Researchers now wonder after a new study whether the nation’s nursing homes can adequately meet the demand of caring for those more complex patients.

“We found that LTCH closures affected some in-hospital and discharge practices in unintended ways. For example, at hospitals that depended on a closing LTCH, people receiving prolonged mechanical ventilation were discharged to skilled nursing facilities more often,” said Anica Law, MD, assistant professor of medicine at Boston University Medical School and corresponding author of research published in JAMA Network Open Tuesday.

“These are patients that CMS reform intended to keep at LTCHs, and it’s not known if skilled nursing facilities are as well-equipped to handle the complexities of long-term mechanical ventilation,” Law added.

Long-term care hospitals were created in the 1980s as a carveout from the acute care hospital Prospective Payment System. Because of longer lengths of stay compared with regular hospitals, the Centers for Medicare & Medicaid Services reimbursed the LTCHs at higher rates, and their numbers grew rapidly in the 2000s.

But since 2005, CMS has implemented several payment changes reforms meant to slow development of new facilities and limit spending on them. The authors cited the Pathway for Sustainable Growth Rate Reform Act of 2013 as a critical turn because it limited higher reimbursement rates for patients requiring more complex care, including those needing prolonged mechanical ventilation. Instead of just limiting admissions, however, many LTCHs — 20% according to this study — closed all together.

In some locations, that decreased length of stay at acute-care hospitals for patients with tracheostomies between 2011 and 2019, likely because the challenges of finding a LTCH placement had been even more difficult than finding placements in more numerous nursing homes.

The study examined conditions before the advent of skilled nursing’s Patient Driven Payment Model in late 2019; it’s unclear whether new pay adjustments intended to support care for nursing home patients with ventilator or trach needs would have improved access or once again driven up Medicare costs.

But even boosted by care they provided to severely ill COVID patients during the public health emergency, some ventilator units have closed in the last few years, citing increasing costs and insufficient reimbursement. The planned closure of one such facility in Pennsylvania last year was expected to leave the entire state with just three similar specialty providers.

Law and colleagues from Boston University, Beth Israel Deaconess Medical Center in Boston and the University of Pittsburgh reported that tracheostomies had been the strongest factor associated with LTCH use over SNF use. As fewer LTCHs are available in many markets, that raises key questions about quality of care provided to those kinds of patients when they must seek long-term support elsewhere.

“Like LTCHs, SNFs are known to vary in quality and capability of caring for complex patients,” the researchers wrote. “The ability of SNFs in the US to care for patients receiving or recovering from prolonged MV [mechanical ventilation] in the US is understudied. Our findings suggest that discharge of a subset of patients recovering from prolonged MV (eg, after weaning or while receiving stable MV) to SNFs may result in similar mortality outcomes with lower spending compared with LTCHs, although functional outcomes, complication rates, and other patient-centered outcomes remain unclear and require further study.”

Another key finding that researchers were unable to fully understand was an increased adoption of do-not-resuscitate orders among patients with trachs at hospitals with fewer LTCH options.

“The plasticity of end-of-life decisions to changes in available postacute resources has not been clearly demonstrated. Whether increased do-not-resuscitate orders after LTCH closure represent improved attainment of goal-concordant care or are the result of institutional pressure resulting from changing discharge options remains unclear,” they wrote.

“It is possible that transitions in goals of care occur gradually over a longer period among patients who are more severely ill, and tracheostomy decisions may occur before patients and families are ready to transition goals or the tracheostomy may be viewed by patients and families as part of a time-limited trial that informs later goals-of-care discussions,” they added.

The Jamestown, NY, skilled nursing facility has been struggling with the same string of problems facing other rural facilities, including Medicaid reimbursement rates that don’t adequately meet the facility’s expenses and a new staffing rule established earlier this year in New York. 

