The study evaluated states on a scale of 100 based on a variety of factors, such as the number of nursing homes per 100,000 residents, occupancy rates, cost of residency and the percentage of nursing homes with no deficiencies. 

Iowa topped the list with a score of 70.67. Iowa was not a leading state in the individual categories, but was consistently in the top third of each category. Around 10% of Iowa homes had no deficiencies, which was well above the national average of 6%. 

Despite a top-five occupancy rate, California was the bottom-ranked state, with an 18.61 rating. This was partially because of its high cost. Private nursing home rooms in the state cost more than $12,000 per month, among the highest in the nation. The state also has the 2nd most deficiencies per facility on average.

Providing insight into nursing home care in the US is only growing more important as the population ages, said SonderCare CEO Kyle Sobko. 

“This data provides a clear insight into which states currently offer the best access to elderly care and outlines the factors contributing to this,” Sobko stated. 

Rural Southern and Great Plains states consistently received high scores in the study. The top 10, in order, were:

• Iowa
• Oklahoma
• Missouri
• Louisiana
• South Dakota
• Kansas
• Montana
• North Carolina
• Wisconsin
• Nebraska

Among more populous states, Texas, Pennsylvania, and Illinois ranked highest, at 11th, 15th and 16th, respectively. 

Sobko noted that there were some notable outliers in the SonderCare study.

“The most surprising finding from this study is that Alaska ranks overwhelmingly as the most expensive state for elderly care, both semi-private and private,” he said. “The cost of a room in a private nursing home in Alaska is $31,512 per month, this is more than $16,300 more than the second most expensive state, Connecticut.”

Those costs helped drag Alaska down to a ranking of 46th, rounding out a bottom five that also included the 2nd most expensive state, Connecticut, as well as West Virginia, Hawaii, and California. East coast states made up nine of the bottom 15.

The state’s Department of Medicaid Services designated the funds, meant to help nursing homes cope with inflationary pressures, as a “forecast error” to provide the funds quickly.

“The initial response from our membership has been positive,” Betsy Johnson, president of the Kentucky Association of Health Care Facilities, told McKnight’s Long-Term Care News Friday. “Our members need dollars in the door right now to deal with increased costs.” 

Kentucky’s Medicaid rate has not been rebased since 2008. The association and providers have been actively lobbying lawmakers and the executive branch for rebasing and funding increases in a desperate attempt to prevent facilities from shuttering. A letter-writing campaign proved particularly effective. 

Across the US this spring, nursing homes have secured sometimes historic Medicaid increases. It’s a trend Johnson hopes her members will be able to take advantage of.

But as negotiations continue, especially in states whose legislatures develop two-year budgets, worries are already arising about how willing state lawmakers will be to sustain increases. Some fear a one-and-done approach, or pay structures that give a big boost that will still leave facilities with daily losses — only to be followed with minimal percentage increases next session.

That was the case in Pennsylvania, where providers won a significant, 17% increase in 2022 after a 10-year dry spell. They faced the possibility of a flat line budget this year until state associations were eventually able to secure a small increase for nursing homes.

In Colorado, where nursing home spending was cut by 2% during the pandemic, a 2024 budget proposal offered a 10% increase, followed by 3% in 2025 and 1.5% in 2026. 

Such fall-offs in Medicaid increases were a topic of concern at the American Health Care’s Association meeting in Washington, DC, last week.

“Continual investment in our Medicaid provider nursing homes is critical to ensuring that facilities can sustain and reward their staffs and that the resources will always be present to care for the most vulnerable among us,” Rick Abrams, president and CEO of the Wisconsin Health Care Association told McKnight’s. “Our nursing homes will always be a critically important long-term care option for our seniors and for people living with disabilities.”

In Wisconsin, Abrams is “encouraged” that historic Medicaid increases in the 2021-23 budget will be maintained because they were added to the state’s rate-setting methodology.

The uptick brought the state’s direct nursing care component of the rate to a “very respectable” level of 125% of median cost; Abrams hopes to secure a similar increase for the state’s support services component for the next two-year budget, which will kick in July 1. That could mean a much-needed Medicaid funding infusion of $55 to $70 per patient day.

In Kentucky, the current, average daily Medicaid rate for providers is $221.20, which includes a $29 per day add-on that has been in place since Jan. 1, 2020. Rural providers can expect an increase of approximately 8% while urban facilities will get an additional 7.9% due to the emergency bridge funding. Johnson said they asked for an increase that would have amounted to approximately $28.80 per patient per day. 

