Shifting state goals put rural nursing homes in death spiral

By Les Zaitz

The Enterprise

ONTARIO – The elderly woman had heard rumors of closure in the hallways of Presbyterian Community Care Center.

She learned the rumors were true when Cathleen Sullivan, the nursing home administrator, came to her room to tell her she would have to find a new home.

“When do I have to leave?” the resident asked.

Similar scenes played out in room after room as Sullivan delivered the news. And word of the impending closure rocketed through eastern Oregon’s nursing home industry. The challenges of rural health care had claimed another victim.

Reliance on nursing homes has declined across Oregon for decades. People now have more options than ever for care that ranges from weeks to years. Use of assisted living, residential care, and foster homes has mushroomed, according to state officials. They say consumers are less likely to resort to nursing homes, a choice dictated by preference or by finances.

Yet in rural Oregon, nursing homes remain a key fixture in health care, providing what no other residential facility can – around-the-clock nursing care. Only hospitals provide more extensive medical attention. Rural nursing homes in 2013 were considered so important legislators once labeled them “essential” assets for rural communities.

State officials still consider them so.

“We don’t want a community not to have a nursing facility option,” said Mike McCormick, deputy director of the state’s Aging and People with Disabilities unit of the state Department of Human Services.

Yet nursing home operators say state policies are to blame for weakening rural nursing homes, which by virtue of their location face higher costs.

“We’re in danger of losing vital access to vital services in rural communities,” said Jim Carlson, president of the Oregon Health Care Association.

In Baker City, the county’s only nursing home closed last year. The home opened in 1987 with 80 beds; by early 2016, just 15 were occupied.

In Prairie City, Blue Mountain Care Center has seen a steady drop in residents, including a decline of an average of 15 residents relying on state help to 10.

The resident count has dropped as well at Milton-Freewater Health and Rehabilitation Center. The center expanded its therapy staff to increase patient numbers.

“We have struggled to have a full therapy department, thus limiting what we can offer for rehabilitation services for the community,” said Russell Patterson, executive director.

In La Grande, two nursing homes merged and La Grande Post-Acute Rehab reports steady client numbers. Yet stays are shorter.

“It just makes running a skilled nursing facility more challenging,” said Steve Hamilton, executive director of the La Grande facility. It now has 38 residents.

Sullivan says state conduct in part forced the decision to close Presbyterian, which has served Malheur County more than 60 years. She and others believe state workers steer consumers away from nursing homes or press residents to move out sooner than they should.

Sullivan said her census of patients who rely on state-paid care has dropped steadily in recent years. In its current budget year, Presbyterian has lost $300,000.

Tom Hathaway, administrator of Pioneer Place, which has a nursing home as well as assisted living in nearby Vale, has seen the same trend. The drop has been so precipitous that Hathaway was preparing his board for a decision to close its nursing home. That decision is forestalled now by the loss of the Ontario home.

But unless something changes, “we’ll be lucky to last a year.”

Hathaway has been pressing the state to explain why it is sending fewer clients to nursing homes.

The health care association is pressing as well.

“It’s been a pretty aggressive program the state’s been running,” said Carlson.

In 2013, state officials and the nursing home industry agreed that Oregon had too many nursing home beds still in use after the shift to less-intensive care took hold. They agreed to eliminate 1,500 beds over three years out of a total of 12,332. The program was aimed at western Oregon and particularly urban areas. The state would reward the industry for hitting targets, and pay less in daily rates if it didn’t.

The industry got close – 1,210 beds.

“Now we’re in the stick era,” said McCormick, to get more beds taken out of service.

Nursing home officials said while it made sense to take empty beds offline in the Willamette Valley, the state seems determined to cut nursing home use in all corners of the state.

McCormick insisted that’s not so.

“The consumer preferences are overwhelmingly obvious,” he said. “People do not want to live in a nursing facility for a long period of time.”

He said state workers help patients get the right care in the right place. He said the state emphasizes independence, dignity and choice.

Sullivan said Presbyterian advocated for residents who wanted to stay in the nursing home rather than move to a lower level of care.

“On occasion, it worked,” Sullivan said. “Often, it didn’t.”

She became convinced that health care wasn’t the only issue.

“The factors were financial” in the state’s recommendations to patients, she said.

Sullivan and others say shifting patients away from nursing homes has more impact than just on the finances of the business.

Carlson, of the health care association, said he hears complaints from members who get patients from nursing homes about “inappropriate placements.” That means, he said, that patients are moved into health care facilities that can’t treat them.

“They get very frustrated when they get people whose care needs are too great,” Carlson said.

Hathaway thinks perhaps one-fourth of those moved out of nursing homes aren’t people who can care for themselves.

“Are they getting the nursing level of care they should be getting?” Hathaway asks. “Probably not.”

One nursing home administrator who spoke on background for fear of angering state officials said residents are moved out of nursing homes too quickly on occasion. He hears about “bad outcomes including deaths” but said no system in the state tracks the impact of such moves.

McCormick said “negative outcomes” happen at all long-term care facilities but the state relies on its case managers and licensing teams to detect issues. He noted that Oregon recently ranked No. 2 in the country in effective nursing home transitions as measured by AARP.

Carlson said his association is urging legislators to examine the issue after the current session. He said the state also ought to consider differing compensation for rural nursing homes just as rural hospitals get extra pay.

Ruth Gulyas of Leading Age Oregon said her group too is pressing the Department of Human Services to consider such an option. She said the response to that recent request was “they were going to look into the situation.”

McCormick said his agency has never considered such an option.

McCormick said that while nursing homes are a “critical” part of the health care system, the state leaves it to the marketplace to determine their financial viability. He was asked what the Department of Human Services is doing to ensure their survival.

“I don’t think we’re doing anything,” McCormick said. “We’re executing the statutes as written.”

Story written and reported by Les Zaitz of the Malheur Enterprise with additional reporting by Kathy Aney of the Pendleton East Oregonian, Susan Parrish of the La Grande Observer, and Rylan Boggs of the Blue Mountain Eagle in John Day.