The American Wellness Treatment Association and National Centre for Assisted Residing (AHCA/NCAL), collectively symbolizing much more than 14,000 nursing residences and assisted residing communities all through the United States, recently released the 2023 “State of the Nursing Home Sector” reality sheet.
The actuality sheet incorporates knowledge from CMS, CDC, CLA, MACPAC, the Kaiser Household Foundation, and investigate carried out by the AHCA/NCAL. The point sheet highlights not only the consequences of the COVID-19 pandemic, but also the prolonged-expression problems influencing the nursing house marketplace.
Crucial Highlights from the Truth Sheet
The truth sheet focuses on how the pandemic has exacerbated the labor lack, resulting in an entry to treatment disaster for seniors. Individuals troubles are paired with the simple fact that the nursing property sector will begin to lose COVID financial aid in 2023, slowing its financial restoration.
Labor Scarcity
For the duration of the pandemic, far more than 210,000 nursing household sector positions were being dropped, and the nursing home workforce declined by more than 13{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}. At the instant, 84{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of nursing residences experience moderate to superior staffing shortages, posing a significant limitation on the excellent of treatment that these nursing households can give. In simple fact, 54{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of nursing households have experienced to limit new admissions simply because of staffing shortages, and 67{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} are involved that their facility may have to near because of serious staffing shortages.
If amenities have to near, they would be signing up for the 465 nursing homes that shut during the pandemic. Of those people that closed, 41{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} have been 4- or 5- star amenities. Those closures displaced 18,071 inhabitants.
In an attempt to address the staffing shortage, companies are performing to bring in caregivers. Nine out of 10 nursing dwelling vendors elevated wages and presented bonuses in effort to recruit and retain staff members. Having said that, 96{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of nursing homes locate it difficult to seek the services of employees, and 97{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} mentioned that a deficiency of fascinated or experienced candidates has become a major obstacle in hiring personnel.
Monetary Worries
The point sheet also highlights the previously precarious financial situation that nursing households experience. Nursing house products and companies fees have increased by 8.5{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} because of to inflation. With 62{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of nursing house people relying on Medicaid, which reimburses only aspect of a nursing home’s costs, many vendors are battling. The simple fact sheet suggests that 55{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of nursing homes are operating at a loss, and if that economic strain proceeds, 52{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} may perhaps have to near within a yr.
The decline of COVID aid, such as Supplier Reduction Fund, Medicaid-increased FMAP, and American Rescue Program point out funding, will exacerbate this economic strain.
Looking to Restoration
These problems are not likely to be solved rapidly. Supplied the present-day staffing problems, it is approximated that nursing residences will not return to their pre-pandemic workforce stages right up until 2027. “We have come a extended way because the beginning of the COVID-19 pandemic, but nursing households are struggling with a mounting disaster that our leaders in Washington can no extended ignore,” says Mark Parkinson, president and CEO of AHCA/NCAL. “This is a connect with to motion. We require lawmakers to move significant reforms, equally fast and extended-phrase, that support vendors in addressing our main troubles.”
Editor’s Note: This is the second report in a four-part series about Connecticut’s aging population and the challenges in finding ways to care for people.
This week: Nursing homes face a reckoning as they deal with fewer residents, a change in pay and plans to ‘right-size’ the industry.
Last week: The country’s aging population is expected to more than double. Connecticut’s network of supports is struggling.
Upcoming: As more people choose home and community options over institutional care, will access to services be equal for all?
Upcoming: More people are aging in place. But the state’s home care industry operates with little oversight.
For many Connecticut nursing homes, the next few years will be about survival.
Along with unprecedented staffing shortages and less-than-ideal occupancy rates, nursing home operators are also facing a state Department of Social Services that is intent on “right-sizing” the industry by directing money away from nursing homes and toward home care programs.
And state legislators, some of whom heard terrifying stories about substandard care in facilities, have proposed laws that would open nursing homes’ books to more scrutiny and increase the mandatory number of hours residents have with their caretakers.
When nursing home operators recently asked the state for $193 million more to meet their mission, they were rebuffed, and lawmakers instead raised questions about how several infusions of money during the pandemic were spent.
About 20,000 people live in Connecticut’s approximately 200 nursing homes. And as the state’s population of older adults continues to grow and show increased interest in home-based care, changes in the nursing home industry appear inevitable.
“This is a time of transition in the nursing home industry, not only because of the pandemic but also the changes in attitudes about nursing homes,” said Deidre Gifford, the state’s former social services commissioner, now head of the Office of Health Strategy. “Somebody who may have a decade or so ago, or even just before the pandemic, been admitted to a nursing home is now figuring out how to remain in place at home.”
“Every year, the state of Connecticut spends $1.12 billion on our state’s nursing homes when we look at the whole Medicaid program,” said Sen. Matthew Lesser, co-chairman of the Human Services Committee. “It is important with that funding, which pays for 70{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of the nursing home residents who are receiving care in the state, that we have certain things. One is transparency, where we know where that money is going; two, that we have adequate staffing; and then three, that we are taking care of our most vulnerable.”
Lawmakers have rolled out a series of sweeping bills this year with the aim of improving care in nursing homes. The proposals would raise the mandatory minimum staffing hours in nursing homes, require more transparency in the way facility operators spend taxpayer money, mandate that owners provide air conditioning in resident rooms and prompt broader disclosures about private equity investment in long-term care, among other changes.
Industry leaders have cautioned against cutting funding from nursing homes as they emerge from the pandemic.
“We have been urging the DSS and state policymakers that they must take a very careful and cautious approach about prematurely and aggressively accelerating their rebalancing objectives,” said Matthew Barrett, the president and CEO of the Connecticut Association of Health Care Facilities.
“We think being too aggressive is dangerous, and it could lead to issues of impeding access to high-quality skilled nursing facility care. If too many homes close, beds come out of the system, and the consequences of that will be harmful to the very population that we want to be sure are cared for,” Barrett said.
He said the state needs to view the system as a whole and not fund one form of care over another.
“We need both, and that’s why we say Connecticut shouldn’t just throw one ball in the air to aggressively enhance and improve the infrastructure of home and community-based services,” Barrett said. “We also have to keep the other ball in the air too by still investing and ensuring that we have a strong supply of high quality skilled nursing facility care.”
Legislators’ focus on nursing homes also comes in the wake of revelations that Athena Health Care Systems, one of Connecticut’s largest long-term care providers, failed to pay temporary employment agencies and health insurance premiums for its staff and faces lawsuits, consent orders and a $1.75 million fine.
“I believe we are in crisis not just in my district, not just in Connecticut, but across the nation,” said Rep. Jane Garibay, co-chair of the legislature’s Aging Committee.
Problems with care in nursing homes have been going on for years, she said. “This is not new, and it’s not just because of COVID. COVID shined a light on what is happening, but it is our responsibility to change it.”
Inside the nursing homes: More empty beds, fewer workers
Bill White’s family owned the Beechwood Post-Acute & Transitional Care Center in New London for 32 years — until last summer, when White sold it.
“I have a five-star nursing home with an outstanding reputation that still hasn’t had a single COVID death. It’s family owned, and I still couldn’t hire anybody,” White said last summer. “[I] had to pay people $300 more a shift just to fill them.”
“If I can’t get people, I’m thinking, ‘Holy crap, what are others doing?’” he said.
White said the timing was right to get out of the industry, and he suspects others will be following suit.
“What I’m seeing since the pandemic is overall occupancy has dropped, it’s probably in the low 80 [percent range] now,” he said in an interview on his last day as a nursing home owner.
They’re lucky they get up for lunch.
John Bilsano, Apple Rehab Shelton Lakes resident
“But the spread in occupancy between the haves and have nots is much more dramatic. There are homes that are at 90{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} capacity and others under 60{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b},” White said. “So I think maybe people are thinking more about where they go from here than they ever did before.”
In February 2023, the statewide occupancy for nursing homes was about 83{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}, below the 90{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} optimal occupancy rate some legislators are calling for and the industry reported just before the pandemic hit in 2020.
Even as the total number of beds in nursing homes decreased because some facilities closed during the pandemic, the number of available beds has increased. In February 2020, there were 3,112 open beds in the state’s then-210 nursing homes. Roughly two years later, in March 2022, that number reached 5,017 open beds in 205 nursing homes.
As of late February, there were about 3,800 open beds in about 200 nursing homes, according to state data.
The inside of the independent living facility Arbors of Hop Brook. “We are used to very high expectations,” said Shery Johnson, who has worked with the Liistro family for one and a half years as a resident service director. Yehyun Kim / ctmirror.org
Some nursing home residents say care has been inadequate in recent years. Many facilities saw a drop in staff when the pandemic began and haven’t recovered since.
John Bilsano, 57, said residents at Apple Rehab Shelton Lakes, where he’s lived for three years, are waiting longer for assistance because the building is short staffed.
“It hurts me to see them wait as long as they do for help,” he said. “When they put their call bell on, it takes almost a half hour, 45 minutes, for [workers] to answer.
“I feel bad. Let’s say they need to go to the bathroom or they’re on a bed pan and they need to be changed, they have to sit in their diaper … for that long until somebody comes to change them.”
Bilsano said some residents don’t make it out of bed for activities until the afternoon.
“They’re lucky they get up for lunch,” he said.