“They’re suffering the same flight of funding shortfalls that most of the facilities in upstate New York are sharing,” Keith Chambery, executive director of New York Provider’s Alliance, told McKnight’s Long-Term Care News. “Along with regulatory staffing challenges, the shortfall in funding has caused facilities to stretch to the limit. This facility got there and saw the writing on the wall.”

New York’s new staffing rules require that facilities provide 3.5 hours of care per resident per day from nurses and nurse assistants. A majority of New York facilities, especially those in rural areas, have struggled to meet this regulatory benchmark, which took effect in April. 

The general shortage of available workers is also exacerbated by the need to increase wages.

“​​About 70% of facilities in New York can’t meet that [regulatory] standard,” Chambery told McKnight’s, “due to the fact that skilled nursing personnel are not available and that the wages for nursing assistants need to be raised to be competitive with other establishments, even outside of the healthcare field.”

Chambery also highlighted that funding challenges have only worsened in the wake of the pandemic. 

“During COVID, facilities were helped out with a lot of COVID funding both from the state and from the federal government, and that helped them continue to be competitive with their wages throughout the pandemic,” said Chambery. “Now that all funding has dried up.”

A historic facility closes

Lutheran Home has been open since 1886 and currently serves 49 residents with a staff of 106. 

The facility has a 148-bed capacity. In statements to local news, Lutheran confirmed that their occupancy rate was around 30% below what they needed to maintain profitability.

“Lutheran is currently working with the New York State Department of Health to ensure that this transition is as smooth as possible,” said Tom Holt, president and CEO of Lutheran. “Our top priority is to work with every resident, their families and our valued employees, to secure new housing options, care and job placement.”

The skilled nursing facility plans to continue operating until Jan. 2 as its residents find new homes. 

Nursing homes in surrounding communities have stepped in to assist Lutheran Home and its residents.

“What some of our members have been doing is to help [Lutheran Home] out in terms of placing their patients and helping them place their employees,” Chambery told McKnight’s.

“It’s probably as important to talk about the ripple effects for the patients and the families in the area,” he continued. “They’ll have to leave a place where they’ve been comfortable and well-cared-for to go to another place that might not be of their choosing.”

Problems for rural facilities

Lutheran Home is not the first upstate New York nursing home to shutter due to these challenges — 10 others have closed within the last three years, according to a press release from NYPA. 

“The unfortunate truth is that Medicaid reimbursement rates for upstate facilities are woefully inadequate to cover the true costs of care,” Chambery stated in the press release. 

NYPA cited a 2022 Medicare cost report that showed, on average, upstate facilities were losing $2.1 million per year.

“A perfect storm of reimbursement disparity, demographics, case mix and occupancy has caused facilities like the Lutheran Home facility to make difficult decisions that affect access to care, especially in small towns where choices are limited,” said Chambery.

He also stressed the need for increased funding to avoid the risk of more closures and the cascading effects they would have on rural communities. 

To match the needs of thinly stretched upstate facilities, Chambery said, “the first step is going to be to get meaningful reimbursement reform in the Medicaid system to facilities in upstate New York — there’s no way around it. Losing $2 million a year is not sustainable for any business.”

Countryside Health Care Center in Sioux City is the most recent to join the unfortunate ranks. Its leaders announced Thursday that the 101-bed facility will close due to financial pressures. That brings to 26 the number of nursing homes the state has lost since June 2022, according to the Iowa Capital Dispatch. The state has lost 29 facilities since 2020.

In an appearance Friday on the Iowa PBS program Iowa Press, the head of the Iowa Health Care Association said that workforce shortages remain the primary cause for closures, particularly for rural nursing homes. 

“The action of the Iowa Legislature this session — pertaining both in terms of a number of policy priorities that assisted facilities as well as appropriations — has helped to slow that down,” association President and CEO Brent Willett said. “But we still have a long road ahead of us.”

