Understanding the Impact of the Gig Economy in NHs, SNFs

Chris Caulfield, RN, NP-C, co-founder and chief nursing officer of IntelyCare, discusses misconceptions as well as advantages and disadvantages for facilities in relation to the gig economy, and provides future predictions for this market.

Podcast Transcript:

Hello, my name is Chris Caulfield and I’m the co-founder and chief nursing officer of IntelyCare, a gig economy-based nurse staffing service that uses a 100% mobile app-based skilled nursing workforce.  

Today I’d like to talk to you about the gig economy for nurses and skilled nursing facilities, including the misconceptions, advantages & disadvantages for facilities, and future predictions of this market.  

As background, back in 2015, I was working at a long-term care facility as a staff nurse and I represented my fellow nurses as a union leader.

Our biggest issue was last minute call offs and mandatory overtime. These two serious issues led to nursing burnout and dissatisfaction. Even though technically illegal in our state, when a nurse doesn’t have a replacement they can’t just ‘leave’ without finding a replacement, so they were forced to stay an extra shift.  

Our nursing leaders and executive director felt horrible about this touchy situation, but when I tried working with them finding solutions to solve this problem, there were no good options.  

The frustration and lack of being able to find a solution to help my facility and my nurses led me to join up with the then director of IT to form our own company to create a mobile-based, on-demand, gig economy for nurses to help post-acute health care facilities get last-minute coverage. Due to the massive need in the industry and a great team to support this mission, we’ve since grown to over 11,000 active nursing professionals serving over 500 skilled nursing facilities across the country.  

The term “gig economy” refers to a general workforce environment in which employees work under short-term engagements or temporary contracts. For the past eight years, this model of the gig economy has been rapidly expanding in other industries, including transportation, delivery, software development, and unskilled labor.  

Most recently, there has been an increase in workforces that also now include employment types with professional certification and license requirements.

As in most innovations, health care is usually the last industry to innovate given the complexities of regulation and compliance. But over the past three years, there has been an explosion of health care related ‘gig-economy’ work for health care professionals including nursing   

This model of a ‘flexible work practice’, is ideal for nursing professionals as there is a structural component that makes providing in-patient nursing services difficult on the work-life-balance of the frontline employees. They have a license or certification, which obligates them to maintain the safety of their patients. If the next nurse doesn’t show up, they have to continue to deliver important medical and nursing care, on schedule, and they typically don’t have their own resources to find a replacement. Often times the facility supervisor, scheduler, or DON either isn’t available to reach out for a replacement and if they are, the chances of someone coming in at a moment’s notice is slim to none, mostly because these other staff nurses, are already burnt out from the vicious cycle of short staffing

Looking at the other side, nurses who have work-life commitments, such as taken care of young children, attending college, or taken care of an elder or sick family member, often don’t have the luxury to commit to the typical ‘inflexible’ schedule that health care facilities are able to offer. The typical nursing schedule includes every other weekend commitments, a rotating weekly schedule, and a holiday schedule. Shift times for nurses start at hours such as 6 a.m. or 7 a.m. making it inconvenient for arranging their children's transportation to school, and the expectation of getting off at 3 p.m., can sometimes turn into 5 p.m. as a ‘last-minute admission,’ at 2:45 p.m. comes in, and this nurse is obligated to finish.  

For these nurses that have these commitments, where the typical schedules or start or finish times doesn’t work, the gig-economy allows them to come off the sideline, and continue working as a nurse.  

I’ve personally heard so many stories of nurses saying, if only they could have a shift start time at 8 am.…. Well, the gig economy supports this 8 a.m. shift start time. As in most areas, there is going to be a ‘call-out’ within 20 miles of their house, that has a nurse being stuck and would happily take a replacement one or two hours into the next shift, rather than staying an extra eight or nine hours.  

Next, let’s talk about some of the misconceptions about the gig economy.  

Some of the misconceptions I’ve frequently heard surrounding the gig economy are related to reported incidents that have happened with some of the larger on-demand ride-sharing platforms such as Uber.

Prior to states implementing additional and more thorough background checks, these services provided a great rating system and review system for their drivers. However, there wasn’t the appropriate systems that forced these companies to do the appropriate pre-employment checks to hire for quality and safety. 

