel Rockwood Rerement
Jessica Wolfrum Sunshine Health Facilies, Inc.
Jodi Rielly Sunshine Health Facilies, Inc.
Julie Kirk Alumnus
Kristen Bright Alumnus
Laura Hofmann LeadingAge Washington
Laura Hopkins Health Career Fund
Leslie Emerick Home Care Associaon of WA
Lori Durham Alumnus
Mark Beaufait Health Career Fund
Mary A Baroni UW Bothell
Ma Fleming Sunshine Health Facilies, Inc.
Megan Filippello Oce of Representave Vandana Slaer
Misrak Mellsie Brookdale Senior Living
Renee Fullerton Workforce Board
Sean Moore Workforce Southwest Washington
Sherri Farber Hya Family Facilies
Stephanie Perry Encore Communies
Steve J. Sterling Seamar CHC
Sydney Kuhn Koels CH Senior
Tina Wille Symmetry Care
Todd Jensen Washington State Health Care Authority
Toni Camp State of Washington
Vicki McNealley Washington Health Care Associaon
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attachment c
Research Team
Bianca Frogner UW Center for Health Workforce Studies
Christopher Dula Workforce Board
Danbi Lee UW Center for Health Workforce Studies
Kezia Scales PHI
LaTonya Troer UW Center for Health Workforce Studies
Lina Stepick PHI
Patricia Hunter Oce of the State LTC Ombudsman Program
Rachel Prusynski UW Center for Health Workforce Studies
Robyn Stone LeadingAge LTSS Center at UMass Boston
Susan Skillman UW Center for Health Workforce Studies
Tracy Mroz UW Center for Health Workforce Studies
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appendiX 1
Innovations: Long-Term Care Program Initiatives Supporting Rebalancing
1980
1985
1990
1995
2000
2005
2010
2015
2020
1981
1984
1993
2001
2008
2012
2015
2017
2019
1983
1985
1989
1995
2000
2003
2009
2013
2016
2022
State-funded in-home program
allows self-directed opon
First steps to control
nursing home growth
State plan personal care for
individuals with physical disabilies
Statewide respite
program implemented
Mandates for nursing home
reducons — state staff
dedicated to nursing home
and hospital transions
State plan eligibility expanded to
those with funconal disabilies
Required training for all in-home
personal care assistance
1915(c) waiver approved
Adult Protecve Services statute
1999
First nurse delegaon law and
law allowing family members
to be paid when providing
skilled tasks
State Family Caregivers Program
Self-directed care
providers vote to unionize
Abuse Registry
Standardized electronic
assessment with acuity based
payment methodology used
across all HCBS populaons
MFP (RCL) implemented
in Washington
Statewide implementaon
of Standardized Caregiver
Assessment Tool
Long-Term Care Worker Training
and Cerficaon requirements
Health Home
Program Implementaon
State Plan Community
First Choice Program
Acceleraon of development
of community capacity to
serve individuals with significant
behavorial health needs
1115 Waiver creates new opons
and eligibility for Long-Term
Support Services
Supporve Housing and Supported
Employment implemented under
1115 Medicaid Transformaon Waiver
Direct Care Workforce
Development Iniaves
Full implementaon of Consumer
Directed Employer Project
40 Years of Innovation
Source: DSHS ALTSA 2022
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appendiX 2
Summary Of NCQAC Long-Term Care Workforce Workgroup Accomplishments
• Idened and obtained 2019 data from over a dozen federal, state, and private sector sources
related to LTC workforce.
• Prepared a high-level summary describing the data (data catalog).
• Integrated the data sources into a preliminary data dashboard with a supplemental detailed data
table.
• Engaged with Regional Workforce Development Councils and the Workforce Training and
Educaon Coordinang Board to examine and understand the data and geographic variaons;
began to idenfy ways to strengthen the workforce pipeline for LTC workers.
• Socialized and developed an HCA-NAC-LPN3 apprenceship program, wrote two grants (pending
decisions), and successfully won legislave funding for a planning year prior to pilong the program.
Accomplishments
The major outcomes of the workgroup include:
• A data catalog
• A preliminary data dashboard to capture what is known about workforce shortages and ongoing
demand.
• Charts and tables showing data ndings related to training, tesng, and cercaon for HCAs,
NAs, LPNs, and RNs; and
• Establishment of connecons with the Regional Workforce Development Councils (RWDCs) for
support in LTC workforce development. Two specic areas where work together is occurring include:
• Eorts to secure funding for the development and implementaon of an HCA-NAC-LPN
apprenceship program; and
• Eorts to use data to target employment sites where LTC workers may need outreach and
assistance to complete cercaon exams (which were delayed signicantly due to COVID-19).
• Demonstraon of the need for a full-me data analyst dedicated to LTC to:
1. Provide an accurate depicon of the LTC workforce.
2. Dene more accurately the pipeline and stang needs for LTC.
3. Make decisions for intervenon.
4. Evaluate intervenons: and
5. Idenfy and respond to trends over me.
• Communicaon to the legislature of the need for a full-me LTC data analyst through the Steering
Commiee’s last report and through a presentaon to the Senate Health & Long-term Care
Commiee on January 27, 2021.
