It’s no secret that the COVID-19 pandemic has exacerbated workforce shortages in healthcare. But no sector has been as hard hit as long-term care.

Since the beginning of the pandemic, employment in nursing homes has been in a downward spiral, even while other healthcare sectors have slowly added jobs. In December 2021 alone, nursing homes lost 5,200 jobs, according to the most recent U.S. Bureau of Labor Statistics jobs report. Operators have struggled to fill the challenging low-wage positions for years, and now are competing with fast food and retail roles that offer higher wages and more benefits, experts say.

To meet the demand for workers, long-term care operators have turned to refugees and immigrants. Foreign-born workers have long been a staple of the long-term care industry and already represent about 25% of direct-care employees, according to consulting firm PHI. But now, rather than relying primarily on word-of-mouth referrals, operators are creating more intentional recruitment programs for immigrants and refugees.

“The long-term care sector would collapse without immigrants,” said Robert Espinoza, vice president of policy at PHI. “Increasingly, I think employers are desperate for workers and have realized, in many ways, immigrants can fill that gap.”

The American Health Care Association/National Center for Assisted Living, which represents more than 14,000 nursing homes and assisted-living facilities across the U.S., identifies workforce recruitment and retention as the most pressing challenge facing long-term care providers and something that has only become more difficult during the COVID-19 pandemic.

“Immigrants, including refugees, make up a vital part of the nation’s healthcare workforce,” AHCA/NCAL said in an emailed statement. “The sector could not survive without these caregivers.”

AHCA/NCAL participated in a roundtable discussion in October hosted by the White House on the administration’s Operation Allies Welcome initiative, looking at ways the private sector can help resettle Afghan refugees. Clif Porter, senior vice president of government relations at AHCA/NCAL, said the association works with groups like Welcome.US, the International Rescue Committee and Lutheran Immigration and Refugee Services to help attract refugees and immigrants to positions in long-term care.

“Providers welcome these newcomers with open arms and will do everything in our power to help them through this transition and moving forward. Together, we can ensure our nation’s seniors receive the highest quality care, while creating a bright future for our new Afghan neighbors,” Porter said in a statement.

Some providers are working with resettlement agencies to attract refugees into the workforce, while others even have residents help some new hires develop greater proficiency in English, according to Natasha Bryant, senior director of workforce, research and development at the LeadingAge LTSS Center @UMass Boston, which conducts research on long-term services and supports.

Wages continue to be a struggle in attracting and retaining workers, said Bryant, who noted that Medicaid reimbursement rates for long-term care facilities aren’t enough to cover higher hourly rates for employees.

“We can’t pretend that wages aren’t an issue,” Bryant said. “We know, at least with the foreign-born workers, a lot also send remittance back to their home countries. Sometimes we will lose people to other industries that can pay more.”

SavaSeniorCare, a for-profit skilled-nursing company, doesn’t have an active program to recruit refugees but would welcome refugees into its workforce, a spokesperson said.

“We are currently recruiting foreign nurses who are legally able to work in the U.S. and are looking at other opportunities to grow our workforce permanently,” the spokesperson said. “COVID-19 has had a significant impact on the industry’s workforce, so looking beyond the traditional workforce is prudent.”

Creating training opportunities

In northern California, the California Association of Health Facilities, an association representing 900 skilled-nursing facilities and 450 facilities for individuals with intellectual disabilities, is launching a pilot program to connect new Afghan refugees with local nursing homes’ certified nursing assistant training programs.

The local arm of the International Rescue Committee already had been funneling Afghan refugees into a community college’s CNA program. But through the CAHF pilot, refugees will be paid as employees of the nursing homes while they are being trained, and then will be retained as employees once their training is complete, said Claire Enright, executive director of CAHF’s Quality Care Health Foundation and the pilot’s point person.

So far, CAHF is working with one long-term care chain in the Sacramento area, Eskaton, to train Afghan refugees.

“They were very interested in getting new employees but also very interested in helping newcomers that want a place in our society, that want to become highly functional members of our society,” Enright said.

She hopes that other chains will see the pilot’s success and want to join in.

“There is a dearth of them; there are not enough CNAs out there,” Enright said.

Entry-level jobs like CNAs are hard to keep filled because workers often move on to higher-paying jobs within or outside the industry, leading to a high turnover rate, Enright said. The same is true for other direct-care jobs in the long-term care industry, PHI’s Espinoza said.

In New Mexico, Encuentro, an adult education center that works primarily with Latino immigrants, operates a 15-week training program for home health aides. They worked with a community college to develop a curriculum entirely in Spanish and first operated the program in collaboration with the school before moving it in-house.

Now in its sixth year, Encuentro accepts 20 people into the program each semester and has a wait list of more than 100, said Mayte Lopez, a health aide training specialist at Encuentro.

“We’re kind of in crisis mode as far as the direct-care workforce goes here in New Mexico. We’re able to bring culturally sound, culturally competent training to our graduates,” Lopez said.

The program certifies students as home health aides and personal care aides and as able to perform CPR—the requirements to be a home health aide in New Mexico. It also addresses language and work authorization barriers and involves training with the National Domestic Workers Alliance on the rights of both documented and undocumented workers.

“It’s in their language, by people from their culture and is an opportunity for them to realize just how important this work is, that it’s dignified work that deserves just wages,” Lopez said.

Because students have various immigration statuses and some fear retaliation from potential employers, the program focuses on teaching them how to become independent contractors, Lopez said.

“Even if they have residency status or any other kind of status, people are scared that their boss or their client will call immigration on them,” Lopez said. “One of the biggest things that’s a barrier is that work authorization and that immigration status being held over their heads.”

Barriers to work

One of the challenges in making systemic changes to recruit refugees and immigrants into long-term care is the lack of data in that space, Espinoza said. Most states don’t collect even basic data on direct-care workers, let alone information on disparities, leaving any data collection in the sector to be done by employers.

“I virtually guarantee many employers don’t have the resources to do that or know how,” Espinoza said. “We’re so far behind in terms of the data infrastructure in this sector that it’s hard for an employer to support immigrant workers or other marginalized workers.”

Without that support, the potential for turnover remains high, and there’s more difficulty attracting workers, he said.

Espinoza recommends developing recruitment measures that provide foreign-born workers with some type of visa, which gives them a clear path to citizenship. That could help reduce the number of workers in what is known as the gray market, where consumers hire workers off the books, and encourage more workers to join the general workforce, he said.

“The truth is that when something is done in the shadows there’s going to be a risk of exploitation for workers and employers. The kind of job protections workers need probably aren’t being offered,” Espinoza said. “It’s those kinds of fears that underscore the importance of really strengthening the sector.”