Short-staffed NC nursing homes win a temporary reprieve — but no long-term solutions

  Patients pay for nursing homes’ staffing shortages

A nationwide struggle to hire and retain caregivers is causing North Carolina nursing homes to reach a crisis point — a trend that endangers thousands of residents, our investigation has found. An influx of for-profit nursing homes and fewer regulations during the pandemic are compounding the crisis. So what should families do to protect their loved ones?

The budget recently passed by North Carolina lawmakers leaves Bill Lamb feeling both relieved and concerned.

“It buys more time,” said Lamb, a board member of Friends of Residents in Long Term Care, a group that advocates for nursing home residents. “But it’s not a long-term fix.”

The budget will extend Medicaid rate increases that had been set to expire on June 30. Legislators hope that will prevent nursing homes from suffering a financial crisis that would have made acute staff shortages even worse. But the spending plan does not spell out what will happen to nursing homes in December, when the additional funding is expected to be depleted.

Some lawmakers say they know nursing homes will need more funding when they convene for the long session next year.

“I think it’s reasonable to say that the health care market has forever changed,” said state Sen. Jim Perry, a Republican who co-chairs the committees on health care and health and human services appropriations. “I think we’re going to have to be prepared to increase our spending.”

Left Alone, a recent Charlotte Observer investigation, documented how a shortage of caregivers has put thousands of nursing home residents at risk of neglect.

While nursing homes nationwide are struggling to hire and hold on to caregivers, few states have problems as severe as North Carolina, the Observer found. Only about one of every five North Carolina nursing homes meet the staffing threshold recommended by a landmark federal study.

Low pay and difficult work conditions have made it tough for nursing homes to attract and retain caregivers. Many certified nursing assistants in N.C. nursing homes got pay raises during the pandemic, but most still earn less than $16 an hour — a lower minimum wage than Costco now offers.

Nursing homes contend the state’s low Medicaid reimbursement rate — among the lowest in the South — prevents them from paying caregivers more.

Adam Sholar, president of the North Carolina Health Care Facilities Association, the group that represents most of the state’s 425 nursing homes, said he’s grateful for the temporary help offered by lawmakers, but sees a need for a solution to “the serious economic challenges facing our industry.”

“The state has an obligation to cover the cost of caring for Medicaid residents, and it is failing to meet that standard,” Sholar said in a statement. “North Carolina must make a long-term commitment to invest in skilled nursing care so we can grow our workforce and provide appropriate levels of care for the growing number of people who need our help.”

The legislature’s proposed 2022-23 budget, which passed with bipartisan support on July 1, would spend about $70 million to extend temporary Medicaid rate hikes for nursing homes. The state initially gave nursing homes those increases in 2020 to help them survive the pandemic.

Gov. Roy Cooper signed the budget into law on Monday.

“Additional funding for nursing homes is critical as staffing shortages and other challenges have been exacerbated over the course of the pandemic,” said Mary Scott Winstead, a spokesperson for the governor. “While this budget takes steps in the right direction, more work is needed.”

Dave Richard, deputy secretary for Medicaid at the state Department of Health and Human Services, said the money approved by the legislature would keep the funding increases in place into December. That would keep Medicaid funding about 40% higher than it was before the pandemic.

In the meantime, Richard said, DHHS officials will talk with industry leaders and advocates about how to improve nursing home care over the long term.

“We didn’t get here overnight,” he said. “We won’t get out of it overnight. … It’s something that we’ll have to continue to work on for the next decade.”

No money for new inspectors

The legislature’s budget is also notable for what it doesn’t include.

Gov. Cooper’s proposed budget would have added 18 nursing home inspectors to increase oversight. But the budget approved by lawmakers provides no money for additional inspectors.

Virtually every nursing home resident lost key protections during the pandemic, the Observer’s investigation found. Routine inspections of nursing homes dropped precipitously. And state legislators passed a law shielding nursing homes from most legal claims related to COVID-19.

On Monday, Cooper announced he will lift the state of emergency next month — a move that will remove that legal shield.

The legislature’s budget doesn’t specify how much money nursing homes must spend on staff or on direct patient care. That troubles advocates, who worry about the many things that can go wrong when staffing is short.

Without sufficient staff, residents can become dangerously dehydrated, miss crucial heart medications and develop life-threatening infections. They can push their call bells, but wait hours before getting help. Such problems have cost some residents their lives, family members told the Observer.

Nursing home leaders have struggled to address the staffing problems. Most homes in North Carolina have increased wages, paid bonuses, used staffing agencies and asked employees to work overtime and extra shifts.

And 84% of providers say they are limiting admissions due to staffing shortages, according to a recent survey. That has created additional problems. When nursing home beds are in short supply, some medically frail people remain stuck in hospitals for long periods, while others must live with family members who aren’t equipped to care for them.

The challenges ahead

In the coming months, Richard said, DHHS officials plan to examine what other states are doing to improve nursing homes, with an eye toward answering a fundamental question: “How do we use the rate structure to drive quality?”

In New York, for instance, a law passed last year requires nursing homes to spend at least 70% of their revenue on direct resident care.

Sen. Perry said it’s time for the state to “think outside the box” about how to attract more workers to the profession. He pointed to one possible approach: Providing tuition-free training to those who want to become CNAs or registered nurses.

Lawmakers are calling on the state’s universities to help search for solutions. By February 2023, the budget stipulates, the University of North Carolina and the State Board of Community Colleges must recommend ways to increase the number of nursing graduates by at least 50%.

Rep. Larry Potts, a Davidson County Republican who co-chairs the House health committee, said government officials must devise a long-term plan to put nursing homes on a solid footing. He likens the state’s nursing homes to hospital patients.

“This is the emergency room,” he said, speaking of the temporary funding increases approved by lawmakers. “We’ve stabilized them. Now they’ll have to go on to a hospital room.”

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