At the height of the COVID-19 pandemic in the spring of 2020, the staff at Cherry Hill Manor Nursing & Rehabilitation Center in Johnston worked in fear that they would spread the deadly virus among the center’s elderly residents. They also feared they might carry the virus home to their families.
After all, numerous residents had died amid the worst of the crisis as COVID-19 seeped into nursing home populations around the state despite the best efforts to stop it.
Toiling for hours at a time in N95 masks, face shields and other personal protective equipment – which had to be constantly changed – was mentally and physically draining for Cherry Hill’s workers.
“The PPE created a difficult barrier to interacting and communicating with residents, which saddened and frustrated the staff,” said Kathleen Gerber, executive director at the 170-bed Cherry Hill facility.
Adding to the stress, the staff took on an additional role: because relatives weren’t allowed to visit for months, nursing staff members found themselves filling the void, often taking calls from worried family members and helping with videoconferencing “visits.”
The worst of the health crisis now has passed, but the challenges ahead remain daunting for the industry. They call into question what the future holds for Rhode Island’s nursing homes and whether families will continue to place elderly relatives there.
Facilities continue to grapple with severe labor shortages, and a more stringent mandatory staffing requirement has gone into effect after Gov. Daniel J. McKee signed executive orders temporarily suspending the new requirements earlier this year at the behest of nursing home owners.
At the same time, industry leaders have complained that Rhode Island’s Medicaid reimbursement rates for care are too low and have further hampered the recovery of nursing homes.
Medicaid is the state and federal insurance program for the poor and disabled that covers the majority of Rhode Island nursing home residents. And the nursing homes say that because of deferred increases or cuts over the years, Medicaid reimbursements don’t come close to covering the cost of care.
As part of the new staffing requirements, the state is scheduled to bump up Medicaid rates by 1% in October and Gov. Daniel J. McKee supports another 3% increase, also for October.
“It’s a start,” said James Nyberg, director of LeadingAge Rhode Island, an industry organization that represents about 15 nursing homes. “But we need a sustained commitment to fund the industry.”
In the meantime, the difficulties have taken a toll.
Five Rhode Island nursing homes have closed since the pandemic began two years ago, displacing hundreds of elderly people. Elderwood at Riverside, a 57-bed facility in East Providence, is the latest casualty, closing its doors at the end of May. Now there are 79 licensed nursing homes left in the state.
More are in danger of closing, according to reports issued by a national health care group in recent weeks.
The American Health Care Association said in survey results released June 6 that 98% of nursing homes nationwide report having trouble hiring even though most have boosted wages and bonuses. And about 60% say the situation has worsened since January.
At the same time, nearly 60% are operating at a loss, and 73% are concerned about closing, the report said.
The problem appears to be more severe in the Ocean State.
Last month, the association found that 95% of Rhode Island nursing homes were losing money and 87% of facilities were at “financial risk,” based on Medicare data through September 2021. That risk percentage was the highest of any U.S. state and had skyrocketed from 19% in 2019, before the pandemic.
Factors putting the squeeze on nursing homes, according to the report compiled by national accounting firm CliftonLarsonAllen LLC: sagging occupancy rates, low insurance reimbursement rates, rising labor costs and higher inflation.
“The COVID pandemic has had a devastating impact in a myriad of ways,” said John Gage, CEO and president of the Rhode Island Health Care Association, which represents more than 60 nonprofit nursing homes. “The whole thing put tons of pressure on nursing homes. It was a pandemic that targeted the elderly and people with underlying conditions, and nursing homes were the bull’s-eye for the pandemic.”
[caption id="attachment_408391" align="aligncenter" width="1024"]
WHAT REMAINS: The sign has been removed and the lawn is uncut outside the former Elderwood at Riverside nursing home in East Providence. The 57-bed facility closed at the end of May, the fifth nursing home in Rhode Island to shutter since the COVID-19 pandemic began.
PBN PHOTO/MICHAEL SALERNO[/caption]
LABOR PAINS
Nursing home owners have been pushing to relieve some of that pressure, but with limited success.
When Rhode Island implemented new minimum staffing levels on Jan. 1, nursing homes urged state leaders to suspend the law for a year to give them a chance to rebuild the workforce.
Instead, McKee signed executive orders that stopped its implementation until the end of March, though the state has not begun enforcing the mandate.
Meanwhile, two R.I. House bills that would put a moratorium on those requirements – one until July and the other until next January – have been held in committee for further study.
The labor union representing nursing home workers has fought delays in implementing the new minimum staffing requirement, which requires an average of at least 3.58 hours of direct nursing care per resident per day starting Jan. 1 and 3.81 hours next year.
“We believe that staffing minimums are the only way to improve conditions for workers and protect residents,” said Patrick Quinn, executive vice president for the Service Employees International Union 1199NE.
But industry leaders insist that the requirements will lead to more closures, and they remain hopeful that one of the bills extending the moratorium will gain approval.
“Five buildings have already closed,” Gage said. “There are more than a dozen buildings currently up for sale that are in the process of transferring ownership because local owners who have run their homes for decades can no longer continue to operate as independent facilities given the real economic and workforce crises and the looming staffing mandate.”
