Waivers will be issued at statewide, countywide, and individual facility levels.

Nursing homes struggling to get uncertified temporary nurse aides (TNAs) trained to federal training requirements by the Oct. 7 deadline now have more flexibility.

The Centers for Medicare & Medicaid Services has issued a revised guidance that will provide waivers to allow nursing homes to continue certifying TNAs beyond the deadline to keep staffing at safer levels.

In the early days of the COVID-10 pandemic, CMS enacted several temporary public health emergency (PHE) blanket waivers intended to provide healthcare providers needed flexibility to respond to the pandemic.

The waivers for TNA certification ended June 6, but TNAs who began the certification process had the traditional four months’ time to become certified, meaning they must become certified before October 7, 2022, to continue working as a nurse aide.

Under the revised guidelines, CMS will issue waivers at two levels:

• To an individual facility “when there are localized barriers to training/testing in a state or county not otherwise covered by a waiver.”
• Countywide- or statewide “when there are widespread barriers to training/testing that are statewide or in a particular county within a state.”

Waivers are time-limited, and state agencies are expected to work toward resolution of barriers to certification, according to CMS. They also may be required to provide progress reports on the submitted action plan in order to maintain the waiver.

A state or individual facility, however, can’t retain a waiver longer than the declaration of a PHE; if the PHE ends during or before the waiver, the waiver also ends. The PHE is set to expire in mid-October, but the Biden administration is expected to extend it into January 2023.

The newest waiver addresses concerns expressed earlier this month by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) in a letter to Xavier Becerra, secretary of the U.S. Department of Health and Human Services.

That letter requested reinstatement of the waiver on training and certification of TNAs “who have been a valuable member of the care team during this pandemic.”

'Work Your Way' offers full-time benefits, along with premium pay and flexibility.

A new mobile internal staffing model at Allegheny Health Network (AHN) will reduce the health system’s reliance on contracted agency nurses while providing their employees with a flexible work option.

Called Work Your Way, the new program is expected to attract nurses who permanently left the health system for travel work, new nurses, and current travel nurses, says AHN Chief Nurse Executive Claire Zangerle, DNP, RN, FAAN. It’s also open to surgical technologists and other team members.

Work Your Way is the latest effort by Pittsburgh, Pennsylvania-based AHN to recruit and retain healthcare professionals amid severe labor shortages affecting the industry.

"The severe nursing shortage across the nation continues to affect all hospitals and health systems. Creating and executing innovative solutions helps us address the staffing challenge and at AHN we are doing just that," Zangerle says.

Zangerle’s previous staffing innovations have included a pilot program in 2021 placing licensed practical nurses (LPNs) on nursing teams and a time management course designed for nurse leaders to help them feel less overwhelmed about their day.

“Our new mobile internal staffing program is one of many solutions relative to the staffing challenges,” she says. “It's also an opportunity for nurses who are interested in joining AHN's community of nursing in a unique way with competitive wages, excellent benefits, and the flexibility of practice at different AHN hospitals.”

How it works

Mobile nurses work rotational shifts in emergency medicine, telemetry, critical care, and perioperative care at eight of AHN’s 14 hospitals. The positions offer premium pay as well as mileage reimbursement for those traveling more than 50 miles to work and lodging reimbursement for those traveling more than 75 miles to work.

Other options include a weekend warrior program for those who prefer to work weekends and a night owl program for those who prefer to work the night shifts.

Each assignment lasts for six weeks and can be renewed if mutually agreed upon by the nurse and AHN. However, if during a six-week assignment AHN has an urgent need at another of its hospitals, a nurse can be moved from the original assignment, Zangerle says.

That is unlike regular travel nurses who stay at the same position for the duration of their contract.

“We did not have the flexibility to move them,” Zangerle says. “But with this program, if I have a team that's idle because we had four surgeons out on vacation at one hospital, and I've got a full load of surgeries at another hospital and we haven't opened rooms because we don't have the teams, I can move those from the low-productivity hospital to the high-productivity hospital,” she says.

Pay rates are non-negotiable

AHN is beginning the program with 50 positions, but fully expects it to grow, Zangerle says.

Contract nurses have responded with much interest, many questions, and even more attempts to negotiate rates based on what agencies are paying, Zangerle says.

But pay rates, she says, are non-negotiable.

“We are not playing that game,” Zangerle says. “This is what it is. We feel that this is market reasonable and that any more we go up is not healthy for our staff who is not taking this opportunity.”

And while some market rates are going down, AHN's Work Your Way rates will remain steady, she says.

“Nurses are somewhat skeptical that these rates will change, but we're going to lock in on these rates for six months; we're going to reevaluate; and then we'll keep going from there, but we don't see these rates changing in the next year or 18 months,” she says.

Work Your Way has a limited number of positions open for AHN’s current nurses, Zangerle says.

“We had to limit that,” she says. “We can't cannibalize our current staff because the goal is to have net-net more nurses.”

Most of the health system’s current nurses are not interested because the mobile program is non-union, and they prefer to keep their union seniority and benefits, and they don’t have the required mobile experience, Zangerle says.

“This is for people who have mobile experience and who've done this before, because gig work is not easy,” she says. “That’s why you get paid the premium rate. To not have a permanent home is what we're paying these nurses for.”

Guiding older adults away from the TV and toward brain-engaging and physical activities decreases the risk of dementia.

Private duty workers and other care companions who engage their older clients in social activities are helping to fend off dementia.

That’s because helping adults aged 60 and older avoid passive, sedentary behavior, such as long periods of television-watching, decreases the risk of dementia, a new study says.

The risk is lower for those who are mentally active while sitting, such as when they use a computer or read, says the study by the University of Southern California (USC) and University of Arizona researchers.

