Nursing Home & Assisted Living Staffing Challenges

A recent Maine Monitor article highlights the closures of birthing units and nursing homes, health care organizations at each end of the life course. The reasons for these closures are a complex mix of public policy, demographic shifts, and long-standing system and institutional factors that marginalize women and older people. 

The public policy factors include low Medicaid reimbursement and pressures to increase staffing requirements. Medicaid (in Maine it is called MaineCare) pays for approximately two-thirds of Maine's nursing residents. This means that nursing home operators rely primarily on the established amount that the State of Maine reimburses for operational costs -- and this amount is inadequate to fully cover actual costs and pay staff a living wage. While Maine enacted legislation to increase the reimbursement for direct care labor to 125% of the state minimum wage, the Maine Center for Economic Policy determined this was insufficient to compete with other business sectors. Direct care work is physically and emotionally challenging compared to other work that is compensated at similar rates or higher. Many staff leave long-term care work and take jobs in less demanding sectors. 
​
The demographic shifts have been playing out for decades. We are living longer, the baby boomers are aging into needing long-term care, and the birth rates have been dropping steadily. In addition, Maine's population growth was flat from 2011 through 2019. While the pandemic generated in-migration into the state, the lack of affordable housing has put downward pressure on additional growth. 

The primary reason that Maine - and national - nursing homes and assisted living homes resisted staffing increases proposed by the federal Centers for Medicare & Medicaid Services (CMS) and Maine's Office of Aging and Disability Services (OADS) was because operators are unable to fill current staffing needs, nevermind mandated increases in staffing. And increasing pay, as noted above, cannot be the answer. Many private pay assisted living organizations, like HillHouse, are unable to continue raising rates to cover increased wages without experiencing declines in prospective residents who can afford higher rates. It is a difficult, no-win situation, that the public often fails to completely understand given the policy complexity and the opaque complexity of the U.S. healthcare system.

Finally, the long-term care system in this country was founded on a medical model that deprived residents of choice and autonomy in favor of institutional practices with established times for daily care and daily activities. It reinforced stereotypes that older people are frail, dependent, and do not need or want person-centered choices. Over the past two decades, the long-term care sector has worked hard to implement more person-centered practices, though these efforts are often hampered by staff shortages and high operational costs such as wages, health insurance benefits, and rising food costs. Our deeply ageist society has overlooked the needs and preferences of people living in nursing homes and assisted living communities. We have failed to deliver a long-term care system that is adequately funded so that operators are able to provide the quality of care that most of us desperately want to provide. Middle class families that do not qualify for Medicaid-funding nursing home care but are insufficiently wealthy to pay privately for care (upwards of $10,000 per month) are left to fend for themselves as they near end of life and their physical and cognitive abilities change. This places an inordinate burden on family caregivers. 

There are no easy solutions. I offer this post as a way to better understand the external pressures on long-term care organizations. They are working within a larger, very constrained system that does not often allow for delivering the care that we all would want as we age.