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AT HOME: Kathleen Gerber stands outside the Cherry Hill Manor Nursing & Rehabilitation Center in Johnston, where she is executive director.
PBN PHOTO/MICHAEL SALERNO[/caption]
The Rhode Island Health Care Association and LeadingAge RI say there are almost 2,000 job openings at Rhode Island facilities right now and hundreds more workers will be needed to meet the staffing mandate.
For those facilities that don’t meet the requirement, fines would follow that could reach into the tens of millions of dollars across all Rhode Island nursing homes, according to James Nyberg, director of LeadingAge RI.
“The concern is that a lot of facilities won’t be able to meet the staffing ratio and they will be subject to these fines that will further burden them and could force them to close,” Nyberg said.
So far, most nursing homes have reacted to the labor shortage – the size of the workforce has decreased by 21% since March 2020, nursing home officials say – by shrinking the number of patients they serve.
According to an industry survey last year, 71% of the state’s nursing homes were either not taking new admissions or closing wings because they did not have enough staff to provide care.
There are currently 8,747 licensed beds in Rhode Island nursing homes, according to Gage. At the start of 2020, the nursing home occupancy was 88.6% or 7,699 residents. By mid-May 2022, the occupancy was 80.8% or 7,068 residents – a decrease of 631 people.
Part of the labor problem, nursing homes say, is the struggle to pay higher wages because low insurance reimbursement rates don’t cover the cost of care.
LeadingAge RI and the Rhode Island Health Care Association have asked state leaders to allocate about $30 million of the state’s $1 billion in American Rescue Plan Act funds to go toward recruiting and retaining nursing home staff. But Nyberg didn’t sound hopeful that money would be coming since state officials are receiving many requests from other special interests, too.
Gerber, the director at Cherry Hill, said that the reimbursements to nursing homes should be increased to pay for additional staffing, the ability to pay nursing home staff more to make it a more desirable field, and to address the rising costs of doing business.
“We don’t have the ability to have that kind of staffing,” she said. “There is no mechanism in place to reimburse facilities to add that additional funding.”
An alternative can be even more expensive – for example, if nursing homes turn to a staffing agency to bolster the nursing staff and attempt to meet the new staffing ratios.
“They have been charging exorbitant rates,” Nyberg said. “We have been pushing legislation to cap the rate that staffing agencies can charge just to provide some relief to the providers.”
THE FUTURE
What remains an open question is whether the safety and financial struggles of the last two years will persuade some families to think twice about placing an elderly relative in a nursing home.
[caption id="attachment_408394" align="aligncenter" width="1024"]
COMING BACK?
The percentage of nursing home beds filled in Rhode Island sank from a high of about 89% before the
COVID-19 pandemic to about 70% in January 2021 as deaths mounted and safety concerns and protocols
lowered the number of new admissions. The occupancy rate has since climbed to about 80% last month. / SOURCES: PAYROLL-BASED JOURNAL FOR 2019 OCCUPANCY,
NATIONAL HEALTHCARE SAFETY NETWORK FOR 2020-21 OCCUPANCY[/caption]
It depends on who you ask.
“I don’t think the public has a shattered image of nursing homes,” said Kathleen Heren, Rhode Island’s long-term care ombudsman. “They worked really hard under horrible situations with COVID and they did the best they could.”
Quinn has a different take.
He says public confidence in nursing homes has been diminished since the pandemic started.
“Consumers, family members, prospective patients, they want to know that they are going into a different circumstance,” he said. “They want to know that there is qualified, trained staff that is committed to the facility, that has an interest in the success of the facility, and they have more opportunities to be more discerning and have more options.”
When it comes to demand for nursing homes, Nyberg isn’t concerned about the long-term viability of the industry.
He says one of his members has told him their nursing home hasn't experienced a decrease in referrals or tours in the past 16 months. Nursing home administrators say that when people need a nursing home for a family member, it's a decision that often comes after the family has patched together care over an extended time period that has exhausted caregivers and they have no other choice.
Still, says Robert Hackey, professor of health policy and management at Providence College, the future perceptions of nursing homes in the wake of the pandemic remain to be determined.
“It’s where we go now,” he said. “If we continue with the status quo, I do not think we will restore public confidence to the degree we should. But if we can show people that we are making meaningful steps towards making nursing homes safer, more home-like, more up to date with a 21st-century model of care, I think that would go a long way.”
At Cherry Hill, aside from the severe staffing shortages, Gerber says she sees a rebound of sorts already happening.
“Now we are back to group dining, group activities and entertainment,” Gerber said, noting that families are again allowed to make visits, providing energy to the building that was missing at the height of the pandemic. “Staff are laughing and joking with residents and co-workers. It’s a difficult job, but spirits are up.”
Correction: The original version of this story incorrectly attributed a quote to James Nyberg. He was relating what one nursing home administrator had told him about there being no decrease in referrals or tours by the families of prospective residents.
Also, the story initially gave an incorrect amount that LeadingAge RI and the Rhode Island Health Care Association had asked state leaders to allocate from the state’s $1 billion in American Rescue Plan Act funds. The organizations requested $30 million.