Although there is a tendency to associate nursing with hospitals, according to the U.S. Bureau of Labor Statistics, approximately 35 percent of licensed practical and vocational nurses (LPNs/LVNs) work in long-term care. In the case of certified nursing assistants (CNAs), long-term care settings constitute approximately 44 percent of current employment. Granted, only 5 percent of registered nurses (RNs) currently work in long-term care settings, such as nursing and residential care facilities. However, the demand for long-term care nurses only increases as the US population ages. More and more people live in nursing homes, assisted living facilities, memory care residences, and adult foster homes or otherwise require these services in their own homes or adult day care centers.
The following guide provides comprehensive information about long-term care for nurses and other healthcare professionals interested in pursuing careers in this promising field.
What Does LTC Stand For?
The abbreviation LTC stands for long-term care. A broad definition of long-term care would include all medical and non-medical services offered to people who cannot independently manage activities of daily living (ADLs) such as eating, bathing, or managing their medication.
What Does Long-Term Care Mean in Medical Terms?
Although most long-term care is non-medical and provided by friends and family members, individuals often need the services of trained healthcare professionals, such as nurses or physical, occupational, and speech therapists. Some medical long-term care services include helping people recover from accidents, surgeries, or illnesses.
Some people require LTC unexpectedly, for example, after a car accident or a heart attack, but for most people, the need for long-term care gradually increases as they age.
Which Facilities Offer Long-Term Care?
According to the American Council on Aging, there are many places where people receive long-term care, such as adult day care centers, adult foster homes, assisted living facilities, memory care or Alzheimer’s care residences, nursing homes, and even private homes.
Adult Daycare Centers
Adult daycare is often offered at community centers and can assist primary caregivers who must work or simply need a break. These centers supervise and help adults with long-term care needs by offering food, recreation, and therapy. Some centers also provide medical care, such as physical, occupational, and speech therapy.
Adult Foster Homes
Adult foster care or adult family care refers to homes for older adults who cannot live independently. These homes offer room and board, companionship, supervision, and help with daily living activities, including eating, bathing, and dressing. Adults requiring long-term care live in these homes with their caregivers and usually with other seniors.
Assisted Living Facilities
Although assisted living facilities offer long-term care, only some living there require medical care. These facilities assist seniors who cannot live independently but don’t necessarily need assistance around the clock. In addition to room and board, these facilities offer help with personal care, medication management, supervision, and social and recreational activities, among other services.
Nursing Homes
Nursing homes and skilled nursing facilities provide a higher level of care than assisted living facilities and are below the level of care patients receive in hospitals. These facilities not only offer room and board, personal assistance, and supervision but also around-the-clock medical care, including skilled nursing care, medication management, and occupational, physical, and speech therapies. Patients who require a higher degree of care usually go to long-term care acute hospitals or LTACHs.
Memory Care Residences
Memory care or Alzheimer’s care residences can be stand-alone facilities or units within assisted living facilities or nursing homes. These facilities or units are specifically geared toward people with Alzheimer’s disease or another form of dementia, with staff trained to work with people with cognitive issues, providing care and supervision 24 hours per day.
Private Homes
When offered the choice, most seniors decide to remain in their homes or relatives’ homes, making private homes places where people can also receive long-term care. In the home setting, seniors can receive as much assistance as they need while remaining as independent as possible. Home care aides or personal care attendants can help seniors bathe, dress, groom, go to the bathroom, eat, change positions, and move around the house. Many healthcare services can also be offered at home, such as checking vital signs, changing bandages, and assisting with insulin injections. Furthermore, emergency response systems are a type of long-term care service. In some cases, seniors can call for help. Still, other systems are automated, detecting a fall, for example, and others can monitor seniors’ locations, which can be especially helpful for people with Alzheimer’s or another form of dementia.
Does the Medicaid Program Pay for Long-Term Care?
The Centers for Medicare & Medicaid Services covers the cost of Nursing Facility Services provided in nursing homes licensed and certified by the state survey agency as Medicaid Nursing Facilities (NFs). Medicaid Nursing Facility services are only available when the individual is eligible for the Medicaid program and other payment options are unavailable.
Many nursing homes are certified as Medicare skilled nursing facilities (SNFs). Most also accept long-term care health insurance and private payment.
Here is a typical scenario:
An individual may enter a skilled nursing facility after a short-term hospitalization. Often, residents require nursing home services after a maximum period of 100 days under SNF coverage. In this case, the individual may use long-term care insurance or pay privately. If the nursing home is a Medicaid-certified nursing facility and the resident qualifies for Medicaid, they may stay in the facility and receive Medicaid benefits. If the facility is not Medicaid certified, the individual must transfer to a Medicaid Nursing Facility to benefit from this coverage.
