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Nursing Home Beds In Short Supply in the Upper Valley

  • Cassandra Gilmore, a support staff member at Bradford Oasis Home and Respite, walks outside with resident Tina Libbey and Mia the dog on Sept. 27, 2017, in Bradford, Vt. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to Valley News file

  • Mount Ascutney Hospital CEO Joseph Perras (Courtesy photograph)

  • Brookside Nursing Home resident Marla Maskell in her room at the nursing home on Nov. 16, 2017, in Wilder, Vt. Maskell is one of a handful of resident still living in the nursing home before it closed two weeks later. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to Jennifer Hauck

  • Dr. Ed Merrens, chief clinical officer at Dartmouth-Hitchcock, talks during an interview on Tuesday, Nov. 14, 2017, in Merrens's office at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. Merrens was recently named to the board of directors for the U.S. Anti-Doping Agency, the body responsible for drug testing and analysis for events such as the Olympics. (Valley News - Charles Hatcher) Copyright Valley News. May not be reprinted or used online without permission. Send requests to Charles Hatcher

Valley News Staff Writer
Published: 12/1/2018 11:57:19 PM
Modified: 12/4/2018 4:15:28 PM

Lebanon — Some Upper Valley hospital patients who are ready to be discharged and transferred to places more appropriate — and less costly — for the care they need are unable to leave because there are simply no places to go.

For the patients, the logjam means longer than necessary hospital stays. For the hospitals, it means beds are being tied up when they might better be used for patients with more acute needs.

One of the major drivers of the problem is inadequate capacity at nursing homes, which itself is the result of staffing shortages, low reimbursement rates and challenges in managing their complex needs.

Dartmouth-Hitchcock Medical Center in Lebanon and its affiliate Mt. Ascutney Hospital and Health Center in Windsor both have trouble discharging patients, particularly those in need of long-term skilled nursing care, in a timely fashion.

DHMC was forced to hold patients for a total of about 400 “avoidable” days of inpatient care between January and May, said Elias Loukas, DHMC’s medical director for care management. At Mt. Ascutney, a 25-bed critical access hospital, the challenge has meant patients awaiting discharge have tied up beds for a total of 1,000 days recently, CEO Joseph Perras said.

“Hospitals are full of patients that we are unable to move on to their next step,” Perras said in an interview last month.

Problems with moving patients out of hospitals create obstacles to moving patients into them.

DHMC has to refuse admission to a couple hundred patients each month due to capacity issues, Edward Merrens, D-H’s chief clinical officer, said.

When beds aren’t available, patients are forced to travel farther from home for their care. For those awaiting discharge, it means they’re stuck in a hospital when they could be in a more homelike setting that is set up to cater more to their physical, mental and social needs.

The reasons for the bed crunch include the fact that the region has lost several nursing homes in recent years. Just last year, Brookside Health and Rehabilitation Center in White River Junction closed after officials identified multiple regulatory violations.

Also in recent years, Mt. Ascutney and New London Hospital, also a D-H affiliate, have closed nursing homes.

But nursing home administrators say it’s not an insufficient number of beds that prevents them from accepting patients ready to be discharged from hospitals. Instead, they point to low Medicaid reimbursement rates, the workforce shortage and the increasing complexity of patients’ needs as reasons they may not be able to accept patients. They also say nursing homes aren’t the right place for some of the patients hospitals are looking to discharge.

While nursing homes generally are equipped to manage patients’ short-term rehabilitation and long-term medical needs, often they are less well-prepared to manage mental and behavioral health challenges. Even if they have an available bed and could in theory manage a patient’s needs, they have to determine whether the patient will make a good roommate or neighbor for other residents.

Between managing staff amid a national nursing shortage, rising costs, declining reimbursement rates and a lack of mental health beds, Patricia Horn, executive director of Cedar Hill Continuing Care Community in Windsor, said nursing homes are feeling a great deal of pressure. It’s pressure that filters through all levels of the health care system, she said.

“It’s a very tough time right now,” Horn said.

Complex Needs

One category of patient that DHMC has found difficult, if not impossible, to place elsewhere, is those struggling with addiction to intravenous drugs who have developed infections requiring IV antibiotics, Loukas said. Such patients can’t safely take their medications at home and there aren’t other facilities equipped to take them, he said. As a result, such patients are stuck at DHMC for the four-to-six-week course of antibiotics.

“These patients do require specialized care … specialized consultations that other hospitals can’t provide,” Loukas said.