The state put into a place a certificate of need moratorium that took effect July 1 and will last for at least 12 months. The law allows the departments of Health and Human Services and Inspections and Appeals to extend the moratorium by six-month increments for no more than 36 months through June 30, 2026. The moratorium can be waived if there is a specialized need or if the average occupancy of all license beds located within a county or contiguous counties exceed 85% occupancy. 

In May, lawmakers approved a $15 million increase in Medicaid rates. Both Willett and Shannon Strickler, president and CEO of LeadingAge Iowa, said the funding would help but is not a panacea.

“It does not address the availability of qualified staff across the state, particularly in rural areas,” Strickler told McKnight’s Long-Term Care News on Friday. “The most significant threat to the long-term care and aging services sector is the availability of a qualified workforce.” 

In April, Iowa Workforce Development announced $13.5 million in grants through its Health Careers Registered Apprenticeship Program for 21 healthcare and education entities to support 1,463 apprentices. The pool for potential nursing home workers could grow by more than 300 due to the grants, McKnight’s Long-Term Care News reported.

At the same time lawmakers increased the Medicaid rates, they approved stricter reporting for providers looking to enter the state that includes information about the ownership structure, including listing all individuals with decision-making authority and their regulatory track record in other states. The Legislature also passed tort reform that Willett described in a LinkedIn post as crucial to addressing a “crisis of access to long-term care.”

“Generational tort reform to kick attorneys who make a living out of putting nursing homes out of business out of our state,” was his observation.

Despite the flurry of legislative wins, the state’s nursing homes continue to struggle. On the PBS program, Willett said that wages have increased by 32% generally, with certified nurse aids seeing a more than 36% increase. Meanwhile, the average nursing home lost $50.19 per patient per day on resident care in 2021 compared to $14.46 per day in 2019. 

Meanwhile, operating costs per resident per day grew by 15% between 2019 and 2021 while revenues for the same period grew by just 6.7%, according to information from LeadingAge Iowa provided to McKnight’s in February. The organization also said that there were more than 5,800 direct care positions open across the state and 1,238 beds had been taken offline since November 2022. 

“Communities unable to find, hire and retain their own staff are forced to rely on staffing agencies, which is not a financially sustainable solution, or halt admissions,” Strickler said. “Additionally, staffing agencies themselves sometimes struggle to find available personnel to help. That’s why the workforce crisis will require a multifaceted approach at the state and federal level, including strategies that help attract people to work in aging services, sustainable revenue streams and legal immigration to boost the amount of available workers.”

Looming over all of this is a federal staffing mandate that the Centers for Medicare & Medicare Services has yet to release. Sector observers expect the agency to require around 4.1 direct care hours per patient per day, which has met with strenuous pushback from providers and their advocates. 

“Every single nursing home in Iowa would hire more staff if that staff were available,” Willett said. “A federal arbitrary mandate … would require, under penalty of ruinous fines, the mandated hiring of people who do not exist to care for people who do. … We should be talking about housing tax credits for direct care workers, childcare assistance, telemedicine expansion. 

“Instead, we are going down the path of an arbitrary mandate which will not create another single worker, but simply penalize employers who are desperately seeking workers today.”

According to the American Health Care Association and National Center for Assisted Living, an estimated 400 nursing homes were projected to close by the end of 2022. More are expected to shut their doors in 2023. Those in the industry know very well how pandemic-fueled staffing shortages and dwindling reimbursements for care have combined to place inordinate pressures on even the best-managed facilities, but the decision to close or sell can still come as a significant shock to the outside world. 

Breaking the news to residents, families, staff, suppliers and local communities requires careful messaging and precise timing to help preserve the reputation of organizations forced to make hard decisions that often run directly counter to their mission and values. Although not crises per se, these are high-stakes situations that require the same approach to communications that sudden, unexpected and reputation-threatening events demand. 

In other words, they should be announced using a comprehensive communication strategy designed to maintain support among stakeholders – including those who may be facing unemployment or the need to find new housing in a market with limited good options. 

