*This report was replaced in its entirety by the Department of Health on April 8, 2021.

As a condition of state licensure, nursing homes are required to provide a sufficient number of nursing staff to meet the assessed nursing care needs of its residents. Similarly, for those nursing homes participating in the Medicare and Medicaid programs, federal regulations require facilities to have sufficient nursing staff to address the number, acuity, and diagnoses of residents. The clinical workforce in Virginia—particularly certified nurse aides (CNAs) and licensed practical nurses (LPNs)—has declined in recent years; as a result, all medical care facilities, including nursing homes, have an increasingly smaller pool of qualified applicants from which to hire. The availability of the clinical workforce directly impacts the quality of care provided to nursing home residents.

The General Assembly directed the Virginia Department of Health (VDH) to convene a work group of key stakeholders in order to “review and make recommendations on increasing the availability of the clinical workforce for nursing homes in the Commonwealth." VDH convened a work group that met eight times between July and November 2020. The work group received numerous informational presentations and received extensive written and oral comments. Through its discussions and deliberations, the work group focused in particular on the following issues and topics within the context of the study mandate:

• Education
• Wages
• Expansion of the existing workforce

Education. The work group identified the need to strengthen the educational pipeline that leads to careers not just in the clinical workforce, but specifically the clinical workforce in nursing homes. Some recommendations developed by the work group may be mutually exclusive (e.g., the multiple service learning options), but the work group felt that adoption of any one option would be beneficial to increasing the availability of the clinical workforce in nursing homes. The following recommendations are made:

1. Permit, but not require, local school boards to offer graduation credit for service learning in clinical care in long term care settings. Service learning is an instructional strategy that combines meaningful hands-on service to and for the benefit of the community with curriculum-based learning meeting specified objectives defined by the local school board in consultation with the Virginia Department of Health Professions (DHP) and VDH

2. Statewide offering of optional graduation credit for service learning in clinical care in long term care settings. Service learning is an instructional strategy that combines meaningful hands-on service to and for the benefit of the community with curriculum-based learning meeting specified objectives defined by the Virginia Board of Education (VBOE) in consultation with DHP and VDH

3. Statewide offering of optional Fairfax County Public Schools model of hours-based service learning (i.e., required for students in grades 6, 8, and 12, with optional diploma seal if additional hours are completed) in clinical care in long term care settings. Service learning is an instructional strategy that combines meaningful hands-on service to and for the benefit of the community with curriculum-based learning meeting specified objectives defined by the VBOE in consultation with DHP and VDH

4. Require changes to nursing home regulations to permit volunteerism in nursing homes, with supervision that includes orientation and training for volunteers consistent with the tasks assigned, recording the type of tasks and time worked, and method by which a volunteer may contact supervisor for immediate assistance

5. Require changes to nursing home regulations to permit service learning in nursing homes, with supervision that includes orientation and training consistent with the tasks assigned, recording the type of tasks and time worked, and method by which a learner may contact supervisor for immediate assistance

6. Establish education and outreach programs for middle school and high school students to promote career pathways in long term care

7. Funding for tuition of the Advanced Certification for CNAs upon conclusion of pilot program

8. Expand eligibility of Nurse Loan Repayment Program in Va. Code § 32.1-122.6:04 (also known as the Mary Marshall Nursing Scholarship) to include CNAs

9. Fund the Nursing Scholarship and Loan Repayment Fund in Va. Code § 54.1-3011.2

Wages. The work group also recognized that one of the major challenges facing the current clinical workforce is low wages, which leads to difficulty in adequately staffing nursing homes, which in turn leads to burnout of existing staff. Some recommendations developed by the work group may be mutually exclusive (e.g., the multiple pay-for-performance programs), but the work group felt that adoption of any one option would be beneficial to increasing the availability of the clinical workforce in nursing homes. The following recommendations are made:

10. Establish financial relief program to support direct care nursing home employees by covering a percentage of childcare or dependent care costs

11. Establish financial relief program to support direct care nursing home employees by covering a percentage of transportation costs to include public transportation costs

12. Establish financial relief program to support direct care nursing home employees by covering a percentage of living costs, which may include housing, transportation, childcare or dependent care, utilities, or other categories of expenses as determined by the General Assembly

