COVID-19 has killed dozens of residents of New Hampshire nursing homes and set off a scramble to find and keep on the job the caregivers and other employees upon whom these elderly, disabled and vulnerable people depend.
The novel coronavirus has proven itself a cruel but selective killer. In New Hampshire, about 95% of the victims have been at least 60 years old, and three in five were over 80, according to the New Hampshire Health and Human Services Department.
The disease has been especially deadly for seniors who live, eat and socialize together in nursing homes and assisted living communities.
“Almost 80% of the people who have died from COVID in New Hampshire are associated with long-term-care facilities,” state epidemiologist Benjamin Chan said on Wednesday. The statewide death toll reached 199 Thursday.
While patient deaths make headlines, the state’s long-term care infrastructure requires the recruitment and retention of workers. “The staffing issue is existential right now,” said Brendan Williams, chief executive of the New Hampshire Health Care Association, a trade group for nursing homes.
As the pandemic loomed, the state’s 73 nursing homes had 6,400 patients being cared for by 4,500 nurses, nurses’ aides and other employees, according to data compiled by the federal Centers for Medicare and Medicaid Services for the fourth quarter of 2019.
As the year ended and COVID approached, about 950 entry-level caregiver jobs remained unfilled, according to NHHCA.
Meanwhile, most of the deaths of nursing home residents in New Hampshire occurred in facilities where staffing levels were below average, according to an analysis of data and assessments compiled by New Hampshire authorities and CMS.
Aurora Senior Living of Derry, a 62-bed nursing home where a COVID-19 outbreak has so far resulted in nine deaths, had the fewest nurses and nurses’ aides per resident of any New Hampshire home — 32 per 100. That was 33% lower than the statewide average of 48. Aurora, which changed owners in October and is now licensed as the Derry Center for Rehabilitation and Healthcare, also had the fourth lowest overall staffing rate: 52 per 100 residents, or 38% below the statewide average of 84.
Even before COVID-19, there were warning signs about the care at the Derry facility. After a February inspection, CMS’ Medicare Nursing Home Compare website rated the facility “much below average,” its lowest score, for staffing, health conditions, quality measures and overall. The February inspection report cited nine health deficiencies including an instance of misuse of personal protective equipment while caring for a patient with a dangerous staph infection.
Dan Estee, administrator of the Derry Center, did not respond to a telephone message seeking comment.
Things seemed a little better at another Derry facility, the Pleasant Valley Nursing Center. While Pleasant Valley had low staffing ratios — third-worst in overall employee to patient ratio and in the bottom quartile for nursing — CMS rated it “average” for staffing and “below average” overall. A February health inspection found only four minor deficiencies. Yet 21 patients have died at Pleasant Valley.
Catherine Ortega, the Pleasant Valley administrator, directed a request for comment to the facility’s owner. According to CMS, the facility is owned by an Atlanta corporation that, according to New Hampshire records, was formed in 2013 by Wynn Sims and Amy Maxwell. Sims did not respond to a telephone message seeking comment.
Better staffing statistics didn’t presage better outcomes at the Hanover Hill Health Care Center in Manchester. COVID-19 has claimed 25 lives at Hanover Hill, the most at any Granite State facility — even though Hanover Hill had nursing (52 per 100 residents) and employee (68 per 100 residents) ratios right around statewide averages, as well as a “much above average” overall rating from CMS.
Hanover Hill Administrator Lori McIntire did not respond to a telephone message seeking comment.
Staffing challenges don’t necessarily lead to virus outbreaks. Hanover Terrace Health and Rehabilitation Center in Hanover ranked second lowest in nurse ratios, with 33 per 100 residents, and 16th lowest in overall staffing (59 employees per 100 residents) and got a “much below average” staffing rating from CMS. But Hanover Terrace got a “much above average” overall rating and has had, according to Administrator Martha Ilsley, no COVID cases or deaths among staff or residents.
Ilsley credited her facility’s performance during the COVID crisis to her “close-knit team of people” and a willingness of administrators with nursing credentials — including herself — to pitch in. “We all get out there and do what we have to do,” she said. “Everybody’s wearing many hats right now.”
Staff shortages in part reflect the low pay endemic to nursing homes and other facilities that deliver care to seniors. “As a society for too long we’ve impoverished those who are caring for the impoverished,” Williams said.
In 2018 the average weekly wage for 14,200 employees in New Hampshire nursing and residential care facilities was $695, far below the $1,084 in the health care sector and $1,106 among all private employees, said Greg David, an economist for the state Economic and Labor Market Information Bureau.
