Residential care at a crossroads

WORCESTER -- Christopher House of Worcester is in relatively good shape for a nursing home. Residents -- some who have lived there for years -- receive attentive care and take part in activities such as the ice cream social several were enjoying on Wednesday. The 24-year-old building is in comfortable condition.

"Nobody wants to go to a nursing home, but sometimes people really thrive here," said Sandra Mahoney, administrator of the nonprofit Christopher House.

Mahoney said it's a constant frustration finding money to adequately pay direct care staff to maintain high quality care and to invest in the physical plant.

That's because Medicaid, the state-administered program that pays for long-term care for people with low income, effectively limits nursing homes' revenue through payment based on costs that are several years old. About two-thirds of nursing home residents, nearly 30,000 frail elders statewide, rely on Medicaid to pay for their care.

Nearly three-quarters, 73%, of Christopher House residents are covered by Medicaid.

Nursing home advocates are calling on legislators to increase payments to nursing homes in the state's fiscal 2021 budget and to pass legislation that will stabilize the financial condition of nursing homes. Such action is needed, they say, to eliminate the continual shortfall in Medicaid reimbursement, which amounts now to $38 per day per resident, or $300 million annually statewide.

With those kinds of shortfalls, said Mahoney and Tara M. Gregorio, president of Massachusetts Senior Care Association, an industry trade group, it's hard to dig out of a financial hole and frail elders are at risk of losing their care safety net as facilities close.

Care for residents at Christopher House who are not covered by Medicaid is paid for by Medicare, commercial insurance or HMOs, or private pay by individuals. But these more remunerative payers generally cover only short-term stays in the facility's rehabilitation unit after a person has been discharged from a hospital or other medical facility.

"That's how we pay our bills," Mahoney said. "It's the short-term care."

Four nursing homes in Worcester County weren't able to keep afloat over the past two years, industry representatives said. Blackstone Nursing Home and TCU at Webster closed in 2018; Royal Spring Valley in Worcester and Royal Sandalwood Center in Oxford closed in 2019. A total of 213 residents were displaced.

Across the state, 34 skilled nursing facilities have closed since 2018, and advocates said 95 are at risk of closure, which would displace 7,500 residents.

Half of the nursing homes in the state were operating at a 3.9% loss in 2017, compared to a 0.8% operating loss in 2013.

Staffing is the biggest expense for nursing homes, comprising typically 75% of facilities' budgets.

Certified nursing assistants, or CNAs, provide much of the care. They earn on average $13 an hour, according to Massachusetts Senior Care Association. Mahoney said CNAs can make $17 an hour for a similar job at a hospital, not to mention retail and restaurant jobs.

Statewide, the vacancy rate at nursing homes for CNAs is 17%, compared with the overall unemployment rate of 2.9%, the association reported. Nearly one in four facilities has or considered limiting admissions because of lack of staff.

"There were years in which my staff got no raises," Mahoney said about the impact of low Medicaid reimbursement.

Christopher House has worked out partnerships with several schools, including Worcester public schools, to provide a clinical training site for CNAs, and has focused on improving its wage scale as a way to attract and retain staff.

For many in the nursing home industry, though, "Right now it's more of a poaching strategy, and nobody wins when we're poaching," Gregorio said.

Plus, Mahoney said, being a CNA isn't for everyone. "It requires somebody who has compassion. It requires somebody who could do a physically challenging job," Mahoney said. "It's frustrating."

The state has actually decreased Medicaid spending on nursing home care to $1.3 billion in 2019 from a five-year high of $1.4 billion in 2017, Gregorio said. During the same time, the proportion of facilities that were free of deficiencies in Medicare and Medicaid surveys dropped to 5% from 11%, while CNA vacancies have increased.

Mass. Senior Care's "Fix-it" state budget solution calls for $150 million, half of which would be reimbursed by the federal government, to prop up quality nursing home care for frail elders.

The proposal includes updating the base year for nursing home cost reimbursement to 2018, from the current 2014 level, and adjusting those costs to fiscal 2021 dollars using the inflation factor applied by the federal government to Medicare payments. The budget proposal includes $9 million to recognize Medicaid's share of the state minimum wage increase.

Two bills have also been filed to update in statute Medicaid nursing home payment rules; recognize new state employer mandates via a pass-through; and establish workforce initiatives. These bills, S. 352, presented by state Sen. President Emerita Harriette L. Chandler, D-Worcester, and H. 610, presented by state Rep. Thomas A. Golden Jr., D-Lowell, are expected to be reported by the Committee on Elder Affairs by the end of March.

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