2021 Occupational Employment and Wage Statistics: Labor Concentration and Complimentary State Level Report.  

In a NIC Notes blog published June 23, 2022, NIC Analytics examined jobs in the skilled nursing and senior housing sectors by looking at employment patterns since March 2020. The analysis included insights on workforce contraction and recovery in the sectors, as well as wage increases, compared with other adjacent healthcare industry groups. The blog provided context on jobs and wages for all employees within select healthcare industry groups.

In this follow-up blog, NIC Analytics compiled 2021 Occupational Employment and Wage Statistics (OEWS) data from the Bureau of Labor Statistics (BLS) to provide a detailed overview of jobs and wages for nursing staff and aides, including registered nurses, licensed practical and licensed vocational nurses, nursing assistants, and home health and personal care aides across all U.S. states. The primary purpose of this analysis and complimentary state report is to pinpoint where skilled nursing (SNF) and senior housing (CCRC and assisted living) jobs stood in 2021 compared with the competitive landscape (i.e., other industries & healthcare settings).

The competitive landscape includes six select healthcare industries that employ 81% of the nation’s four occupations listed above (nursing staff and aides). These are: (1) skilled nursing facilities, (2) home health care facilities, (3) continuing care retirement communities and assisted living facilities for the elderly (CCRC & AL), (4) general medical and surgical hospitals, (5) individual and family services, and (6) offices of physicians. These industry groups are based on the Office of Management and Budget’s (OMB) standard industry classification codes known as the NAICS or the North America Industry Classification System.

Skilled Nursing and Senior Housing vs. Select Healthcare Settings: Workforce Mix

• Four occupations, including (1) registered nurses, (2) licensed practical and licensed vocational nurses (LPNs and LVNs), (3) nursing assistants, and (4) home health and personal care aides (aides) accounted for roughly 60% of all staff within the skilled nursing sector and about 52% of all employees within the senior housing sector (CCRC and assisted living) in 2021.
• For other healthcare industry groups, these four occupations represented 40% of all employees for general medical and surgical hospitals in 2021, 65% of all employees for individual and family services, and 79.8% of all employees for home health care services. This was the largest share across the select healthcare industries in Exhibit 1 below.
• The skilled nursing workforce mix had the largest share of nursing assistants and LPNs & LVNs compared with adjacent healthcare industry groups. The skilled nursing workforce comprised 33.5% of nursing assistants, equivalent to (471,160) and 12.6% of LPNs and LVNs (177,960).
• Registered nurses for skilled nursing had employment of 131,320 in May 2021 in the U.S., representing 9.3% of all employees, while aides had employment of 62,400, accounting for 4.4% of all employees for skilled nursing.
• For senior housing, aides and nursing assistants comprised the largest shares of all employees, with 27.6% (245,910) and 15.8% (140,850), respectively, followed by LPNs and LVNs with 5.1% (45,200), and then registered nurses with 3.6% (32,220).
• Compared with skilled nursing, senior housing employed less nursing staff (registered nurses, LPNs and LVNs, and nursing assistants) but more aides in 2021.
• Individual and family services had the largest number and highest proportion of aides across all healthcare industries, with 1,657,960, accounting for 62.4% of all employees and representing 49.2% of total national employment.
• Home health care services employed fewer nursing assistants, but more registered nurses and aides compared with the skilled nursing and senior housing sectors in 2021. Home health care services comprised 56.9% of aides, equivalent to 861,740, and 11.5% of registered nurses (173,790), while nursing assistants represented 5.5% of all employees, equivalent to 83,560.
• General medical and surgical hospitals employed the largest number of registered nurses across all healthcare industries at 1,752,210, accounting for 31.3% of all employees and representing 57.5% of total national employment.

The complimentary state occupational employment and wages report at the end of this blog provides state level data.

Exhibit 1 – Workforce Mix Within Select Healthcare Industries

Skilled Nursing and Senior Housing vs. Select Healthcare Settings: Hourly Mean Wages