Curriculum
• Developed a person-centered common curriculum for nursing assistants that meets all federal and
state requirements and centers the person receiving care as an individual deserving of respect,
compassion, understanding, and autonomy. This is a marked shi from legacy curricula that focus
on procedures and diagnoses.
• Built enthusiasm for adopng the new curriculum from training partners across the state by
regularly seeking advice and including them in the development of the materials.
• Produced professional quality curricular materials, with instruconal support, audiovisual
components, and digital/printable content.
• Planned for pilot tesng for the curriculum..
• Worked closely with the Tesng Workgroup to link planned revisions for tesng to the new
curriculum.
• Incorporated three specialty training courses into the basic curriculum - mental health, demena,
and developmental disabilies.
• Achieved total program training hours that are near current program averages, even with the
incorporaon of 32 hours of specialty training. The total esmated hours for the new curriculum,
including specialty training, is 138 hours: the average hours for exisng programs, not including
specialty training, is 136.7.
• Achieved training program hours that fall within the 150-hour limit for federal reimbursement to
nursing home training programs.
• Analyzed and revamped the HCA alternate/bridge program to arculate fully with the new
common curriculum for tradional nursing assistant training, which supports smooth progression
of experienced HCAs. Addional training hours for this program were carefully designed to provide
essenal content and support improved pass rate averages. Pass rate averages for the HCA alterave/
bridge students have been lower than those for tradional students over several years.
1. The curriculum content includes knowledge and skills relevant to current nursing assistant
pracces and in fact uses a exible framework to allow for currency with the natural
evoluon of pracce- without the need for constant curriculum revisions.
2. The curriculum meets all applicable federal and state laws, which has been assured through
the compleon of detailed crosswalks of the curriculum with those requirements.
3. The curriculum integrates all three specialty trainings (demena, mental health, and
developmental disabilies) into the standard curriculum.
4. The curriculum can support seamless progression from NAC into nursing through the
development of an HCA-NAC-LPN Apprenceship pathway. Work that has been done to
realize this pathway includes a change in rules by the NCQAC to allow for an "LPN technician"
employment posion (mirroring the RN technician posion). The LPN technician posion
allows a student enrolled in an LPN program and in good standing to work to the level of
their educaon and training as it expanded and to be paid accordingly.
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• Based on the proposal for this pathway, the state budget includes $450,000 over the next year to
plan the pathway for launch.
• Applied for pilot implementaon funds through the congressional Community Project Funding
opportunies in two areas of the state.
• If these aempts to receive funding are not successful, addional aempts to obtain fundings will
be made.
• Changes to the tradional nursing assistant training program necessitated changes to the alterave/
bridge program curricula:
1. the workgroup analyzed the HCA alternave/bridge training program curricula in relaon
to the new common curriculum.
2. to support improved pass rates tor alternave/bridge program students and adjust
the curriculum to align with the new common curriculum, the Steering Commiee and
workgroup proposed an adjustment to the current program hours, which are currently set
in statute at exactly 24. They included language to allow an adjustment to alterave/bridge
program hours in ESHB 1120, which passed in the 2021 legislave session.
Curriculum Updates Since the Report
• Piloted and rened the curriculum and made it available for voluntary adopon by training
programs while we completed rules work to formally incorporate it into all training programs.
• Implemented approximately 30 training programs voluntarily implemenng the new curriculum.
Feedback is posive and pass rates on the state exam are increasing in Washington. We have
formal plans for ongoing evaluaon/connuous quality improvement related to the new
curriculum; evaluaon will include quantave data (#s served, numeric rangs from instructors
and students, instructor# tesng, # passing, etc.) as well as qualitave data (i.e., narrave feedback
from instructors and students). We would also like to conduct electronic surveys of employees
regarding new NAC readiness for pracce.
• Designed curriculum for exible use—in-person or online delivery by training programs (live
online or hybrid with asynchronous elements) to provide maximum access to training by all. When
combined with use of the NAR Work Pathway, which we developed during the pandemic, students
can complete didacc at a distance and complete skills lab and clinical on-site locally (and receive
clinical credit for their work hours).
• Designed curriculum to successfully feed into the hybrid curriculum developed by Edmonds College
for the LPN Apprenceship.
• Established melines for all programs to adopt the new tradional and alternave/bridge curricula
by Sept. 2024 and supporng rules work has been completed. Full incorporaon of specialty
training will follow in 2025.
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Workgroup:
• Moved to secure remote-proctored tesng so students can take the wrien exam via computer
from home or other convenient locaon.
• Separated the wrien and skills tests so students can sign up for them on separate days if they
want (they can also do them the same day). This helps students to focus on one test at a me. It
also saves them me because they can schedule a specic tesng me (they used to have to slate
the enre day).
• Infused massive skills tesng slots so that students can access in a mely manner (immediately
following graduaon), moving to allow training programs to provide skills tesng for their students
right aer graduaon.
