OMAHA -- As high school students, Camila Delgado Garcia and Joerdy Flores-Garcia both were interested in health care careers.
So the Omaha youths signed up for a health and wellness internship offered by the Latino Center of the Midlands and CHI Health. Their internships helped them decide what they wanted to do.
Both became certified nursing assistants through the program, which covered their costs. Both will be freshmen at the University of Nebraska at Omaha this fall and have their sights on becoming dental hygienists. Garcia-Flores plans to apply to work through college at CHI Health to help cover expenses.
Delgado Garcia said a lot of careers are available in health care that people don't know about. "If you don't like one, there's hundreds more that go into it," she said.
The program is one of a growing number of initiatives in Nebraska aimed at helping attract and connect young people to health care careers. The larger goal: Grow the state's health care workforce.
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Even before the COVID-19 pandemic, the state had long-running shortages of many types of health care professionals. The pandemic has exacerbated those shortages, causing some health care workers to retire early or leave the profession. Others left for more lucrative traveling medical jobs. Hospitals, long-term care facilities and home health and hospice outlets all have struggled to maintain adequate staff.
Jeremy Nordquist, president of the Nebraska Hospital Association, said hospitals still are seeing a staff vacancy rate of somewhere between 10% and 15%, with some as high as 20%. Some larger systems still rely on a significant number of traveling medical professionals.
On the positive side, he said, some travelers are starting to return to their former employers. Rates charged by medical staffing agencies for travelers have begun to inch down. Anecdotal reports from large systems also indicate that some retired nurses are reassessing the impact of inflation on their finances and returning to the job.
But just as worker shortages have helped drive wage increases in other industries, employers in the health care sector also are seeing increased labor costs. Many hospitals and nursing homes have increased wages and offered bonuses to recruit and retain staff. They also have had to pay more for travelers to fill needed positions.
Those higher costs, combined with inflation, increased medication costs and other expenses are putting pressure on the bottom lines of hospitals, nursing homes and home health and hospice providers.
Reimbursements from Medicare and Medicaid, which make up 60% to 70% of a typical hospital's revenue, are set to increase only slightly, Nordquist said. But internal surveys of members indicate that labor costs for hospitals were up nearly 20% over the past two years, while supplies were up 15%, utilities 8% and medication 30% to 40%. Those numbers align closely with a national report prepared earlier this year by the Kaufman Hall consulting firm.
"It's a tough situation right now," Nordquist said. "We thought COVID would be the worst of the worst and we'd all be able to catch our breath ... But hospitals are in a real tough spot now financially, and it's going to take some creative work to pull our way out of this. The big driving piece of it really is the limited workforce and the costs needed to keep up with workforce costs."
Many of the state's hospitals are trying different models to make nursing in particular more attractive and bring people back in. Meanwhile, health systems and health colleges are stepping up efforts to recruit young people to fill the pipeline, including offering more scholarships.
State lawmakers earlier this year put a share of the state's federal COVID relief dollars toward initiatives to bolster the health care workforce. The Legislature allocated $5 million to help rural health care providers pay off college loans, $5 million to provide scholarships for nursing students and $60 million for a rural health complex on the University of Nebraska at Kearney campus, a joint project with the University of Nebraska Medical Center. Also included was $60 million for capital projects at community colleges to grow the state's workforce, including in health care.
Those efforts are important, Nordquist said, because the state will face a tremendous demographic challenge over the next 10 years as practitioners in the baby boom bracket retire.
According to the Nebraska Center for Nursing, Nebraska will face a shortage of 5,435 nurses by 2025.
A health care workforce report by UNMC, based on 2021 data, indicates that the number of nurse practitioners in the state had increased significantly and the number of pharmacists increased modestly since 2020.
However, rural areas of the state still lack needed health care professionals, including physicians. Nicole Carritt, director of the UNMC Office of Rural Health Initiatives, said the report doesn't capture the full impact of the pandemic. She said shortages have been exacerbated since the data was collected.
UNMC has two long-running, successful pathway programs in collaboration with UNK and state colleges focused on bolstering the rural health workforce, Carritt said. Studies show recruiting students from rural and underserved areas and training them close to those communities increases the likelihood that they will practice there.
Nordquist said the Legislature is conducting an interim study under a measure introduced by Sen. Terrell McKinney, who represents part of North Omaha, to look at ways to grow and diversify Nebraska's health care workforce.
The hospital association, he said, also is considering ways to collaborate with nursing schools to make sure they don't lose applicants. The goal would be to make sure that applicants who are turned down by one nursing college are provided information about other programs or are enrolled in a program where they can earn an associate's degree.
Selene Espinoza, a surgical assistant with CHI Health, said she got involved in the Latino Center/CHI program last year when it added the CNA certification option. She wanted to make sure Latino students were exposed to health care settings and could see people like themselves in those workplaces.
