Published September 14th, 2023 at 6:00 AM7 minute read
Last spring, Olathe resident Thomas Byrne fell getting into the shower and broke his ankle. The 76-year-old had multiple sclerosis, which already affected his mobility, and he couldn’t have ankle surgery because of damage from a prior heart attack. So began his journey through long-term care.
Rehabilitation was deemed his best bet to keep him living independently.
After a long stint in rehab, Byrne was cleared to return home, with some intensive care. He had a scooter to get around. But he needed help transferring himself from his bed to chairs and other places. A home health service was scheduled for four hours each morning and four hours at night.
But his daughter, Janelle Stanley, said the family realized quickly that even eight hours a day wasn’t sufficient.
“The most stressful part of all of this was trying to do home health,” she said. “And I can see both sides, they overcommitted, and Dad overpromised what he could do.”
The fundamental problem was that there weren’t enough staff to cover the hours they pledged to provide.
There were times when Stanley was called to pitch in until someone could show up. Other times the owners of the business covered, or the nurse who ran human resources. Byrne also couldn’t transfer himself from bed to scooter, as he thought he could.
The final straw came when he had a terrible stomach flu one evening and spent eight hours violently ill and unable to move his body to the bathroom.
Between the agency and her and her husband (who both have full-time jobs and three children) doing what they could, the situation simply wasn’t tenable.
“He realized he needed someplace that could react quicker to his needs. He couldn’t stay at home anymore,” Stanley said. “He could have switched to other home health, but he needed more care and shortages were happening everywhere because we had already seen it in assisted living where he did his rehabilitation.”
Byrne ended up at The Cottages at Shawnee, a small facility that Stanley praises. He was there until he passed away from cancer a few months later.
“I was so glad we found it because his other experiences were not ideal,” she said. “He stayed there and received hospice care, and we didn’t have to move him again.”
Almost anyone who has had a family member in a nursing home or needed at-home care can relate to Stanley’s experience. And this was in Kansas, which has one of the better staffing ratios in the country, according to a recent report by the Long Term Care Community Coalition (LTCCC).
The organization looks at national data to gauge how much time nursing home residents receive care daily. In its latest ranking, Kansas was 14th nationally, with beneficiaries receiving 3.88 hours of nursing care per resident day (the national average was 3.61). On the other side of the state line, Missouri ranked last in the country for number of hours per day at 3.10.
Staffing shortages in long-term care facilities isn’t a new problem. But they were spotlighted when nursing homes were ill-equipped to handle the rampant spread of COVID-19 inside their walls. The existing staffing shortage in long-term care facilities only got worse during the pandemic as the workforce fled from many of those low-paying, difficult jobs.
The alternative, at-home care, became a more appealing solution for many seniors wanting to live independently. But their staffing situation is just as bleak, if not more so. And federal funding cuts and potential minimum staffing requirements will only put more of a squeeze on the industry in the next year.
Stanley saw workforce shortages in both nursing homes and in-home care because the entire industry is struggling.
The American Health Care Association and National Center for Assisted Living, a national organization representing nursing homes and other long term care facilities, released a report in August highlighting the obliteration of the workforce since the pandemic.
According to the report, 579 nursing homes have closed nationwide since 2020, displacing more than 21,000 patients. On the flip side, only three new nursing homes have opened this year – from 2020 to 2022 an average of 64 opened annually.
The report also noted that 24% of homes have closed a wing, unit or floor because of labor shortages. According to the report 15%, or 250,000 workers, were lost to the industry during the pandemic. Industry staffing isn’t expected to rebound to pre-pandemic levels until 2026.
“The workforce problem is huge,” said Carol Hudspeth, executive director of the Missouri Alliance for Home Care, an association focused on education, training, advocacy and research for the home care industry.
“Pre-COVID, our nonskilled personal care agencies would compete with nursing homes or hospitals,” Hudspeth said. “Now they compete with Walmart and Amazon and Target – anybody who is paying $15 or more per hour. It’s not a glamorous job helping folks to go to bathroom and bathe them. And the challenge is funding and always has been.”
Home health can be paid for by the individual receiving care, but it is also reimbursed by Medicare and Medicaid, depending upon the type of care. Skilled care – like nurses and physical therapists – is often paid for by Medicare. Unskilled care, like personal attendants, are paid for through Medicaid – which Hudspeth said doesn’t reimburse enough to fully pay for the workers.
And the skilled personnel side isn’t any easier.
“It’s not just home care or the nursing home industry. All of health care has a nursing shortage, which makes it even harder for everyone to compete for that nursing pool,” she said. “And a roadblock we run into is our reimbursement isn’t as high as hospitals and nursing homes, so we can’t compete for some of those nurses.”