• In early 2024, skills tesng will move to a holisc evaluaon approach, which will support the
internalizaon of key concepts and the crical thinking nursing assistants need in the eld. These
concepts have been built into and reinforce throughout the curriculum so that curriculum and
tesng are fully integrated. This will improve pass rates and, more importantly, the care of the
public. The four key concepts or principles for evaluaon are: Did the student provide the care
according to standard/acceptable steps overall; did the student do so safely; did the student do so
without a violaon of infecon control; and did the student do so without a violaon of resident
or paent rights.
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appendiX 3
Public Use Datasets from the Centers for Medicare & Medicaid Services on Nursing Facilities
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Payroll Based Journal
(PBJ) – Aggregate Nurse
and Non-Nurse Staffing
Payroll Based Journal
(PBJ) – Employee Detail
Nursing Home Staffing
Skilled Nursing Facility
Change of Ownership
(SNF CHOW)
Skilled Nursing Facility
All Ownership
(SNF Ownership)
Nursing Home Compare
(NHC)
Skilled Nursing Facility
Public Use Cost Report
Skilled Nursing Facility
Value Based Payment
(SNF VBP)
Medicare Post-Acute
Care and Hospice Public
Use File (PAC PUF)
COVID-19
Nursing Home Data
Q1 2017 –
Q4 2022
Q2 2020 –
Q4 2022
Q1 2022 –
Q1 2023
Sept 2023 –
May 2023
Jan 2016 –
May 2023
2011 – 2019
FY2023
2013 – 2020
June 4, 2023
Quarterly
Quarterly
Quarterly
Monthly
Monthly
Annually
Annually
Annually
Weekly
Data on demographic and clinical characteriscs of
short-stay residents/post-acute paents in SNF, service
ulizaon, and payment groupings aggregated at the
facility-level
Data on SNF VBP rankings, scores for achievement, improve-
ment & overall performance, achievement thresholds &
benchmarks, & incenve payment mulpliers by facility;
FY2023 dataset represents baseline period FY2019, perfor-
mance period FY2021, & payment period FY2023
Data on COVID-19 with respect to admissions, confirmed
cases among residents and staff, deaths of residents and
staff, staff shortages, availability of PPE, and vaccinaon of
residents and staff
Data on owners of SNFs currently enrolled in Medicare,
including name, ownership type, ownership interest, and
effecve date; gathered from the Provider Enrollment,
Chain, and Ownership System (PECOS)
Data on ownership changes that occurred on or aer Jan
2016, including buyer and seller, effecve date, and type of
change (change of ownership, acquision/merger,
consolidaon); gathered from the Provider Enrollment,
Chain, and Ownership System (PECOS)
Data on facility characteriscs, ulizaon data, costs and
charges by cost center, and financial statement data which
represent a subset of data gathered from the Healthcare
Provider Cost Reporng Informaon System (HCRIS)
Data from the skilled nursing facility Quality Reporng
Program data, including five-star summary rangs and
individual measures of quality for long-stay and short-stay
residents from the Minimum Data Set, Medicare claims,
and health inspecons
Data on number of hours individual staff members are paid
to work each day by staff reporng category using a system
generated employee idenficaon number, allowing for
examinaon of staff working across more than one staffing
category and turnover
Data on nurse and non-nurse staffing, including number of
hours staff are paid to work each day by staff reporng
category (e.g., RN, LPN, CNA, PT, OT) and daily census from
the Minimum Data Set
appendiX 4
Stafng Disciplines Included in the Payroll Based Journal Dataset
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Director of Nursing
Registered Nurses
Nurse Aides in Training
Administrators
Other Physicians
Pharmacists
Feeding Assistants
Respiratory Technicians
Physician Assistants
Respiratory Therapists
PAYROLL BASED JOURNAL DISCIPLINES
appendiX 5
Number of Nursing Homes / Skilled Nursing Facilities in Washington
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4
8
1
56
10
22
20
18
3
9
1
1
4
4
5
0
0
0
0
4
Grays Harbor
Island
Jefferson
Klickitat
Lewis
Lincoln
Mason
Okanogan
Pacific
Pend Oreille
San Juan
Skagit
Skamania
Thurston
Wahkiakum
Walla Walla
Whitman
Yakima
3
1
1
1
0
3
0
2
4
1
1
0
5
0
7
0
4
3
11
NURSING HOMES / SKILLED FACILITIES IN WASHINGTON
Rural
Urban
Source: UW Center for Health Workforce Studies analysis
of Centers for Medicare & Medicaid Services
Payroll Based Journal data
Benton
Clark
Columbia
King
Kitsap
Pierce
Snohomish
Spokane
Stevens
Whatcom
Adams
Chelan
Clallam
Cowlitz
Douglas
Ferry
Franklin
Garfield
Grant
218
appendiX 6
Licensed Practical Nurse Regisitered Apprenticeship Q & A with Edmonds College,
Navigators & Employers
Interview with Kyra McCoy, Director of Nursing at Edmonds College
McCoy: During the crical stang shortages during the COVID-19 pandemic, the state’s LTC community
reached out for help from lawmakers. The response was an HRSA grant to increase the stang pool in LTC. As
a result of this grant, the Department of Labor and Industries, the Workforce Board, and the Department of
Health convened to form a group and began meeng to try to solve workforce shortages in LTC. The Legislature
had also recently funded another LTC group with similar goals to focus on creang apprenceships, so the two
joined eorts.