Representatives for Apple Rehab could not be reached for comment.
It is time we realize the nursing home of 20 or 30 years ago that cared for people who needed basic personal assistance has evolved into a complex clinical setting.
Lurlette Newell, certified nursing assistant
The problems reached the state Capitol this year. Several residents and their loved ones testified and wrote to lawmakers about the situation inside nursing homes.
“I have personally experienced the problems with short-handed staff and personnel … when both my mother and father were in the nursing home,” Joseph Swart wrote to legislators. “There was one time I went there only to find my mother lying on the bathroom floor. When they finally got her out of there and back in bed, I asked her why she was on the floor, and she told me she had rang for the nurse, but it took them so long to come in she decided to go to the bathroom on her own and she tripped and fell.
“I also witnessed that the meals … were often cold when they should have been hot.”
Cynthia Hadden, of South Windsor, described the conditions her father lived with during his two years in a nursing home.
“The lack of staffing did not allow for quality care as time with each resident is not sufficient,” she said. “His phone was often placed in a hurry where he could not reach it. Water was outside of his reach; meals were left on a table without assistance, becoming cold. His diaper hanging down between his knees, obviously soaked for hours.
“A person with dementia does not remember what the call bell is for, therefore someone needs to be checking on residents consistently and timely. When staffing levels are low, the residents suffer.”
Lurlette Newell, a certified nursing assistant at the Westside Care Center in Manchester, told lawmakers that every year, the ratio of caregivers to residents gets worse.
“On top of that,” she said, “the acuity of our residents and the amount of care they need grows. It is time we realize the nursing home of 20 or 30 years ago that cared for people who needed basic personal assistance has evolved into a complex clinical setting.”
Staffing and the move to home care
Finding staff is a major challenge — not only for nursing homes but also for anyone in the health care sector, including home health care agencies or home companion agencies, where turnover can be as high as 50{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} annually.
State officials believe many nursing home beds aren’t filled because family members who worked from home during the pandemic were able to keep their parents or relatives at home, while others turned to private caregivers or home companion agencies when possible.
The pandemic has sped up a process that was already underway, with more people transitioning from institutional care to home services. The number of people seeking home care now is about where the state projected the numbers to be in 2028, said Dawn Lambert, co-leader of the Department of Social Services’ Community Options Unit.
If we can just provide enough support to the family caregiver … it is preferable for the client and for the family to keep them at home.
Deidre Gifford, former social services commissioner
“We’ve made this quantum leap and landed in 2028 because there are thousands more people now already living in the community today who are no longer in nursing homes,” she said.
“There are definitely more people at a nursing home level of care [who] right now are living in the community with informal caregivers like their relatives, and that’s the No. 1 thing for me, that we be able to support them so they avoid getting burned out.”
Gifford said the increase in “informal caregiving,” while hard to quantify, is something the state must address.
“There is a lot of informal caregiving going on, and sometimes if we can just provide enough support to the family caregiver, whether it’s some respite or adult day care or some other kind of support, it is preferable for the client and for the family to keep them at home,” she said.
But the state’s narrative that people are afraid of nursing homes post-COVID doesn’t add up, Barrett said. National data from February shows nursing homes at about 74{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} occupancy, while in Connecticut the occupancy rate is about 83{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}.
“The notion that the skilled nursing facility model was completely undermined by the pandemic was a concern being expressed during the very worst and traumatic part of a pandemic in the spring and the summer of 2020,” he said. “I really challenge the idea that that would be an accurate portrayal of how the system is characterized today.”
Barrett said the staffing issues are having an outsized impact on the quality of care in nursing homes.
“Our quality was much higher pre-pandemic, when staffing was stronger, and there’s every reason to believe that quality improvement will flow as the staffing situation improves,” he said.
A new funding system focuses on health needs
In July, the state quietly started a new funding method for nursing home providers called “acuity-based reimbursement.” Under the new system, providers will get paid based on the level of care needed for their residents. It requires putting data into a federal system that determines per diem rates and is based more on the needs of the residents than total numbers of beds filled.
Over the next three years, the state will invest $90 million to phase in the new system and help facilities deal with more medically complex residents. Some providers, who consistently have four- or five-star rated homes and who treat patients with the most severe health needs or have specialized units such as a dedicated respiratory unit, will get more money.
Each provider will be required to assess every resident’s health needs and submit that information to a federal database so a “Case Mix Index,” or analysis of medical needs, can be established. Homes with patients who have a greater CMI Index will get an increase in Medicaid payments.
State officials are hoping the new system will improve the quality of care and get providers to open more specialty units to treat diseases such as dementia or provide services like dialysis.
Rosemary Fahey, left, a resident at Arbors of Hop Brook, talks to the previous owner, Paul Liistro. “I will miss Paul,” Fahey said. Yehyun Kim / ctmirror.org
Paul Liistro, whose family owned two nursing homes in Manchester and Vernon until last year, expected an increase of $4 million to $5 million in Medicaid payments based on the state’s formula. He believes that’s why it was so easy to sell his business over the summer.
Liistro was a frequent critic of state officials during the pandemic and was skeptical of the state’s plan to switch the funding model. Some homes won’t fare as well under the new system.
“They don’t want to see beds go down, the state wants to see nursing homes closed,” he said. “At the same time, they’re talking about putting the money into home health care because it is cheaper, but we don’t think the care is better for the patient.
“At the same time, they now have an acuity-based system … and that’s going to keep nursing homes alive, because people are going to figure out how to make the system work for them.”
State Long-Term Care Ombudsman Mairead Painter hopes DSS will push the new payment system and force providers to make improvements to their buildings that she said are long overdue.
“A lot of the buildings here in Connecticut are just outdated, and we haven’t seen owners put the money back into the structure, the physical structure of the nursing homes,” Painter said. “We just haven’t seen it. They take a lot of the money out but it doesn’t go back in. And because of that, these buildings are just old and in need of repair.”
The survey
Even as legislators debate bills, the state’s social services department has been working on a plan to shift funding away from certain nursing homes. Last April, DSS required every provider to submit a survey detailing occupancy rates and future plans in a post-pandemic setting for their facilities.
DSS made it clear the survey would be a vital part of what they are calling the “rebalancing” or “right-sizing” of the industry.
State officials warned providers the surveys would be used to determine which nursing homes receive funding under the new payment model.
Despite that, nearly 20{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of the nursing home providers didn’t properly fill out the survey, state officials said, and the majority of them had no plans for changes other than to seek additional state funding.
Gifford said it is the state’s job to distribute funding to providers that adapt.
“Our job is to understand what’s going on and with our payment model do whatever we can to ensure it’s the highest quality facilities that remain in operation to the extent that any of them are going to close,” she said.
Brian Liistro, Paul Liistro’s brother and manager, looks at the property map to prepare for the renovation of the facility to meet the Americans with Disabilities Act standards. “Family businesses are being bought. Slowing going away,” Brian said. Yehyun Kim / ctmirror.org
The surveys due in April 2022 were supposed to be the providers’ chance to share with the state not only their occupancy levels but also any changes they planned to make to their buildings.
While 169 of 195 providers who were sent the survey initially responded, the majority said they had no plans for change, and only 22 replied that they were actively seeking building renovations. Another 11 nursing home owners said they were looking into adding specialty units. The Department of Public Health had already approved two ventilator specialty units before the surveys were submitted.
These were not the forward-looking responses DSS officials had expected.
“The industry will obviously have to respond to the need and the demand in the community and adapt to those needs,” Gifford said.
The survey showed 85 nursing homes are over 85{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} filled, and 83 are under that mark. Almost all complained about the difficulty in attracting and keeping staff, the biggest issue facing providers right now.
Barrett said the April surveys are a good view of where the industry is now, but they are not the final word on where it will end up.
“It’s an extremely important scan in terms of where the sector stands at this point coming out of the public health emergency. But by no means is it a final analysis or the final word on where the sector is going to land,” Barrett said. “Nationally, most observers believe the nursing home sector will recover. The question becomes, to what extent? … And will it recover its occupancy to pre-pandemic levels?”
A shift away from nursing homes?
The state is now putting more of its Medicaid funding into home health care.
In 2018, for the first time ever, Connecticut spent more Medicaid money on home and community-based services than on institutional care, 53{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} to 47{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}, state data show. By 2022, it had spent 58{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of its Medicaid long-term care funds on home services, versus 42{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} for nursing homes and other facilities.
DSS eventually sees that gap increasing to as much as 75{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} for home care and 25{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} to nursing homes.
Barrett said it would be a mistake to substantially dilute funding for nursing homes.
“Let’s not make the mistake of overemphasis on reducing nursing home bed supply,” Barrett said. “We are really urging the[state] to not be prematurely basing any new aggressive approach to right-sizing and rebalancing … on where we are right now or on the April survey reports.”
I think it is a bunch of bunk that they aren’t making any money.
Mairead Painter, State Long-Term Care Ombudsman
In the survey, some providers said they expect to take over other nursing facilities that don’t make it financially.
