Best and Worst States for Senior Care Staffing in 2024

A record 4.1 million Americans will turn 65 in 2024 – and every year through 2027 – in what is being called the ‘Silver Tsunami’.  And as life expectancy rises and adult children increasingly live further away from their parents, an unprecedented number of Americans will need senior care in the years and decades ahead. While senior care providers are gearing up for the projected demand, a critical piece of the congregate senior care model is at risk. 

At the beginning of 2024, 3.23 million people worked in long-term care facilities – rebounding from a low of 2.96 million in 2022. Though that is welcome news, these facilities still remain 120,000 staffers short of the pre-pandemic level in early 2020, according to the American Health Care Association. In addition, 99% of nursing homes reported having unfilled jobs in a recent AHCA survey.

For older adults and those with aging loved ones, this data should raise concern because staffing levels have been proven to be a leading indicator of senior care quality. As JAMA reported in early 2023, there is a positive correlation between stable RN staffing levels and quality of care, while a 2020 study showed a positive correlation between overall staffing levels and quality of care. In short, staffing levels and quality can make or break the senior care experience.

Yet despite the widely recognized importance of staffing levels, recruiting efforts have been hampered by burnout, low wages and the rise of remote work. Retaining staff has also proven challenging evidenced by a 52.1% median turnover rate at nursing homes.

At the same time, occupancy rates at senior living facilities have increased for the 10th consecutive quarter and are on pace to eclipse pre-pandemic levels in 2024.

Amid these alarming trends, American families are left to wonder if the system will be able to accommodate their loved ones in the years ahead. 

To help families better understand the senior care landscape where they live, Seniorly analyzed federal data across six metrics in all 50 states and Washington, D.C. to determine the best and worst states for senior care in 2024. 

The study analyzed the most recent data for staffing shortages and turnover in nursing homes, the ratio of health care workers to occupied nursing home beds, occupancy rates, primary care workforce adequacy, and the supply of home health aides. The complete methodology is listed at the bottom. 

Key findings

• California is the best state for senior care staffing: Due to the availability of home health care relative to the older population (3.3 adults ages 75+ per employed aide), fewer nursing homes with staff shortages (4%), and lower nursing home staff turnover than most other states (45.7%). The top five also included Alaska, Washington, D.C., North Dakota, and Minnesota.
• Southern states dominate the bottom 10: Oklahoma ranked last, largely because there were fewer nursing home staffers per occupied bed — 1.4, better only than the 1.3 seen in Texas and Georgia, which were also among the worst states. Utah and Montana were the only non-Southern states to land among the bottom 10.
• Most states are poorly equipped to care for aging populations: 38 states have nursing home staff turnover rates above 50%; only 17 states have the primary care workforce to meet demand for medical services; and 24 states have at least 10 older adults per home health aide.

Top states

California claimed the top position, fueled by its robust supply of home health aides. With a ratio of 3.3 adults aged 75+ per home health aide, California was second only to New York, which had a ratio of 3 older adults per home health aide. Additionally, in March 2022, only 4% of nursing homes in California reported staffing shortages, while the staff turnover rate of 45.7% was far below most states.

Alaska, Washington, D.C., North Dakota, and Minnesota rounded out the top five. Alaska, Minnesota, and North Dakota were propelled by their high ratio of staff to occupied beds in nursing homes (2.7, 2.3, and 2.1, respectively), as well as being over-equipped on primary care, with a workforce supply that exceeded demand. No. 4 North Dakota also had an occupancy rate of 93.7% in nursing homes, only slightly below No. 12 West Virginia (93.8%).

Notably, Alaska and Minnesota ranked well despite having a high number of nursing homes with staff shortages in 2022 (80% in Alaska to Minnesota’s 64%). 

Finally, Washington, D.C., landed as No. 3 because it had the lowest staff turnover rate in the country, at 37.8%.

Bottom states

On the other end of the spectrum, Oklahoma ranked as the worst state, driven by its low ratio of nursing home staff to occupied beds (1.4 staffers per bed) and low occupancy rate (63.8%). The state has been grappling with chronic understaffing for long-term care, which could help explain the low occupancy rate – nursing homes simply don’t have the capacity to take on more residents.

Missouri, Georgia, Tennessee, and North Carolina also landed among the bottom five; all of them also had poor ratios of nursing home staff to occupied beds. Missouri, which came in at No. 50, had an exceptionally high nursing home turnover rate of 61.4%, while No. 49 Georgia had one of the lowest rates of home health aide supply, with 18.6 residents 75+ per home health aide in the state. Alabama and Tennessee also ranked poorly for home health availability, with ratios of 18.2 and 17.7 older adults per aide, respectively.

Best and worst states by metric

Health care providers per occupied bed: The ratio of nursing home providers to residents in 2024 indicates how much attention can be afforded to residents. The top states are Alaska (2.7), Minnesota (2.3), and Wisconsin and North Dakota (2.1 each), while the bottom are Georgia and Texas (1.3 each), followed by New Mexico, Missouri, Louisiana, Illinois, and Oklahoma (1.4 each).

