This past week Kaiser Health News published an article titled “The Coming Nursing Home Shortage” It recited the usual and well known statistics about the rapidly aging baby boomer generation. AARP then excerpted that article with one of their own. “Strange Math: More Seniors But Fewer Nursing Homes”. I find these articles to be annoyingly frustrating because they take a few facts and paint them in away to create alarm then ignore other facts that provide balance. Here is what is wrong with their thinking:
- While it is true the number of nursing homes have shrunk by almost 9% from 2000 – 2009 in order to have a meaningful picture, we need to know the change in number of available beds. I did a web search and the data was not readily available (or at least I couldn’t find it)
- There was zero data that shows the average length of stay trend.
- There are clearly some pockets that have a real skilled nursing bed shortage, but overall, the occupancy rate for skilled nursing is well below 90%. This means there is not a real shortage. One might even argue, that the reduction in number of facilities will improve the health of the industry and as an extension, the care for seniors.
- The biggest incongruity I see is that several times a month I get a call or an email from organizations or individuals that have money burning a hole in their pocket wanting to purchase nursing homes.
- Recently I was talking to a friend who’s family owns a facility they are getting ready to sell. They have received two dozen offers on the building and the offered prices were stratospheric.
- While as one of the articles points out, no new nursing homes have been built in California (a fact I have not verified) I am aware of a number of facilities across the country that are under construction or in development.
More Choices
One of the reasons the crisis is overstated is that seniors and their families have more choices:
- Seniors with complex medical and ADL needs are staying at home longer using Medicare funded home health and hospice care.
- Assisted living communities have figured out how to keep medically frail residents longer by increasing staffing, hiring licensed nurses and partnering with home health agencies.
Are we staring down the barrel at a real problem? Maybe, but the implication of these articles is that the solution revolves around putting more money into the existing system. I believe there is already enough money in the system, but that we need to take a fresh look at how we spend that money, something I will tackle next week. Steve Moran ++++++++++++++
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Finally: If you know anyone who is looking at emergency call systems I would appreciate the opportunity to talk with them about Vigil Health Solutions.
The skilled nursing model is outdated and for the most part boomers are intent on not ever ending up in skilled nursing. As someone in the industry I have yet to see a skilled nursing facility I would want to live in. The need for innovation and new acceptable alternatives is much greater than the need for more of the same.
Kathy I agree with all your comments please contact me on facebook at JanettaBouman or email me I am interested in solutions my mom is in a nursing home now we are in a nighmare for her.
Hi Kathy:
That is one of the things I will address next week. Maybe you should be writing that blog for me.
Steve
I agree with the comment about the orientation of nursing homes or assisted living facilities, using the “what we will do to the patient…” in daily life rather thab having it resident-oriented. There are enough great models for elder residents but many would rather use them for investment. The comment of a person calling you with money to invest is scary, but all too true. what was your comment? Educational I hope.
Two important possibilities now being done; 1) better training. we know a lot more about gerontology issues, but only a too small group seems to know about them. Persons especially lleaders such as administrators need to know and emphasize continual learning. 2) Technology. advancements. Technology for helping elderly live longer but better quality lives now exists in many formats, such as personal communication, but how much of this is used in residential facilities. I have even seen a computerized box on the wall of a leading facility in wwhich nurses and attendants entered information for administrative purposes. The residents, however, had nothing, most just sitting around doing nothing or staying in bed. One enterprising resident (four in her room) did have an older smartphone, so at least she was able to communicate with her family, but the others just sat slept or watched television. This doesn’t have to be so. The technology is available. The public needs to protest and we need persons to see how they can help ellderly rather than just find a real estate investment.
Editor, Community Informatics journal issue on technology and older persons, Director, Center for technology andd Mental Health of Older Persons.
Dr. Gene
You make some great points. There are some solutions, I will offer some suggestions next week and would be interested in your thoughts about those as well.