“Eleven nursing homes believe neighboring nursing homes will close within the next 18 to 36 months, and they anticipated increased occupancy by absorbing residents and staff from those neighboring facilities that close,” according to a review of the DSS surveys.
At least six nursing homes have shut down since 2020, and several family-owned providers and large chains are selling their facilities to private equity companies, mostly based in New York and New Jersey.
Sergio Esteves, right, licensed practical nurse, sits in an office at Jewish Senior Services. The nursing home follows a household model, where each resident has their own room and bathroom and shares common areas, including kitchen. Yehyun Kim / ctmirror.org
The influx of private equity money into the nursing home field has caught the attention of legislators who are proposing a transparency bill, seeking to make providers reveal quarterly where state funds they receive are going.
Painter said she has grown tired of nursing home owners complaining they don’t have any money.
“I think it is a bunch of bunk that they aren’t making any money,” Painter said. “People wouldn’t continue buying them if that were true.”
Painter is calling for full disclosure by nursing home providers of how many ancillary companies — pharmacies, laundry and food operations — get state money that is supposed to go toward patient care.
One of the bills before the legislature would require providers to be more transparent about where the state’s money is going. Providers would have to reveal whether private equity firms or other silent partners were getting a share of funds that could go toward staffing.
“We’re not going to be able to improve the quality of care in nursing homes unless we first address the financial practices that some … owners use to divert money from patient care in order to make their facilities more profitable,” said Nora Duncan, AARP Connecticut state director.
“Many nursing homes operate under complicated ownership structures that limit financial transparency and make it difficult to understand how facilities are spending taxpayer dollars.”
Bridgeport model
Between them, Liistro and White have more than 70 years’ experience operating family-owned nursing homes. They left the field within a few months of each other, alarmed by the uncertainty of what long-term care will look like in a state with an expanding aging population.
For White, the struggle to find and keep employees has been almost as difficult as fighting COVID.
“I can’t tell you how much effort you have to put into this business, and you start to think, why are we doing this?” White said. “It was never to make money. We never made a ton of money, but you don’t even really get the satisfaction of helping people anymore. It just got frustrating.”
Painter would like to see the state pivot away from hospital-like facilities and approve “smaller homes.”
“I’m really promoting small, community-sized nursing homes. I would love to see maximum 30- to 40-bed nursing homes scattered throughout the state,” she said.
Painter points to the Jewish Home in Bridgeport as an example of what a future building should look like. The Jewish Home is the newest facility in the state, having opened six years ago, and while it has 294 beds, it is designed like a series of small neighborhoods.
The first floor of The Jewish Home in Bridgeport. The facility offers one room and bathroom for each resident. Yehyun Kim / ctmirror.org
“There’s a front door — you have to ring the doorbell. There’s a mailbox. They have a living room, a centralized living room with bedrooms off of it, and many have individual rooms,” Painter said.
The Jewish Home is currently full, according to its director, Andrew Banoff. When submitting their survey in April, officials at the facility asked the state for more skilled nursing beds because of a long wait list.
“For those that do need skilled nursing care, which I think there will forever be that need, the concept of smaller units, private rooms and more personalized care is obviously a good thing,” Banoff said. “I’d love there to be more organizations that rebuild, renovate and find ways to invest in better environments for those we take care of.”
At least a dozen organizations have reached out to The Jewish Home’s leaders to inquire about their model.
“Not shocking, the money and the capacity to invest in new buildings is a challenge for most,” Banoff said. “I think it’s really important to look at, what are the other models? What are the other tools that organizations have to help people live safely in the community, including the adult family living home model, which is for people who are at a nursing home level, but we provide a caregiver in their home, and it’s funded through Medicaid.”
Both Liistro and White say there is still a need for nursing homes, and the state should be wary of eliminating too many beds or letting too many facilities close.
“There is absolutely a future for nursing homes. … There isn’t a substitute for it,” White said. “There’s always going to be a large segment of people who either can’t afford or don’t have a home, or their clinical needs are such that they can’t be supported at home.”
CT Mirror staff writer Katy Golvala contributed to this story.
Yehyun Kim / ctmirror.org
“CT’s Elder Care Reckoning” is a four-part series about Connecticut’s aging population and the challenges in finding ways to care for people.
Want to share what you know? Send your tips to Jenna Carlesso at jcarlesso@ctmirror.org or Dave Altimari at daltimari@ctmirror.org.
PROJECT CREDITS
Reporting: Dave Altimari, Jenna Carlesso Photography: Yehyun Kim Data visualization: Katy Golvala Editing: Elizabeth Hamilton, Stephen Busemeyer, Keila Torres Ocasio Social media: Gabby DeBenedictis, Nicole McIsaac Web development: Kyle Constable
For many Connecticut nursing homes, the next few years will be about survival.
Along with unprecedented staffing shortages and less-than-ideal occupancy rates, nursing home operators are also facing a state Department of Social Services that is intent on “right-sizing” the industry by directing money away from nursing homes and toward home care programs.
And state legislators, some of whom heard terrifying stories about substandard care in facilities, have proposed laws that would open nursing homes’ books to more scrutiny and increase the mandatory number of hours residents have with their caretakers.
When nursing home operators recently asked the state for $193 million more to meet their mission, they were rebuffed, and lawmakers instead raised questions about how several infusions of money during the pandemic were spent.
About 20,000 people live in Connecticut’s approximately 200 nursing homes. And as the state’s population of older adults continues to grow and show increased interest in home-based care, changes in the nursing home industry appear inevitable.
“This is a time of transition in the nursing home industry, not only because of the pandemic but also the changes in attitudes about nursing homes,” said Deidre Gifford, the state’s former social services commissioner, now head of the Office of Health Strategy. “Somebody who may have a decade or so ago, or even just before the pandemic, been admitted to a nursing home is now figuring out how to remain in place at home.”
“Every year, the state of Connecticut spends $1.12 billion on our state’s nursing homes when we look at the whole Medicaid program,” said Sen. Matthew Lesser, co-chairman of the Human Services Committee. “It is important with that funding, which pays for 70{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of the nursing home residents who are receiving care in the state, that we have certain things. One is transparency, where we know where that money is going; two, that we have adequate staffing; and then three, that we are taking care of our most vulnerable.”
Lawmakers have rolled out a series of sweeping bills this year with the aim of improving care in nursing homes. The proposals would raise the mandatory minimum staffing hours in nursing homes, require more transparency in the way facility operators spend taxpayer money, mandate that owners provide air conditioning in resident rooms and prompt broader disclosures about private equity investment in long-term care, among other changes.
Industry leaders have cautioned against cutting funding from nursing homes as they emerge from the pandemic.
“We have been urging the DSS and state policymakers that they must take a very careful and cautious approach about prematurely and aggressively accelerating their rebalancing objectives,” said Matthew Barrett, the president and CEO of the Connecticut Association of Health Care Facilities.
“We think being too aggressive is dangerous, and it could lead to issues of impeding access to high-quality skilled nursing facility care. If too many homes close, beds come out of the system, and the consequences of that will be harmful to the very population that we want to be sure are cared for,” Barrett said.
He said the state needs to view the system as a whole and not fund one form of care over another.
“We need both, and that’s why we say Connecticut shouldn’t just throw one ball in the air to aggressively enhance and improve the infrastructure of home and community-based services,” Barrett said. “We also have to keep the other ball in the air too by still investing and ensuring that we have a strong supply of high quality skilled nursing facility care.”
Legislators’ focus on nursing homes also comes in the wake of revelations that Athena Health Care Systems, one of Connecticut’s largest long-term care providers, failed to pay temporary employment agencies and health insurance premiums for its staff and faces lawsuits, consent orders and a $1.75 million fine.
“I believe we are in crisis not just in my district, not just in Connecticut, but across the nation,” said Rep. Jane Garibay, co-chair of the legislature’s Aging Committee.
Problems with care in nursing homes have been going on for years, she said. “This is not new, and it’s not just because of COVID. COVID shined a light on what is happening, but it is our responsibility to change it.”
Inside the nursing homes: More empty beds, fewer workers
Bill White’s family owned the Beechwood Post-Acute & Transitional Care Center in New London for 32 years — until last summer, when White sold it.
“I have a five-star nursing home with an outstanding reputation that still hasn’t had a single COVID death. It’s family owned, and I still couldn’t hire anybody,” White said last summer. “[I] had to pay people $300 more a shift just to fill them.”
“If I can’t get people, I’m thinking, ‘Holy crap, what are others doing?’” he said.
White said the timing was right to get out of the industry, and he suspects others will be following suit.
“What I’m seeing since the pandemic is overall occupancy has dropped, it’s probably in the low 80 [percent range] now,” he said in an interview on his last day as a nursing home owner.
They’re lucky they get up for lunch.
JOHN BILSANO, APPLE REHAB SHELTON LAKES RESIDENT
“But the spread in occupancy between the haves and have nots is much more dramatic. There are homes that are at 90{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} capacity and others under 60{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b},” White said. “So I think maybe people are thinking more about where they go from here than they ever did before.”
In February 2023, the statewide occupancy for nursing homes was about 83{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}, below the 90{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} optimal occupancy rate some legislators are calling for and the industry reported just before the pandemic hit in 2020.
Even as the total number of beds in nursing homes decreased because some facilities closed during the pandemic, the number of available beds has increased. In February 2020, there were 3,112 open beds in the state’s then-210 nursing homes. Roughly two years later, in March 2022, that number reached 5,017 open beds in 205 nursing homes.
As of late February, there were about 3,800 open beds in about 200 nursing homes, according to state data.