13. Increase wages for CNAs proportional to regional living wage standards, with living wage standards derived from United For ALICE project data aggregated according to the local workforce board region

14. Increase wages for CNAs proportional to regional living wage standards, with living wage standards derived from Massachusetts Institute of Technology (MIT) Living Wage Calculator aggregated according to the local workforce board region

15. Increase minimum wage proportional to regional living wage standards, with living wage standards derived from United For ALICE project data aggregated according to the local workforce board region

16. Increase minimum wage proportional to regional living wage standards, with living wage standards derived from MIT Living Wage Calculator aggregated according to the local workforce board region

17. Rebase the Medicaid reimbursement rate annually based on regionalized living wage standards (derived from United For ALICE project data aggregated according to the local workforce board region) and mandating rate increases are passed on to direct care workers by implementing a wage pass-through program

18. Rebase the Medicaid reimbursement rate annually based on regionalized living wage standards (derived from MIT Living Wage Calculator aggregated according to the local workforce board region) and mandating rate increases are passed on to direct care workers by implementing a wage pass-through program

19. Rebase the Medicaid reimbursement rate triennially based on regionalized living wage standards (derived from United For ALICE project data aggregated according to the local workforce board region) and mandating rate increases are passed on to direct care workers by implementing a wage pass-through program

20. Rebase the Medicaid reimbursement rate triennially based on regionalized living wage standards (derived from MIT Living Wage Calculator aggregated according to the local workforce board region) and mandating rate increases are passed on to direct care workers by implementing a wage pass-through program

21. Pay for performance program through the Virginia Department of Medical Assistance Services (DMAS) to provide additional reimbursement to facilities meeting minimum staff-to-resident ratios and meeting minimum quality of care standards as determined by DMAS, with such threshold ratios for additional reimbursement increasing every biennium for three biennia

22. Pay for performance program through DMAS to provide additional reimbursement to facilities meeting minimum staff-to-resident ratios and meeting minimum quality of care standards as determined by DMAS, with such threshold ratios for additional reimbursement beginning at 12-to-1 and increasing to 6-to-1 over for four biennia

23. Pay for performance program through DMAS to provide additional reimbursement to facilities meeting minimum hours of nursing care per resident, with such threshold hours for additional reimbursement increasing every biennium for three biennia

24. Pay for performance program through DMAS to provide additional reimbursement to facilities meeting minimum hours of nursing care per resident and meeting minimum quality of care standards as determined by DMAS, with such threshold hours for additional reimbursement beginning at 3.5 hours and increasing to 4.1 hours over for three biennia

Expansion of the existing workforce. The work group examined ways to expand the clinical workforce in nursing homes, both now and in the future, by investigating means and methods to incentivize the inclusion of veterans, persons with disabilities, and other groups. The work group also looked at ways to incentivize the existing clinical workforce to remain in nursing homes. The following recommendations are made:

25. Creating a workforce program similar to Virginia Values Veterans (V3) Program for people with disabilities to increase employment opportunities and promote economic development by training and certifying organizations in disability workforce best practices

26. Require changes to nursing home regulations to permit care by non-credentialed individuals in the Military Medics and Corpsmen (MMAC) program

27. Civilian credentialing/licensing reciprocity so state regulatory bodies recognize civilian equivalency of certain military allied health specialties

28. Civilian educational credits for statewide standardized recognition of military medical education and awarding of equivalent credit hours

29. Funding for awareness campaign for MMAC Program and the healthcare employment opportunities provided by the program

30. State version of the federal work opportunity income tax credit for private-sector businesses that hire individuals who have consistently faced significant barriers to employment, as determined by the General Assembly

31. State income tax credit for CNAs, LPNs, and registered nurses (RNs) working at licensed nursing homes and certified nursing facilities

32. State income tax credit for for-profit nursing homes based on expenditures aimed at providing access to employees with disabilities

33. Tax relief program for not-for-profit nursing homes that would allow them to offset part of their payroll tax for expenditures aimed at providing access to employees with disabilities

34. Direct Joint Commission on Health Care to conduct a study on direct care staff recruitment and retention, workplace culture improvements, and internal leadership development in nursing homes