What’s good about the skilled nursing facility space, and the nursing gig economy, is some of the toughest laws regarding the criminal record and background checks are already in place for these facilities. With the disqualification lists, abuse and neglect registries, reference verification requirements, licensure checks, and training and competency requirements, the standard is already there, and don’t allow a gig economy platform to try re-create the standards.

The platform that’s provided from your on-demand nurse staffing vendor, should contain a transparent and visible view of everything that’s required for your Department of Health, to ensure compliance of your health care facility.

Next, let’s discuss what are the benefits that nursing home executives and directors of nursing get from having a higher utilization of their short-term needs and last-minute shifts filled.

One of the clear cut answers to this question is decreased burnout and churn from internal nursing home staff.  With a decreased burnout, you’ll have nurses calling out less from of their shifts, and ultimately less last-minute shifts to fill.  With this decreased burnout out, you’ll also have fewer nurses churning out, the cost of recruiting and retraining will be drastically reduced which is especially important for those in areas that are difficult to recruit.

Another major benefit is in relation to the updated CMS reimbursement structure, such as PDPM and value-based purchasing.  With the recent change to PDPM, the structure of reimbursement now has a more diversified approach which is no longer tied to the quantity of physical therapy. The driver of reimbursement now has a large emphasis of the diagnostic code of each patient’s medical needs.  

With this option to generate more revenue for bringing in a higher acuity of patient census, the need to supplement the nursing workforce, or at least have a better maintenance of adequate staffing levels is essential.  While at the same time, patients with a higher acuity level also can have a higher risk of hospital readmission.  With the implementation of value-based purchasing, this opportunity is now there for an additional bonus, for a lower readmission rate, while those who don’t have appropriate staff, likely will now face a higher than average readmission rate and now face financial penalties. 

With all these additional benefits the gig economy provides to skilled nursing facilities, a question I frequently get asked: “how do you evaluate for quality?”  A supplemental staffing partner is only as good as they deliver quality personnel. Some important considerations to take into account include reliability, quality, cost, and transparency.

First, reliability is essential. When a partnering organization has a high rate of their own last-minute call-offs, or no-call no-shows, without sending a replacement, they can actually cause more damage to a facility’s internal staffing pool and patient care.

Some essential questions to evaluate this partner include:

• What type of quality system is utilized, to screen and remove nurses who call out frequently?
• What type of confirmation system is place?
• What type of contingencies for last-minute call-outs are there? And is there an on-call system to cover call-outs?

Next, the quality of the supplemental workforce is essential. Both from a professional and clinical standpoint, the service provider who is covering the gaps in your schedule needs to have their quality practices implemented to continuously improve their service.

Some essential questions to ask include:

• Is this staffing partner ‘Joint Commission-certified’?
• What types of transparent feedback can you submit as a client, and what is the typical queue time of a quality investigation?
• Is there a re-prioritization process in place to prioritize nurses who are rated high to return back to my facility?

And finally, the gig economy has brought a revolutionary approach to transparency in other markets, and this transparency should also be present in your nurse staffing partner as well.  

Some questions to ask concerning transparency include:

• What types of updates are received for updated shift request statuses?
• Are there ‘Estimated Time of Arrival’ updates?
• Are all credentialing documents easily viewable, and in a form that’s easy to present during an audit?
• Are there insights and metrics into my request behavior, fill rate, call out rate, and recommendations to improve my experience?

So what are my future predictions for the gig economy for nurses in the next decade?

I believe the mobile-app based workforce will be the standard, rather than the exception in five years from now.

They’ll be an exponential growth of internal scheduling tools, that internal staff nurses to connect with mobile gig-economy ‘like apps’ that allow for picking up additional shifts, swapping shifts, and even helping nursing administration to create their own internal per-diem pool.  

Some of these internal software scheduling platforms have been rather expensive, but I foresee the cost will continue to drop. These scheduling systems will also connect to the outside supplemental nurse services as a Vendor Management System, allowing for one streamlined on-demand workforce management system ensuring adequate coverage that’s based on acuity and patient census in real-time.

Ultimately, this will result in better patient care and decreased burnout from nursing personnel.  

With the ever-changing reimbursement structure to promote better patient outcomes, the future of the gig economy for nurses is going to NOT only promote better patient outcomes but will also allow skilled nursing facilities to increase their bottom line and have a positive financial future.