Some nursing home residents say care has been inadequate in recent years. Many facilities saw a drop in staff when the pandemic began and haven’t recovered since.
John Bilsano, 57, said residents at Apple Rehab Shelton Lakes, where he’s lived for three years, are waiting longer for assistance because the building is short staffed.
“It hurts me to see them wait as long as they do for help,” he said. “When they put their call bell on, it takes almost a half hour, 45 minutes, for [workers] to answer.
“I feel bad. Let’s say they need to go to the bathroom or they’re on a bed pan and they need to be changed, they have to sit in their diaper … for that long until somebody comes to change them.”
Bilsano said some residents don’t make it out of bed for activities until the afternoon.
“They’re lucky they get up for lunch,” he said.
Representatives for Apple Rehab could not be reached for comment.
It is time we realize the nursing home of 20 or 30 years ago that cared for people who needed basic personal assistance has evolved into a complex clinical setting.
LURLETTE NEWELL, CERTIFIED NURSING ASSISTANT
The problems reached the state Capitol this year. Several residents and their loved ones testified and wrote to lawmakers about the situation inside nursing homes.
“I have personally experienced the problems with short-handed staff and personnel … when both my mother and father were in the nursing home,” Joseph Swart wrote to legislators. “There was one time I went there only to find my mother lying on the bathroom floor. When they finally got her out of there and back in bed, I asked her why she was on the floor, and she told me she had rang for the nurse, but it took them so long to come in she decided to go to the bathroom on her own and she tripped and fell.
“I also witnessed that the meals … were often cold when they should have been hot.”
Cynthia Hadden, of South Windsor, described the conditions her father lived with during his two years in a nursing home.
“The lack of staffing did not allow for quality care as time with each resident is not sufficient,” she said. “His phone was often placed in a hurry where he could not reach it. Water was outside of his reach; meals were left on a table without assistance, becoming cold. His diaper hanging down between his knees, obviously soaked for hours.
“A person with dementia does not remember what the call bell is for, therefore someone needs to be checking on residents consistently and timely. When staffing levels are low, the residents suffer.”
Lurlette Newell, a certified nursing assistant at the Westside Care Center in Manchester, told lawmakers that every year, the ratio of caregivers to residents gets worse.
“On top of that,” she said, “the acuity of our residents and the amount of care they need grows. It is time we realize the nursing home of 20 or 30 years ago that cared for people who needed basic personal assistance has evolved into a complex clinical setting.”
Staffing and the move to home care
Finding staff is a major challenge — not only for nursing homes but also for anyone in the health care sector, including home health care agencies or home companion agencies, where turnover can be as high as 50{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} annually.
State officials believe many nursing home beds aren’t filled because family members who worked from home during the pandemic were able to keep their parents or relatives at home, while others turned to private caregivers or home companion agencies when possible.
The pandemic has sped up a process that was already underway, with more people transitioning from institutional care to home services. The number of people seeking home care now is about where the state projected the numbers to be in 2028, said Dawn Lambert, co-leader of the Department of Social Services’ Community Options Unit.
If we can just provide enough support to the family caregiver … it is preferable for the client and for the family to keep them at home.
DEIDRE GIFFORD, FORMER SOCIAL SERVICES COMMISSIONER
“We’ve made this quantum leap and landed in 2028 because there are thousands more people now already living in the community today who are no longer in nursing homes,” she said.
“There are definitely more people at a nursing home level of care [who] right now are living in the community with informal caregivers like their relatives, and that’s the No. 1 thing for me, that we be able to support them so they avoid getting burned out.”
Gifford said the increase in “informal caregiving,” while hard to quantify, is something the state must address.
“There is a lot of informal caregiving going on, and sometimes if we can just provide enough support to the family caregiver, whether it’s some respite or adult day care or some other kind of support, it is preferable for the client and for the family to keep them at home,” she said.
But the state’s narrative that people are afraid of nursing homes post-COVID doesn’t add up, Barrett said. National data from February shows nursing homes at about 74{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} occupancy, while in Connecticut the occupancy rate is about 83{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}.
“The notion that the skilled nursing facility model was completely undermined by the pandemic was a concern being expressed during the very worst and traumatic part of a pandemic in the spring and the summer of 2020,” he said. “I really challenge the idea that that would be an accurate portrayal of how the system is characterized today.”
Barrett said the staffing issues are having an outsized impact on the quality of care in nursing homes.
“Our quality was much higher pre-pandemic, when staffing was stronger, and there’s every reason to believe that quality improvement will flow as the staffing situation improves,” he said.
A new funding system focuses on health needs
In July, the state quietly started a new funding method for nursing home providers called “acuity-based reimbursement.” Under the new system, providers will get paid based on the level of care needed for their residents. It requires putting data into a federal system that determines per diem rates and is based more on the needs of the residents than total numbers of beds filled.
Over the next three years, the state will invest $90 million to phase in the new system and help facilities deal with more medically complex residents. Some providers, who consistently have four- or five-star rated homes and who treat patients with the most severe health needs or have specialized units such as a dedicated respiratory unit, will get more money.
Each provider will be required to assess every resident’s health needs and submit that information to a federal database so a “Case Mix Index,” or analysis of medical needs, can be established. Homes with patients who have a greater CMI Index will get an increase in Medicaid payments.
State officials are hoping the new system will improve the quality of care and get providers to open more specialty units to treat diseases such as dementia or provide services like dialysis.
Rosemary Fahey, left, a resident at Arbors of Hop Brook, talks to the previous owner, Paul Liistro. “I will miss Paul,” Fahey said.
Paul Liistro, whose family owned two nursing homes in Manchester and Vernon until last year, expected an increase of $4 million to $5 million in Medicaid payments based on the state’s formula. He believes that’s why it was so easy to sell his business over the summer.
Liistro was a frequent critic of state officials during the pandemic and was skeptical of the state’s plan to switch the funding model. Some homes won’t fare as well under the new system.
“They don’t want to see beds go down, the state wants to see nursing homes closed,” he said. “At the same time, they’re talking about putting the money into home health care because it is cheaper, but we don’t think the care is better for the patient.
“At the same time, they now have an acuity-based system … and that’s going to keep nursing homes alive, because people are going to figure out how to make the system work for them.”
State Long-Term Care Ombudsman Mairead Painter hopes DSS will push the new payment system and force providers to make improvements to their buildings that she said are long overdue.
“A lot of the buildings here in Connecticut are just outdated, and we haven’t seen owners put the money back into the structure, the physical structure of the nursing homes,” Painter said. “We just haven’t seen it. They take a lot of the money out but it doesn’t go back in. And because of that, these buildings are just old and in need of repair.”
The survey
Even as legislators debate bills, the state’s social services department has been working on a plan to shift funding away from certain nursing homes. Last April, DSS required every provider to submit a survey detailing occupancy rates and future plans in a post-pandemic setting for their facilities.
DSS made it clear the survey would be a vital part of what they are calling the “rebalancing” or “right-sizing” of the industry.
State officials warned providers the surveys would be used to determine which nursing homes receive funding under the new payment model.
Despite that, nearly 20{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of the nursing home providers didn’t properly fill out the survey, state officials said, and the majority of them had no plans for changes other than to seek additional state funding.
Gifford said it is the state’s job to distribute funding to providers that adapt.
“Our job is to understand what’s going on and with our payment model do whatever we can to ensure it’s the highest quality facilities that remain in operation to the extent that any of them are going to close,” she said.
The surveys due in April 2022 were supposed to be the providers’ chance to share with the state not only their occupancy levels but also any changes they planned to make to their buildings.
While 169 of 195 providers who were sent the survey initially responded, the majority said they had no plans for change, and only 22 replied that they were actively seeking building renovations. Another 11 nursing home owners said they were looking into adding specialty units. The Department of Public Health had already approved two ventilator specialty units before the surveys were submitted.
These were not the forward-looking responses DSS officials had expected.
“The industry will obviously have to respond to the need and the demand in the community and adapt to those needs,” Gifford said.
The survey showed 85 nursing homes are over 85{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} filled, and 83 are under that mark. Almost all complained about the difficulty in attracting and keeping staff, the biggest issue facing providers right now.
Barrett said the April surveys are a good view of where the industry is now, but they are not the final word on where it will end up.
“It’s an extremely important scan in terms of where the sector stands at this point coming out of the public health emergency. But by no means is it a final analysis or the final word on where the sector is going to land,” Barrett said. “Nationally, most observers believe the nursing home sector will recover. The question becomes, to what extent? … And will it recover its occupancy to pre-pandemic levels?”
A shift away from nursing homes?
The state is now putting more of its Medicaid funding into home health care.
In 2018, for the first time ever, Connecticut spent more Medicaid money on home and community-based services than on institutional care, 53{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} to 47{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}, state data show. By 2022, it had spent 58{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of its Medicaid long-term care funds on home services, versus 42{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} for nursing homes and other facilities.
DSS eventually sees that gap increasing to as much as 75{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} for home care and 25{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} to nursing homes.
Barrett said it would be a mistake to substantially dilute funding for nursing homes.