Long-term care residents who qualify for Medicaid may not be charged for the following services:
- Nursing and related services
- Specialized rehabilitative services for residents with intellectual disability or mental illness not provided or arranged for by the state
- Medically-related social services
- Pharmaceutical services
- Individualized dietary services
- Professionally directed activities programs to meet the interests and needs and contribute to the wellbeing of each resident
- Emergency dental services and routine dental services based on the coverage of the state plan
- Room and bed maintenance services
- Routine personal hygiene items and services
The following services are not covered by the Medicaid program and may result in charges to the resident:
- Private room, unless medically needed
- Specially prepared food (not typically prepared by the facility)
- Special care services excluded from the facility’s Medicaid payment
- Telephone, radio, television
- Personal comfort items, such as confections and tobacco products
- Cosmetic and grooming items and services outside of the basic service
- Personal clothing and reading materials
- Flowers, plants, and gifts purchased on behalf of a resident
- Social events and activities outside of the activity program
Who Works in Long-Term Care Facilities?
The primary workforce in long-term care settings includes nurses, nursing assistants, and personal care aides. In general terms, nurses monitor residents’ health conditions, perform wound care, give medicine, and provide education. Under RN supervision, CNAs take vital signs and assist with activities of daily living. Personal care aides have many of the same duties as CNAs, such as helping residents with ADLs. However, they may also assist with cleaning and laundry if needed.
What Do RNs Do in Long-Term Care?
Allowing for some differences from one facility to another, the following are typical RN responsibilities in long-term care settings:
- Promoting and restoring patients’ health by following the nursing process
- Collaborating with physicians and other multidisciplinary team members
- Performing various treatment procedures
- Providing physical, emotional, and educational support to patients, friends, and family members
- Supervising assigned team members
- Developing and documenting individualized care plans with the help of the interdisciplinary healthcare team as needed
- Preparing equipment and assisting physicians during patient examinations
- Providing IV therapy and wound care
- Giving therapeutic massages or assisting patients with range-of-motion exercises
- Maintaining effective communication to convey patient health status, treatment plans, and progress
- Demonstrating proficient use of an Electronic Health Record (EHR), including accurate patient and provider documentation and communication
What Does an LPN/LVN Do in Long-Term Care?
The role of LPNs/LVNs varies from state to state and may vary from one facility to another. However, licensed practical or vocational nurses typically carry out the following duties in long-term care settings:
- Promoting and restoring patients’ health by following the nursing process
- Monitoring and recording vital signs
- Collaborating with physicians and other multidisciplinary team members to carry out patients’ treatment plans
- Performing various treatment procedures
- Providing physical, emotional, and educational support to patients, friends, and family members
- Supervising assigned team members
- Administering medication
- Giving and receiving relevant written and verbal reports from/to appropriate staff as per protocols
- Ensuring concise, pertinent, and complete documentation using computerized medical records
- Ensuring clinical areas are adequately supplied and exam rooms are available and stocked
What Do CNAs Do in Long-Term Care?
Throughout healthcare settings, CNAs typically assist patients and residents with activities of daily living. In long-term care facilities, they also help residents get to and from the dining room and diverse leisure activities. The following responsibilities provide a glimpse of a CNAs typical day in long-term care settings:
- Assisting residents in activities as per individualized care planning, including feeding, bathing, grooming, using the toilet, dressing, and changing positions
- Transporting to and from activities as needed
- Providing leisure activities as needed
- Performing evaluation and reporting
- Providing residents and family members with emotional support
- Assisting in maintaining a clean and safe resident environment
- Supporting families and directing them to appropriate professional staff
- Responding to resident requests promptly
- Receiving and giving reports to team members and leaders
How to Become a Long-Term Care Nurse
The pathway and time required to become a long-term care nurse depend on the desired degree and nursing license.
How to Become a Long-Term Care RN
An aspiring registered nurse who wishes to work in long-term care must complete an accredited RN program, typically a two-year Associate Degree in Nursing (ADN) or a four-year Bachelor of Science in Nursing (BSN). A candidate must also pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN) and meet other state-specific requirements to obtain an RN license. Besides holding a current RN license valid in the state of nursing practice, a registered nurse is typically required to have a Basic Life Support (BLS) certification.
RNs typically don’t need previous nursing experience to work in long-term care unless they apply for supervisory positions.
How to Become a Long-Term Care LPN/LVN
An individual interested in working in long-term care as a practical or vocational nurse must complete an accredited LPN/LVN program, which typically takes one year, and pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN). Once candidates meet these and other state-specific requirements, they obtain their nursing licenses and are ready to work. LPNs/LVNs generally must obtain BLS certification to work in long-term care.
How to Become a Long-Term Care CNA
Those interested in working in long-term care as nursing assistants generally must hold high school diplomas or the equivalent and complete CNA training programs, which may take as little as four weeks. Other requirements vary by state and facility but often include BLS certification.
