Sep. 19—With under 30 beds, Somerset Rehabilitation and Living Center is among the smallest of Maine's more than 90 nursing homes.
But for nearly 40 years, the Bingham facility has served a critical niche for older Mainers and those in need of rehab among the small western Maine communities stretching from Skowhegan to Jackman. Yet when COVID-19 hit Maine's nursing homes with deadly ferocity in the spring of 2020, that rural location made an already challenging staffing situation all but untenable.
"We can't keep staffed appropriately to give the kind of care that we want to give to the people that live there," said John Orestis, president and CEO of North Country Associates, which has owned and operated the home for 37 years. "We just got to a point where we couldn't staff it and we couldn't hire — and we were concerned."
Somerset Rehabilitation and Living Center is one of four "skilled nursing" facilities to inform residents and families this month that they are shutting down permanently. The latest is Shaw House Residential Care in Biddeford, whose owner cited the combination of the pandemic and staffing challenges as top factors in his decision to close.
Roughly 120 residents across the four homes will be displaced. While the facilities are obligated under law to find "safe and appropriate" housing for the residents, the closures come at a time when even hospitals are struggling to find nursing home or rehab beds for discharged patients because the facilities they normally rely on are too short-staffed to accept new residents.
With that relief valve closed or severely restricted, some of Maine's largest hospitals are filled to capacity as the delta variant drives up COVID-related hospitalizations to some of their highest levels of the pandemic. Maine Medical Center, for instance, has had as many as 70 to 80 patients ready for discharge but stuck at the Portland hospital because there was nowhere to send them.
"It's a huge impact. When you think of (Maine Med) normally having 500 or 600 patients, that many patients is a significant impact," said Dr. Joan Boomsma, chief medical officer at MaineHealth, which operates Maine Med and six other hospitals around the state. "It's really a crisis. It's a staffing crisis."
And more closures may be coming.
Facility administrators are warning that the staffing crisis is likely to deepen through late October as some workers either quit or are fired because they refuse to comply with the state's COVID-19 vaccination mandate for health care workers.
On the day that the first three closures were announced, the administration of Gov. Janet Mills said it was speeding up disbursement of a $123 million infusion of emergency cash for Maine's long-term care homes. The money is aimed at helping facilities boost staff retention and recruitment — such as through higher pay and bonuses — during the current crisis, but it cannot correct the long-standing financial issues facing a critical industry in a state with the oldest population in the nation.
Angela Westhoff, executive director of the Maine Health Care Association, a trade group that represents nursing homes and long-term care facilities, called the $123 million a welcome development that provides "some hope" to the industry. But, she added, "I don't think we are out of the woods yet."
"I hear rumors. ... I think we may see a few more (closures)," Westhoff said. "I would like to be optimistic, but I fear there might be others coming."
STAFFING THE 'BIGGEST FRUSTRATION'
At the time of Westhoff's comments early last week, only three facilities had announced closure plans: Somerset Rehabilitation and Living Center, Country Manor Nursing Home in the Coopers Mills village of Whitefield and Island Nursing Home in the Hancock County community of Deer Isle.
Days later, Shaw House Residential Care in Biddeford became the fourth facility to notify residents, family members and the state about a pending closure.
For owner and administrator Edward Hunt, the decision to close the 20-bed nursing home wasn't entirely because of the workforce challenges. Instead, Hunt said it was a combination of the pandemic — including a recent COVID scare involving a staffer — plus the workforce challenges and the fact that he, himself, is 70 years old and has worked in health care for 44 years.
But Hunt said staffing was "the biggest frustration" over the past several years.
"I was going to try to hang in there," said Hunt, adding that COVID-19 relief grants helped but were a temporary fix. "Eventually it gets so bad that the government and the pay sources have to do something. ... But something has got to happen soon."
Hunt said he and his staff are busy making calls to find new homes for residents, but it's tough going. Among the facilities that have called him back, a few have space but many others have no available beds.
On a recent afternoon, 82-year-old Darellene Hussey of Sanford said she hoped to get her own place after Shaw House, which she described as "like a little family."
"I don't want to move to a big facility," Hussey said. "I like it here because it's small. ... It's more like a home than it is a nursing home."
Resident care manager Terry Cooper, who is helping look for placements for residents, echoed those sentiments.