Steve
From LinkedIn Groups
This is my field, and here’s what I see in Phoenix…
SNFs are not full, if I had to give an average, I would say they are in general at about 80%, maybe a little less in the summer, but the seasonal swings are not as wide as they used to be.
The only new SNFs I am aware of are small, high-end, Medicare only buildings.
The entire continuum of care has shifted acuity–those who used to be in the the hospital are now in SNFs, those who used to be in SNFs are now in ALs, and those who used to be in ALs are now being cared for at home or in lower costs group homes.
Length of stay in SNFs is decreasing. It depends on the facility, and the contracts the facility has, but I have seen avg LOS anywhere from 9 days to 21. The 9 days is a facility which is specifically set up as a feeder for longer rehab stays. I would say 15-18 days is more common. That’s a far cry from the 30-45 days we saw a decade ago.
Finally, although there is a lot of press about Medicare cuts, and capitated stays, well-run SNFs can still make a decent profit. Case mix is key, and unfortunately many Administrators (or their corporate bosses) do not understand it. Heads in the bed is a recipe for disaster, as counter-intuitive as that seems.
Posted by Louise Johnson, MBA, LNHA
I agree with you Louise- the same is true out here in Southern California. The occupancy rate is rarely close to 100%, and many of the residents now have HMO insurance rather than Medicare. In fact, I read that 70% of older adults in Orange County have HMO rather than Medicare.
I’ve worked in the senior industry for many years, for several different SNF chains. This is what I observed:
– Most people who work with older adults have passion and compassion for them
– Some of the companies have great compassion for providing great care for older adults
– Some only care about the head in the bed
– There is a huge need for ongoing training for staff in these facilities
– 50-80% of older adults in LTC have dementia, and there is not nearly enough training. For example, the CNAs in California are mandated to have 5 hours of training per year. In my observation, that is not enough
– There is a huge need for person-centered care training and implementation, but that is not regulated by any of the state or federal agencies. They just choose some part of that, and survey that particular issue, i.e. reducing anti-psychotic drugs as an off label use for residents with dementia. But, again, if the staff are not trained to deal effectively with the behavior issues that they are trying to stop, reducing the drugs and not having an alternative will not be effective.
From LinkedIn Groups
Reading this article and worked in Nursing Home Administration what about different types of housing for dementia residents who are not frail? What about different community alternatives for residents who suffer from psychiatric disorders primarily and need supported living? Also not mentioned are the Medicaid Waivers available to support seniors in their own homes: The Nursing Home Transition and Diversion Waiver (NHTD) and Traumatic Brain Injury (TBI) Waivers being utilized in many states now? There can be and are more alternatives to nursing facilities being utilized! Laurie Biederman, MPA, LNHA
Posted by Laurie Biederman
Laurie- I SO agree with you! In my many years of working in SNFs, there is a huge lack of understanding on how to deal effectively with people who have dementia, as well as people with psychiatric issues. Training is the key to this, but sometimes there are facilities that do not invest in training the staff, and sometimes they are worried more about the bottom line (making money) rather than providing the care that residents need.
From LinkedIn Groups:
I have worked in the nursing home industry for five years. There is a shortage of workers and the problem is excaberated by turnover of staff.
Posted by Cassandra Hill
From LinkedIn Groups
The negativity published by the media is typical for them. Unfortunately, this is a subject that makes many fearful which expounds the drama.
Posted by Amy Bair
In my opinion, people are tired of the traditional nursing home model. Our seniors are no longer willing to accept the institutional feel that many of them have. Seniors want options and choices in beautiful environments. The challenge is finding a balance for the under-served Medicaid population, while appealing to the private pay. A soltution is smaller 10-12 bed facilities that are home-like and can be quickly and easily changed to accommodate a variety of needs. My company is doing this. Trinity Innovative Group, LLC. Contact me at 970-903-0574. Trisha Kellogg
Could you send me information on your 10-12 model?
Thanks,
MarY A. Lee R.N. B.S.N.