With a total of $1.7 M awarded in funding for the program, three colleges were inially interested, but Edmonds
College took the lead in building the state’s rst-ever LPN Registered Apprenceship program from the ground
up. It’s a lot of work because several government agencies are coming together to do something brand new.
But in the end, the concept is a good one—for both students and LTC facilies.
McCoy: We oer a well-established nursing program designed for working healthcare professionals, such
as nursing assistants and medical assistants, to be able to connue their educaon. Our program is hybrid,
meaning students take didacc courses online, perform skills labs and simulaons in-person twice a week on
campus, and acquire clinical experience in the community at various facilies.
McCoy: The LPN Registered Apprenceship follows the same hybrid model as our exisng nursing program, but
the key dierence is that clinicals are done in the same Long-term
Care (LTC) facilies where students currently work. The dierence
with the apprenceship is that students can connue their jobs (such
as NAs assisng with showers, feeding, etc.), but as they progress
through the apprenceship program to become a nurse technician,
for example, they can start using their new skills immediately in the
workplace as long as they are supervised by a nurse.
It’s a real win-win. Students win with on-the-job training hours and
higher pay as they progress to become nurses. Facilies win because
they get to retain their employees who connue to increase their
skill levels with what they’ve learned in school.
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McCoy: In order to be considered for the LPN Registered Apprenceship, potenal apprences must be
nominated by their LTC employers, apply to the program, and be accepted. The facilies’ execuve directors
pick out their best and brightest—the true rock stars of the facility—and ask them to apply. These folks have
never been to college, many are immigrants and speak English as a second language, most have young children
to take care of, and some are already working 60-80 hours a week to make ends meet.
McCoy: We hit the ground running to develop plans for the apprenceship curriculum, skills labs and simulaons,
and prerequisite navigaon with a goal of formal admission in Fall
of 2024.
First our faculty went to work to develop an online curriculum
that now lives on the Washington State Board for Community and
Technical Colleges website for all to access as an open educaonal
resource. It was approved through the Nursing Board and they
are working to make it available on Canvas (Washington’s Learning
Management System). The college is also developing four satellite
labs around the state for skills labs and simulaons using paent
rooms in LTC buildings and video instrucon from Edmonds.
We are currently working with 30 apprenceship students to obtain
all necessary prerequisites before formal admissions begin. To
help students understand the system and the process, Navigators
were hired to orient and guide apprences. The Navigators also
help students with tasks like scheduling, me management,
transportaon, childcare needs, food security, nancial aid and
more.
The rst group of students admied to the LPN Registered
Apprenceship are considered our pilot group. Once the pilot
group begins the program in Fall of 2024, data will be collected to
netune the process and set up the permanent program. Nursing
Consultant Mary Baroni of UW, Bothell has also conducted focus
groups to get feedback since the students’ prerequisite work
began.
Nothing like this has ever been done before. Once we collect the
data, we’ll have a good idea of what does and does not work. We’ll
be able to iron out the creases so other schools can join us and
provide opportunies to people in rural areas.
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Rebecca Adams lives in
Mason County. She worked
at the Division of Youth
Services (DYS), Child
Protective Services (CPS),
and was an NAC for the
Department of Children,
Youth and Families (DCYF).
She is currently taking her
nursing prerequisites so she
knows what it’s like to go
back to school and how to
apply her experience to help
serve students.
Erica Wollen came to the
apprenticeship program
after more than a decade
at the Workforce Board
in Olympia. She also had
personal experience
providing 24-hour in home
care for her grandparents
and directly experienced the
need for improvements in
the LTC system. She is using
both her work experience
and personal passion for
caregiving to improve
opportunities for students
and for the state of LTC in
Washington.
McCoy: Our students are rst generaon—the rst people in their enre family to ever go to college. These
are people who have been told ‘no’ all of their lives. Either their English was not good enough, or they didn’t
have the right credenals, and the list goes on. But with this program, we are able to tell them ‘yes, you CAN
do this—and we will help!’
The result is that LTC employers get beer nurses and employees get beer jobs while making a higher wage.
And, if students choose to connue their educaon, this program will meet those requirements too. We are
diversifying our workforce and improving our LTC stang shortages while liing everybody up.
An incredibly valuable role in the LPN Registered Apprenceship program, the Navigator guides students
(mostly rst-me students) through the enre process of nursing school—from the applicaon process and
fullling prerequisite courses to compleng labs, simulaons and clinicals in the eld. What’s more, Navigators
help students overcome the very barriers that kept them from further educaon in the rst place. This help
can include anything from assisng students with creang more ecient schedules that make me for study,
work and aending classes to securing aordable childcare, geng assistance with rent and ulies, and more.