She talks them through the training required for various careers, from CNAs to physicians, as well as their earning potential. She takes them on tours of hospitals and clinics, where they meet health professionals, don gowns and gloves and get their hands on equipment, including a surgical robot.
Espinoza moved to the United States from Mexico as a preteen. As a student at Omaha Bryan High School, Espinoza said she didn't think a career in health care was possible because of language and financial barriers. Her parents hadn't gotten a higher education and didn't know the U.S. education system. But she was exposed to career options in a program through CHI Midlands. She now serves on the hospital's community board and is a member of the Douglas County Board of Health.
"I feel like I've walked the path and can do a little bit of guidance," Espinoza said, noting that the pandemic also highlighted the need for health care workers who could speak patients' languages and understand their cultures.
Ricky Solis, a UNO junior who joined the program this year, had thought to one day work for an international health organization. But he has shifted his focus to local public health after working for the Central Public Health District in Grand Island during the pandemic and for the Latino Center/CHI program.
"I'm working on the stuff I've studied in college," he said.
Bolstering the existing workforce
While the staffing crunch for hospitals has eased since the last pandemic peak, hospitals still are busy, in part because they're catching up with delayed care.
Sue Nuss, chief nursing officer at Nebraska Medicine, said the health system had 450 employees out with COVID at the peak of the omicron surge in January and February. Both that and the number of patients ill with COVID have decreased significantly, although COVID continues to sideline some employees.
Since then, the health system, like many others, has increased compensation packages for bedside nurses. Like other health systems, Nebraska Medicine still employs travelers, although Nuss said it has fewer than at the pandemic peak. It also added 130 nursing school graduates and 90 nurse residents this spring.
But with projections indicating that the number of nurses never will be adequate, Nuss said, the health system is trying out different care team models. It has brought licensed practical nurses back to inpatient units, a role it had eliminated years ago, and also has some paramedics working in those units.
Rather than having one nurse alone oversee four or five patients, for instance, that nurse might instead cover eight or nine patients with the help of an LPN, nursing assistant and paramedic, Nuss said. While stretching nurse-to-patient ratios can impact quality of care, having a team allows nurses to delegate some tasks. By working together, a team may be able to care for more patients.
Tim Plante, chief nursing officer for CHI Health, said that health system also has focused on incentivizing nurses who have stayed and working to get new ones in the field.
A number of health care workers who left to travel have started to return, he said. So far, 100 practitioners, from nurses to respiratory therapists, have joined the health system's new internal travel pool. Some have come from across the country.
CHI Health also is trying several new programs aimed at increasing job flexibility, Plante said. Under a weekend option, instead of working every third weekend, the local standard, a nurse could work every weekend or every other weekend in exchange for additional pay. That option works for a lot of nurses with families who want to arrange child care around their shifts.
The health system also is incentivizing nurses to learn new skills and work in different areas — say, the intensive care unit in addition to labor and delivery — and to work in different metro-area hospitals.
CHI Health also has two pilot programs that involve bringing pharmacists and occupational therapists onto floors to help nurses with tasks such as administering complex IV medications and helping patients with strength training.
Russ Gronewold, president and CEO of Lincoln-based Bryan Health, said the system is down to 470 open positions from a peak of 550 during the last pandemic surge. It's also down to 110 travelers of all types from a high of 170.
In the short term, Bryan has adjusted wages, offered retention bonuses and restored team-building activities such as company picnics and zoo nights. Health system officials are trying to figure out how to accommodate workers' desire for flexibility, which has increased as wages have increased.
The health system also has started an internal traveler pool, Gronewold said, and has been able to get some employees who had been traveling elsewhere to commit to moving among Bryan's hospitals in Lincoln, Grand Island, Kearney and Central City.
Gronewold said he also sees a role for more technology. Bryan is using artificial intelligence to extend staff in some areas, including working with a Lincoln software firm to monitor patients at risk of falling with 3D cameras and a fall-predicting algorithm. That has freed about 30 people a day who otherwise would be sitting with patients.
Other systems monitor incoming test results and alert nurses if interventions are needed right away and pre-sort lab results and CT scanner images to help practitioners pick up on any problems more quickly.
"These are things that make their job more efficient, but it doesn't replace the person who does the job," Gronewold said.
Ivan Mitchell, CEO of Great Plains Health in North Platte, said his hospital also is bringing back LPNs, medical assistants, certified nursing assistants and paramedics.
If a task doesn't have to be done by a nurse, he said, "we're having it be done by someone else." The same generally goes for physicians.
Mitchell and Gronewold said Nebraska practice standards required some professionals to perform tasks that could be done by others with lesser training. Making such changes would require legislation, and hospital officials are discussing the idea with state lawmakers.
