America’s long-term care system needs new resources and fundamental reform, veteran nurse says

Retired nurse Dorothy Gall has seen every aspect of America’s elder-care system. And her verdict on the system will be hard to hear for anyone whose loved ones need care now – or those nearing the age of needing care for themselves.

 “The system is broken,” says Gall, 63, of Green Cove Springs, Fla. “And it’s headed for a crisis.”

Few could know better than Gall. She’s had hands-on experience in nearly every part of the U.S. health- and elder-care system, across 40 years and six states. She’s worked at hospitals, assisted living facilities, nursing homes, rehabilitation hospitals, home health agencies and even on a Native American reservation. A majority of Ms. Gall’s career was spent in skilled nursing and rehabilitation hospitals. Her experience includes being a nursing director in an assisted living facility, a nursing supervisor in a rehabilitation hospital and a nurse educator training other nurses.

The core of the issue, according to Gall, is a regulatory and reimbursement system that over-emphasizes administrative functions, shortchanges frontline care and emphasizes reimbursement through Medicare, Medicaid, insurance and private care over the delivery of high-quality care to residents and patients

And Gall readily admits that solutions will not be inexpensive or easy. “It’s so complex and there’s no simple solution right now. We have gradually gotten into a bad situation with so many factors and that’s why it is going to be so hard to fix it.”

Any solutions, she believes, will have to focus on staffing for frontline elder care. “Staffing is the heart and soul of long-term care." Staffing has been a problem for a long time, and it was further exposed and exacerbated by the COVID-19 pandemic. “It is obviously worse now and I see it getting much worse in the near future.”

The most challenging issues, Gall says, center on getting and retaining well-trained, effective frontline staff in elder-care institutions. “I don’t see how they’re going to keep nursing assistants at the number that is needed for safe care. There’s never been enough staff to do everything that’s demanded and needs to be done. What needs to be done is impossible for the numbers they have. Now you have even less available bodies to bring on staff, that’s why I say it’s headed for a crisis.” 

“If a CNA (certified nursing assistant) is going to be paid $11.50 per hour and a delivery driver is going to be paid $15 per hour, you’re going to constantly struggle to find nursing assistants. And it’s hard for the CNAs to manage on what they’re paid. So CNAs often are working at two facilities. In my experience, CNAs are mostly doing two full-time jobs.”

At every step, an already exhausted nursing staff is struggling with a system that over-emphasized administrative details that add little value and take resources away from quality frontline care, Gall says. 

For example, regulations require that every resident of an elder-care facility must have a care plan. These plans can be quite detailed, often running 20 pages. Each CNA may be assigned to care for 10-15 residents, depending on the shift and the staffing available that day.

On the front lines, Gall describes a job that plunges CNAs into a high-pressure, near-crisis situations as soon as their work shift starts, and the pressure doesn’t let up until the shift ends.  

“First thing in the morning, you get reports and you hit the floor. You’ve got call lights going off, vital signs to check, you’ve got people to toilet. Then you have people to get washed for breakfast, serve breakfast, which means hand feeding some who take 20 to 30 minutes to hand feed. You’ve got to be monitoring patients who are fall risks. You may have someone who is in isolation and you have to gown up every time you go into the room.” 

“You may have some patients who ring the bell all the time. Their hand literally stays on the bell.” 

At the skilled nursing level, Gall sees a similar pattern. “Nurses have daily reports to read, 20 to 30 pages sometimes, medications to give; testing blood sugars; supervising CNAs, assisting when someone needs two people to move them, nurses are expected to help with that; administering pain medication, calling a doctor because someone fell or someone’s sick, treatment and wound care, doing a full assessment on someone who’s ill, and with every step there’s tons of required charting.”

In addition to these responsibilities, nurses also must answer family calls, deal with any complaints, take care of new admissions, discharges or hospital transfers. “You end up checking and checking and checking the boxes; there’s just too much paperwork.” 

Lawmakers “need to look at why it costs so much. Those dollars are going to people who are sitting in the office rather than the nurses and CNAs who are caring for the residents. Who’s doing that care plan? It’s not the nurses who are already running nonstop, it’s someone sitting in an office.”

In 2021, the Florida Legislature revised state law to lower the amount of time that CNAs had to provide in daily direct care to residents, allowing personal care assistants (PCAs) to take on some of the load. While a CNA certification requires 120 hours of classroom training, a personal care assistant’s training requires only eight hours. Pay is also less, often $10 per hour on average. The Florida nursing home industry lobbied again in 2022 to slash the nursing staffing hours by 20% across the board. These changes reduced direct nursing care from 2.5 hours per resident per day to 2 hours. The new law also allows activities directors and other non-medical workers to provide direct resident care that would normally be performed by a nurse or certified nursing assistant.

One side effect of increasing the role of PCAs is a heavier impact on already stressed skilled nursing staff, Gall says. “The more untrained they are, the more work is on the nurses to supervise and train. They still have to know what they’re doing. The nurse on the unit is already overwhelmed. You just can’t pull Joe Blow off the street and expect them to care for people. It falls on the nurse who is already strained to the max.” 

Ms. Gall believes that all of the issues she saw in decades of firsthand experience were made worse by the COVID-19 pandemic. One of the pandemic’s worst impacts was that residents’ families were not present routinely during this time due to infection concerns. 

“You have no one to oversee that their family member is taken care of properly,” Gall said. “We all know there are nursing homes that are not doing good care and now you have no one who can come in. You have so many families who are coming in and helping with feeding them, helping to comfort them, helping to share in the workload. Some families are there all three meals to hand-feed their loved ones.”

“The worst part is they died alone – well, not alone, because nursing home staff becomes family.”

The death toll of the pandemic was especially hard on staff, Gall believes. Residents’ deaths were always stressful. “It really depended on the circumstances. Sometimes it was joy in knowing that you helped them and the family through the end of life, and sometimes it was just devastating. And some of them are still hard to think about. And then you magnify that by the number they’re dealing with now. I’ve had patients that I called my adopted grandmother and grandfather. And they treated my kids like their grandchildren. That’s how close we would get. It’s like losing a grandma every week.”