Other patients who are difficult to place are those who lack any insurance and those who require a legal guardianship due to a psychological issue, Merrens said.

“It’s a spectrum of things,” he said.

On the nursing home’s end, it’s not just finding a bed; it’s finding the right bed. For example, if a hospital is seeking a short-term stay for someone recovering from surgery, that person can’t be accommodated by a nursing home that has a bed available but is located in a wing filled with patients with dementia.

“That’s really not an appropriate place for someone who has no memory loss and is trying to recover from a hip fracture,” Horn said.

Cedar Hill also sometimes declines to accept patients who are too young to fit in at a place where the average age of the residents is in the 90s, Horn said.

“I don’t feel I can offer them the quality of life they deserve,” she said.

Often, Horn said, hospitals are backed up with patients with complex mental and behavioral health needs that are not appropriate for nursing home care. Patients who, for example, exhibit aggressive behavior may not fit in with frail seniors, she said.

“It’s put hospitals in a very, very difficult position,” Horn said. “We can’t accept them if we can’t meet their needs by law.”

But without a place to send a patient, hospitals can’t discharge them, she said. And, she added, Vermont doesn’t have enough appropriate settings.

State officials say that the right facilities might be available, but it can still take time to find a good match. Vermont has a sufficient number of nursing home beds, said Monica Caserta Hutt, commissioner of the state’s Department of Disabilities, Aging and Independent Living, DAIL. Though she was not familiar with the difficulties at Mt. Ascutney, she said sometimes the challenge may be that hospitals are trying to place patients in nursing homes who would be better accommodated elsewhere.

In some cases, appropriate community settings can be found for patients, but that’s not a quick fix, Hutt said.

“We have had success at DAIL in developing more individualized placements through an adult family care model, matching individuals with independent, individuals care providers in the community but that is an intentional, deliberate process that takes time,” she said.

But, she said, state officials are aware that there is demand for at least one type of residential bed — step-down beds for mental health patients.

Brendan Williams, the CEO of the New Hampshire Health Care Association, which represents New Hampshire’s nursing homes, said his state may wish to take a look at its nursing home bed moratorium at some point in the future. He cautioned, however, that adding new facilities that siphon off Medicare patients without taking patients covered by lower-paying Medicaid could destroy the viability of the state’s existing nursing homes.

Now is not the time to discuss bed expansion, he said. Instead, it’s time to focus on shoring up existing resources.

“In the near term, we have enough beds,” he wrote in an email. “We can’t staff the ones we have.”

Losing Money andShort on Workers

Horn said she doesn’t make decisions about whom to accept based on whether potential residents are on Medicaid, but instead based on whether the facility has the capacity to meet their needs and whether they will fit in with the rest of the community.

But Medicaid rates are a factor in how much Horn can afford to pay her staff, she said. Since the region is in the midst of a labor crunch, there have been times in the past two years when she simply hasn’t had the staff capacity to accept new residents, she said.

Because Medicaid rates are based on the facility’s overall “acuity level,” a measure of the severity of the illnesses and needs of the people in their care, Horn has to take that into consideration when she decides whether to accept a patient. If a patient’s needs are relatively low, that could pull down the facility’s acuity level and the rate Medicaid pays, she said.

They “may not actually need a nursing home,” she said.

At Grafton County Nursing Home in North Haverhill, where the majority of rooms are semi-private, administrator Craig Labore said his capacity is limited by how patients interact.

“Roommate pairing becomes very, very difficult,” he said. Those difficulties are “the majority of the reason why we have empty beds at the moment.”

For example, patients with complex needs such as dementia, post -traumatic stress disorder or traumatic brain injuries can be especially difficult to place.

The Grafton County facility, which has 135 beds, is running at about 95 percent occupancy for the first six months of its fiscal year, Labore said.

While increasing Medicaid reimbursement rates might not make it easier to match roommates, it would make it easier to attract and retain staff, he said.

“It does all come back to funding,” he said. “If we were reimbursed according to our costs, nursing homes would be able to do more.”

Labore and other nursing home administrators are hopeful that the Legislature will act to increase Medicaid reimbursement rates this session.

“The state needs to step up to the plate and do more and stop pushing it off to the counties,” he said.

Fundamentally, nursing homes know they will lose money on every Medicaid patient they care for, Chris Martin, the administrator of the 53-bed Woodlawn Care Center in Newport, said.