"There are no projections that suggest it's going to be anything but a long-term issue," Gronewold said of the shortages. "Simply increasing the folks going to nursing school by 10% or 20%, that still doesn't even address 50% of the shortage. We have to come up with other programs, of how do we use technology, how do we use other individuals."
Great Plains has taken a different approach to recruiting. Mitchell said the health system began recruiting nurses from the Caribbean, the Philippines and other nations after he arrived more than six years ago. The nurses all have passed the certification exams that allow them to practice. Since 2018, the hospital has employed about 175 international recruits.
Many move on after their three-year contracts run out, Mitchell said. But some stay. And while they're in North Platte, their children go to school there. They pay rent and shop in the community. If they move elsewhere in the U.S., they remain part of the larger pool of health care workers.
Nursing home challenges
Meanwhile, both nursing homes and home health and hospice outlets face workforce and financial challenges of their own. A side effect, Mitchell said, is increased length of stay for patients in hospitals because nursing homes don't have the staff to take them. Some nursing homes have closed.
Jalene Carpenter, president and CEO of the Nebraska Health Care Association, said a lot of nursing homes still are ending up in outbreak status due to COVID, meaning a single resident or employee has tested positive. Some employees have left due to requirements for testing and protective gear, which are stricter than in other industries.
A survey of 759 nursing home providers in mid-May by the American Health Care Association indicated that 98% of homes are having difficulty hiring staff. In addition, 73% are concerned about having to close their facilities over staffing woes.
In Nebraska, home operators have not only raised wages but also are looking at other strategies to grow their workforce, Carpenter said. At the national level, the association recently advocated for shortening the wait time for people in the country who are on certain visas to be eligible to work.
Still relatively new to the industry is an online labor platform for long-term care facilities called KARE, which is in place in Omaha and Lincoln. It works a bit like an Uber program for staffing and is "seeing incredible success," Carpenter said.
With KARE, facilities can post available shifts, and caregivers interested in work can select the ones that work for them — say, a four-hour shift on a Tuesday. Employers, rather than staffing agencies, set the wages. If the employer likes the worker, they can offer to hire the person.
"Those are the things that give me hope," Carpenter said. "Innovation comes from times of crisis, and we are seeing (people) coming up with new and innovative things."
Janet Seelhoff, executive director of the Nebraska Association for Home Healthcare and Hospice, said agencies are having to turn away patient referrals because they can't staff enough nurses and aides. That comes in the face of growing demand for such services.
"Need is greater than it's ever been," she said, "but at the same time, there are challenges in staffing." Costs have gone up with inflation, and home health and hospice agencies can't compete with the hiring bonuses and benefit packages hospitals and other health care settings are offering.
Building the pipeline
Meanwhile, the push continues to get more people into the health care pipeline, with the help of a host of programs, scholarships and loan repayment programs. Colleges and universities continue to reach out across the state to build programs in more locations.
Deb Carlson, president of Nebraska Methodist College, said the pandemic could have scared people away from the field, but it hasn't.
"People are saying they want to go into health care because they want to make a difference, they want to make an impact," she said, acknowledging that publicity about salary increases and loan payback programs also have helped spur interest. For those who don't want to work directly with patients, plenty of careers are available that aren't at the bedside.
Employers now are focused on how they can get students in the system even before they have degrees and are offering tuition assistance to help them continue their education once they're in the door, Carlson said.
Nebraska Methodist College, for instance, offers a free student nursing assistant program that allows people 16 and older to study to become nursing assistants at Methodist Hospital and get paid, on-the-job training with a two-year work commitment. The college also began offering its first full-ride scholarships last year for traditional bachelor's of nursing students.
Carlson said the college also is doing more to reach out to minority communities and has a free master's program for existing minority providers who want to go into nursing education, which also is a shortage area.
People who earn degrees in health care have no trouble finding jobs, she said. This year, for the first time, even junior nursing students were being hired.
Gronewold said Bryan is automatically offering jobs to junior nursing students at Bryan College of Health Sciences. The health system also is offering more tuition reimbursement for employees seeking additional education and just rolled out a program covering half the tuition for the children of employees who have been with the system for three years, as long as they stay with the system.
Over the course of the next few years, said Dr. Bo Dunlay, dean of Creighton University's medical school, Creighton will increase the number of graduating physicians from 600 to 1,000. The university also has created two physician assistant programs that eventually will add at least 100 practitioners to the workforce each year. The university also accelerated bachelor of nursing programs in Phoenix and Grand Island.
"It's created an opportunity for growth," he said of the expansion. "But the important thing is we've got clinical partners there whose missions are aligned with ours, and that's what makes it so successful."