"This is their home. This is their big family," Cooper said. "It's going to be hard on everybody, all of us."
Island Nursing Home in Deer Isle weathered a severe COVID-19 outbreak last fall that sickened all 62 of the facility's residents — 15 of them fatally — along with 38 staff members. The facility turned to short-term contract staff to fill shifts for sickened staffers and eventually negotiated a unique arrangement with the University of New England to enlist students from the medical and nursing schools to work shifts.
On Aug. 30, however, Island Nursing Home's board of directors announced the 72-bed facility would close on Oct. 26 after the pandemic exacerbated a decade-long staffing challenge.
"For INH, it is no longer a matter of location or funding; ... there are simply not enough qualified staff available in a rapidly declining healthcare workforce," the board wrote. "We have spent months exhausting every staffing resource at our disposal and beginning this fall, we will no longer be able to meet our minimum staffing requirements."
A long-term care facility closure announcement triggers a regulated response that, among other things, requires the facility to find suitable placement for any residents. In Maine, it also invokes the participation of the Maine Long-Term Care Ombudsman Program, a nonprofit agency that advocates for the rights of residents.
Agency staff immediately send letters to residents or their legal guardians sharing information and offering assistance, and they visit the facility to inform residents of their rights and answer questions from people about to have their often-fragile lives disrupted.
"It's really important that residents and their family members have information about what their options would be and that their rights are protected," said Brenda Gallant, a registered nurse who serves as the state's long-term care ombudsman.
Ideally, residents are placed as close to the original facility as possible unless they or their family members request placement near a different community — say, closer to an elderly person's children or grandchildren. Married couples living in the facility should be kept together, and any receiving facility must be able to provide the same level of care as the original.
Gallant said that, for many older people, moving out of their own home and into a facility is a "huge transition in an individual's life."
"Once they make that transition, the long-term care facility becomes their life — they get to know the staff, they get to know the other residents and the routine," Gallant said. "To have that interrupted and have to move can be extremely difficult."
Frank Slason, who is in his 90s, is experiencing that difficult, frustrating and sometimes traumatic transition firsthand with his wife. Diane Slason lived at Country Manor in Whitefield two years before the closure announcement several weeks ago.
Slason had hoped to move his wife, a highly accomplished equestrian rider who now has Alzheimer's disease, to a facility relatively close to him. But the Damariscotta home didn't return his repeated calls and another option was ruled out because his wife would be severely allergic to the home's resident cat.
Finally, Slason agreed to have his wife moved to Heritage Rehabilitation and Living Center, another North Country Associates home in Winthrop. The new home has hardwood floors, updated features and other amenities in the new wing where his wife will reside.
Last week, Slason made the roughly hourlong drive to Winthrop so he and his wife could celebrate their 64th wedding anniversary together. But the long drive is stressful given his age, he admitted, so his doctor recommended he scale back from daily visits.
"It's a beautiful place," he said. "I just wish it was closer."
As for the worker shortage, Slason said he has been well aware of the plight that Country Manor and other homes have faced and he thinks Gov. Mills should have stepped in sooner with more financial relief, particularly during the pandemic. He also has nothing but praise for the workers he described as "underpaid, overworked and not really appreciated."
"I really have a lot of respect for these caregivers — the care that they give everyone, with love and compassion," he said. "And it's not their relatives."
A LONG-TERM PROBLEM
Workers as well as their employers have been warning about a cratering of Maine's long-term care network long before COVID-19 further undercut the industry. Including the four pending closures, Maine has lost 15 nursing facilities since 2014.
Before the pandemic, many of the workers who perform some of the most physically and emotionally difficult, hands-on jobs in long-term care facilities — such as moving, cleaning and feeding bed-bound or physically limited residents — were often paid minimum wage. State reimbursement rates for MaineCare, which is the state's Medicaid program, also failed to keep up as Maine's minimum wage increased 60 percent, from $7.50 to $12 an hour, between 2016 and 2020, leaving facilities to make up the difference.
A 2020 report by the Commission to Study Long-Term Care Workforce Issues in Maine recommended, among other things, increasing the starting pay for direct care workers to at least 125 percent of minimum wage and promoting the jobs as a career choice.