And things haven’t gotten better. In 2018, the average hourly pay for nursing assistants in New Hampshire was $15.04 which, after adjusting for inflation, was 1% lower than a decade ago, according to PHI, a New York-based nonprofit that advocates for better nursing home care.
That lag is especially tough on facilities that operate in the shadow of large and wealthy private, nonprofit and public institutions. “It’s hard to match the benefits and the rates of pay that hospitals can offer their staff,” said Ilsley, the Hanover Terrace administrator, who noted that her nursing home offers starting pay of about $13 an hour for non-medical entry level jobs and $15 for licensed nursing assistants — less than neighboring Dartmouth College pays cafeteria workers.
Currently, nursing homes face the added challenge of recruiting and retaining workers to labor in the path of a pandemic. Williams said that COVID had added to existing workloads such tasks as screening, feeding outside of dining halls and bringing activities to private rooms.
Kezia Scales, policy research director at PHI, said that in the crisis, nursing assistants in understaffed homes “are literally running from one resident to another.”
Four patients died in the last 24 hours at the Hillsborough County Nursing Home in Goffstown, Administrator David Ross said in an interview Friday morning. So far, 45 patients have tested positive for COVID, five have died and 19 have recovered, Ross said.
The outbreak exacerbated a staffing crunch, Ross said. About 20 employees left after the pandemic began, and another 22 tested positive for COVID, he said, adding that employees who remained on the job “truly see it as a vocation.”
At least 20 employees are staying away from their families in hotel rooms provided by the state, Ross said. He and other employees have sought to protect their families by adopting a pattern of “very ritualistic behavior” including doffing clothes at the door and showering when they return home and before they share meals or have contact with their families.
Staff shortages were a pre-existing condition at Hillsborough, according to Bobby Jones, staff representative for American Federal of State, County and Municipal Employees Council 93, which represents employees at the facility. “Prior to COVID-19, Hillsborough had 60 open LNA positions,” he said.
Jones worried that managers might respond to staffing shortfalls by instituting mandatory overtime. Ross said that the Hillsborough facility has an emergency staffing plan that includes mandatory overtime as a last resort but added: “We’re not there yet.”
Federal and state officials have tried to help nursing homes recruit and reward staff.
The biggest boost came in April, when Gov. Chris Sununu signed an emergency order establishing a COVID-19 Long Term Care Stabilization Program to pay full-time “frontline workers” in nursing homes and other Medicaid-funded services weekly stipends of $300 ($150 to part-timers). As of mid-May, stipends had been awarded to 22,000 workers, Sununu said.
The program is slated to run through June and expected to cost $30 million a month. Asked last week whether he would consider extending it, Sununu demurred. “We’re trying to create some parity there on a short-term basis,” he said. “I don’t think it’s practical to think we can keep that going for the long term.”
Another short-term boost came on May 11, when Sununu signed an order that allows long-term care facilities to employ “temporary health partners” who, after viewing an eight-hour training video, can go to work assisting licensed nursing assistants in moving, toileting, bathing and dressing seniors and making beds. The state nursing homes association sought the measure to enable some new employees to bypass conventional three-week training programs.
Nursing home industry leaders say they need more help to survive the pandemic. In a May 5 letter to federal officials, Mark Parkinson, chief executive of the American Health Care Association, which represents nursing home operators, called for the establishment of a $10 billion “emergency response fund” to finance a series of lump-sum payments ranging from $50,000 to $400,000 per nursing home. That money could be used to pay for protective equipment, testing, new hires, incentivize current staff and replace revenue lost due to the current paucity of new admissions, according to the proposal.
Advocates have also begun to consider what will follow the crisis. Said Scales, “We need to think about what happens when the emergency is over.”
In New Hampshire, that will probably entail going back to the future to discuss Medicaid, the $2-billion-a-year, state-federal program that provides health insurance to thousands of low-income families and individuals including about three of five nursing home patients.
Last summer Sununu, a Republican, and Democratic legislators wrangled over how and how much to increase the rates paid by Medicaid to health care providers. Looking back, Sununu described the resulting agreement to enact two annual 3.1% increases as “a very good step, a very needed step” toward elevating rates “that were simply not on par with our peers in surrounding states and the New England region.”
But the Medicaid question is likely to rise again. State Sen. Cindy Rosenwald, D-Nashua, noted that the pressure on the state’s Medicaid program is mounting, including in the nursing home sector where the pandemic has driven patient populations down and operating costs up.
As Sununu wrote in a letter to the Concord Monitor last summer: “We all agree that Medicaid provider rates affect workforce, access to care, and quality of services.”
Rick Jurgens can be reached at rjurgens_2000@yahoo.com or 802-281-6641.