David McKenzie, the owner of The Jordan Center, a 110-bed facility in Lawrence County, one of the poorest counties in the state, sent a letter to Eric Friedlander, secretary for the Cabinet for Health and Family Services, saying the facility “will not make it” unless it sees a Medicaid increase by July 1. Fully 90% of the facility’s revenue comes from Medicaid, McKenzie wrote. 

“We did everything the government asked of us,” McKenzie’s letter said. “We spent the money as we were asked, we were good stewards of the funds. … We have no one else to turn to for help.”

In an interview with McKnight’s Friday, McKenzie, who sits on the KAHCare board, said he was forced to close a wing during the pandemic due to staffing shortages, which also resulted in denying admissions. The facility regularly operated at 97% capacity prior to COVID-19. 

“I recalculate and recalculate my break-even every month,” McKenzie said. “Although [the bridge funding] is not enough to put me in the black, it’s certainly better than nothing. I’m grateful. And the [funding] — it’s close, which means hopefully that I can hang on a little longer.”

The Jordan Center has operated in Louisa, KY, as a family-owned business since 1974. McKenzie’s letter indicated that the facility did not have to lay off any employees during the pandemic, despite being in a “valley of death” as the one-two punches of COVID-19, inflation, and staffing problems continue pummeling the facility. He said on Friday that a single catastrophic event such as a broken sprinkler system or roof repairs could doom the nursing home. 

“I don’t know,” he said, when asked if the bridge funding would be enough to keep the facility afloat. “It’s touch and go. I’m in a high-risk situation and holding on by my fingertips. It’s a scary place to be.” 

One of the most heart-warming long-term care stories of the last week came from a somewhat unlikely source. For a variety of reasons, state veterans homes just don’t typically seem to warm the hearts of those not directly involved.

But this week, there was good news about them. We’re talking specifically about new and/or upgraded facilities.

As our report noted, this could represent a “renaissance of sorts for state-run homes.” Several states are in various stages of adding or improving nursing home options for former service members and their spouses.

Bravo, to Pennsylvania, Florida, Kentucky and Wyoming. They aren’t the only ones, but they are recent examples. They, just as the rest of the “civilian” country should have been seeing already, have recognized a need for their aging veterans. This is all in addition to state Medicaid concerns, of course.

The federal Veterans Administration also is taking part in this mini-wave. A VA spokesman told McKnight’s this week there are plans for new facilities in Atlanta and West Virginia, for example.

Anything that would add to the capacity of the 162 homes currently run by the states would be welcome news. All told, they currently comprise about 30,000 beds. 

That’s not nearly enough, of course. And the heck of it is, the new additions will not be anywhere near enough, either. But it’s a start and a bid to keep progress flowing.

Just as general long-term care society is simultaneously grappling with shrinking workforces and soaring clientele pools, so must the VA — only with less diverse resources.

That’s why it’s so encouraging to see any strides to take care of our vets headed in the right direction. Because even if there hasn’t lately been the carnage of a World War, or something like Korea or Vietnam, we are ensured of a big wave of aging vets. Ironically, that’s a very good “problem” to have. Even if it’s tempered a bit if you’re struggling to figure out how to serve that booming aging clientele.

Kudos to those trying to do so — and putting their money where their mouths are.

James M. Berklan is McKnight’s Executive Editor.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

“Although many healthcare providers have received rate increases through temporary federal COVID-19 relief and state funding, only a limited number of states have policies to ensure funds are passed on to direct care workers,” the report stated. “The direct care workforce represents a critical component of the United States employment market, yet pay remains low. States have taken a variety of actions through provider rate increases and minimum wage policies through the Medicaid program as two strategies to address recruitment and retention.”

The report is the third in a series on the direct care workforce.

Medicaid is the largest payer for facility-based and home and community based settings care, paying for 42.1% of all long-term services and supports in 2020. 

The report summarized approaches in 19 states to increase wages, with a focus on those that have reporting requirements, enforcement vehicles or other mechanisms to help ensure funds go to intended recipients.

In Illinois, for example, state officials are trying to support direct care workers and CNA retention with supplemental payments to providers that prove certain CNA tenure metrics.  Retained workers are supposed to receive an extra $1.50 hourly for the first year retained, and then $1 more hourly for every additional year, up to a max of $6.50 per hour. In addition, CNAs can receive $1.50 per hour for promotions associated with additional training and skills like dementia care and/or responsibility levels

Providers are required to report on costs and revenue, but there is no enforcement policy in place.

The program started last July as part of larger rate methodology reform efforts, Matt Hartman, executive director of the Illinois Healthcare Association, told McKnight’s Long-Term Care News Thursday. The youth of the program means impact is to be determined, Hartman said.