Below we’ll hear from the program’s rst two Navigators on what they do, how they do it, how their role
benets the students and the changes needed to ensure students’ success.
Interview with Navigators Rebecca Adams and Erica Wollen
Adams: I want to be able to provide resources during the applicaon process, set up placement tests, netune
schedules, help students nd childcare, gure out transportaon—whatever it takes to get them through
school. I help them gure out how to manage their me so they aren’t overwhelmed. A lot of our people are
rst me college students and don’t understand how to t this new goal into their life, so I help them navigate
all of that.
Wollen: There are a lot of lile things we do to help our students, but keeping them encouraged is most
important to me. Many students are very young and don’t want to tell anyone if they are not doing well in a
certain class. They think they are going to let people down (us or their family). So I’m there to support them and
just keep them moving forward through the program.
Adams: I love seeing how empowered all of the HCAs/NACs become. They’ll say things like ‘my dream was to
be a nurse, I am working hard toward that lifelong dream now, and I was able to t college into my schedule
with work life and kids.’ In essence, they’re saying, ‘I can do this.’ Many of my parcipants have commented
that they can’t wait to get to LPN now, and that they just want to keep going.
We are able to make a dierence by helping them navigate school and life. I had a student falling behind in
chemistry class, so I met with both her work and her school to arrange tutoring, childcare, and work schedules.
She passed the class, accomplished her goal and learned from the experience.
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Wollen: I’ve received many thank you notes and comments from students on how they couldn’t do this without
our support. Somemes something as simple as forwarding an email to the right person can go a really long way.
But many students need signicant support. I have one student who was having a hard me with her math
class. This student kept calling into work saying she couldn’t come in that day because she needed to study.
That plan was not working out well for her or her employer, so I worked together with the student and her
employer on planning a schedule that priorized her learning while keeping her employer happy.
I also had a student who immigrated from Africa with her mother and three sisters. She had been going to
school in Oregon when her program lost accreditaon and was having to retake all her prerequisites. I was able
to help her get on track instead of spinning her wheels.
When there is so much chaos in your brain—thinking you’re going to fail a class, or you’re leng your boss
down at work, or let down your family who is counng on you to succeed—it’s hard to see that you just need
to stop and ask for what you need. As a neutral party, I step in and help.
Adams: One of our biggest challenges is that this is a brand new program and because we are all learning as we
go, we don’t always have all the answers right away.
For example, orientaon is a challenge because Navigators want to give students all the necessary informaon
without overwhelming them—but it’s too much informaon to not overwhelm them. So I break it up into steps
and explain one step at a me, but it’s not an easy task.
Another huge challenge is the Federal nancial aid form. If students answer one queson wrong, the enre
process is compromised. It’s very confusing and frustrang.
Wollen: The biggest challenge is educaon and how it’s funded. We have resources, but the bureaucracy
behind dispersing them is incredibly cumbersome. Say your pipes burst and you need assistance right away, it’s
not set up to help people in the now, in an emergency situaon. We have got to make this happen to get out
of our own way.
Adams: One simple thing I’ve done to help overcome the challenge of not overwhelming students with
informaon is to oer open oce hours via Zoom to ask quesons face to face. While our work is remote, it helps
to see who you’re talking to. In fact, I’ve driven to meet almost all my NACs in person at least once—whether
they are in Longview, Montesano, or Marysville, I’ll spend hours in the car to get to my students. Meeng in
person helps immensely in building relaonships and becoming someone students can feel comfortable with
and conde in.
Adams: Erica and I agree that the single best way to overcome their daily challenges is to have access to an
emergency fund—a pool of funds that could help students in the moment. A at re means they aren’t geng
to school or work—where they need to be. Coming up a couple hundred dollars short on rent or bills could have
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dire consequences. Of course we always check with community resources for low income assistance rst, but
if nothing is available, we could provide that if we had an emergency fund.
I honestly feel in my heart that this program is made for HCA/NACs. The fact that we are able to give so much
support is why we’re going to get more LPNs. If it wasn’t for this apprenceship, these sta would be struggling.
We just need a lile bit more support to make things run smoothly.
Wollen: If Navigators could gain access to same system and real me data sharing through the CTC link, it
would be a game changer for us.
I would also like to see that we have both the me and the money to help students succeed. Our program needs
to be properly funded and given the correct amount of me to be helpful and benet the cizens of this state.
We need to get established and grow, and it’s going to take more than two to ve years to do so.
A key component of the LPN Registered Apprenceship are the Long-Term Care (LTC) employers who are
dedicang their me, eorts, experience, and their valuable employees as students to build a rst-of-its-kind
program from square one. Three brave and passionate individuals from noteworthy LTC facilies have taken
charge to pave the way for this apprenceship and change the state of LTC in Washington—for the beer.
Making an impact on the lives of employees, the outlook of their own facilies, and the future of the state
through expansion of the program, here is how they are doing it.