Personal care aides, who perform many of the same tasks as CNAs, generally receive little training and have few opportunities to advance in their careers. However, as with other care roles, requirements and career opportunities vary by state.
General physical requirements for long-term care healthcare workers include the following:
- Occasionally exerting 20 to 50 pounds of force
- Frequently exerting 10 to 25 pounds of force
- Constantly exerting up to 10 pounds of force to move objects
- Being able to walk, stand, and squat frequent
Long-Term Care Nursing Certifications
LPNs/LVNs and RNs can work in long-term care settings without requiring additional certifications, except the widely required Basic Life Support certification, which can be obtained in one day through the American Red Cross or the American Heart Association. However, there are many certifications available for nurses, including the following:
- The American Nurses Credentialing Center offers the Gerontological Nursing Certification (GERO-BC™) for RNs with active licenses who have practiced as registered nurses for a minimum of two years and have completed at least 2,000 clinical practice hours in gerontological nursing within the last three years. Candidates must also have accrued 30 hours of continuing education in gerontological nursing within the previous three years.
- NAPNES offers a long-term care certification for LPNs. This certification covers the entire life span of chronically ill people, including geriatric nursing care and excellent nursing care for all age groups with chronic illnesses. After obtaining the certification, practical and vocational nurses adopt the LPN, CLTC, designation.
- The Certification Board of Infection Control and Epidemiology, Inc. (CBIC) offers the Long-Term Care Certification in Infection Prevention (LTC-CIP) for anyone with post-secondary education in a health-related field. The CBIC recommends but does not require one year of full-time infection prevention experience. This certification indicates competence in infection prevention and control within a long-term care setting, including responsibility for infection prevention and control programs and activities in long-term care settings.
Additionally, the Washington State Nurses Asociation recommends all of the following specialization options for long-term care nurses:
- Education
- IV therapy
- Wound, ostomy, and continence
- Diabetes management
- Leadership
- Case management
- Chronic pain management
- Dementia care
How Much Do Long-Term Care Nurses Make in the US?
Interestingly, whether long-term care is a high-paying or low-paying setting for nursing professionals depends on their license type. It is among the highest-paying settings for LPNs but one of the lowest-paying settings for RNs. For CNAs, it offers mid-to-low pay in comparison to other work settings.
Certified nursing assistants working in long-term care earn below the national average CNA wage of $39,610 annually or $19.04 hourly. However, they earn more than their counterparts working in home health ($35,640 per year or $17.13 per hour).
Unlike CNAs and RNs, most long-term care settings offer licensed practical and vocational nurses higher pay than the average LPN/LVN wages ($60,790 per year or $29.23 per hour).
Unfortunately, RNs earn significantly less in long-term care facilities than in most other work settings. Compare the average RN wage of $94,480 per year or $45.42 per hour to the average wages in the table below.
According to the U.S. Bureau of Labor Statistics, the following are average CNA, LPN/LVN, and RN wages in different long-term care settings:
Why Choose Long-Term Care Nursing
Nurses are and will continue to be in demand in the United States for the foreseeable future due to an ongoing nurse staffing shortage. This shortage will only become accentuated as the US population ages since an older population will require more healthcare services. Therefore, the demand for long-term care nursing is expected to grow even more over the next decade.
The US population aged sixty-five or older grew from 13.58 percent in 2012 to 17.13 percent in 2022. Furthermore, the U.S. Census Bureau estimates that in 2030, people over sixty-five will outnumber children for the first time in US history, and one in five Americans will be of retirement age. This demographic shift will result in an exponential increase in the need for long-term care nurses.
Is Long-Term Care Nursing Difficult?
One of the main challenges of long-term care nursing is managing the stress caused by understaffing. Research has shown that sufficient staffing is one of the most significant factors affecting nursing home quality. Specifically, a direct relationship exists between lower patient-to-nurse staffing ratios and better outcomes, such as lower mortality rates, fewer infections, fewer pressure ulcers, and less weight loss. It is stressful for nurses to know they could avoid patients’ ulcers, infections, and even deaths if only they weren’t stretched so thin.
An Agency for Healthcare Administration (AHCA) survey of 759 nursing home providers, cited in “Long Term Care and Skilled Nursing Facilities”, a journal article published in the National Library of Medicine, showed that the staffing crisis has only become worse for 60 percent of nursing homes since January 2022. Specifically, 87 percent of nursing homes have moderate to high staffing shortages, and hiring new staff has been challenging for 98 percent of nursing homes. Based on these shortages, 73 percent of facilities are worried about having to close. From the beginning of 2020 until March 2022, 406,200 employees left jobs in long-term care facilities. Nursing homes lost 15.2 percent of their workforce, equal to 241,000 employees.