From LinkedIn Groups
I believe that the US will be facing a major social crisis as the over age 85 group grows, we simply lack the caregiving manpower, facilities and long term care programs to grapple with this. I was a homecare nurse for 29 years and the homecare Medicare benefit is a stop gap at best. The nation will have large numbers of seniors with limitations in activities of daily living with very limited resources to tackle their care needs. We are saving people beyond our desire to provide for them.
Posted by Diann Martin
From LinkedIn Groups
I feel the “Gloom and Doom” for seniors is when they are in-between being totally independent and ready for a Nursing home. The interrum where they need help with homemaker/companion type things is where most seniors are in a bind. The only funding that they can get is either thru a Long Term Care Policy (which most pay only after 100 days) and paying out of pocket.
Seniors could prolong going to that dreaded Nursing Home a whole lot longer if they had assistance with paying for the Non-Medical Care. Surely care in their own home is far less expensive than in a Nursing Home Facility?
Posted by Jackie Omicioli
Federal and state gov. invest 1.5 trillion dollars in long term care. When they increase the dollars more expanion when they decrease dollars contraction takes hold…. The notion of need or increase poulation creates expansion of beds is false! Investors look to see if there is funding first and build. The only reason we have long term care beds is the medicaid and medicare program. Before the prorgrams there was no long term care facilities…. Investors will expand based on funding not need… Remember 93% of elderly do not use longterm care beds. The CON programs restrict new construction in most states because they do not want to fund. Investors will not build even though need is overwhelming…
The comments I have read all make valid points from different perspectives. I still see a need for long-term care, especially for those elderly folks who are without family and friends. Even with a support system in place, e.g., a home health aide, some residents are too lonely or afraid to be at home and assisted living may not be a possibility due to finances. Elders may well run out of money and become medicaid recipients. Long term-care may be helpful but in some cases, long-term care can be impersonal also. Home-like environments are slowly coming along, but there are many variables that make a home-like environment, e.g., staff education, commitment, and compassion. A long-term care facility may have a great appearance and offer wi-fi, but are the residents content?
Yes, Kathy is right. Boomers are determined not to end up in SNFs and with good reason. I founded Angel House because my own dad feared death less than he feared a nursing home.
We do need to concentrate on Assisted Living as Steve said, and on how best to spend the existing money. However, there is a move by Florida for example, to “crack down” on ALF’s, making it harder to provide quality care at a rate people can afford. This is in large part motivated by the fact that nursing homes Tend to be Large, and thus are Perceived as major employers, so they get more Help – they Lobby government, make noise and are quoted in the media as a “safer” alternative for seniors…
After all, they have doctors and nurses, and the typical 6-bed facility in FL is run by a single mom or other entrepreneur who is according to this profit-motivated and sensationalist view, woefully ill-prepared for the job. I have to disagree in the strongest terms with that biased assessment and propaganda.
Steve,
Many points here can be discussed in terms of shifting reliance upon in home and Assisted Living as—at least so far—more than offsetting the assumed increase demand in SNFs. I will, however, only highlight one: The trend in moving Medicaid funds from historically only SNF to Assisted Living. CiminoCare is proud to be on the relative ground floor on the emerging California Assisted Living Waiver Program, of which Federal Waiver Program over 30 plus other states have preceded California in utilizing. Under this program, Medicaid (Medi-Cal, in my state) will now open up Assisted Living to people who would have otherwise only been in a SNF. Fortunately (for SNFs) the program in California is being implemented very carefully and slowly, only in limited counties. This should give the SNFs time to adjust to this new “competition” so to speak.
Mark
Steve,
And by the way, I recently witnessed a 125-bed SNF simply shut down, not because of census challenges, but because it was predominantly a Medi-Cal facility and operating expenses had exceeded revenue for several years.
Mark
Louise:
Those are some great observations. I was recently in the Phoenix area and met we some developers/operators who are doing small high end buildings. You are right case mix is everything.
Steve
Trisha I like what you are describing I would interested in talking to you about how you are managing this. . . . sounds like another blog article.
