Nursing home transfers see longer delays amid staffing, payment issues

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Around 400 nursing homes have closed since 2020, according to Centers for Medicare and Medicaid Services data through January 2023. Nursing and residential care facilities shed more than 210,000 jobs over that span, Bureau of Labor Statistics data show.

“A lot of facilities do not have the personnel needed to take care of residents,” said Deb Burdsall, an infection prevention specialist and board member of the Association for Professionals in Infection Control and Epidemiology who worked in long-term care for more than 40 years.

Employment is slowly starting to rebound: Nursing homes filled an average of 3,700 jobs per month from May 2022 through January. But at that pace, it would take until 2027 for staffing at nursing homes to reach pre-pandemic levels, according to a recent report from the American Health Care Association and National Center for Assisted Living, which represents long-term care and post-acute providers.

“When I speak with my peers, all are suffering extreme staffing shortages, especially in nursing and nursing assistants,” said Tonja Myers, administrator of Christian Health Care Center, a nonprofit skilled-nursing and rehabilitation facility in Lynden, Washington. “Without those professionals in place, we cannot afford to take as many admissions as in the past.”

Christian Health Care Center only accepted 4% of referred patients in 2022 due to a lack of staffing, compared with 5% in 2021, 9% in 2020 and 17% in 2019.

“Without having [a patient] census at previous levels, we don’t have the revenue needed to stay in business,” Myers said. “Most of us long-term care facilities are using our savings to stay afloat, and many will close within the next year or two.”

The lack of workers has disrupted the care transition process, presenting potential dangers. Protracted waits can mean patients don’t get referred to the post-acute facilities best suited to treat their needs, said Jean Harpel, operations manager for aging services at ECRI, a patient safety organization.

A 2022 study published in the Journal of Patient Safety found that the longer patients were held in the emergency department after they were ready to be discharged, the more likely they were to experience a fall, medication error or other safety event.

COVID-19 outbreaks and prior authorization hurdles have also stalled hospital discharges, said Glen Roebuck, executive director of home, outpatient and senior services at Genesis Health System, which operates six hospitals and a network of home health, hospice, rehabilitation and long-term care facilities headquartered in the Quad Cities area of Iowa and Illinois. Pre-authorization processes cannot begin until a patient’s discharge is imminent, and insurers typically take between two to five business days to respond to authorization, prolonging hospital stays, Roebuck said.

The slowdowns can mean transitions take place after normal business hours, when skilled-nursing facilities don’t usually have physicians or pharmacists on site. Any potential gaps in care plans or pharmaceutical needs then become extraordinarily difficult to fill, he said.

“Those types of discharges come with great risk to the patient, as well as regulatory risk for the facility,” Roebuck said.

A looming regulation from CMS may further constrain nursing homes, operators warned. The agency announced plans in February 2022 to implement minimum staffing requirements by this spring in an attempt to improve safety across skilled-nursing facilities.

The move would disproportionately impact access to providers in rural settings, which already have trouble filling employment rosters, said Nathan Schema, president and CEO of Evangelical Lutheran Good Samaritan Society, a post-acute and home health provider that merged with Sanford Health in 2019.

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