“Let’s not make the mistake of overemphasis on reducing nursing home bed supply,” Barrett said. “We are really urging the [state] to not be prematurely basing any new aggressive approach to right-sizing and rebalancing … on where we are right now or on the April survey reports.”
I think it is a bunch of bunk that they aren’t making any money.
MAIREAD PAINTER, STATE LONG-TERM CARE OMBUDSMAN
In the survey, some providers said they expect to take over other nursing facilities that don’t make it financially.
“Eleven nursing homes believe neighboring nursing homes will close within the next 18 to 36 months, and they anticipated increased occupancy by absorbing residents and staff from those neighboring facilities that close,” according to a review of the DSS surveys.
At least six nursing homes have shut down since 2020, and several family-owned providers and large chains are selling their facilities to private equity companies, mostly based in New York and New Jersey.
Sergio Esteves, right, licensed practical nurse, sits in an office at Jewish Senior Services. The nursing home follows a household model, where each resident has their own room and bathroom and shares common areas, including kitchen.
The influx of private equity money into the nursing home field has caught the attention of legislators who are proposing a transparency bill, seeking to make providers reveal quarterly where state funds they receive are going.
Painter said she has grown tired of nursing home owners complaining they don’t have any money.
“I think it is a bunch of bunk that they aren’t making any money,” Painter said. “People wouldn’t continue buying them if that were true.”
Painter is calling for full disclosure by nursing home providers of how many ancillary companies — pharmacies, laundry and food operations — get state money that is supposed to go toward patient care.
One of the bills before the legislature would require providers to be more transparent about where the state’s money is going. Providers would have to reveal whether private equity firms or other silent partners were getting a share of funds that could go toward staffing.
“We’re not going to be able to improve the quality of care in nursing homes unless we first address the financial practices that some … owners use to divert money from patient care in order to make their facilities more profitable,” said Nora Duncan, AARP Connecticut state director.
“Many nursing homes operate under complicated ownership structures that limit financial transparency and make it difficult to understand how facilities are spending taxpayer dollars.”
Bridgeport model
Between them, Liistro and White have more than 70 years’ experience operating family-owned nursing homes. They left the field within a few months of each other, alarmed by the uncertainty of what long-term care will look like in a state with an expanding aging population.
For White, the struggle to find and keep employees has been almost as difficult as fighting COVID.
“I can’t tell you how much effort you have to put into this business, and you start to think, why are we doing this?” White said. “It was never to make money. We never made a ton of money, but you don’t even really get the satisfaction of helping people anymore. It just got frustrating.”
Painter would like to see the state pivot away from hospital-like facilities and approve “smaller homes.”
“I’m really promoting small, community-sized nursing homes. I would love to see maximum 30- to 40-bed nursing homes scattered throughout the state,” she said.
Painter points to the Jewish Home in Bridgeport as an example of what a future building should look like. The Jewish Home is the newest facility in the state, having opened six years ago, and while it has 294 beds, it is designed like a series of small neighborhoods.
“There’s a front door — you have to ring the doorbell. There’s a mailbox. They have a living room, a centralized living room with bedrooms off of it, and many have individual rooms,” Painter said.
The Jewish Home is currently full, according to its director, Andrew Banoff. When submitting their survey in April, officials at the facility asked the state for more skilled nursing beds because of a long wait list.
“For those that do need skilled nursing care, which I think there will forever be that need, the concept of smaller units, private rooms and more personalized care is obviously a good thing,” Banoff said. “I’d love there to be more organizations that rebuild, renovate and find ways to invest in better environments for those we take care of.”
At least a dozen organizations have reached out to The Jewish Home’s leaders to inquire about their model.
“Not shocking, the money and the capacity to invest in new buildings is a challenge for most,” Banoff said. “I think it’s really important to look at, what are the other models? What are the other tools that organizations have to help people live safely in the community, including the adult family living home model, which is for people who are at a nursing home level, but we provide a caregiver in their home, and it’s funded through Medicaid.”
Both Liistro and White say there is still a need for nursing homes, and the state should be wary of eliminating too many beds or letting too many facilities close.
“There is absolutely a future for nursing homes. … There isn’t a substitute for it,” White said. “There’s always going to be a large segment of people who either can’t afford or don’t have a home, or their clinical needs are such that they can’t be supported at home.”
CT Mirror staff writer Katy Golvala contributed to this story.
For the very last calendar year, federal regulators have taken actions to maximize nursing house possession transparency, as part of the White House’s reform agenda. The most the latest actions have centered on a lot more evidently defining unique kinds of possession teams and creating facts extra client-friendly – and have drawn concern and criticism from within the sector.
About a single thirty day period ago, the Centers for Medicare & Medicaid Solutions (CMS) proposed a rule necessitating more ownership disclosures and floating definitions of non-public fairness and authentic estate investment trusts. Suppliers are pushing back again on things of this proposal, declaring that they increase one more “redundant” layer to forms and downplay the difficulties experiencing the sector. What’s more, the proposed policy’s definitions of distinctive possession constructions is nonetheless much too obscure, critics say.
In addition to the latest CMS proposal, the Govt Accountability Business (GAO) previous month issued a report contacting for nursing household possession information to be shared in a extra shopper-pleasant fashion. And also past month, the journal Health and fitness Affairs published a study that elevated concerns about the top quality of treatment in nursing homes owned by genuine estate financial investment trusts (REITs).
Though business gurus and advocates say they are in favor of higher transparency, they also have registered fears that REITs are being unfairly tarnished and that operators — however struggling to recover from the troubles of Covid-19 and grappling with a severe staffing disaster — are staying saddled with nonetheless a lot more burdens rather than obtaining needed guidance.
Defining ownership groups
Just after the Biden Administration specific possession transparency as a crucial pillar of its nursing property reform thrust, unveiled final 12 months, nursing residence leaders took situation with the absence of distinction concerning distinct kinds of possession buildings and entities. For occasion, President Biden made use of the broad expression “Wall Avenue firms” when criticizing non-public possession of nursing houses in his 2022 Point out of the Union tackle.
“I really do not like owning all this lumped with each other mainly because they are all totally distinctive,” mentioned Rick Matros, CEO of California-primarily based Sabra Health and fitness Treatment REIT (Nasdaq: SBRA). “In final year’s State of the Union, when we acquired that popular, or infamous 19 seconds, it was obvious to me that whoever wrote that speech, definitely didn’t know the change in between all these entities. And it is form of gotten perpetuated since then.”
CMS has taken methods to make clear definitions.
In asserting the proposed rule lately, CMS mentioned that a “private equity” firm would suggest “a publicly traded or non-publicly traded corporation that collects money investments from folks or entities and purchases an ownership share of a company.” And CMS available this definition of a REIT: “A authentic estate financial investment have confidence in be outlined as a publicly traded or non-publicly traded enterprise that owns component or all of the properties or genuine estate in or on which a provider operates.”
At problem, in certain, is the agency’s absence of difference concerning non-public equity, private capital and REIT possession – the three main types of possession within the sector.
Underneath present-day CMS policies, amenities are only expected to report 5{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} or increased of indirect possession in the facility. But the new rule would pressure operators to especially recognize whether or not a disclosed celebration is a “private equity company” or a real estate investment have faith in (REIT). CMS will also request additional disclosure of ownership and managerial info as nicely as the organizational structure from suppliers.
The simplistic definition of possession versions inside the nursing dwelling market can cause problems, gurus mentioned.
For Sabra, Matros explained the CMS proposal’s monetary influence will probably be negligible. However, with out distinct definitions, the initiative and the resulting confusion has the likely to unjustly taint the image of huge, publicly traded REITs these as his individual, which are already subject matter to disclosure guidelines and discover a lot of of their running partners publicly.
“It doesn’t effects us in a tangible way for the reason that it does not affect us financially or just about anything like that. But for the public…I feel it results in a negative impression. So that impacts us it’s just not tangible,” Matros reported.
Matros supports transparency, but not if the outcome is confusion.
“I believe that transparency is important. So I do not consider anybody should really truly battle transparency. Everyone that is not intrigued in obtaining transparency, you know, begs the concern, ‘why?’” he reported.
And Matros isn’t the only one particular who thinks the boundaries concerning these forms of possession need to have a lot more nuanced assistance from the CMS.
CMS by itself acknowledges that the distinctions never essentially align with the nursing residence industry’s individual definitions.
Just after a ask for by Competent Nursing Information (SNN) for far more clarity, a spokesperson for the company explained to SNN, “As we observed in the proposed rule, we figure out that these definitions may be modestly various from definitions of the similar conditions used in other configurations. We solicited remark on the propriety of our proposed definitions and welcome any proposed revisions … We are significantly intrigued in feedback on no matter whether our proposed definition of private equity business must include things like publicly traded non-public fairness corporations. We also welcome general public feed-back regarding any other forms of non-public ownership in addition to personal fairness corporations and REITs about which CMS need to look at gathering data from qualified nursing services as component of the enrollment approach.”
Comments on the proposed rule and the proposed definitions are owing April 14, 2023, the spokesperson claimed.
Legislators, who back again the transfer for transparency in nursing home ownership, are also urging CMS to situation the proposed rule quicker rather than afterwards. Relating to the different styles of ownership, Sen. Chuck Grassley (R-Iowa), who has pushed for a long time for ownership transparency, instructed SNN in an emailed assertion: “CMS’s hold off in issuing a personal fairness ownership ruling is unacceptable and need to be finalized as before long as feasible. Any last rule need to include not just personal equity possession, but non-public capital possession as very well as REITs.”