Here are some of the elements taken from the crisis communications playbook that we employ to help clients successfully announce this life-changing news.

Identify the groups that need to know. Take the time to carefully consider everyone who will be affected. Don’t forget to add important influencers such as vendors, donors, volunteers, referral sources and local officials.

Map out the order in which stakeholders will hear the news. You have a hierarchy among the groups that are important to you. Board members need to know before vendors. Major donors should hear before casual contributors. Directors should hear before line staff. Families need to hear as soon as residents hear.

Recognize that news does not keep. In a world where social media serves as a primary news source for many, you need to realize that announcements shared with one group will quickly reach others thanks to personal Facebook pages and Twitter accounts. You want to make sure that each group important to you hears the news directly from you, not from others who may distort or omit important details. That means orchestrating your announcement with precision and having as small a gap as possible between the time you inform your first stakeholder group and your last.

Make sure everyone hears the same story. A critical first step in creating a communications plan for an announcement involving a closure or ownership change is deciding what to say. The second is communicating that information consistently. Yes, your board will know more details than your employees, but the basic facts should not differ from one group to another. Creating a core group of messages and sticking to them will help reduce the amount of misinformation and confusion your announcement generates.

Use the communication method that works for each audience. Every organization has a different culture. In some, employees hear important news from their managers, who have heard it from their directors, etc. In others, everyone gets an email from the ED. Others congregate for an all-staff meeting. 

When announcing a significant change, use the channel you’ve already established for each audience – unless there’s a compelling reason to do something different. Making sure the announcement goes out as planned, to every critical group, in precisely the right order and at the right time is complicated enough without testing out new technology or some other novel presentation approach that hasn’t been used before.

Remember special cases. Organizations making significant announcements need to keep in mind the individuals and groups that need special attention to make sure they hear the news appropriately. Senior living facilities that run 24/7 operations will need to find a way to make sure second and third shift staff don’t get overlooked when the news is announced at 9 a.m. Significant donors who typically get a personal call from the board chair may feel slighted when they receive the same email message as less generous contributors. 

Don’t stop with an initial announcement. In the days after an announcement of significant change, those most affected may still be absorbing the news. Set up a process for those who have questions to get answers. Keep an ear to the ground to make sure the news you thought you were sharing has been received that way. Be ready to address concerns before your non-crisis event evolves into a situation that needs crisis management skills.

And finally, remember that change typically takes time to become reality. Keep your stakeholders in the loop as you implement your change so they understand what is happening and – ideally – accept the reasons that went into the decision. If you have set a date to cease operations, make sure to remind residents and others as critical dates in the timeline approach. If a new owner is coming on board, find a way to introduce the new management team as soon as possible and give residents and families the opportunity to ask questions and discuss the changes the new team intends to put in place. 

Most important, keep in mind that individuals are more likely to accept news that is delivered with respect and compassion. A well-structured communications plan can help an organization convey its appreciation for the immense impact this type of news will have on those involved and will let them know they will have support as they adapt to new ownership, new staff and, potentially, new homes.

Nora Jacobs is senior vice president at Hennes Communications, one of the few firms in North America focused exclusively on crisis management and crisis communications. Nora is an experienced crisis communications counselor with three decades of agency and corporate experience.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Gove County Medical Center announced last week it would close down its long-term care facility in Quinter, KS, which has 29 residents and employs 34 personnel in a quintessential rural community of fewer than 1,000 residents. Facility leaders tried to sell the business but could not find a buyer, according to local media. 

“We get federal subsidies to run our hospital, and we actually receive, essentially, a penalty for running our long-term care,” Gove County Medical Center CEO Conner Fiscarelli told KSN.com. “Even if they are a ‘break-even’ or profitable long-term care, we actually get a penalty, and for us, it was a significant penalty year over year.”

