The shortage of staff in long-term facilities and home care agencies has gone from a problem to a crisis.

  • Three rural nursing homes in Maine close because they cannot hire enough staff to maintain care for patients and residents.
  • A nursing home in Oklahoma shuts its doors due to a staff shortages. Same in Kansas.
  • A new industry survey reports that only 1 percent of nursing homes and 4 percent of assisted living facilities (ALFs) say they are fully staffed, while 89 percent of nursing homes and 82 percent of ALFs report moderate or severe shortages.
  • Fifty-eight percent of nursing homes and 28 percent of ALFs say they are limiting admissions because they do not have enough staff to care for residents.

“It is awful.”

And more than one-third of nursing homes and about one in five ALF operators say they are “very concerned” they’ll have to shut their doors if the labor shortage does not turn around.

One industry expert tells me “It is awful. Consumers finally are returning, but we cannot meet the demand because we do not have the staff.”

And it isn’t just care facilities. The operator of a Maryland home health agency says it is turning away families looking for assistance because it does not have sufficient aides. “We cannot provide the care our clients deserve with the staff we have,” she says.

Long-term care labor shortages are not new (here is a column I wrote in 2018, long before the pandemic). They have been a severe and growing problem for years. Older aides have been retiring, Trump Administration immigration policies slammed the door on foreign workers who might have helped filled the gap.

The pandemic

Then the pandemic came along. High levels of illness and death in facilities drove away many staffers. Many mothers stopped working to care for their children, who were unable to attend school in person. Those willing to work are choosing to stay in the profession are taking jobs in hospitals and physician offices, where the work often is easier and safer, and the pay better. Not just aides, but nurses as well.

And many long-term care workers are leaving the health care profession entirely. Widespread shortages of low-wage workers in the hospitality industry give aides the opportunity to work for as much money—or even more—at jobs that are far less physically and emotionally demanding.

On top of all that, vaccine mandates may be driving away some workers, though research suggests that concern may be overblown.

Many of these shortages are in rural communities or small cities. Limited numbers of available workers make those facilities especially vulnerable. And the consequences for families can be much more severe. Often, the next-closest available facility may be 100 miles or more away, making visits difficult at best.

Pay more

What can be done?

The economist answer could not be simpler: Want to hire in a tight labor market? Pay more.

The industry survey suggests operators have not quite confronted this. They blame worker shortages mostly on two factors: continuing unemployment benefits and “lack of interested or qualified candidates.”

Interestingly, the facility operators were more than twice as likely to blame lack of interest by workers than to blame their own inability to pay competitive wages. That implies they may have the resources to pay higher wages, despite their persistent complaints about low government reimbursement.

Let’s unpack this a bit: The extra covid-19 unemployment benefits authorized by Congress last year have ended. Thus, perceptions aside, they appear to have little to do with current labor shortages.


The lack of interest by job candidates might still be about low wages. But it also may have to do with poor working conditions, including the well-documented hierarchical management structure and lack of advancement opportunities. That suggests facility operators are going to have to rethink their entire management model if they are to fill all those vacancies.

What about Covid itself? The operators believe it still matters. But the pandemic is far less important than other factors and manifests in conflicting ways. About 45 percent of nursing home operators say vaccine mandates are the biggest reason for staff shortages while about 20 percent say the biggest problem is fear of contracting the virus.

These labor shortages appear to be growing at the same time the long-term care industry is confronting another equally important trend: consolidation. Not only are facilities closing, but operators are selling out. Small facilities being acquired by mid-sized chains and large chains are selling out to bigger ones, often owned by private equity firms.

How will these owners, often obsessively focused on the short-term bottom line, confront these labor shortages? It is hard to know, but the answer will be critically important to workers as well as to residents and their families.