In addition, even researchers who have been vital of the purpose played by REITs and who support larger disclosure of possession guiding particular person experienced nursing amenities (SNFs), such as data on ancillary companies, connect with for a additional consumer-pleasant method. The GAO envisions a process that correlates data of particular person facilities with the greater ownership business and its star rankings.
And certainly, advocates for nursing homes, especially in all those states hardest hit with closures, query the timing of the CMS go as properly as the requirement when these guidelines are now in spot.
Brent Willett, president and CEO of Iowa Overall health Care Association (IHCA), explained to SNN, “There’s a level of issue that in a time period of extraordinarily weighty regulation from the federal federal government, this is another just one that vendors who are less than an tremendous quantity of financial pressure and staffing shortages are going to struggle to comply with, and the problem is heading to be actually for what explanation are we currently being redundant here.”
A much more consumer-friendly procedure to make improvements to top quality
Underpinning initiatives by policymakers to maximize transparency in ownership of nursing properties is exploration that implies there may well be a decrease in excellent of care when corporations backing personal services are not named. And although REITs do disclose their operators, Treatment Assess, the buyer software used by inhabitants to gauge high quality at nursing properties, doesn’t make it uncomplicated for people to discover a unique nursing home’s proprietor.
In the meantime, new scientific tests level to a declining high-quality of treatment linked with (REIT) expenditure. The Wellness Affairs research printed very last month pointed to a minimize in much more qualified staff members when a REIT took over. The findings show that the high-quality of staffing at nursing households declined two to a few a long time immediately after a REIT took about, ensuing in a 6{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} minimize in the employment of registered nurses (RNs). Scientists even more located that a drop in registered nurse staffing levels was supplemented with an increase in licensed sensible nurses (LPNs) and certified nursing assistants (CNAs).
Robert Tyler Braun, assistant professor of inhabitants health sciences at Weill Cornell Health care University, who co-authored the examine, said that REIT involvement could force operators to be far more price powerful, foremost to these kinds of techniques as changing more skilled employees with considerably less highly-priced solutions.
On the other hand, CMS’ move for increased ownership transparency will not have an impression on excellent of care unless CMS also enhances its customer system for comparing nursing households, these researchers feel.
Braun stated that the proposed disclosure regulations will not deliver worth to consumers of Treatment Compare until policy makers also connect with for a method that far more easily makes it possible for individuals to make nursing house choices.
There needs to be a centralized process to accessibility ownership knowledge.
“Researchers, policymakers are not likely to individual…publicly traded serious estate expense rely on web-sites, downloading [their] portfolios. There wants to be a systematic and consolidated database, which tracks these [data] longitudinally over time,” Braun stated.
Vendors force again facts on good quality of staffing
Field leaders who spoke with SNN disputed the notion that REIT possession will cause a drop in quality of staffing.
“With the operating organizations and operators that are taking care of services owned by REITs, we undoubtedly never detect a various solution – operationally and from a good quality standpoint – than other possession classes that I’m informed of,” stated IHCA’s Willett, including as a caveat that he does not have a immediate line of sight offered that his affiliation offers with individual operators and not the much larger corporations.
Meanwhile, Sabra’s Matros stated neither his enterprise nor other REITs in the house influence the amenities that lease from them on these decisions as staffing high quality. In addition, the declining top quality of staffing probable stems from labor shortages fairly than a REIT influencing a facility to employ the service of affordable, much less certified staff members, Matros said.
“I issue the validity of some of [these studies],” Matros stated.
For REITs, he mentioned, “None of us would ever ask or notify an operator to reduce their staffing. We just do not do anything like that. Most operators workers based mostly on the acuity of the individual that they are offering treatment for, and to the extent that they really do not meet their have specifications, it’s commonly simply because of nursing shortages and items like that.”
CMS ownership move ‘misses the point’
Matros is mindful to distinguish among REIT possession and other kinds of possession, since frequently shoppers — and it appears to be even plan makers — have missed crucial distinctions concerning the a variety of financial preparations well known in the nursing house sector.
“All a few groups, private funds, non-public fairness and REITs are distinctly unique,” Matros stated.
Now, it is believed that about 12{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of nursing homes have REIT investments with extremely several private-fairness investments, at least from huge corporations, equating to about 1,870 facilities, according to JAMA Overall health.
Fiscal associations among private equity companies and nursing property operators enormously lessened by the early 2000s, Matros claimed. The interval of significant PE investment ended with the 2018 bankruptcy of ManorCare, which at the time was beneath the possession of one particular of the largest and richest personal-equity groups, the Carlyle Team Inc. (Nasdaq: CG). The Carlyle Group, which manages property upwards of $373 billion, held ManorCare for a 10 years, through which time the nursing house operator struggled financially amid reviews of neglect and very poor disorders at its services. And right now, personal fairness teams such as BlackRock Inc. (NYSE: BLK), which manages $10 trillion in belongings, and TPG Inc. (Nasdaq: TPG), which controls $135 billion, and were being also when current in the sector, have all still left.
“(Private equity groups) never like nursing households since of all the government regulation and reimbursement issues that we have,” Matros reported. In its place, private fairness favors senior housing property mainly because these are private pay, he explained.
Nursing residences demand far more notice for a gradual but continuous price of return on investment, which doesn’t in good shape the standard PE design on rapidly driving income, Matros stated..
With non-public fairness mainly owning exited the sector, the other class of ownership inside the nursing house sector remains non-public capital. Private capital administration features related to personal equity in exerting management and, additionally, also functions beneath the radar.
“For personal money, the possession buildings are likely to be opaque, so you don’t definitely know how lots of facilities a private funds entity may possibly possess,” Matros mentioned. “Private capital can arrive in distinctive sorts. A ton of situations it’s a household business. And their conditions for investing, how extended they hold (the facility), is very distinct depending on who they are. But like non-public equity, when they buy corporations they have a lot of regulate and effects.”
Also, pretty often when private money buys services, they may well have an affiliated functioning corporation operating for them.
So those are quite distinct types of entities with several differences that can in flip impression the high quality of and situation of the facility.
In the meantime, publicly traded REITs have an solely distinct structure. They generally disclose their services – one thing that researchers of the Wellness Affairs’ staffing study even acknowledged.
“In the qualified nursing sector, we have all triple web leases, so by definition, and so that we really do not violate the REIT guidelines and tax regulations, we never get involved in the operations of operators. We really don’t operate them,” Matros explained. “Now, that does not necessarily mean we won’t give responses or we do not act as a sounding board if an operator is battling, and we have other operators that are in our portfolio, we may perhaps want to share greatest tactics or join them.”
For the duration of thepandemic, when smaller, independently owned nursing homes had been closing their doors, REITs assisted reduce facility closures by furnishing money, Matros said.
“The REITs, more than the last a few-as well as many years, stepped up and restructured leases to assist operators out, gave hire reduction, hire deferrals, functioning funds loans, where by we had been the cash companions,” he stated.
And this resourceful presence of REITs in the space is what is getting missed, he said, reiterating, “And that’s why I do not like having all this lumped alongside one another.”
Compliance with CMS’ new regulations tricky
IHCA’ Willett stated even though transparency is important, as a blanket rule, the proposed disclosure will only insert much more bureaucratic layers to a process that will not have a extensive reaching influence specified that a lot less than 5{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of Iowa households are owned by “private equity” corporations, and most vendors are complying with disclosing these kinds of data now.
“We’re skeptical that the CMS proposal is likely to achieve what it purports to achieve. That is since suppliers are presently needed to report relatively thoroughly, at minimum in Iowa, like possession and financing via a sequence of necessities that, I feel, are Medicare and Medicaid cost reviews,” Willett stated. “We are asking the wide greater part of the place to comply with the new regulations [but] it feels to us like a answer in lookup of a trouble.”
MARCH 8, 2023 (New York City, NY) – Marcum LLP these days introduced its fifth once-a-year benchmarking assessment of nursing residence operations, covering the period of time 2019-2021.
The 2023 Marcum 3-Yr Nursing Home Statistical Evaluation examines an unprecedented and deeply complicated time for the nursing home marketplace formed by the COVID pandemic – prior to, in the course of and soon after. It is supposed to provide a strategic scheduling highway map for the nation’s proficient nursing facilities.
“We imagine COVID-19 has improved the shipping and delivery of healthcare completely, and that these modifications are just setting up to manifest. The ‘great resignation’ has revealed not only the operators but also the regulators that there is ongoing have to have for qualified individuals. This year’s investigation illustrates how COVID-19 has significantly impacted general spending” said Matthew Bavolack, a Marcum advisory principal and nationwide leader of the Firm’s Healthcare Products and services follow.
Vital Findings
This year’s report confirms that the proficient nursing facility (SNF) census has gradually begun to rebound, and although COVID-19 prompted facility closures in the course of the state, desire continues to rise. Persistent nursing employees shortages, on the other hand, continue on to push operating expenses per affected individual day (PPD) greater. In combination with historically lower occupancy and the expiration of COVID reduction funding, gross earnings has not been capable to cover total PPD expenditures, producing web losses for SNFs throughout the nation and in each and every region.
Highlights of the report’s key results include things like the pursuing:

Hourly nursing wages trended upward in all a few several years of the research, growing by 7.63{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} from 2019 to 2020, and 9.87{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} from 2020 to 2021. In 2021, contract nursing charges doubled PPD as compared to pre-pandemic 2019 ranges.

Whole operating expenses improved 9.27{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} nationally from 2020 to 2021, practically double the PPD profits increase of 4.73{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}.

Ordinary occupancy declined the two nationally and regionally. The Midwest (-5.19{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}) and Rocky Mountains (-2.43{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}) registered the greatest and least expensive improvements among 2020 and 2021, while occupancy declined by 4.08{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} on a countrywide basis.

The Medicare payor mix percentage amplified just about every calendar year protected by the research and was 1.27{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} concerning 2020 and 2021. The new Medicare PDPM (Individual Driven Payment Design) that took result on October 1, 2019, produced sizeable increases in average Medicare gross reimbursement for each client working day (PPD).
The once-a-year Marcum 3-12 months Nursing Property Statistical Analysis of extended-term treatment field trends is a yardstick to enable skilled nursing facilities improve both equally operational and economic efficiency and to manual strategic arranging. The study is based mostly on a meticulous critique of the Centre for Medicare and Medicaid Expert services (CMS) databases of Medicare value experiences (Sort 2540-10) submitted annually by the nation’s nursing homes.
Far more than 38,000 Medicare cost stories were being reviewed for the 2019-2021 examination. To illustrate traits and discover any area deviations from the norm, facts are presented the two nationally and regionally. Locations consist of the Midwest, Northeast, Pacific, Southeast, Rocky Mountains, and Southwest.
Information are analyzed in 15 economical and operational categories. These contain:

Occupancy and payor blend

Occupancy percentage by point out

Typical of total price PPD by condition

Normal size of keep

Nursing

Dietary

Laundry

Housekeeping

Typical assistance charge for each client working day

Therapy

Ordinary hourly wage

Staff benefits to total income

Profits analytics

Medicare gross income for each patient day

Balance sheet analytics

Facts reference tables are also provided for each individual of the three many years included by the research.
About Marcum LLP Marcum LLP is a best-rated nationwide accounting and advisory agency focused to assisting entrepreneurial, center-market place businesses and significant web well worth individuals achieve their ambitions. Marcum’s field-targeted techniques offer deep perception and specialized products and services to privately held and publicly registered corporations, and nonprofit and social sector companies. The Firm also provides a comprehensive enhance of technological innovation, wealth management, and executive search and staffing providers. Headquartered in New York Town, Marcum has workplaces in big business enterprise marketplaces across the U.S. and choose global locations. #AskMarcum.
Wes Thompson, administrator of Valley View Residence in the northeastern Montana city of Glasgow, believes the only causes his proficient nursing facility has avoided the destiny of the 11 nursing households that shut in the state past year are community tax levies and luck.
Valley County, with a populace of just about 7,500, handed levies to assist the nursing household amounting to an approximated $300,000 a year for a few many years, commencing this calendar year. And when the Hi-Line Retirement Middle in neighboring Phillips County shut down past year as the covid-19 pandemic introduced extra stressors to the nursing house business, Valley Perspective Residence took in some of its individuals.
Thompson stated he foresees extra nursing property closures on the horizon as their money struggles go on. But lawmakers are trying to decrease that risk as a result of measures that would raise and established expectations for the Medicaid reimbursement fees that nursing homes depend on for their operations.
A research commissioned by the last legislative session identified that Medicaid suppliers in Montana were staying reimbursed at premiums much decreased than the price tag of care. In his two-calendar year state price range proposal prior to lawmakers, Republican Gov. Greg Gianforte has proposed increases to the provider rates that drop limited of the study’s suggestions.
Legislators drafting the state health division price range bundled costs better than the governor’s proposal, but continue to not more than enough for nursing houses to include the price of supplying care. All those premiums are matter to change as the condition spending budget bill goes by means of the months-long legislative approach, although the vast majority-Republican lawmakers so much have turned down Democratic lawmakers’ makes an attempt for total funding.
In a different hard work to tackle the extensive-time period care industry’s extensive-expression viability, a bipartisan monthly bill going by way of Montana’s legislature, Senate Monthly bill 296, aims to revise how nursing properties and assisted living facilities are funded. The monthly bill would direct health officers to take into account inflation, price-of-living adjustments, and the precise fees of companies in placing Medicaid reimbursement premiums.
SB 296, which obtained an preliminary listening to on Feb. 17, has created conflicting viewpoints from authorities in the extensive-phrase care area on whether it does ample to stay away from nursing dwelling closures.
Republican Sen. Becky Beard, the bill’s sponsor, mentioned that despite the fact that the monthly bill comes far too late for the nursing properties that have currently closed, she sees it as shining a light on a trouble that’s not going absent.
“We require to quit the attrition,” Beard mentioned.
Sebastian Martinez Hickey, a investigation assistant at the Financial Plan Institute, a nonprofit imagine tank, stated wages for nursing household workforce had been really lower even ahead of the pandemic. He reported the aim requires to be on elevating Medicaid reimbursement rates beyond inflationary components.
“Increasing Medicaid prices for inflation is likely to have constructive effects, but there’s no way that it is likely to compensate for what we have skilled in the very last many many years,” Martinez Hickey claimed.
Colorado, Illinois, Massachusetts, and North Carolina are between the states that have adopted legislation or laws to maximize nursing house employees wages considering the fact that the pandemic commenced. Michigan, North Carolina, and Ohio adopted will increase or a person-time bonuses.
In Maine, a 2020 review of prolonged-phrase treatment workforce challenges prompt that Medicaid charges should really be large ample to support immediate-care employee wages that total to at the very least 125{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of the least wage, which is $13.80 in that point out. In mix with other goals outlined in the examine, just after a calendar year there had been modest boosts in residential treatment properties and beds, enhanced occupancy premiums, and nods towards stabilization of the immediate-care workforce.
Rose Hughes, executive director of the Montana Health and fitness Care Association, which lobbies on behalf of nursing residences and senior concerns, stated several of the troubles plaguing senior care come down to reimbursement fees. There’s not more than enough revenue to hire workers, and, if there were, wages would even now be as well reduced to bring in employees in a aggressive marketplace, Hughes claimed.
“It’s hoping to deal with systemic troubles that exist in the process so that extended phrase the reimbursement system can be much more stable,” Hughes explained.
The governor’s business mentioned Gianforte has been apparent that Montana requirements to elevate its supplier prices. For senior and lengthy-term treatment, Gianforte’s proposed point out spending budget would raise provider charges to 88{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of the benchmark encouraged by the state-commissioned analyze. Gianforte’s spending budget proposal is a beginning stage for lawmakers, and legislative price range writers have penciled in funding at about 90{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of the benchmark level.
“The governor continues to work with legislators and welcomes their enter on his historic service provider price financial investment,” Gianforte spokesperson Kaitlin Cost stated.
Democratic Rep. Mary Caferro is sponsoring a invoice to fully fund the Medicaid company prices in accordance with the study.
“What we genuinely, truly require is our invoice to pass so that it delivers suppliers present-day with ongoing funding for predictability and balance so they can do the superior operate of caring for people,” Caferro stated at a Feb. 21 press briefing.
But Thompson claimed that even the reimbursement level proposed by the review — $279 for every client, for each day, in comparison with the existing $208 amount — isn’t significant ample to protect Valley Check out Home’s costs. He stated he’s going to have to have a “heart to heart” with the facility’s board to see what can be finished to hold it open up if the area tax levies in combination with the new charge aren’t ample to go over the charge of functions.
David Trost, CEO of St. John’s United, an assisted-residing facility for seniors in Billings, stated the recent reimbursement price is so very low that St. John’s works by using price savings, grants, fundraising income, and other investments to make up the big difference. He reported that though SB 296 seems at elements to go over operating prices, it doesn’t account for other prices, this sort of as repairs and renovations.
“In addition to paying out for current working charges as wished-for by SB 296, we also have to have to glance at funding of capital enhancements via some bank loan system to support nursing services make improvements to existing environments,” Trost said.
Another element of SB 296 seeks to increase assisted-dwelling companies by creating extra federal funding.
Extra dollars could aid decrease or do away with the ready list for assisted-living houses, which now stands at about 175 people today, Hughes explained. That waiting around record not only alerts that some seniors aren’t finding service, but it also benefits in far more men and women becoming despatched to nursing homes when they could not require that level of treatment.
SB 296 would also ensure that income appropriated to nursing homes can be utilised only for nursing houses, and not be readily available for other programs in just the Office of Community Wellbeing and Human Solutions, like dentists, hospitals, or Medicaid enlargement. In accordance to Hughes, in 2021 the nursing residence finances experienced a remainder of $29 million, which was transferred to distinctive packages in the Senior and Long Time period Care division.
If the funding safeguard in SB 296 had been in place at that time, Hughes claimed, there may have been much more revenue to sustain the nursing properties that shut final calendar year.
Keely Larson is the KHN fellow for the UM Legislative News Support, a partnership of the College of Montana College of Journalism, the Montana Newspaper Association, and Kaiser Health and fitness Information. Larson is a graduate scholar in environmental and natural methods journalism at the University of Montana.