“To date over a third of (nursing home) providers are taking part, and we expect participation to continue to grow,” Hartman said. “That said, there are probably some ways in which additional providers could be enticed to participate, and thereby improve the program. 

“Most of these would center around additional ways funding could be passed through to employees, and some flexibilities in how the program is managed.”

The report notes that benefits, such as health insurance, paid time off, childcare and transportation, also represent important tools that states can use as recruiting and retention tools.

“These strategies have a clear monetary value and these non-wage benefits can give employers a competitive advantage over other professions that may offer similar or even slightly higher wages without such benefits,” the report said.

The report noted two types of strategies. A wage/benefit increase through a rate increase or supplement, as a payment in addition to the statewide provider rate. In addition to programs like the one in Illinois, these strategies include enhanced payments for meeting overall performance metrics, such as in Rhode Island; or formula-based enhancement such as one provided in Iowa that requires a wage pass through.

Some states are also pursuing minimum wage hikes for all direct care workers, as in Florida, or a specific category of direct care workers, as in Louisiana. In New Jersey, a minimum wage for direct care workers is a specific percentage or dollar amount above the state minimum wage.

“Importantly, states may implement multiple strategies to address direct care worker wages, which may intersect in important ways,” the report said.

Investigators identified more than 1.3 million Medicare beneficiaries aged 65 years and older who were prescribed any antipsychotic or benzodiazepine during a day of hospice enrollment in 2017. The most common hospice diagnoses in qualified study participants were cancer, heart disease and dementia. 

The analysis, representing more than 4,200 hospices, resulted in state-level averages of adjusted prescribing rates. Using that data, large prescribing variations by state were found for each drug class. For antipsychotics, prescribing rates ranged from 62% for hospice beneficiaries in Oregon to 15% in Oklahoma. Benzodiazepine prescribing rates varied from 77% in Oregon to 42% in New York. 

Benzodiazepine prescription fills were higher than antipsychotics in all states. And for each class of drug, five states topped the prescriptions list: Oregon, New Mexico, Washington, New Hampshire and Florida.

Hospice drug standards lacking

Antipsychotics and benzodiazepines are routinely used to treat distressing end-of-life symptoms. Yet guidance and consensus on best prescribing practices is limited, according to lead author Donovan Maust, MD. 

The drugs also are tied to adverse side effects such as sedation and falls in older adults, and appropriate use will vary, he and his colleagues wrote. 

For example, “for those patients who are not imminently dying, patients and their care partners may prefer avoiding such medications in order to maintain function and minimize sedation,” the authors wrote.

Without clear evidence and guidance for hospice, use of these drugs may remain varied and inconsistent, they wrote in the Journal of the American Geriatrics Society.

Understanding variation in practice patterns may help in efforts to develop “appropriate prescribing in hospice and to clarify the current standard of care,” they concluded. 

Related articles:

Validating fears helps shift patients’ palliative care expectations: study

EDs rarely send seniors with dementia to hospice care: study

Study data came from the 2019 Behavioral Risk Factor Surveillance System. In that year, the median prevalence of arthritis was 24% across 49 states and the District of Columbia (ranging from 18% to 36%). Rates were highest in Appalachia and in the Southeastern states.

In addition, adults with arthritis reported high rates of physical inactivity, fair and/or poor health status and severe joint pain, according to Lindsey Duca, Ph.D., of the Centers of Disease Control and Prevention in Atlanta, and colleagues. 

Across states, a median of 30% of participants with arthritis (ranging from 20% to 42%) said that they’d been physically inactive over the past 30 days, the researchers reported. And a median of 33% reported severe joint pain — compared to 30% in 2015.

Eight states stood out, with the highest rates of pain, inactivity and poor health in arthritic adults. These include Alabama, Arkansas, Indiana, Louisiana, Mississippi, South Carolina, Tennessee and West Virginia.

The results suggest that arthritis-attributable joint pain, physical inactivity and self-rated health status are connected and influence each other, the researchers said. This should be a wake-up call to health officials and clinicians in these and other U.S. states, they concluded.

“This interplay represents an opportunity for concentrating efforts to increase promotion and use of evidence-based nonpharmacologic public health interventions in these states,” they wrote.

Full findings were published in the CDC’s peer-reviewed online journal, Preventing Chronic Disease.

Related articles:

CDC: Senior care challenges ahead as nearly one-half of U.S. older adults say they have arthritis

The plan is part of a three-year, $2.1 billion investment of American Rescue Plan funds to improve infection prevention and control (IPC) activities across the U.S. public health and healthcare sectors. The Biden administration and Centers for Disease Control and Prevention made the announcement on Friday.

