A nursing home closure ripples through a community. Families that chose a home based on its location or service might have to drive farther or settle for a facility with lesser appeal. Caregivers must find new employers. Residents have to adapt to new spaces and routines.
Pennsylvania had 695 nursing homes in 2019. That number is down to 669, as of Aug. 30. The Pennsylvania Health Care Association, which represents long-term care facilities, warns that more could soon shutter or declare bankruptcy.
PHCA says the nursing home industry has long suffered from a lack of funding, and argues that facilities are struggling under a new state mandate that increased the daily amount of direct care nursing home residents receive.
“Despite recent attempts to close the Medicaid reimbursement gap, funding still falls short of the actual cost of care due to years of underfunding, inflation, staffing mandates and more reliance on the state Medicaid program,” a representative of the organization told Spotlight PA via email.
Pennsylvania’s Medicaid program pays for a resident’s nursing home care if they don’t have any income or assets. PHCA says that the state needs to accelerate the process of determining a resident’s Medicaid eligibility, and also that the current rate is too low to cover the actual cost of care. It also wants high-performing nursing homes to be rewarded with supplemental funds.
Kathy Cubit — the advocacy manager at the Philadelphia-based Center for Advocacy for the Rights and Interests of Elders, or CARIE — agrees that Medicaid rates could be higher, and that eligibility should be determined faster. But in the following conversation, which has been edited for clarity, she argues other structural issues contribute to closures, including training gaps, and a lack of transparency around how nursing homes use taxpayer dollars.
Spotlight PA: When a nursing home closes, how does it affect the people who reside in that facility?
Cubit: It’s always a traumatic experience, even when it’s planned closure where things can be done in a more methodical way. But we’ve had a couple of recent closures in Pennsylvania that were done more in an emergency. There was one instance in the facility where there were no staff. The state had to go in and immediately transfer all the residents to somewhere else, and that happened within less than 24 hours. So you can imagine the trauma for not only the residents but also families in those situations. But it’s always upsetting, even when you’re moving from a poorly performing facility.
As long as there’s been nursing homes, there’s been closures. But we’ve also seen this other troubling trend of private equity [purchasing nursing homes]. These owners are coming in, and, quite frankly, their business models are not conducive to quality care. So it really strips not only the residents but also the community of a good workplace and a community asset for people to go to when they need quality nursing home care. I’ve yet to see a positive situation with a private equity owner.
What challenges do nursing home operators contend with to keep their doors open?
Well, you’re caring for people that need a high level of care, whether it’s for short-term rehab type purposes — coming out of a hospital setting as an example — or people that have multiple chronic conditions, serious illnesses, or end-of-life issues that require a lot of care. And a number of folks that live in nursing facilities have dementia or related disorders; that requires a lot of training.
And nursing homes have a lot of turnover right now, not only among direct care workers, but we’re hearing instances of high turnover rates with administrators and office staff. It is challenging because if you’re chronically understaffed, you’re not an attractive workplace for people.
Typical wages for nursing home aides, according to federal data, are between $30,000 and $40,000. How much are low salaries part of the reason these facilities struggle with staffing?
It’s one of many factors. This is very hard work. It’s very rewarding work. But people who do this work should be at least earning a livable wage. And often, folks have to rely on public benefits to make ends meet or work multiple jobs.
We have to start looking at these workers in more of a professional way. And I think a lot of the work is trying to be done through the unions and other initiatives on workforce development, and career paths and things of that nature. So those are as important as salary.
The PHCA puts some of the blame for the recent closures on Medicaid reimbursements, which they say are too low. Would you agree that Medicaid payments are a driving force behind some of the dysfunction in this industry?
That’s a complicated question. But there needs to be a lot more transparency with where the dollars go, particularly with a lot of these private equity and other business models that are taking over. Because the owners and their shareholders profit by drawing money away from care, staffing, and supplies.
Honestly, every provider of Medicaid services is probably underresourced. And I think that points to larger issues in our country that we just don’t adequately fund long-term services and support systems overall.
This summer, the number of direct care hours a Pennsylvania nursing home resident receives increased from 2.87 hours a day to 3.2 hours. But many nursing homes say this new mandate is too high, especially when they’re having a hard time hiring.
It’s too low of a bar. This isn’t something that should be aspirational.
There’s well-established research that this is even too low of a minimum, and that is why we wanted to see [the mandate] be higher. But nonetheless, we’re pleased to see an increase. We need to have very basic standards because some of the conditions in some nursing homes right now are really unacceptable.
I don’t want to make it sound like it’s all the providers’ fault. We have some really good providers, and we need more. And this is not only a state issue but a national issue and … an international issue. We’re not the only country that’s struggling with trying to provide quality care.
When it comes to policy solutions, what are some of the things that need to start happening so we can have better long-term care?
I’d like to see the office of Long Term Care Transformation in the Pennsylvania Department of Health funded. They received federal funding but no state funding this year, and they’ve done great work.
Also, there’s a long-term care learning collaborative through the Jewish Healthcare Foundation; they’ve been doing a lot of positive trainings with facilities.
We also did work at CARIE with Community Legal Services of Philadelphia and other stakeholders around racial disparities in nursing facilities, and we would like to see more action taken around closing those gaps. And there’s a whole list of recommendations in that report.
But the bottom line is we need to keep working on staffing and on training.
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