Interview with Misrak Mellsie (Brookdale Senior Living), Mindy Schaner (Pennant Healthcare Washington),
and Jane Davis (Hya Family Facilies)
We currently have four apprences in the program and three more are being added in the fall. The
program has impacted my employees’ abilies to follow their dreams. I have one young lady who has been
going to school forever and literally ran out of money because of it. She is already a medicaon aid and wants
to be a nurse. This program was just the answer for her. Now she can take the classes she needs and it’s all paid
for. We’re going to support her all the way through and she’s going be a great nurse!
Mellsie: We have 25 employees in the program currently working on prerequisites to start the program next
year. While the full impact of the program is not palpable yet, the hope is. In assisted living we don’t have CNAs,
but our home care aides deserve the same opportunity. My personal involvement is dierent than the other
employers because I had to ght for a seat at the table for my employees in assisted living to be included. There
was a lot of push back, but I fought for them and refused to leave. Now we have created a special program for
them. Going from being a home care aide to becoming a nurse is a big deal and now it’s happening.
This program is not only helping employees and their employers, it is also bringing providers together
(who would tradionally be in compeon with each other), to work for the greater good. It’s important that
we’ve all come together for a common goal—working closely with each other and being supporve of one
another. Everyone recognizes the need for the good of whole LTC system, not just skilled facilies but assisted
living, and home care too.
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Are your employees receiving the necessary
support through this program to help meet
Yes. We’re in desperate need of nurses
in Yakima Valley. We actually ght over them.
I’ve had a nurse opening here for an evening
shi for over nine months now! This program
will eventually help ll our stang vacancies,
which we’ve needed for quite some me and
will connue to.
Our employees’ needs have been
evolving. First, we had to do the work necessary
to get students into the pipeline. Then came
academics. With the help of the Navigators,
my employees are geng what they need to
succeed. Keep in mind, many of our students
have no experience with college (and neither
do their families), so they don’t even know what
quesons to ask. But they are excited. The word
is spreading. And things are gaining momentum. People keep knocking at my door to ask when we are going to
open the next applicaons. My current employees in the program are thankful for the opportunity and see it
as a privilege. Once they succeed, the employer succeeds.
Mellsie: These are not tradional students. These apprences have to work to pay for living expenses and they
oen have children as well. But if they can make it through the program, which employers are condent they
can, both the student and the employer benet greatly.
We have one student at Bates who had all the prerequisites done, but because of transportaon and childcare
challenges she gave up further educaon to work as a caregiver full me. She was never going to be able to be
a nurse unl she heard about this program. Now she has help navigang these challenges and she has hope she
can be a nurse.
I like to set a goal, realize it, and then move onto the next thing. But I’ve found it frustrang to be working
at a dierent pace than state agencies involved in the program. We need to make decisions, be able to act on
those, and move forward. With LTC stang needs as urgent as they are, there is simply no me to waste in
rehashing things mulple mes. It might not be perfect, but things need to move forward, now.
I would like to see every process and procedure documented. It’s hard to spend me documenng
when you’re working so hard just to get things done. But we have to get ahead of the academics and college
calendars in order to get students in the program and increase our numbers. I am condent the process will get
smoother with good communicaon and documentaon.
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From left to right: Vicki McNealy from the Washington Healthcare
Association with employers Misrak Mellsie (Brookdale Senior Living),
Mindy Schaffner (Pennant Healthcare Washington), and Jane Davis
(Hyatt Family Facilities) receiving the 2023 For The Good of The
Order Award for their apprenticeship work at the annual convention.
Mellsie: Improvements are hard to pinpoint when it’s not done yet! None of us are experts as this is all brand
new, so we’re learning as we go, growing every day. Things are very promising.
Absolutely! I have already been approached numerous mes, especially aer we received the award
for our work at the Washington Healthcare Associaon’s annual convenon. Being recognized for what we’re
doing is a real honor. Numerous employers want to be involved—there are just such great opportunies. We’re
going to be able to set a precedent in this state—to be a leader in making change. In fact, other states like Idaho
are already looking to us as an example of how they could follow suit.
Oh yes, denitely. I’m counng on it. We need it for sustainability and we can do so more once we
have more in our pool. The next step is for the apprenceship commiee to hire a director so the program can
start adding more employers to the group and expand the program.
Mellsie: For me, truly, I appreciate everyone involved in this; they are commied to bring this to fruion.
My establishment wasn’t in the original thinking process, but now everyone wants to accommodate us, so it
means a lot to me and to these students as well.
Given the opportunity, any organizaon should be happy to join because there is literally no down side—every
way you look at it, there is a benet to join forces.
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appendiX 7
Stakeholder-Identied Barriers to the ideal State of Long-Term Care in Washington
The following are a collecon of problem statements, barrier areas and policy recommendaons as developed
by the three subcommiees.
Problem Statements
Barrier Area 1A: Insucient Career Development and Training Opportunies
1. Proximity to educaon opportunies limits career development of promising LTC sta
interested in advancing in their careers. Rural communies are parcularly impacted by
limited access to educaon and training programs.
2. Limited access to exible course mes, instructor-led training online, or hybrid training
models, including registered apprenceship, for care providers.
3. Insucient clinical training resources limit the number of new sta preparing for careers
in LTC.
