We Surveyed Our Stakeholders on COVID-19. Here’s What We Learned.

Last month, PHI quickly launched a national survey to learn how long-term care employers and direct care workers are managing the COVID-19 pandemic. We wanted to hear about the field’s most pressing workforce concerns, and what long-term care providers—including nursing homes, assisted living, and home care agencies—are doing to support workers through this crisis.

In this article, we draw out five key findings from the survey and propose immediate responses for both state policymakers and long-term care employers.

But first: here are the top five direct care workforce concerns reported by survey respondents:

• Nearly everyone (82 percent of respondents) is worried that direct care workers will become infected with COVID-19;
• Three quarters of respondents (75 percent) are concerned that workers will carry the virus from the community to their residents or clients;
• Just over two-thirds (69 percent) fear that workers will have to leave their jobs to care for their children or other relatives;
• Sixty-nine percent worry that workers will choose to leave their jobs because of fear about the coronavirus; and
• Sixty-six percent of respondents are concerned that there won’t be enough workers to replace those who take time off or leave their jobs.

Finding 1: Direct care workers deserve recognition.

Survey respondents emphasized that direct care workers should be recognized for their contribution to the health and long-term care system—now more than ever, as they put their lives on the line to support their clients through this crisis.   

One survey respondent wrote: “Lots has been mentioned about nurses and doctors… [but CNAs] should also be addressed as heroes during this time.” Another said: “Caregivers are some of the least respected workers in our economy. The stigma needs to end.” A direct care worker requested: “Please help by treating [direct care workers] like they are essential. I am an aide and don’t feel like I’m being treated right! We have a big job and are taking a chance and should be treated in a better manner, like what we are doing is appreciated!”

What can state policymakers do? Designate all direct care workers as “essential” health care workers—New York sets a good example in this regard—to ensure they can access targeted financial assistance, employment supports, and supplies during the pandemic.   

What can long-term care employers do? Take every opportunity to explicitly appreciate and provide practical support to direct care workers, recognizing that everyone is busy and organizational resources are limited. As an example, one employer reported including some key supplies for staff in the grocery order for their facility.

Finding 2: Protective supplies are desperately needed.

Survey respondents made it overwhelmingly clear that direct care workers need personal protective equipment (PPE) and other infection-prevention supplies to keep themselves and their clients safe—and they need these supplies immediately.

Nearly every respondent expressed concern about the lack of PPE for direct care workers, with 72 percent citing this shortage as a key barrier to supporting workers during this crisis. One direct care worker shared: “It’s difficult to choose between my health and my job. My home care agency does not provide PPE to caregivers and it is completely unavailable to us to purchase on our own.” An employer stated: “I’m afraid that we will lose a large percentage of our workforce to this pandemic. The surviving caregivers won’t choose to stay in such a dangerous profession… We wouldn’t ask [a police officer] to work without a vest or gun. Our direct care workforce is asked to work without protective equipment on an almost daily basis.”

What can state policymakers do? Ensure that direct care workers’ needs are included in PPE supply-chain calculations. As an example, the Illinois Department of Public Health is surveying community-based organizations (including home care agencies) to better estimate statewide PPE needs.

What can long-term care employers do? Contact regional and state public health officials about the extreme shortage of PPE in long-term care, providing quantitative evidence if possible. Provide clear guidance for workers about how to keep themselves and their clients safe, for example reinforcing proper handwashing technique, while waiting for more supplies to become available.

Finding 3: Information and education are critical.

Survey responses indicated that more information on the COVID-19 pandemic response is needed by long-term care employers and direct care workers alike.

Sixty percent of respondents reported that long-term care employers are providing COVID-19 training and 62 percent said that employers are prioritizing communication during this crisis, but there were notable exceptions. One direct care worker simply stated, “my employer hasn’t informed us about anything” and another respondent said, “I’m the only one at my company trying to get information out to caregivers.” At the same time, we learned that long-term care employers also need more targeted information and guidance. One respondent wrote: “[We need] the state to give us guidance on our specific situation… [We] are not getting any answers.” Another said, succinctly: “We don’t know what to do if there’s an outbreak.”

What can state policymakers do? Ensure that long-term care providers have access to relevant, up-to-date information on COVID-19 to inform their organizational decisions and share with staff. For example, North Carolina’s Division of Public Health is hosting weekly webinars for health and long-term care providers during the pandemic.

What can long-term care employers do? Update staff, clients, and family members as regularly as possible about COVID-19 (by phone, email, webinar, and/or in person). More specifically, provide direct care workers with concise guidance about how to implement best practices in infection prevention and control during the pandemic.

Finding 4: Visible leadership makes a difference.

With limited information and guidance, long-term care employers are struggling to navigate their organizations through this crisis—but they must still model strong, supportive leadership.

A number of survey respondents spoke to the difficulty of leading their organizations through this unprecedented moment. As one summarized: “Very importantly, no employer/leader has ever been here before so lack of experience and dealing with so many unknowns impact their abilities to lead and respond appropriately.” However, other respondents indicated that this uncertainty may be perceived by direct care workers—many of whom experience limited organizational support during the best of times—as a lack of leadership. One direct care worker reported: “The only thing my company has given us is information on COVID-19 and signs to hang up on our doors saying not to enter if you feel sick. Our office secluded [themselves] while the rest of us report to direct contact with our clients.”

What can state policymakers do? Facilitate opportunities for long-term care providers to share and learn about best practices in organizational leadership and workforce management during COVID-19. Examples include virtual roundtables, peer-to-peer online forums, and expert-led webinar series.

What can long-term care employers do? Maintain a visible presence among direct care staff and share regular updates on the organization’s response to the coronavirus. Individual check-in calls can be a helpful way to monitor workers’ health status while also soliciting and directly addressing their questions and concerns.

Finding 5: Long-term care providers need emergency funding.

Long-term care employers need targeted funds to better support and compensate the direct care workforce during the COVID-19 pandemic.

Long-term care employers, especially those reliant on Medicaid reimbursement, report that they are struggling to implement workforce supports without additional funding. One employer called for “financial incentives/pay incentives for our caregivers to show appreciation to their dedication and help them stay afloat,” while several others noted their inability to pay hazard wages to workers on the frontline. Several respondents also mentioned the prohibitive cost of infection prevention and control supplies, including PPE (where available).

What can state policymakers do? Implement pass-through requirements to ensure that a proportion of increased federal matching funds for Medicaid are designated for direct care workforce supports, including wages, paid leave, training materials, and more.

What can long-term care employers do? Reach out to long-term care membership organizations for information on financial resources that may be available through federal or state coronavirus legislation. Also, explore collective purchasing options with other local providers, for example when sourcing PPE, to maximize financial resources within the sector.

Across all the survey responses, the main message was clear: the coronavirus crisis is exacerbating existing direct care workforce challenges, not creating entirely new ones—and without action, this crisis will have both an immediate and lasting impact on workforce supply. Simply put by one respondent: “Workers will leave the work and never come back.” These five steps are just the beginning of what’s needed to survive this crisis and ensure sustainable long-term care services for those who need them.

We want to continue learning from long-term care employers, direct care workers, and other leaders and advocates about what’s happening in the field at this critical time. Please take a few minutes to complete our ongoing survey.