Amid widespread staffing shortages, hospice and other health care workers may seek to leverage collective bargaining to secure higher wages or improved working conditions.

Meanwhile, many providers have leaner resources, having been hit with inflation, rising wages, lingering pandemic headwinds and the labor shortage itself. For these reasons, a number of hospice leaders and industry groups have said that the U.S. Centers for Medicare & Medicaid Services (CMS) 3.1% base rate increase for 2024 is inadequate.

While the pandemic and its aftermath have put providers as well as workers in a “bad situation,” employees need an opportunity to feel heard in decisions that affect them, according to Michelle Esparza, a home health aide from Sharp Grossmont Hospital in California.

“The pandemic made us understand that we need more representation other than ourselves,” Esparza told Hospice News. “We understood that it was a bad situation all the way around, but I think because of the situation that it was, it opened our eyes to understand that we just weren’t being represented.”

Esparza was among home health and hospice workers at Sharp who voted to unionize with the Service Employees International Union earlier this year.

About 1,500 hospital workers at Sharp Grossmont joined SEIU in February, and employees from the affiliated Sharp HospiceCare followed suit in April. The hospice workers are now in contract negotiations with the health system, seeking not only higher pay and pensions, but also more help on the job.

“Staffing is going to be a huge one,” Esparza said. “The hospice and home health aides are with our union and it was really important to them that staffing was a huge issue — and just being heard. We want to be able to sit at the table and help make decisions that are going to affect us directly.”

Statements like these echo workers from other hospice organizations that are also involved in wage disputes or unionization.

Workers from Oregon-based Providence Home Health and Hospice, part of the Providence Health System, also decided to unionize in March with the Oregon Nurses Association (ONA). In May, those workers voted to launch a five-day strike in search of higher wages, more paid time off, improved health benefits and better staffing, Beckers Hospital Review reported.

Also in Oregon, nurses at St. Charles Home Health and Hospice in Bend also joined ONA in late 2022 to negotiate for improved working conditions, compensation and other issues.

Again, the staffing shortage reared its head, as reduced caseloads were among the unionized nurses’ goals in negotiations with their employer. Some nurses reported that they had to cover more than 100 miles a day to visit 25 or more patients. Burnout was also becoming more prevalent among their home health and hospice teams.

St. Charles Health System acknowledged the difficulties associated with travel and indicated that it supports employees’ rights to organize, Debbie Robinson, director of home-based care for St. Charles Health System,

“While we don’t think it is necessary and would prefer to work directly with our staff on issues related to employment, St. Charles Health System supports the rights of its employees to organize and be represented by a union,” Robinson told Hospice News in a March email. “St. Charles has a long-standing relationship with ONA. Our teams do our best to work collaboratively with ONA representatives to solve issues whenever possible.”

Among the nation’s more than 3.05 million nurses (across all settings), about 230,000 belonged to a union in 2021, according to the U.S. Bureau of Labor Statistics. This was a little more than 20%.

A number of providers have also found themselves at the center of wage disputes this year, according to Russell Bruch, partner at the law firm Morgan Lewis.

“Claims alleging off-the-clock work, failure to take required meal or rest breaks and failure to properly calculate the overtime rate of pay are some of the wage and hour issues that pose the greatest risk to companies in the hospice industry,” Bruch told Hospice News in an email in June.

In addition to organization-specific concerns, developments like these demonstrate the toll that the staffing shortage — and reimbursement rates— can take on frontline hospice workers, according to Logan Hoover, vice president of policy and government relations for the National Hospice and Palliative Care Organization (NHPCO).

Broadly, with CMS’ recent final rule,  hospices are being asked to do more with less, and that certainly impacts frontline employees,” Hoover told Hospice News. “We’re seeing burnout across the board. That’s not unique to hospice, but certainly that’s something that we’re very concerned about. We provided CMS with a solution to go back to [Fiscal Year (FY)] 2021 and FY 2022 to ensure that their inflation increases accurately reflected the cost of providing hospice care and accurately reflected inflation. It really should have been a lot higher.”

Hoover and NHPCO did not comment specifically on unionization or wage disputes at any organizations.

One potential opportunity for improvement could come from the Palliative Care and Hospice Education Training Act (PCHETA), which has come before Congress time and again but has not yet been passed. The bill was reintroduced in July by Sens. Tammy Baldwin (D-Wisconsin) and Shelley Moore Capito (R-West Virginia).

If enacted, PCHETA would authorize $100 million over the course of five years to support programs designed to bolster clinical education in hospice and palliative care, along with related interdisciplinary professions such as chaplaincy, pharmacy and social work.

The legislation would establish fellowships through new palliative care and hospice education centers to provide short-term, intensive training, as well as incentivized award programs across all the relevant disciplines. Additionally, it would support programs to develop career paths within the field.

“PCHETA is focused around education, training and additional research. There could be opportunities to increase retention,” Hoover said. “That’s a two-part challenge: to increase the pipeline of people coming into the field, but also to increase retention and reduce burnout.”