4. Current standards for training LTC sta does not adequately promote LTC as a desnaon
in healthcare.
5. The ability of educaonal instuons to train sucient numbers of new sta to meet a
growing need in the state of Washington is at risk due to stang challenges and disincenves
to work in educaon instead of in the eld, due to the rerement of a generaon of highly
trained healthcare professionals and exacerbated by COVID-19.
6. Pursuing a career in healthcare through tradional pathways is oen perceived as
prohibively expensive for many of the next generaon healthcare workers who are forced
to take on signicant debt to advance their career choices.
7. LTC Leadership, driven by immediate needs of their facilies and nancial goals, are
struggling to oer opportunies for career development for direct care sta.
Problem Statements
Barrier Area 1B: Credenaling Failures
1. Navigang the process of training and credenaling is a barrier, including access to assistance
for quesons, and duplicave standards when requirements cross mulple agencies or
regulators.
2. Tesng availability, costs, and access to nearby tesng locaons, as well as delays in
credenaling may contribute to the loss of potenal LTC workers. – 40 percent
3. Stang challenges and backlogs have slowed the compleon process for credenaling
authorizaon.
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1.
2.
3.
4.
5.
6.
7.
Problem Statements
Barrier Area 2A: Challenges Related to Regulatory Oversight
1. Need for a review of rules for LTC seng oversight to limit duplicaon and improve clarity
of expectaons.
2. Encourage a culture of support and educaon by quality assurance and regulatory bodies
before punive acon, wherever possible for health, safety, and resident rights.
3. Lack of access to technical assistance, oen fueled by insucient resources and sta at
the state level, to support workers and facility compliance with state, federal, and other
regulaons.
Problem Statements
Barrier Area 2B: Percepons of LTC
1. LTC is oen portrayed in a negave light by the media and public; leading to general
misunderstanding about the quality of care provided by the majority of facilies and care
providers in LTC.
2. LTC is not eecvely marketed as a challenging, yet rewarding, career choice.
3. Students in healthcare training need more informaon for exploring the potenal for a
quality career pathway in LTC.
4. Lack of acknowledgement for LTC as an integral part of the healthcare system, oen due to
negave percepons of the workforce (frequently women and marginalized populaons)
and those they are caring for every day (elderly and vulnerable individuals).
Problem Statements
Barrier Area 2C: Compeon Between Healthcare Sectors
1. The disregard of LTC sengs, including recruing away LTC sta by other care sengs, is
causing negave impacts to the healthcare system as a whole and the quality of care. When
LTC services are not available due to limited sta or other resources, this impacts family
members who may need to leave employment to care for loved ones, harming the overall
economic resiliency of our communies.
2. Workforce shortages of direct care sta has created a compeon between venues, oen
based on available resources for higher wages and bonuses. This provides an advantage for
some facilies over others resulng in a loss of sta due to the inability of some facilies to
match higher wages and benets.
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Problem Statements
Barrier Area 3A: Recruitment & Retenon
1. Sta are looking for employment that allows them to feel valued and supported as part
of the healthcare team, pays a living wage with benets, has predictable scheduling, and
oers career growth and opportunies for addional responsibility.
2. LTC sengs, including facilies and home care services, face stang shortages and retenon
challenges at all levels (including care providers and support of that workforce—dietary,
administrave, and environmental services, etc.), that connues to impact the care of the
people that they serve as well as the stability of these service providers.
3. Many LTC sengs oer compeve salaries that are enhanced by lucrave shi dierenals,
signing bonuses, rerement benets, and OT pay, and yet sll oen struggle compeng
with larger providers with more resources.
4. Agency/traveler services oer higher salaries than most LTC sengs can oer, or even
plan for in their budgets. Addionally, the temporary nature of the services provided may
impact the quality of care to clients, as those providers lack the connuity of care for that
individual.
Problem Statements
Barrier Area 3B: Inadequate Pay and Benets
1. There has been a systemic undervaluing of the caring profession in society. This is a crical
point, as LTC services are overrepresented in terms of the general populaon by women,
women of color, and immigrants.
2. The reimbursement rates for individuals served under Medicaid (and how those funds are
distributed to the workforce) are insucient to recruit and retain a high-quality workforce
and cover the daily cost of care.
3. LTC entry-level salaries are comparable with salaries of other entry-level roles that don’t
require the same level of required training, licensing, and regulaons. Many entry level
sta are choosing to take higher paying jobs out of healthcare; jobs that have less stress,
training, credenalling and responsibility for caring for a highly vulnerable populaon.
4. LTC sengs cannot compete with many salary types in acute care facilies.
5. A signicant amount of LTC is provided by unpaid family members. Aenon to programs
that support these caregivers is crical to their health and well-being, to the ability of
individuals with disabilies and older adults to remain in their own homes and needs to be
priorized along with strategies to support paid caregivers.
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Problem Statements
Barrier Area 3C: LTC Worker Expectaons of Care & Burnout
1. Frontline supervision and mentorship—the engagement and availability of this support is
a crical component of ensuring the success of the direct care providers and is not always
available at the level necessary. Limited training opportunies for supervision, parcularly
at smaller organizaons, also impacts the support needed for these new care workers.