• Registered Nurses. The highest paying healthcare industry for registered nurses was general medical and surgical hospitals, with an hourly mean wage of $40.88, 2.8% above U.S. average wage for registered nurses ($39.78). All other healthcare industries paid an hourly mean wage below the national average wage. Skilled nursing and senior housing were the lowest paying healthcare industries with $34.74 (12.7% or $5.04 below U.S. average wage) and $32.59 (18.1% or $7.19 below U.S. average wage), respectively.
• LPNs and LVNs. At $25.80 per hour on average, LPNs and LVNs within skilled nursing were paid the highest among the select healthcare industry groups, nearly $1 or 3.5% above the national average wage of $24.93. For senior housing, LPNs & LVNs were also paid above national average at $25.22 (1.2% or $0.29 more) and nearly the same or better than all other healthcare settings including general medical and surgical hospitals (at $23.10 – more than $2 less per hour than skilled nursing and senior housing).
• Nursing Assistants. Wages for nursing assistant workers in skilled nursing and senior housing were also competitive at $15.43 and $15.15, respectively. Nursing assistants in skilled nursing and senior housing were paid slightly lower than the national average ($15.99) and about $1.50 less per hour than in general medical and surgical hospitals ($16.92), but better than those in home health care services ($14.39) and individual and family services ($13.84).
• Home Health and Personal Care Aides. Average hourly earnings for aides in skilled nursing ($14.49) and senior housing ($14.06) were also competitive compared with the national average ($14.07) and other industries and healthcare settings, including individual and family services ($14.20) and home health care services ($13.52), which employed the largest number of aides across all healthcare industries.

Other than registered nurses, skilled nursing and senior housing wage rates were somewhat competitive compared with the U.S. average wages and other healthcare industries (based on the vintage of the BLS data which is date stamped May 2021). This suggests that workforce attraction and retention are more about a mix of other factors than just workers’ pay.

The complimentary state occupational employment and wages report at the end of this blog provides state level data.

Exhibit 2 – Wage Rates in Senior Housing, Skilled Nursing, and Select Healthcare Industries

Labor Concentration

Labor availability continues to be a major challenge for the skilled nursing and senior housing sectors. Labor shortages have been exacerbated by a shrinking labor force. Many workers have dropped out of the workforce or changed industries. Further, the labor force participation rate remains well below pre-pandemic levels at 62.2% as of June 2022, 1.2 percentage points below the pre-pandemic level of 63.4%. Due to the COVID pandemic and its related economic cycle, there are fewer jobs today in skilled nursing and senior housing than in March 2020. See the NIC Notes blog published on June 23, 2022, for more details.

For this blog, we have created a labor concentration ratio as a measure of job intensity or concentration, where the ratio is defined as the number of employed workers in a specific occupation per 100 persons aged 80 and older, i.e., how many workers are employed per older adult.

For the LPNs and LVNs occupation category, this equates to 5.2 LPNs and LVNs for every 100 eighty-year-olds, while for nursing assistants, this ratio is 10.7. By comparison, there are more workers for each older adult for registered nurses (24.8) and aides (27.4). Notably, as Exhibit 1 shows, LPNS and LVNs and nursing assistants comprised the largest share of total employees in skilled nursing (46.1%), while registered nurses and aides accounted for a smaller share at 13.7% of all employees.

Among the Findings – The Concentration of Workers in these Four Occupations Vary by State

A higher or lower labor concentration ratio is a factor of both the number of employed workers in a specific occupation and the number of persons aged 80 and older. For this metric, a labor concentration ratio is considered higher or lower than the national average if it’s above or below the national average by at least +/-10%. See the complimentary state occupational employment and wages report at the end of this blog for more details.

Registered Nurses. There are some states with higher ratios and some with lower labor concentration ratios. Overall, 18 states had labor concentrations higher than the national average of 24.8 by at least +/-10%. Some of these states include Colorado (30.2), Indiana (27.8), Massachusetts (32.0), Ohio (27.9), and Texas (27.6). The lowest labor concentration ratios (below at least +/- 10% of national ratio) occurred in New Jersey (21.2), New Mexico (20.6), and Florida (16.8)

LPNs and LVNs. Overall, 16 states had labor concentrations higher than the national average of 5.2 by at least +/-10%. The largest labor concentration ratios were seen in Louisiana (11.4), Oklahoma (8.6), and Texas (8.2). Some of the lowest labor concentration ratios (below at least +/- 10% of national ratio) were seen in New Mexico (2.2), Oregon (2.2), Utah (1.5)

Nursing Assistants. 27 states had labor concentrations higher than the national average of 10.7. Kansas (19.3), Nebraska (19.1), and Wisconsin (13.2) were among the states with the highest labor concentration ratios, while California (7.0), Nevada (8.2), and Florida (7.4) were among the states with the lowest labor concentration ratios. Interestingly, California employed the largest number of nursing assistants in 2021 (94,450) across all U.S. States. At the same time, the number of persons aged 80 and older in California was relatively high (1,352,968), resulting in a lower labor concentration ratio for nursing assistants than the national average.

