Care for elderly in jeopardy as nursing homes face crisis

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Nursing homes in Pennsylvania are in crisis, leaving many seniors without a place to find long-term care when they need it.

A report issued by the Independent Fiscal Office in October shows that while more older Americans are seeking long-term care, the supply falls short, leaving families with few options.

Zach Shamberg, president and CEO, Pennsylvania Health Care Association (PHCA), said the report validates PHCA’s concerns.

“Even before COVID, we sounded the alarm,” he said.

At issue is the low reimbursement from Medicaid, staffing shortages which create less capacity, and increased demand as the Baby Boomer population ages.

In its report, the Independent Fiscal Office showed that a Wall Street Journal analysis of nursing home data from the Centers for Medicare and Medicaid found that from 2019 to 2023, the number of nursing homes decreased 3.3% from 695 to 672.

The number of certified beds decreased during the same period by 2.8%, dropping from 87,900 to 85,500 and the number of beds per 1,000 for people aged 75 and older decreased 10.8% from 85.9 to 76.6.

According to the report, as capacity dropped, nursing home and residential care facility staff decreased as well. In 2019, the workforce was nearly 216,000 people. The preliminary data suggests a decline of 13.7% to 186,300 in 2023.

“Supply is outpacing demand and access to care is in crisis,” Shamberg said. “This is a diverse path for the vulnerable.”

Shamberg said the pandemic forced nursing homes and residential care facilities to take beds offline due to staffing shortages, or increase the number of contract nurses to keep beds open, increasing costs.

In a February 2023 PHCH survey of its members, nearly a quarter of respondents said they have between 21% and 40% of their beds available, but unable to be used due to lack of staff.

A staggering 98% said they have direct care positions that need to be filled and 81% said they are using contracted agency staffing to fill vacant positions.

Nurses left the profession during the pandemic due to fear, childcare issues or burnout, he said. Many of those that stayed turned to nurse staffing agencies, that Shamberg said charge three to four times what nurses are paid.

“They may take 50% of that, but nurses still get higher pay,” he said, adding these agencies attract nurses from other states as well.

House Bill 2293, which created new oversight and accountability for temporary health care staffing agencies operating in the state’s assisted living communities and personal care and nursing homes, was signed into law by former Gov. Tom Wolf on Nov. 3, 2022, but Shamberg said the state Department of Health was given two years to implement, which it hasn’t done to date.

“This will provide accountability and oversight of these agencies. It is dire and needs to be implemented,” he said.

And in November, Sen. Dave Argall, R-Schuylkill, announced his intention to introduce a package of bills that would modernize caregiver training and break down barriers that limit workers from careers in long-term care.

The package, being created in conjunction with PHCA, would provide statewide training credits for high school students that Shamberg said would make a career in long-term care attractive.

Also in November, the Senate passed SB 668, which would enable certified nurse aids (CNAs) to train to become certified medication aids (CMAs), allowing them to deliver some prescribed medications to nursing home residents. Currently, registered nurses (RNs) and licensed practical nurses (LPNs) must administer the medications.

“We want to make it attractive for people to work in long-term care,” Shamberg said. “It’s hard for nursing care facilities to compete with hospital systems and

insurance providers. We want to showcase long-term care careers as careers of compassion.”

And, he said, long-term care facilities have been competing with other businesses that attracted health care workers facing burnout because they are offering good pay with no stress. PHCA wants to see those caregivers return to the profession.

Currently, there are 672 nursing homes – those that provide 24/7 care — and 1,200 personal care facilities across the state, Shamberg said.

Shamberg said that while there are enough beds currently, they might not be close to where people live.

“We are facing a ‘Silver Sunami’ and if we don’t look to the next five to 20 years, we won’t keep pace,” he said.

During the past three to four years, up to 20 homes have shut their doors to new residents and some have closed altogether.

Shamberg said the rising costs to operate these facilities is only exacerbated by the low reimbursement rates from Medicare and Medicaid. While Medicare is funded federally, Medicaid rates are set at the state level.

“We are working to ensure those rates meet the rising costs,” he said, citing a 17.5% increase last year. “But that didn’t get the providers even. Most had an operating margin of –12% in 2022. That is not sustainable moving forward.”

And recent mandates to increase the amount of direct care for each patient that is unfunded will only further hurt the bottom line, he said.

The PHCA survey showed increased waiting lists for beds, which Shamberg said causes families to travel further to find care. When they can’t, he said, it creates the possibility of homelessness.

“This is expected to rise through 2030,” he said. “Nursing homes are people’s homes and as they close, the rate of homelessness will climb even higher.”

To make matters worse, Shamberg said many Baby Boomers didn’t save enough for such expenses and may not be able to afford personal care or assisted living homes, many of which don’t receive Medicaid reimbursement.

“So those residents are discharged to nursing homes when they don’t need that level of care, or to their homes, where there is not enough care,” he said.

Shamberg said that in the short term, Pennsylvania must prioritize long-term care and highlight the good work the facilities do.

“We need to provide sustainable investment in staff, the workforce pipeline and the support sector,” he said. “And Medicaid reimbursements need to increase.”

In the long term, Shamberg said, facilities need to get creative to stay afloat. Unfortunately, Pennsylvania is one of the most regulated states in the country, making creativity difficult.

“These facilities are getting creative in what they offer staff to attract and retain them. They used to operate with three shifts, but we are now seeing two shifts, same day pay, and, in some cases, childcare, tuition and transportation help,” he said. “But offering incentives comes with a cost and when you are on a reimbursement model, it makes a difference.”

Unless things turn around, Shamberg said the big question is “Where will our seniors and people with disabilities go?”

“Our population is getting older, and the number of nursing homes and available beds are shrinking. That is a recipe for disaster over the next five to 10 years,” he said.