2. LTC workers oen feel unprepared and overwhelmed by the level of care expected of
them in their work in their inial educaon/training and onboarding. LTC residents have an
average of seven chronic condions and 10 medicaons–the populaon served oen has
a wide range of physical and behavioral health challenges. The infrastructure of educaon,
training, and support available to the workers lacks the ability to fully prepare individuals
for the complexity and variety of condions of the populaon served.
3. Sta are burned out from working short-staed with mixed access to educaon and career
advancement opportunies and have no relief in sight.
4. The prolonged COVID-19 pandemic exhausted LTC sta (physically and emoonally) and
caused many to exit healthcare for less strenuous employment.
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appendiX 8
Strategy for Ongoing Research Efforts
The University of Washington Center for Health Workforce Studies (UW CHWS) in collaboraon with the
Workforce Board will connue to study the LTC workforce in Washington to provide mely, state-specic
informaon on key health professions and quality metrics to inform guidance and policy recommendaons.
This study will include quantave and qualitave components.
The quantave study will describe workforce trends in nursing homes/SNFs in Washington, examine variaon
by facility characteriscs, and invesgate associaons between workforce characteriscs and nursing home/
SNF stang and quality care outcomes. Findings from this work will be used to develop performance metrics for
monitoring and evaluaon of policies and programs designed to address the LTC workforce shortage, including
evaluaon of the LPN Registered Apprenceship Program, which will be led by the Workforce Board.
• What are the stang trends, including longitudinal, seasonal, and weekday versus weekend
trends, across nursing and non-nursing disciplines in nursing homes/SNFs?
• How do these stang trends vary based on use of contract versus in-house employees?
• What is the rate of turnover overall across nursing and non-nursing disciplines in nursing
homes/SNFs?
• How do stang levels and turnover vary based on facility characteriscs (e.g., prot status,
size based on number of cered beds, chain aliaon, urban-rural status, percent
Medicaid)?
• In what ways are stang levels and turnover associated with nursing home/SNF quality,
including the overall quality 5-star rang, short-stay quality measures 5-star rang, and long-
stay quality measures 5-star rang?
This study will be a secondary analysis of publicly available data from the CMS, such as the Payroll Based
Journal, Nursing Home Compare, Skilled Nursing Facility Public Use Cost Reports, as well as addional data from
other federal and state agencies, e.g., Occupaonal Employment Stascs from the Bureau of Labor Stascs.
Data from mulple sources will be linked to examine stang levels for each disciplines adjusted for the resident
census. Descripve stascs will be provided for each disciplines in nursing homes/SNFs, including contract
versus in-house employees, and by facility characteriscs; meseries trends will also be provided. A mixed eects
logisc regression model to be used to examine associaons between stang levels and 5-star quality rangs.
Timeline
Analysis will begin in Summer 2023 with the rst round of ndings presented in the 2024 report. Updates with
the most recent data, as well as ndings from any new analyses, will be presented in the 2025 report.
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Publicly available data being used for this study are aggregated at the nursing home/SNF-level and does not
contain resident-level informaon. Therefore, analyses cannot examine resident interacons with specic sta.
In addion, stang data from the PBJ are collected as part of mandatory reporng of daily hours paid by type
of sta, so any unpaid hours are not included. Finally, some data are missing for specic quarters, e.g., Q2 2020
during the inial wave of the COVID-19 pandemic. Finally, nursing home/SNF are only one type of seng. The
Qualitave study will be inclusive of other sengs.
The qualitave study will collect and analyze interview data in order to idenfy factors that inuence recruitment,
job sasfacon, and retenon of the LTC workforce in Washington. Data from workers in a variety of direct care
posions across mulple sengs will examine the barriers and supports experienced by LTC workers.
The UW CHWS team will develop, pilot, and deploy a semi-structured interview guide based on the study aims
and informed by inial ndings from the quantave study. Quesons for the sta parcipants will focus on
challenges, support, and needs in performing their jobs as well as perspecves on what constutes high quality
of care and their perceived barriers and supports to providing high quality care.
Data will be collected using of interviews of paid LTC workers. Purposive sampling will be used with the goal
of represenng a range of sta across sengs, including nursing homes/SNFs, assisted living facilies, and
community based LTC seng in both urban and rural areas..
Individual interviews will be recorded and transcribed with consent from parcipants. Themac analysis will
be used to analyze transcripts and summarize those themes with quotes for support. The researchers will code
transcripts independently and develop themes through a reiterave process of coding and recoding allowing
for discussion to rene codes and achieve consensus. Given the potenal dierences in LTC sengs, and policy
implicaons, constant comparave analysis may be used to examine how ndings are convergent or divergent
by sengs.
Timeline
Parcipant recruitment is ancipated to begin in Fall 2023. We ancipate some preliminary ndings to be
available for the 2024 report.
LTC sta in Washington have been increasingly asked to parcipate in research studies. As a result, research
subject recruitment may require an extended me frame.
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