Steve
Bruce this is a great observation. It sort of makes you wonder what the would would look like for seniors if there were no Federal dollars available. First blush would suggest it would be terrible . . . but maybe that is not really true.
Steve
Hi Janet:
You make some great points.
I do think there is a place for skilled nursing and while I have been in some pretty terrible SNF’s I have also been in some really great places, where the physical plant was nice and the staff really cared.
No matter how nice, Skilled nursing is never going to be a lifestyle choice, but for many of the reasons you described it is a necessary and important option.
Steve
Mark you are right about the waiver program being a great way to reduce costs and improve quality of life.
That is interesting, though I will tell you that there are a number of SNF’s that are primarily Medi-Cal and are managing to turn a profit. They tend to be facilities, that have been held by the same owner for a long time and have little or no debt. It would be impossible to build a new Medi-Cal only building in California and and manage to break even.
Steve
From LinkedIn Groups
Diann, well said. Not only do we lack in caregiver manpower, facilities, and programs, their is a poor understanding and utilization of the services that do exist that would benefit and help our seniors age in place.
Posted by Jo Fasen
From LinkedIn Groups
Case mix is not only the key to profitable SNF. Medicare will spend more money despite the cuts. Hospital days are reducing and many of those responsibilities are shifting to SNF. The labor cost is going up also. SNF business model is going through challenges and competition with newer resort like SNF. There are many challenges ahead of us in this industry.
Posted by Gary Kumar, LNHA; MBA
From LinkedIn Groups
http://wp.me/p1NmYk-6L
Also having worked in the industry (Assisted Living) for five years, I certainly agree with that staffing shortages and employee turnover are a huge concern. I see this issue becoming increasingly prevalent within facilities (such as my own) which feature special Alzheimer’s and Dementia care units; it has become almost impossible to satisfy the demand for individuals possessing that “special touch” which is absolutely essential in caring for Seniors with memory impairments. The hiring process, however, seems a bit of a catch-22, so to speak. Companies want to hire individuals with college degrees and knowledge in the field, but the pay rate for direct care providers is rather low…therefore, those individuals with degrees and specialized skills seek other employment, and many of the individuals willing to work for $10/hr (ball park base rate in this area) are not able to make the necessary emotional connection with their work.
Therefore, if the nursing home economy has sufficient funding and is capable of physical expansion, perhaps it would be wise to direct more funding towards increasing wages for front-line staff….we could build a nursing home on every block from here to China, but without employees capable of providing exceptional service, our managed care facilities will likely fall short when compared with the increasing number of alternative options like home companion care.
Posted by erica taylor
From LinkedIn Groups
Senior housing options that exist will probably all see diminished patronage in the years to come. It looks like nursing homes will retain their relevance as long as they are well- positioned for service to high acuity individuals. However, the senior co-housing model is catching fire around of the country. I think we will see this model brought to life for all income levels of consumers. In my opinion, this will change the face of all other services outside of the nursing home realm.
Posted by Gayle Funk
This is exactly what I have been trying to get across some of the closed minded corporate folks. The traditional nursing home model is out dated. Having a SNF / Nursing home is ridiculous; it’s 2012 for goodness sakes. It is very emotional for a family to accept not having a loved one at home, and to have to go do rehab at a nursing home is crazy. No matter how you sell it…it’s a nursing home with rehab. As for the under-served Medicaid population, people, that can walk, talk, and be participates in activities are being lump in with those who are bed bound, total feed assistant and close to end of life just because they are Medicaid. There are plenty of people that need a place to live with minimal health issuses that qualify for Medicaid and would benefit from a facility designed to help them out. I know that if I owned a place that took care of Medicaid only residents that are functional I could make it turn a profit and it would stay full with a waiting list.
Hi Kathy;
You are absolutely right. But, there is a model that is so radical, so improved, so vastly superior to anything else in the industry, that you or I would want to live in this place. It is that cool! Baby boomers will accpet nothing less than that. The old nursing home model is dead, and needs to be buried. The sooner the better.