The Mills administration and the Legislature did increase reimbursement rates for nursing homes, and the $123 million announced earlier this month offers additional help, at least temporarily. Officials at the Maine Department of Health and Human Services are also exploring a host of reforms focused on training, career ladders and attracting people to Maine to do the work.
"It is very impressive," said Gallant, the ombudsman, "but those are long-term strategies."
But as businesses across the state and the nation struggle to fill open jobs, long-term care facilities found themselves competing against entry-level jobs offering the same or more money for less physically or emotionally draining jobs.
"We used to not have to worry about competing with every business on the street," said Orestis, whose North Country Associates owns or operates roughly two dozen facilities in Maine. "But now, fast food establishments and other jobs in the neighborhood pay as much as us, and they are very difficult competition. They aren't constrained by Medicaid pay and they beat us on pay."
John Bolduc, executive director of the Odd Fellows' & Rebekahs' Home of Maine in Auburn, said he was down about six or seven employees out of a payroll of 65. Bolduc said his dedicated staff pulled together to get through the first year of the pandemic but during the past six months "it's just been downhill" because there are so few candidates to fill vacancies.
"There have to be changes in the future to the way things are done," Bolduc said.
On a recent afternoon, Bolduc was looking at staffing schedules littered with red lines showing shifts that will need to be filled because of vacancies, child care necessities or other issues. He and other homes have sometimes resorted during the pandemic to staffing agencies to fill shifts, but at significant cost.
One staffing agency recently quoted him $90 an hour for an overnight nurse position plus extra to cover the person's housing, travel and relocation costs. That same, highly trained person would be making $30 to $40 an hour if they were part of the regular staff.
"We are all paying much, much higher than we have in the past and when this is all over, we are not going to be able to go back down," Bolduc said. "And the ($123 million) the state has been giving us, it sounds like a lot, ... but when this is all done, we won't have that money, but will still have to pay those costs."
Westhoff, president of the Maine Health Care Association, hopes the spate of facility closures will help lead to action.
"I think we can't leave any stone unturned at this point," Westhoff said. "Out of the crisis, hopefully, there will be some silver linings. We've talked about it, there have been commissions, ... but now is the time that we need to roll up our sleeves. We have talked about it to death."
'ALL IN THE SAME BOAT'
Federal law sets strict patient-to-staff ratios for nursing homes and other long-term care facilities in order to provide a minimum level of care to residents. With their staffing ranks shrinking or workers having to call out because of COVID-19 exposure or child care, many homes have had to reduce the number of beds available in order to avoid violating those federal minimum staffing requirements.
Meanwhile, hospitals facing their own staffing shortages must also grapple with the growing patient bottleneck caused by the surge of COVID-19 patients and the lack of available nursing home or rehab beds for discharged patients.
MaineGeneral Medical Center in Augusta frequently has 20 to 30 patients a day who are unable to be discharged because no one can take them. Dr. Steven Diaz, an emergency medicine physician and chief medical officer at MaineGeneral Health, said the hospital is consistently at 98 to 100 percent capacity largely due to staffing and bed shortages in long-term care.
While MaineGeneral has yet to send away, or "divert," ambulances bound for the emergency room, the hospital regularly has to ask smaller, tertiary hospitals to delay patient transfers to Augusta for more specialized care.
"The whole system is impacted when something gets bottlenecked," Diaz said. "The census in the emergency department has been high for months now. Our partners understand and they will often hold onto patients in their ER until we have a solution. ... We are all in the same boat. We are supporting each other. But we are also up to our necks in terms of busyness."
It can also affect patient recovery if, for instance, a post-surgical patient's transfer to a rehab center is delayed.
Both MaineGeneral and MaineHealth, which operates Maine Medical Center, are bringing physical therapists into the hospital to begin that intensive therapy for some patients awaiting discharge. Boomsma, MaineHealth's chief medical officer, also said her organization is working with home-care providers to see if they can provide skilled nursing care to individuals who are sent home rather than to a facility.
But unlike MaineGeneral, Maine Medical Center has had to divert ambulances on several occasions because there was no capacity in the emergency department due to the COVID-19 surge and the patient bottleneck. The result, Boomsma said, is a "strain on the entire system" that requires care teams to work even harder.
"And this is on top of a staff that is already worn out from the past 18 months of COVID," Boomsma said.