Home Health and Personal Care Aides. 10 states had labor concentrations higher than the national average of 27.4. The highest labor concentration ratios for aides occurred in New York, (57.5), Washington, DC (53.6), and California (53.0). Illinois (21.5), Alabama (10.6), and New Jersey (19.8) were among the states with the lowest labor concentration ratios.

Exhibit 3 – Labor Concentration Ratios for Registered Nurses, LPNs & LVNs, Nursing Assistants, and Aides

This article has highlighted the state of the labor market for nursing staff and aides in skilled nursing, senior housing, as well as adjacent healthcare industries. In addition, NIC Analytics compiled 2021 data from the Bureau of Labor Statistics (BLS) to provide a detailed overview of occupational employment and wages by state, available to download below or on our website. For questions about the complimentary state occupational employment and wages report, please contact us at analytics@nic.org.

The complimentary state occupational employment and wages report provides another alternative measure of job intensity or concentration for skilled nursing – full-time equivalent ratio (FTE Ratio) – where the ratio is defined as the total number of persons employed in skilled nursing by a specific occupation per 100 certified beds. Both the FTE and labor concentration ratios are an important distinction in the context of policy discussions currently underway regarding staffing mandates. For example, if staffing mandates were to change, skilled nursing facilities in states where these ratios are low may be required to implement higher minimum nursing staff-to-resident ratios, and meeting those requirements could be challenging.

Complimentary State Occupational Employment and Wages Report (PDF)
Complimentary State Occupational Employment and Wages Report (Excel)

The senior housing and care sector is constantly evolving, but fresh industry, economic, and societal pressures force owners and operators to be nimbler than ever to thrive. On July 13, NIC hosted its final Leadership Huddle of 2022 – Chris Taylor, managing director of Capital One Healthcare Real Estate led the conversation between senior living experts Cindy Baier, CEO of Brookdale Living, and Kimberly Lody, CEO of Sonida Senior Living, to explore how leaders can navigate change and utilize it to improve their organizations.

For more insights, view all past leadership huddles in the 
NIC Leadership Huddle Archives.

Baier and Lody are focused on ushering their companies through some of the biggest challenges facing the industry, including a tough labor market. “One of our top priorities is to attract, engage, develop, and retain the best workforce,” Baier said. As Sonida works to attract new staff, Lody explained, “it’s about leading through the inflationary pressures that are impacting everyone… understanding the pressures that people are faced with every single day.”

As organizations change and adapt, encouraging team members to embrace transformation by involving them in the process is critical. “I think that people are much more likely to embrace change if they’re a part of the solution,” Baier said. Lody agreed, adding that mapping and sharing goals can create a shared mission. “It [allows] people to embrace the concept and have ownership in it,” she said.

Speaking broadly of leadership, Lody believes that a willingness to collaborate sets senior living apart from other industries. “There’s really not a moment of hesitation for people to raise their hand and say to you, ‘I’m happy to share with you what we’re doing.’” Baier sees the amount of passion among senior living leaders as a key differentiator. “It’s really the heart of people in this industry that I think is truly unique… how much people will sacrifice for others in this industry.”

Both speakers agreed that growing as a leader requires a constant pursuit of knowledge and a willingness to listen. “I’m really proud that Brookdale is a learning organization,” Baier said. “The day you stop learning is the day you stop adding value.” Lody relies on her board of directors and feedback from professional and personal relationships to continue growing as a leader, “I ask for feedback all the time… I think you can learn from everyone.”

NIC Co-Founder and Strategic Advisor Robert Kramer has identified “Six Key Drivers” that will shape the senior living industry over the next 10 years. Kramer is also Founder & Fellow at Nexus Insights, a think tank to advance the well-being of older adults through innovative models of housing, community and healthcare. NIC Notes will publish a bi-weekly series detailing each key driver. What follows is an introduction to the series.

What will the senior housing and care environment look like in 2032? It’s a question that has broad implications for the decisions we make today.

Do we understand the long-term impact of the pandemic and the changing make-up of our customer base? Can we anticipate their housing and service preferences? How is technology changing the senior living landscape? Where can we find the workers to meet the needs of our residents? How does healthcare fit in? Are we prepared for what’s ahead?

To anticipate the next decade, we need a clear understanding of the social, technological, and economic factors that form an ever-changing senior living environment. As a result, in my role as NIC’s strategic advisor, I have identified “six key drivers” that will shape our industry over the next 10 years.

To put the “six key drivers” in perspective, I’d like to highlight a quote: “The historic challenge for leaders is to manage the crisis while building for the future.” The quote appeared in an April 2020 op-ed in the Wall Street Journal by Henry Kissinger. He was comparing certain aspects of the COVID crisis to World War II.