The Woodlawn facility has a waiting list of about 10 patients, he said. The facility has seen greater demand for its beds since New London Hospital’s William P. Clough Extended Care Center closed in 2016, he said.

The private daily rate at Woodlawn is about $250. While Martin estimates it costs $197 per day to care for each Medicaid resident, the state reimburses him about $145.

“Medicaid reimbursement rates have not been keeping up with just even regular inflation let alone health care,” he said.

These low rates, combined with a tight labor supply — requiring staff to work overtime — make it difficult for nursing homes, especially independent ones like Woodlawn, to balance the books, Martin said.

“It’s really hard to be competitive in the red-hot job market,” he said.

Beyond Nursing Homes

The reimbursement problem isn’t unique to nursing homes. It carries through to other levels of care.

Some Medicaid patients at Hanover Terrace might be able to do well in a lower level of care such as assisted living, said administrator Martha Chesley. But, there are very few assisted living beds available to people on Medicaid, she said.

This creates a “domino effect in some ways,” she said.

Options are limited for low-income patients in need of dementia care in the Upper Valley, Mike Byers, who runs the dementia unit at Valley Terrace — an assisted living facility — in Wilder, said.

If patients’ only diagnosis is dementia, Byers said, they don’t really need nursing home-level care. But those reliant on Medicaid to pay for their care often end up in nursing homes, he said.

“It would be so much better for them to have a place where they can just live their lives,” he said.

Meanwhile, the region is at risk of losing some of the facilities it has that provide lower levels of care to Medicaid patients.

Teresa Hemingway, who manages the 11-bed residential care home Bradford Oasis — which provides services including meals, laundry and assistance with transportation and medication — said that when she started in January, the staff were starting at $15 per hour. But in order to keep the doors open in light of Medicaid rates of $37 per person per day, she had to cut employees’ rate of pay.

“The system is not made for little residential homes like this to sustain (themselves),” Hemingway said.

Her staff is overworked. She herself works Mondays through Saturdays.

“Those of us who have families, it’s like ‘hi/bye,’ ” she said.

She said she’s cut everything out of the budget that’s not essential.

“I’m going to try my damnedest to keep us open as long as we can,” she said.

Care at Home

In addition to advocating for increases in Medicaid rates, Merrens said D-H is working with its member hospitals as well as the Visiting Nurses Association for Vermont and New Hampshire, which is also an affiliate, to address the bed crunch.

Both DHMC and Alice Peck Day Memorial Hospital in Lebanon have geriatric services that provide some care to frail, elderly patients in their homes. Expanding on this care at home may help keep people out of the hospital in the future, Merrens said.

“Part of our future (is) how can we have more at-home work?” Merrens said.

But that solution may also be limited by low Medicaid rates. In some cases, home care agencies are unable to provide the support people need to stay at home because reimbursements are insufficient to cover expenses, Jim Culhane, CEO of Lake Sunapee Home and Hospice, said.

If the care a patient needs upon returning home from the hospital is short-term, rehabilitative and intermittent, it will be covered by most insurance plans until the patient has healed, Culhane said. But, when a patient’s needs are long-term and Medicaid is required to pay for services such as help showering, getting dressed or cleaning the house, reimbursement falls far below the cost, Culhane said.

As a result, several agencies are considering or have already stopped providing the service, he said. Those who remain, including Lake Sunapee, are struggling to recruit and pay the necessary staff.

That means it can be a long wait for patients in need of such assistance.

This problem is “rising to the level of crisis,” he said.

It will only worsen as the population continues to age and more people need care, he said.

Lack of help at home can put patients at risk of an inpatient hospital stay or a higher level of care at another facility, which has a much higher cost to the system, Culhane said.

Culhane drew a parallel between the state’s ongoing mental health and addiction crisis, and the challenges facing the long-term care system.

He said he’s glad to see that more attention is being paid to the mental health and addiction crisis of late. But he’s critical of what it took to get that attention — mental health patients crowding emergency rooms and people dying of drug overdoses — and says he hopes that it doesn’t take something that extreme to get policymakers to take note of the challenges facing long-term care providers.

“If I could be blunt, the lack of attention to those issues (is what) led us to the current crisis,” he said.

Staff Writer Nora Doyle-Burr can be reached at or 603-727-3213.


Dr. Joseph Perras is the chief executive officer of Mt. Ascutney Hospital and Health Center. His last name was misspelled in an earlier version of this story.

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