Share of nursing facilities reporting any staff shortages: This metric goes back to March 2022 in order to assess staffing consistencies in recent years. The states reporting the lowest shortages are Connecticut (4%), California (4%), and Massachusetts (8%), while the bottom are Alaska (80%), Minnesota (64%), and Maine (59%).

Nursing home occupancy rate: As most congregate senior care models rely on a certain level of occupancy to cover fixed costs, a low occupancy rate can signal staffing or other quality cuts. The states with the highest average occupancy rates are West Virginia (93.8%), North Dakota (93.7%), and New York (92.8%), while the bottom are Oklahoma (63.8%), Texas (66.7%), and Montana (69.4%).

Nursing staff turnover in nursing homes: A 2022 study found that turnover rates vary significantly across nursing homes, and that higher turnover is associated with lower quality of care. The states with the lowest turnover are Washington, D.C., (37.8%), Hawaii (39.7%), and New York (41.9%), while Montana (67.8%), Missouri and New Mexico (61.4% each) had the highest level of turnover.

Primary care workforce adequacy: The availability of primary care, which also covers geriatric medicine, sheds light on the health care system’s capacity to meet the needs of an aging population. States that shine are Alaska (145%), Minnesota (129%), and North Dakota (119%), meaning their supply exceeds demand. Meanwhile, the  Connecticut (41%), New Jersey (50%), and New York (56%) all appear to be ill-prepared to meet demand.

Home health aide supply: Many adults prefer to age in place, and the ratio of older adults (aged 75+) to home health aides shows how accessible this care can be. The top areas are New York (3 older adults per aide), California (3.3), and Washington, D.C. (3.4), while the bottom states are Florida (31.7), Hawaii (19.4), and Georgia (18.6).

What should families do? 

To help tackle this crisis, the federal government has proposed a rule that would raise minimum staffing requirements for about 75% of nursing homes. Among other requirements, nursing homes would have to offer residents at least 0.55 hours of care from a registered nurse and 2.45 hours from a nurse aide everyday. The government has also committed to incentivizing people to enter long-term care careers through scholarships and tuition reimbursement.

Governmental support for long-term senior care is crucial, but the complexity of the challenge ahead means it will undoubtedly be a slower road to improvement. In the short term, Seniorly gerontologist Marlena Del Hierro offers guidance for families looking to find quality care today.

5 tips to find a great senior living facility amid staffing shortages

1. Staffing levels: Ask about staffing levels, turnover, and caregiver qualifications, such as the ratio of registered nursing staff to residents during various shifts. A long-term care facility director should be able to tell you about the background and training of caregivers, whether staff provides 24-hour assistance, and the range of services offered. 
2. Onboarding & training: Inquire about the community's onboarding process for new staff and the amount of time devoted each month to ongoing training for staff members. As industry turnover levels are generally high, it's important to choose a provider who is committed to ensuring that caregivers have the necessary skills, knowledge, and updates to provide high-quality care.
3. Licensing & citation history: Check the facility's licensing and accreditation history to ensure the facility meets regulatory standards for care and safety. These standards cover everything from emergency response systems to adaptations that make the facility more accessible for older adults. You can find this information for many communities on Seniorly.com.
4. Stop & chat: Take a moment to engage with caregivers as you tour senior living communities. Staff interactions with residents offer valuable insights into the quality of care provided, and the culture of the community. Asking caregivers about their experiences and approach to care can help you gauge their dedication, compassion, and suitability for meeting your loved one's needs.
5. Phone a friend: Don't forget to reach out to friends and family for recommendations. Personal testimonials and experiences shared by those within your network can highlight the strengths and potential concerns of various communities from a first-hand perspective. 

The state of senior care varies considerably across the U.S., and identifying staffing differences at the state level can help people plan for themselves and loved ones as they age. By understanding regional trends, we can push to improve the quality of care for older adults and ensure that seniors receive the support they need – regardless of where they live.

Methodology

We used the most recent data for six metrics to determine which states are best and worst equipped to handle senior care staffing. We used a Z-score distribution to scale each metric relative to the mean across all 50 states and Washington, D.C., and capped outliers at +/-2. We multiplied Z-scores by -1 when a higher score was negatively associated with being above the national average, such as nursing home staff shortages, turnover, and the ratio of older people to home health aides in a state. A state’s overall ranking was calculated using its average Z-score across the six metrics. Here’s a closer look at the data we used:

• Median ratio of health care providers eligible to work per occupied nursing home bed, 2024 (Centers for Medicare & Medicaid Services)
• Nursing home occupancy rates, 2024 (Centers for Medicare & Medicaid Services)
• Share of nursing facilities reporting any staff shortages, March 2022 (Kaiser Family Foundation analysis of federal data)
• Median nursing staff turnover in nursing homes, 2024 (Centers for Medicare & Medicaid Services)
• Projected adequacy of the primary care workforce, including geriatric medicine, 2024 (Health Resources & Services Administration)
• Home health aide supply, measured as the number of people 75+ per home health or personal care aide, 2022 (Bureau of Labor Statistics and Census Bureaus)