“It isn’t the time spent sitting, per se, but the type of sedentary activity performed during leisure time that impacts dementia risk,” said study author David Raichlen, professor of biological sciences and anthropology at the USC Dornsife College of Letters, Arts and Sciences.

“We know from past studies that watching TV involves low levels of muscle activity and energy use compared with using a computer or reading," he said. "And while research has shown that uninterrupted sitting for long periods is linked with reduced blood flow in the brain, the relatively greater intellectual stimulation that occurs during computer use may counteract the negative effects of sitting.”

Cognitive training and physical activity are key

Caregivers can benefit their clients by using cognitive training, which some evidence suggests can delay or slow age-related cognitive decline, and appropriate increased physical activity, according to a 2017 study, Preventing Cognitive Decline and Dementia: A Way Forward by the National Academies of Sciences, Engineering, and Medicine.

Cognitively stimulating activities could include increasing proficiency in daily activities, playing cards, doing crossword puzzles, or learning a new language, the National Academies study says.

Increased physical activity has been recognized as benefiting both physical and cognitive function, and can include walking, dancing, resistance training, stretching yoga, the National Academies study says.

In 2011, more than 1 million cases of Alzheimer’s disease could be attributed to physical inactivity and a 25% reduction in physical inactivity could potentially have prevented about 230,000 cases in the United States, the 2017 study says.

Countering the effects

For this new study, more than 145,000 participants aged 60 and older—all of whom did not have a diagnosis of dementia at the start of the project—self-reported their levels of sedentary behavior during the 2006-2010 baseline examination period.

After an average of nearly 12 years of follow-up, the researchers used hospital inpatient records to determine dementia diagnosis, finding 3,507 positive cases.

“Although we know that physical activity is good for our brain health, many of us think that if we are just more physically active during the day, we can counter the negative effects of time spent sitting,” said study author Gene Alexander, professor of Psychology and Evelyn F. McKnight Brain Institute at the University of Arizona.

“Our findings suggest that the brain impacts of sitting during our leisure activities are really separate from how physically active we are,” said Alexander, “and that being more mentally active, like when using computers, may be a key way to help counter the increased risk of dementia related to more passive sedentary behaviors, like watching TV.”

The start-up healthcare chain is designed to emphasize wellness and continuity of care through a unique NP-driven model.

Editor's note: This article appears in the September/October 2022 edition of HealthLeaders magazine.

A primary care clinic start-up is differentiating itself by staffing its facilities only with nurse practitioners (NPs).

Minneapolis-based The Good Clinic chain is designed to emphasize patient engagement, continuity of care, and an emphasis on wellness and convenience through a unique nurse practitioner-driven model, says Larry Diamond, CEO of Mitesco Inc., which operates The Good Clinic brand.

More than half of U.S. states—26 states, Washington, D.C., and two U.S. territories—have granted patients full and direct access to care by NPs in adopting Full Practice Authority (FPA), according to the American Association of Nurse Practitioners (AANP).

FPA is the authorization of NPs to evaluate patients, diagnose, order, and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure authority of the state board of nursing. This regulatory framework eliminates requirements for NPs to have a collaborative practice agreement with a physician to provide patient care.

Shortage of physicians

The Good Clinic’s NP model evolved from the shrinking volume of primary care practices in the United States, which has occurred for a variety of reasons, including a sizable gap between specialty and primary care salaries, Diamond says.

As a result, physicians graduating from medical school are tending to choose specialization rather than practicing primary care, he says.

“The AMA (American Medical Association) says there's a shortage of about 25,000 to 35,000 primary care providers, which is one of the reasons why all of these urgent care centers have popped up, because in America today, it's typically two to five weeks’ waitlist to get in to see your primary care provider for just a normal visit, a physical, or just a follow-up,” Diamond says. “So, America learned, ‘Oh, if I have an earache, a sore throat, or a cut, let me run over to the urgent care clinic,’ and the challenge there is that we stopped providing care and just started fixing problems.”

But the prevalence of chronic diseases requires that healthcare do more than simply fix problems, he says.

“Diabetes is at an all-time high, and pulmonary issues, well, they all start somewhere and it's typically because they're not addressed earlier in their disease process,” he says. “If you focus on prevention, you can avoid a lot of the costs associated with people developing chronic illnesses, and then deteriorating with them, where it always costs more to address a problem later in its cycle.”

Nursing is well aligned to primary care from a philosophy perspective, Diamond says. “Nursing is about working with a patient over time, to help them overcome some of the challenges that they're experiencing, where the industry has evolved to be much more about ‘one and done. Let me do something and solve the problem,’” Diamond says. “And with chronic illness in America, it's not typically a ‘one and done’ type of solution.”

Whole-person focused

Good Clinics began when former leaders involved in starting MinuteClinic, which has since been sold to CVS, added Diamond to their team to create a primary care model that was whole-person focused—one that considered physical health, behavioral health, stressors, and how they use the healthcare system.

“The concept is about, ‘How do I take care of a person soup to nuts?’ [by] considering complementary and alternative medicine or whatever the person is interested in—yoga, meditation, supplements, vitamins, standard medicine—and to have a relationship where we co-develop a wellness plan with that person.”

Starting in FPA-friendly states

The company’s first clinic opened in February 2021, and by the end of the year it had six clinics operating around Minneapolis. Next year, it expects to open additional clinics in Minnesota, Colorado, and Arizona, with plans to expand nationwide in the coming years, particularly in states where NPs can freely practice at the top of their license.

And though NPs have FPA in slightly more than half of U.S. states, that doesn’t preclude The Good Clinic from expanding into states where NPs don’t have FPA, Diamond says. These states have reduced or restricted practice authority, but NPs are able to practice under a collaborative agreement with another health provider.

This story was updated August 26, 2022.