Report: Pa. nursing home crisis deepens

Pennsylvania’s older residents who can no longer live independently and need long-term care are facing a growing crisis — one accelerated by the pandemic.

While more people are seeking and receiving care in a long-term community setting, a report released by the Independent Fiscal Office in late October shows that the supply continues to fall short. Shrinking nursing home staffing and capacity has prolonged waitlists for placement and posed significant financial burden on families.

When Pennsylvania Health Care Association President and CEO Zach Shamberg saw the report, he found that it reflected trends that have troubled his organization for years.

“It validates the concerns that we’ve been sharing on behalf of our long-term care provider members,” he said. “Our population is getting older, and the number of nursing homes and available beds are shrinking. That is a recipe for disaster over the next five to 10 years.”

The number of facilities and certified bed capacity in state nursing homes plummeted between 2019 and 2023. The number of beds per 1,000 Pennsylvanians age 75 or older declined from about 85 in 2019 to 76 in 2023.

The same trend emerged in staffing numbers. Pennsylvania lost more nursing home employees than the nationwide average, declining by 13.7% versus the 8.6% loss seen across the country.

And more seniors are clamoring for spots in these strained facilities — the number of people getting care through community waiver-funded services has increased 13% since 2019.

Based on a PHCA survey cited in the report, the average number of Pennsylvanians on a nursing home waiting list is three. Applying this to the 672 certified facilities across the state, the data suggests that roughly 2,000 residents are waiting for a slot on any given day.

Seniors are getting forced out of their own communities as a result.

“We never thought that waitlists would exist in nursing homes in Pennsylvania, but here we are,” Mr. Shamberg said. “If they can’t find care in their own town or community, unfortunately, what we’re hearing and what we’re seeing is that families are traveling further than they’ve ever had to before just to find a nursing home that will accept their loved one.”

The PHCA is hearing from the providers, too, and “overwhelmingly” so in regard to staffing gaps, Mr. Shamberg said. In 2019, the industry had a payroll workforce of nearly 216,000, the report states. Preliminary data suggest that the number will decline to 186,300 by this year.

When there aren’t enough nurses and caregivers, nursing homes may be forced to operate at minimized capacity, with open beds being left empty. Or, they might have to shut down, leaving seniors with fewer options from an already limited pool of resources.

“We have an access-to-care crisis in Pennsylvania,” he said. “What we’re seeing more and more is facilities effectively closing their doors to new residents and to new patients. The biggest question is, where will our seniors go? Where will our adults with disabilities go to receive care? We don’t have that answer right now.”

The issue proves larger than the nursing home industry, putting a great burden on the hospital system as well.

When a hospitalized senior can’t secure a certified bed in a nursing home, they may have to remain there. The delay creates a backlog of people waiting for care placement. Mr. Shamberg said the pandemic made the problem much worse, as the volume of patients sick from the virus were already overwhelming local hospitals.

With a career spanning 28 years in long-term care, Jim Pieffer, president and CEO of Presbyterian SeniorCare Network, said the past several years have posed the greatest challenges yet to senior care.

“COVID just took it to a whole other level,” he said. “There’s always been a workforce issue in long-term care since prior to the pandemic, but the last three years have really accelerated that issue, and it’s become a full-blown crisis.”

The result? Closures, and a lot of them. Nearly 580 nursing homes shut their doors nationwide during the pandemic.

Mr. Pieffer says his own organization, the largest senior services provider in Western Pennsylvania, had some tough calls to make.

The network, which has six nursing home facilities in its portfolio, sold two of their northwest communities this year. And their 200-bed facility in Oakland is currently operating with only about 150 beds because they don’t have enough staff and state reimbursement money for services. He estimates they turned down 500 hospital referrals this year alone.

“People have had to stay in emergency rooms in some cases in our Washington community,” he said. “It’s really a whole systems problem now.”

Such delays in hospital transfers also come with financial implications. The IFO’s report estimates that it costs roughly 10 times more to keep a patient in a hospital than to discharge them to a long-term care facility, when looking at a $2,838 average daily hospital rate versus a $282 average daily nursing home rate. Even short delays can result in higher costs, according to the report.

“This should sound the alarm right here that backlogs are not only bad for the patient, but they’re bad for the state and our state’s fiscal responsibility,” Mr. Shamberg said.

What makes the access to care crisis especially consequential for Pennsylvania is its rapidly expanding elderly population.

From 2019 to 2023, the age 75-plus cohort grew by 9% and is projected to jump by another 13.6% from 2023 to 2027. But not only is the older population growing, younger age cohorts are on the decline. Between 2019 and 2023, the 0 to 19 age cohort fell by 3.6% and is expected to decrease by 1.9% by 2027.

“Our fastest growing demographic is aged 85 and older,” Mr. Shamberg said. “We need to be prepared to care for that older population. Today, we are not.”

Pennsylvania lawmakers are taking steps to address the crisis, introducing new regulations for long-term care facilities that took effect this summer. Facilities must now provide at least 2.87 hours of direct care each day. That number will tick up to 3.2 hours by July 2024.

At the same time, new directives may be coming from the federal level. Last month, the Centers for Medicare & Medicaid Services proposed several new staffing requirements for long-term care facilities, including requiring registered nurses to be on-site 24 hours a day. The proposals are in the 60-day comment period.

Mr. Shamberg says there’s just not enough staff to meet the federal mandate. The PHCA had supported the state’s regulations, but that was because they also came with commensurate Medicaid funding for providers. Until last year, the Medicaid reimbursement rate for nursing homes had not increased in Pennsylvania for nearly a decade.

“We have providers who are now attempting to meet new state regulations that went into effect just a few months ago,” Mr. Shamberg said. “They’re looking at impending federal regulations, and they’re asking themselves, how do we make this work?”

Mr. Pieffer said the premise behind the guidelines make sense — guaranteeing more consistent hours of care from qualified practitioners. But he feels the additional requirements will strain already-strained facilities.

“We would love to have more staff in all of our communities,” he said. “But to try to mandate this at this time, it’s like trying to put out a fire with gasoline.”

In the meantime, providers are doing what they can to assist families.

“If we have people on our waiting list, we’ve been trying to look at ways to help them, like can we provide some services in their home?” he said. “But we’re still under-reimbursed about $80 to $100 a day for every person that we serve, so how can this be a sustainable model?”