The same article mentioned a survey of 120 assisted living facilities conducted by the National Center for Assisted Living (NCAL) with similar results. This June 2022 report shows staffing problems have only worsened for more than 50 percent of assisted living facilities since the beginning of 2022. Specifically, 63 percent of facilities have moderate to high levels of staffing shortages, and it has been difficult for 87 percent of facilities to hire new staff. A lower percentage of assisted living facilities (16 percent) were very worried about the possibility of having to close, while 32 percent were somewhat concerned about closing due to understaffing.
Understaffing has led nursing homes and assisted living facilities to ask workers to work overtime, rely on contingency staff, and reduce new admissions.
To help retain and attract nursing staff, both types of facilities have resorted to providing bonuses and benefits, increasing wages, enhancing the workplace culture, and paying for staff training. Additionally, approximately 90 percent of nursing homes and over 90 percent of assisted living facilities have increased wages.
Despite the challenges long-term care nurses face, many nursing professionals are better suited to working in these facilities than in faster-paced acute care settings. Learn more about nursing in hospitals vs. long-term care.
What Makes a Good LTC Nurse?
There are many misconceptions about long-term care nursing. Many think LTC is easy and even boring work. However, this conception couldn’t be further from the truth. LTC nursing requires sharp critical thinking, both mental and physical fitness, and the ability to work in and even lead teams.
Critical Thinking Skills
People receiving long-term care have complex healthcare needs and comorbidities. Therefore, LTC nurses must have strong critical thinking skills to analyze clinical situations and make the best decisions. For instance, nurses in this setting must be well-versed in medication knowledge to dose and manage medication correctly and also identify adverse effects of medication that can endanger patients’ lives.
Mental and Physical Fitness
Long-term care nurses must be physically fit since they often help patients change positions, move about, bathe, etc., which can involve a lot of heavy lifting. Furthermore, LTC nurses also tend to have a heavy caseload, requiring them to multitask and keeping them on their toes both literally and figuratively.
Teamwork and Leadership
LTC nurses constantly collaborate and communicate with others, including clinical and non-clinical staff, patients, and family members. They must educate patients, family members, and CNAs on topics such as disease management and infection control. They must coordinate with the rest of the healthcare team to carry out patients’ care plans. They even coordinate with hospitals, pharmacies, and medical equipment companies. In most of these situations, others will turn to them for leadership and decision-making.
Tips for New Long-Term Care Nurses
Have you recently started a position in long-term care, or are you considering pursuing this route after graduation? Here are some tips to help you succeed as a long-term care nurse.
Prioritize and Delegate
In long-term care facilities, nurses care for many residents at a time. Therefore, they must learn to delegate as much as possible to CNAs or other staff members to prevent nurse burnout.
Communicate, Communicate, Communicate
Effective communication among healthcare team members is indispensable in long-term care facilities to improve the quality of patient care and reduce adverse events. Research has shown that ineffective communication significantly contributes to adverse events, nurse turnover, and negative healthcare outcomes. Asking questions, writing clear reports, and offering and receiving help can improve team members’ communication.
Obtain Certifications
Although certifications are mostly optional in long-term care, having them offers nurses many benefits. Holding certifications increases nurses’ confidence, helps them offer patients better care, and facilitates teamwork in nursing.
Work PRN
Long-term care work can be highly stressful due to high caseloads, understaffing, and frequent resident deaths. Therefore, nurses should consider taking advantage of the flexibility that working PRN or per diem nursing shifts offers, allowing them to take time off whenever they need it or alternate facility types when they need a change of scenery.
What Does Working PRN Mean in Long-Term Care?
Working PRN means picking up nursing shifts as needed. In other words, PRN nurses can pick up shifts on demand to cover facilities’ staffing needs. The way PRN nursing works varies depending on whether a nurse is employed by a hospital or a staffing agency or whether they are independent contractors.
PRN nurses picking up shifts with Nursa are independent contractors or freelance nurses. They decide when, where, and how much they want to work by only requesting the shifts that interest them and fit their needs and schedules. In this way, nursing professionals can maintain flexibility and improve their work-life balance. Another advantage of picking up PRN jobs in long-term care is that nursing professionals can make significantly higher hourly pay than their payroll counterparts.
Is Long-Term Care Right for You?
A significant consideration for choosing a career path in nursing, as in any other field, should be the projected demand for that profession or nursing specialty throughout the foreseeable future. Regarding demand in the nursing industry, the need for nurses in the long-term care setting is guaranteed to continue growing exponentially.
That said, nurses are in high demand throughout healthcare settings, so nursing professionals should also consider which roles best align with their personalities, interests, and abilities. Some nurses live for the thrill of helping to bring babies into the world or responding to diverse emergency situations; others prefer to care for older adults and help them live a dignified and comfortable life in their final years. Which description sounds more like you?
If you’d like to give long-term care a try, it’s as simple as signing up with Nursa and picking up PRN long-term care jobs near you.
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