The soon-to-launch long-term care component will allow states and other U.S. jurisdictions to “staff, train and deploy” strike teams to help long-term care operations with known or suspected COVID-19 infections, the CDC said in a statement posted on its website.

“The strike teams will allow jurisdictions to provide surge capacity to facilities for clinical services; address staffing shortages at facilities; and strengthen IPC activities to prevent, detect and contain outbreaks, including support for COVID-19 vaccine boosters,” it said.

Katie Smith Sloan, president and CEO of LeadingAge, applauded the investment in staffing — a longstanding problem that has been exacerbated by the pandemic, she said. 

“Frontline staff are weary from battling COVID for 18 months; the promise of fresh teams is both heartening and greatly needed to ensure the well-being of older adults,” Smith Sloan said in a statement released following the federal announcement. “Our members across the country look forward to working with their state leaders to ensure these funds directly address the staffing shortages they’re intended to address.”

Building resiliency

Another $385 million, also to be awarded in October, will go to state, local and territorial health departments to support five areas across multiple healthcare settings. These include assisting public health departments to improve care quality; improving laboratory capacity; IPC training through Project Firstline; data monitoring programs and antibiotic stewardship.

The pandemic era has brought an unprecedented urgency to IPC efforts — especially in vulnerable nursing home and hospital settings, CDC said. Recent data point to “substantial increases” in healthcare-associated infections.

“The data show an urgent need to strengthen infection prevention and control capacities and build healthcare resiliency to withstand future pandemics and maintain national prevention progress.”

Federal investment in IPC activities acknowledges the interdependence across the public health and healthcare sectors, added Smith Sloan, “and the support needed to ensure safety and well-being.”

Researchers examined data from the nursing home Minimum Data Set and Medicare claims for more than 1.5 million long-stay residents (at least 120 consecutive days). They analyzed the proportion of variation in chronic opioid use that is attributable to states or to nursing homes, defining chronic opioid use among residents as use for 90 or more days. Each year’s results were controlled for resident, nursing home and state characteristics.

“Variation in chronic opioid use declined by one-third at the state level but not at the nursing home level,” reported first author Hemalkumar B. Mehta, Ph.D., of the Johns Hopkins Bloomberg School of Public Health and coauthors. Chronic opioid use declined from 14% in 2014 to 11% in 2018, they found. The variation in use among states also declined from 3% in 2014 to 2% in 2018. In contrast, the variation among nursing homes increased from 6% in 2014 to 7% in 2018.

The changes in state-level variation may reflect the response to national guidelines and federal policies on opioid use as regulations evolved from being primarily state- to federally based, Mehta and colleagues concluded.

The study was published online ahead of print in the Journal of the American Medical Directors Association.

Although the average U.S. case rate is falling overall — 32% in the last month — almost a third of all states have seen their average rate increase by at least 10%, according to ABC News. In six states — Delaware, Idaho, Minnesota, Nevada, Oregon and West Virginia — new case averages increased by at least 25% in the last week.

Two likely culprits are loosened public health restrictions and the spread of virus variants, industry observers say. 

“I don’t expect to see something as bad as we just recovered from, but if we’re not careful, cases can rise again if we let our guard down too soon,” epidemiologist Tara Smith, Ph.D., told ABC. 

Smith, of the Kent State University College of Public Health in Ohio, said she is most concerned about the effect of variant spread, and news of a recent outbreak in a Kentucky nursing home appears to confirm her fears. In that facility, a previously unidentified variant of COVID-19 had infected 27 residents, whether vaccinated or unvaccinated, and 14 staff members as of March 16.

Among those who were infected, 30% of those who were vaccinated had been symptomatic since testing positive. That’s in contrast with 83% of unvaccinated residents who showed symptoms after contracting COVID-19.

“Vaccination appears to have markedly reduced the risk of serious infection and hospitalization,” Kentucky Public Health Commissioner Steven Stack said in a press briefing. “Seventy-one people were vaccinated, one of whom is in the hospital. There were 13 residents unvaccinated, four of whom are in the hospital.”

It appeared that an unvaccinated person brought the variant into the building, he added.

Major urban areas are struggling with upticks linked to variants as well. In New York City, the U.K. and the New York variants now may account for most of the city’s cases, ABC reported.

“The best way to circumvent the variants is to continue to vaccinate as many people as quickly and as efficiently as possible at the same time as maintaining your public health measures,” Anthony Fauci, M.D., the White House’s chief medical adviser, told the news outlet.

The 15 states with surges include Alaska, Connecticut, Delaware, Idaho, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Nevada, New Hampshire, New Jersey, Oregon and West Virginia, according to an ABC analysis of federal data.

Additional reporting by Kimberly Marselas, senior editor of McKnight’s Long-Term Care News.