The name of the solution is: “Senica”. We have the plan in place ready to go. We just need some additional committed leadership team members and the funding to launch.
I am interested in your project, have funding available and request more information. Adam Smith: [email protected], 870-275-5275
Thanks
Dennis,
We need to talk!!! I am on the same page with creating afforable, sustainable, and adorable villages here in the US! But it looks like you are one steop ahead of me. I see these as sort of the golden gal model (from the TV show) where we take care of each other and our community as much as posssible. We need a purposeful life and I firmly believe residents will degress to the level of care they recieve.
I am wanting to build these moduarly and provide a new manufacturig base to my state which desperately needs some revival. Here in Michigan we have the infastructure to get these across the country. They would be affordable like I said…but the key here is and it is wht I bring to the table is that they would be adorable. Oozing with fun, creatiity and orginality.
I can’t go on because I get preaching and can not stop but would love to talk and I am so excited about what you are doing!!!!
I am very interested in this project Senia I have looked at the Green House but they need to get community funds. My mom is in a terrible nursing home now. please contact me on the development I am on facebook at Janetta Bouman
or email me please
From LinkedIn Groups
I think that the cuts to Medicaid and state budget cuts are really straining the nursing home systems who work on a fairly low margin. They have labor intensive businesses and they may have to go to soliciting volunteers to make up the difference or training family members to contribute. Other countries have had to require families to contribute more.
Posted by Diane Keefe
From LinkedIn Groups
The options available to seniors have rapidly expanded. The only accurate picture is one painted with all senior care resources. Perhaps the crisis will arrive when all of us baby boomers, who have not saved enough for the 25 predicted years of retirement, need state-funded care. Nursing homes developed out of the need for financially efficient care delivery for seniors.
Posted by Karolee Alexander
From LinkedIn Groups
You know my parents are part of the “boomers” I guess my father passing the one blessing is not having to see him put into a nursing home. My husband is MSW and works for Hospice and gets to see the grievances and alot of the times it is not the facility it is the caretakers aka nurses and staff. We need people who care to over see these homes and make sure their staff cares as well. If you chose to work in this particular type of facility you better be prepared and want to from your heart.
Posted by Sasha Hartzog
From LinkedIn Groups
Simply, yes. The drastic cuts to the RUGs rates starting Q4 of 2011 were and continue to be crippling. They hit all catagories and some to the point where just the cost of rehab labor exceeds the reimbursement rate, at least in my neck of the woods. Combine that with the change in the regs which require more staff time to achieve and document the appropriateness of the catagories and you have a very volatile situation. And let us not forget that unless our lawmakers make some changes there is another round of deep Medicare cuts waiting in 2013. We need not even to go into the Medicaid cuts in each state.
This country’s health care system, especially Medicare and Medicaid, is woefully unprepared for the tidal wave of baby boomers cresting over it. So, yes, the industry is in deep trouble and we in it should know it, express it and require our elected officials to do something about it.
Posted by Jeff Philbrick
Unfortunately many nursing homes are neither, homes nor nursing facilities. One nurse for Many of their residents need a home, but not 24 hour nursing care availability. Dementia is the elephant in the rooms of many nursing homes. The medical model doesn’t work for people living with the symptoms of dementia at home, nor does it work in nursing homes. Caring for these folks (I am soon to be one of them) requires a stigma free appreciation of who these folks are, what they need/want. This is what is lacking in many, many nursing homes. Setting up an Alzheimer’s wing doesn’t make it the home of humanizing dementia care. Paternalism rules, the long good bye rules, fading away, dieing twice, losing your soul, sufferers, shells of themselves – these stigmas rule. The result being that style rules over substance and staff ratios. Until staff ratios are dramatically reduced, and the reason that this is a necessity is accepted by the entire staff/management, care will fail to meet the real needs of those who are being cared for.
ROI’s are much too high, placing budget constraints on everyone, and all these constraints add up to failed care. Moving the chairs around in a nursing home does not change the fact it is one of a fleet of Titantic like residences.
Richard