In both cases, the challenge for leaders has been to manage the crisis, but at the same time to build for the future. That’s where our industry finds itself today.

Internal and External Threats

Our industry faces both internal and external threats. Internally, particularly among operators and their workforce, the mood is one of “exhaustion.” Exhaustion in every sense—physical, emotional and mental.

The senior living workforce from top to bottom is dealing with post-traumatic stress syndrome. But the real internal threat is exactly what Kissinger is talking about. It’s exhaustion that leads to a failure to anticipate and to prepare and therefore to build for the future.

The greatest external threat to senior living has long been considered “the home.” Elders would rather stay put in their long-time residences. But taking a wider perspective, the greatest external threat is from those outside our field who see the opportunity to serve our customers in a different, better and less expensive way than we do presently.

The threat comes at a time when the industry is not only exhausted but also under enormous financial pressure. We are depleted in terms of energy and resources. This is the classic prescription for “disruptive innovation,” the powerful concept developed by Harvard Business School Professor Clayton Christensen.

Big tech is making an advance into healthcare. Google, Microsoft, Apple, and Amazon all see an opportunity. So does big retail. Walmart, Best Buy and even Dollar General have major health initiatives under way. When I talk to the Health Strategy Officer of Walmart about our “Forgotten Middle,” he says: “That’s not only our customer, that’s our workforce. That’s the group we think we have the opportunity to serve.”

Retail pharmacy chains such as CVS and Walgreens see an opportunity too, along with the major insurers, including United Healthcare, Humana, Blue Cross Blue Shield, Anthem, and others. What do many of these outside disruptors have? In contrast to us, they have huge, positive brand recognition. They customize their services for the convenience of the consumer. These companies have great tech platforms that they’re constantly improving. Notably, they aren’t cash strapped, and they aren’t exhausted.

These companies can easily spend $50 million on an initiative and if it doesn’t work, it doesn’t really matter. That kind of money is a rounding error to them. In contrast, a $1 million tech investment for a senior living operator that goes sideways could have a huge impact or at least end any innovation by that operator.

Six Key Drivers

With that backdrop in mind, here are the six key drivers, in brief, which will impact our industry over the next decade. (Individual blog posts detail each driver.) Any futurist is never going to be 100% correct. But these key drivers are meant to serve as a challenge for the industry to think about how to manage the changes ahead.

1. The COVID-19 Pandemic. The crisis has changed the way we work and ushered in the third generation of senior living.
2. The Endemic Staffing Crisis. The labor shortage will continue. How can providers recruit and retain the best workers?
3. A New Customer Arrives with a Different Take on Longevity. Our new customers want their lifespan to match their healthspan or wellspan. We need an engagement view of aging and retirement shaped by growth and opportunity, not by deficits and decline.
4. Reframing Health and Healthcare. The focus will be on well care, not sick care. Senior living and healthcare providers, and insurers will partner to proactively keep our residents out of the expensive acute care system.
5. The Increasing Importance of Data and Analytics. Market data by itself has limited value. In the future, market data will be coupled with personalized health, genomic, social determinants of health (SDOH), lifestyle and psychographic data, and aggregated by local market. The applications for the future use of this kind of data will be transformative for the industry.
6. Moving from Siloed to Seamless. We will see a shift from the current fragmented, single-point healthcare solutions and technology applications to integrated longitudinal solutions that are setting, disease, and payer agnostic.

These six key drivers provide a discussion starter for senior living stakeholders to reflect on where the industry stands today, and how it will respond to emerging trends as the next decade unfolds. We welcome you to be a part of that discussion.  

• Senior housing occupied units vacated during the pandemic are on track for full recovery, across both the NIC MAP Primary Markets and the NIC MAP Secondary Markets.
• Senior housing occupancy bouncing back but remains far below pre-pandemic March 2020 levels.
• The senior housing market continued to experience a high acuity trend, with occupancy for majority assisted living properties recovering relatively fast compared with majority independent living properties.

According to just released quarterly NIC MAP Vision data, the recovery for senior housing regained pace in the second quarter of 2022 after the momentum weakened in the prior quarter due to the Omicron variant. The graphs below depict the recovery progress for senior housing demand and occupancy for both the NIC MAP Primary Markets (Primary Markets) and the NIC MAP Secondary Markets (Secondary Markets).

NIC MAP Primary Markets. Demand, as measured by the change in occupied units, largely outpaced new supply while marking its fifth consecutive quarter of positive increases, with a net absorption gain from the prior quarter of more than 8,600 units, or 1.6% for the Primary Markets. The improved demand dynamics in the second quarter of 2022 increased the share of senior housing units vacated during the pandemic that have been re-occupied to 78%, up 19pps from the prior quarter (59%).