Twenty-four nursing homes have shuttered while another 28 have delicensed parts of their buildings or campuses, according to LeadingAge Kansas. Eleven of the shuttered facilities were nonprofits. 

In November, LeadingAge Kansas and the Kansas Health Care Association partnered to survey their members about workforce and operations challenges. Of 116 nursing facility respondents, 59% acknowledged that insufficient staff was the primary reason to limit or pause admissions; 44% had an admissions’ wait list; and 25% had delicensed beds since the start of the pandemic. 

The situation in Kansas is similar to most other states, which are battling inflation, workforce problems, and legislative fights over increasing Medicaid rates. The American Health Care Association/National Center for Assisted Living launched a national campaign earlier this year to boost hiring at nursing homes.

A statewide situation report from LeadingAge Kansas issued in January found that nearly 85,000 Kansans live in an area with just one skilled nursing facility within a 30-minute drive. Another 23,000 live in a “care desert” with a SNF at least one hour away. The report also found that labor costs were up 22% since the start of the pandemic, while the nursing home workforce is down 12%. 

Meanwhile, staffing agency costs are up 270%, and LeadingAge Kansas is lobbying for agency reforms, said President and CEO Rachel Monger.

“There is no Medicaid funding increase or workforce program that can balance that level of market exploitation,” she told McKnights Long-Term Care News on Tuesday, adding that providers are grateful that the state Legislature approved $151 million in new funding for senior care programs over the next fiscal year. That bill has not been signed into law yet by Gov. Laura Kelly (D). 

Dignity Alliance and Stavros Center for Independent Living petitioned the state Department of Public Health through letters to put the facilities into receivership, alleging the facility owner is “blatantly in violation” of state regulations. It said that the closure process is not supposed to begin until the department of health approves the plan, but facilities are already moving residents out. Spanish-speaking residents are being transferred to nursing homes without Spanish-speaking staff, and other patients have been sent to facilities on the other side of the state, the protesters claim. 

“What is happening is outrageous, tragic, and needs to be halted by immediately placing at least two of the homes in receivership,” the Dignity Alliance letter said.

The Department of Health confirmed to McKnights Long-Term Care News Friday that it received the letters and will determine whether an investigation is warranted. The Massachusetts Attorney General’s office confirmed that it also has received the letters.

The Northeast Health Group, which owns the Chapin Center in Springfield, Governor’s Center in Westfield, and Willimansett Center East and West, both in Chicopee, had not responded to McKnight’s requests for comment as of late Friday. 

An employee who answered the phone at Willimansett Center East confirmed that only four patients remained there and that they were told to vacate by early April. Messages left at the other three facilities were not returned Friday. 

The advocacy groups said that the nursing homes are telling residents’ families and representatives that they must find other housing by early April instead of by June 6, which is the state deadline based on when Northeast Health Group told state regulators it would shutter the SNFs. 

 Last month, McKnights reported that the Northeast Health Group unsuccessfully applied for a waiver from an April 2021 state rule limiting nursing home occupancy to no more than two residents per room. The closure plans submitted for each of the four facilities said they were built to accommodate three to four residents per room and making them less dense would also make them financially insolvent. 

The state department of health held public hearings on March 1 and March 2 on the proposed closures and will either approve the plans or request additional information by March 15, a spokeswoman said. As part of state requirements for nursing home closure plans, facilities must provide psychological counseling or preparation to each resident, detail efforts to find appropriate placements in facilities capable of meeting each resident’s specific needs, and consult with families or legal representatives on placement options. 

“The Department will monitor the closure process to ensure the safe and orderly transfer of residents and that safe, high-quality resident care is maintained throughout,” a  health department said in an email Friday. Thirty-one providers have filed a lawsuit in Suffolk County seeking to stop the two-bed per room capacity limit. While private rooms do a better job of helping manage infection spread, providers have said they cannot comply with that mandate without additional state or federal resources to build more rooms or redesign current ones, leaving them with few options other than closing or reducing admissions.