Reimbursement isn’t going to increase anytime soon.
Hudspeth said the industry is bracing for cuts “that will decimate the home health industry,” proposed by the Biden administration for 2024. As part of the Home Health Prospective Payment System, reimbursement rates would decrease by about 2.2% or around $375 million less than 2023 levels.
“Home care is proven one of cheapest forms of health care out there and it seems that, instead of investing dollars into it, the government wants to keep cutting,” she said. “It just doesn’t make sense.”
Sarah Schlemeier, director of public relations and advocacy at the Missouri Health Care Association, said chronic government underfunding and inflation are also an issue for nursing homes.
“Our facilities are being paid less than what it costs to care for their residents, and this has certainly left us in no position to keep up with the inflated labor rates,” she said. “The reimbursement rates for Medicaid are set by the state legislature, so part of the solution would be having the state set reimbursement rates at the cost of care level.”
According to the Kaiser Family Foundation (KFF), about 62% of nursing home residents’ care is paid for by Medicaid, making it the predominant payer for these facilities.
While Medicaid payments for nursing homes compared to the cost of care varies widely, the Medicaid and CHIP (Children’s Health Insurance Program) Payment and Access Commission crunched the numbers in January 2023. The group found that Medicaid base payments ranged from about 70% to 100% of costs. The median base payment in 2019 was 86% of facility costs.
Nursing homes also received supplemental Medicaid payments, which the group estimated to be about $3.4 billion that year. The facilities that received the lowest payments tended to have lower staffing levels, according to the report authors.
Though labor shortages and reimbursements are working against proper staffing levels, those are important numbers. Stanley found this out when her father was at the first rehabilitation facility, the Healthcare Resort of Olathe.
“While we were there, there were a lot of staffing issues,” she said. “They were great to work with and had a good social worker and case manager, and Dad had a positive experience. But when he pushed the button to call a nurse, it would take hours for someone to come and attend to him and if it was urgent, that was a big problem. The quality of care was good, but the response time was bad.”
The current staffing regulations for nursing homes are based on the 1987 Nursing Home Reform Act. The hours covered are based on the size of the home. A 100-bed facility must have 24/7 licensed nursing services and a registered nurse on duty eight hours a day. On top of other staffing such as a nursing director and dietician, the numbers equate to 0.3 nursing hours per resident day.
But on Sept. 1, the Centers for Medicare & Medicaid Services (CMS) announced a proposed rule that would require facilities to provide at least 0.55 hours of care from a registered nurse and 2.45 hours of care from a nursing aide for every resident daily. According to a recent Kaiser Family Foundation report, about 85% of facilities nationally would be able to meet these guidelines.
“Establishing minimum staffing standards for nursing homes will improve resident safety and promote high-quality care so residents and their families can have peace of mind,” said Xavier Becerra, secretary of the U.S. Department of Health and Human Services, in a press release announcing the rule. “When facilities are understaffed, residents suffer. They might be unable to use the bathroom, shower, maintain hygiene, change clothes, get out of bed, or have someone respond to their call for assistance.”
The rule also calls for facilities to report workforce compensation as it relates to Medicare reimbursements to ensure facilities are paying the workforce fair wages. And CMS recently announced its intention to invest more than $75 million in financial incentives for the nursing home workforce, including tuition reimbursement and scholarships.
There are no answers to the long-term care staffing issues that will change the industry overnight, but groups are looking to find some long-term solutions.
The American Health Care Association and National Center for Assisted Living created the Care For Our Seniors Act with recommendations to support the workforce. They include loan forgiveness and tax credits for people in the field along with affordable housing and childcare assistance.
Hudspeth said her organization is working to keep home health on the table any time reforms are being discussed among policy makers. She has advocated including home care as part of nursing curriculum and rotations. Members in her organization go to high school job fairs touting the flexibility of working in home care.
One good thing for the industry that came out of the pandemic was the importance of sufficient staffing in nursing homes and the role home care plays for so many individuals in need of help. When nursing homes were shutting down and families were pulling loved ones out because of fear of the spread of COVID-19, long-term care became an increasingly viable option.
“Home care really came out on top because we were able to provide so much of that high-quality care in the safest place,” Hudspeth said. “We were excited because we thought we had learned so much and were going to come out a big player in health care. But because of all the reimbursement cuts, we’re just scrambling again.”
Tammy Worth is a freelance journalist based in Blue Springs, Missouri. Julie Freijat, a Dow Jones reporting intern at Kansas City PBS and a masters student at the University of Missouri, contributed data analysis and graphics.
Support for “Age-Old Questions” is provided by William T. Kemper Foundation, Commerce Bank, Trustee. Additional support is provided by Husch Blackwell.