The all-occupancy rate for senior housing for the Primary Markets increased to 81.4% in June 2022, up 0.9pps from March 2022, with a gain of 0.6pps in April 2022, 0.2pps in May 2022 and 0.1pps in June 2022. From its time series low of 78.0% one year ago in June 2021, occupancy increased by 3.4pps but remained 5.8pps below pre-pandemic March 2020 levels of 87.2%.

All-occupancy increased or remained stable in 26 of the 31 Primary Markets for senior housing in the June 2022 reporting period compared with March 2022.

NIC MAP Secondary Markets. Senior housing demand for the Secondary Markets also regained momentum in the second quarter of 2022, with a net absorption gain from the prior quarter of more than 4,500 units, or 1.5%. And now, the share of senior housing units vacated during the pandemic that have been re-occupied increased to 86%.

At 83.0%, the all-occupancy rate for senior housing for the Secondary Markets was up 0.8pps from March 2022 and 4.2pps from its nadir in June 2021, but still 4pps below March 2020 levels of 87.0%. Overall, senior housing occupancy for the Secondary Markets is bouncing back quicker, mainly due to a relatively balanced new supply.

All-occupancy increased or remained stable in 55 of the 68 Secondary Markets for senior housing in the June 2022 reporting period compared with March 2022.

Data highlights by majority property type. Occupancy for majority independent living and majority assisted living properties, inventory growth patterns, and select NIC MAP Primary markets’ performance along with analysis and insights from the NIC Analytics team, including myself and NIC Chief Economist, Beth Mace are provided in the complimentary NIC Intra-Quarterly Snapshot monthly publication, available for download on our website. The data underlying every Intra-Quarterly Snapshot report is available to NIC MAP Vision clients.

Interested in learning more about NIC MAP Intra-Quarterly data? To learn more about NIC MAP Vision data, schedule a meeting with a product expert today.

The U.S. Bureau of Labor Statistics reported that nonfarm payrolls rose by 372,000 in June 2022 and the unemployment rate held steady at 3.6%. The June increase was in line with the average monthly gain over the prior three months (383,000). Revisions subtracted 72,000 to total payrolls in the previous two months. The market consensus had been for a gain of 268,000. 

Nonfarm payrolls were still down by 524,000 or 0.3% from their pre-pandemic level in February 2020. Notably, private-sector employment has now recovered the net job losses due to the pandemic and is 140,000 higher than in February 2020, while government employment is 664,000 lower.

Employment in business and professional services is 880,000 higher than in February 2020, while manufacturing jobs have returned to its pre-pandemic level. However, employment in leisure and hospitality services are down by 1.3 million or 7.8% since February 2020, while jobs in social assistance which includes child day care services are 2.0% below their February 2020 level.

Employment in health care rose by 57,000 in June, including 8,000 new positions in nursing and residential care facilities. But jobs in health care remain 1.1% or 176,000 less than in February 2020.

The report confirms that the labor market remains strong, despite inflationary pressures, waning consumer confidence, the war in Ukraine and on-going supply-chain pressures. Concerns about rising wage costs and inflation are also supported by this report, although wage pressures appear to be easing. Average hourly earnings for all employees on private nonfarm payrolls rose by $0.10 in June to $32.08. This was a gain of 5.1% from year-earlier levels but was less than the 5.3% gain seen in May and the 5.5% gain seen in April. 

The report supports the Federal Reserve’s intention of continuing to raise interest rates further following the 1.5 percentage point hike in the fed funds rate that has already occurred so far this year. Another 0.75 percentage point hike is anticipated at the next FOMC meeting later this month.

In a separate survey conducted by the BLS, the jobless rate was 3.6% for the fourth month in a row. The jobless rate is only 0.1 percentage point above the pre-pandemic level of 3.5% seen in February 2020, and well below the 14.7% peak seen in April 2020. The number of persons unemployed was essentially unchanged at 5.9 million but was still above the 5.7-million-person level seen prior to the pandemic. 

Among the major worker groups, the June unemployment rates were 3.43% for adult women, adult men (3.3%), teenagers (11.0%), White (3.3%), Black (5.8%), Asian (3.0%), and Hispanic (4.3%).

The labor force participation rate edged down 0.1 percentage point to 62.2% in June and was below the February 2020 level of 63.4%.

The June underemployment rate or the U-6 jobless rate was 6.7%, up from 7.1% in May 2022. This figure includes those who have quit looking for a job because they are discouraged about their prospects and people working part-time but desiring a full work week.