The TPS Staffing Crisis Is a Margin Event

The potential loss of employees with Temporary Protected Status creates immediate human and operational consequences for long-term care providers. Experienced employees can disappear from schedules that were already difficult to fill.

But operators still have to run the facility.

The response cannot begin and end with filling open shifts. Find the capacity that already exists. Calculate the true cost of protecting it. Invest now to reduce exposure to the next disruption.

---

1. Model Labor Capacity Before Buying It Know where the staffing gap exists and what each coverage option costs before approving agency hours.

A vacant shift does not automatically equal an agency shift.

Start with staffing by unit, shift and day. Add census and acuity, overtime concentration, recurring call-outs, PRN availability, internal employees willing to pick up premium shifts and employees who can safely work across units.

Then price the alternatives.

Research published in Health Affairs using 2018–2022 Medicare Cost Report data found that agency nursing labor averaged approximately 50% more per hour for RNs, 57% more for LPNs and 66% more for nurse aides than directly employed labor. In 2022, median nurse aide labor cost was $22.15 per hour for directly employed staff versus $36.34 for agency staff.

That is a $14.19 hourly differential.

Across one 40-hour week, that difference is approximately $568 for one nurse aide position. Maintain 10 equivalent positions for 12 weeks and the premium approaches $68,000.

(These figures are historical benchmarks based on 2018–2022 data, not estimates of current 2026 agency pricing. Operators should use current agency rates and payroll data to calculate their actual differential.)

That is not simply a staffing decision. It is a margin decision.

Agency labor will sometimes be necessary. Before approving it, compare agency coverage with overtime, internal premium shifts, PRN coverage and schedule redistribution.

Coverage option	Cost calculation	Evaluate
Agency	Bill rate × hours	Cost, duration, dependency
Overtime	Wage × OT multiplier + burden	OT concentration, burnout risk
Internal premium	Regular cost + incentive	Participation, premium, duration

Do the calculation by shift. An internal premium that looks expensive against an employee's regular wage can still be substantially cheaper than agency coverage.

The problem starts when emergency coverage becomes recurring operating expense without anyone challenging the economics.

---

2. Put a Dollar Value on Retention Do not let the first staffing loss trigger a second one.

When employees disappear from the schedule, the remaining workforce absorbs the disruption.

Overtime rises. Schedules become less predictable. The same dependable employees get called repeatedly for extra shifts. Managers solve today's coverage problem by increasing pressure on employees they cannot afford to lose.

Track that pressure.

Review overtime, vacancies, call-outs and turnover by position, unit, shift and supervisor, not only at the facility level. Identify where the disruption is concentrating and which employees are carrying the additional workload.

Then calculate the cost of losing another employee. AAPACN cites an estimated $3,000 to $6,000 in direct costs to replace a CNA, giving operators a starting point for putting retention decisions into financial terms. Once replacement cost has a dollar value, retention spending can be evaluated against it. The math is more useful than the instinct.

Consider a facility evaluating $20,000 in targeted retention incentives for CNAs at greatest risk of leaving. At $3,000 to $6,000 in direct replacement cost for each CNA, management can calculate the number of avoided departures required for that investment to break even.

And direct replacement cost is only part of the exposure. Vacancies create additional overtime, temporary coverage and operational pressure on the employees who remain.

The question management should put against every proposed retention investment is:

How many departures does this investment need to prevent to pay for itself?

Apply that calculation to retention bonuses, targeted wage adjustments, shift incentives and other interventions instead of evaluating those costs in isolation.

Retention is not simply an HR issue when every departure creates another vacancy to cover. It is margin protection.

---

3. Build the Workforce Instead of Continuously Buying It Redirect recurring vacancy and agency expense toward permanent staffing capacity.

A 2025 longitudinal analysis of Medicare- and Medicaid-certified nursing homes found that greater reliance on agency RNs, LPNs and CNAs was significantly associated with lower operating margins.

That makes the long-term problem clear: sustained agency dependency is not just a workforce issue. It is a financial one.

Emergency coverage buys hours. It does not build capacity.

Operators should identify employees already inside the organization who want a path into higher-need roles. Dietary, housekeeping and other employees interested in direct care can be supported through CNA training and certification. Pair those efforts with community college, vocational school and CNA training partnerships to create a recurring local pipeline.

Then put the pipeline investment against what vacancies are already costing the facility.

Pull the previous 12 months of actual facility costs for:

Agency CNA premiums + vacancy-related overtime + recruitment advertising + hiring costs

and compare them with:

Tuition assistance + certification fees + paid training time + wage progression + retention incentives.

Do not use an industry benchmark for this exercise. Pull the numbers from the facility's own cost reports, payroll and recruiting data. The purpose is to determine what the organization is already spending to compensate for chronic vacancies.

For example, if that analysis shows $100,000 in annual incremental costs associated with CNA vacancies, management can evaluate whether redirecting $25,000 of that existing expense toward internal training produces a better return. Those numbers are illustrative. The investment decision should be built from the facility's actual costs.

Are you renting workforce capacity or building it?

Measure those outcomes against the dollars invested. Workforce development should be held to the same financial accountability as any other operating investment.

The question operators should keep asking is simple:

How much are you spending every year to rent workforce capacity that you could be investing to build?

---

Stop Managing Workforce Disruption One Shift at a Time

TPS is the immediate disruption. The larger margin risk is allowing temporary staffing responses to become permanent operating costs.

The facilities that come through workforce disruptions with margin intact will know where each labor dollar went and what it bought.