Nursing homes struggle to retain workers, stay viable amid a boom in demand

Howard Sharp Butte figures waiting for help on his medications is a small price to pay, given the alternative.

Worse than slow service would be no service.

It's an alarmist view he shares with other residents at the 52-bed White River Health Care Center and with workers and administrators across South Dakota. They see a collision of human needs and economic trends that threaten the ability of the state's elderly-care centers to meet daily expenses, to keep employees on the payroll and, perhaps, to exist at all.

"I've lived here in this area all my life," says Butte, a former farm and ranch worker who at 74 relies on a cane to compensate for bad knees. "I like this place because I don't have to travel back and forth to see the town I know, and people who want to see me can just walk right over. That's how it should be if you get old and sick and need to be in a retirement home."

No one argues with that sentiment. But industry watchers do warn that without a significant change in approach to the logistics of long-term care, South Dakota could start losing nursing homes in large numbers during the next decade.

The challenges run from staffing to welfare payments to the industry's need to supply the expanded services that an aging population demands.

Just as with Social Security benefits of the next generation, when fewer wage-earners will be supporting more retirees, so it is with nursing home care. A smaller pool of employees will be pressed to serve a larger group of elderly. And if more elderly rely on the government to pay the bills, nursing homes will have to scramble even more to make up for losses that come with the Medicaid program.

"It is a crisis," says Mark Deak, president of the South Dakota Health Care Association. "These places are simply struggling just to keep their doors open."

Low pay, high turnover

An Argus Leader survey of 92 long-term care facilities in South Dakota found that the average age of nursing staff - registered nurses, licensed practical nurses and certified nursing assistants - is 41. About 94 percent of all nurses and assistants in the industry are women. Turnover among nursing staffs in 2004 was 25 percent. 

A South Dakota Health Care Association survey found that, among nurse assistants alone, turnover was 43 percent. It's much higher at many places, including White River. Administrator Karen Schmidt says turnover last year was 138 percent.

"We do everything we can, but we just barely meet our bills. There's no money left to raise pay or make anything much for capital improvements," she says. "So people don't stay too long."


White River Health Care Center resident Lorraine Eastman, 83, waits as nurse's assistant Colleen Bouman (left) prepares her shower.

Such warning signs appear as long-term care providers strive to find a winning formula to keep a steady work force. Low wages for front-line workers known as certified nurse assistants lead to high turnover. But providers hope job satisfaction will sustain their employees even as pay is modest and many tasks are unappealing. Under those circumstances, administrators are counting on their employees finding success in the intangible benefits of the job.

Making a difference

"People say, 'I don't know if I can do this,' but if they'll stick there 30 days, they're hooked," says Dan Fosness, South Dakota regional director for the Good Samaritan Society. "If you go into a room with a 100-year-old resident, who grabs you with this little wrinkled hand and says, 'Thank you, I don't know what I'd do without you,' that's where it's at."

Such bonding between worker and resident is the classic nursing home portrait. But it doesn't always work that way. Charlie Ward, who lives in Ellis and is in a partnership that owns or manages eight care centers in South Dakota, says front-line nursing home workers come and go "by the millions."

Shonnie Kratochvil, a social worker who lives near Alcester, gave the nursing home business 20 years before quitting out of frustration over regulations that cater to the bureaucracy rather than the welfare of the residents. 

"I burned out," says Kratochvil, 60, who now sells fragrances at Younkers. "The paperwork we're expected to do by the federal government is intense and, for the most part, only financial. I can't pretend I'm taking care of residents giving them the best care when I know we can't. So I walked away and I won't go back."

When a worker does connect with the job, however, the other issues fade. Ruby Sanftner, 55, took an $8,000 pay cut two years ago to leave restaurant work and become chief operating officer at the 23-bed Kadoka Care Center. "I'm never going to be a millionaire," she concedes, and neither will her 30 employees as long as they work for her. "There are very few raises at this facility," she says.

Sanftner wanted a job that allowed her to make a difference in others' lives, and she found it. But not everyone is smitten with the same fever. Her turnover rate is 45 percent, meaning she must replace 13 or 14 employees a year and then hope some of the rest will stay.

Educational opportunities

One who has stayed is Heidi Coller, 25, who grew up in Kadoka and returned in 2003 to work for Sanftner as a licensed practical nurse. "You fall in love with these residents," Coller says. "They become part of your family."

Coller, who earned her LPN through a 12-month program at Western Dakota Technical Institute in Rapid City, plans to upgrade her credentials to registered nurse through a home-study course capped by four days of clinicals.

Similarly, 132 employees in Good Samaritan's six-state region are working on their RN degrees through an online study program endorsed by the University of South Dakota, South Dakota State University, Lake Area Technical Institute of Watertown and Bellevue University of Omaha.

"This is very good news," says Margot Hood-Rogers, a learning consultant for Good Samaritan. 

"Employees and staff are very excited about learning opportunities, particularly those who are so place-bound in those small communities. Having access to education that takes them beyond where they are is very positive."

Under the best of circumstances, the demographics still would be ominous. South Dakotans older than 65, one-tenth of the population in 1960, will make up one-fourth by 2025. At the same time, women ages 25 to 55, the group most likely to work in nursing homes, will decline in relative strength. South Dakota today has 1.38 women in that age range for every person older than 65. By 2025, the ratio will be 0.65-to-1.

The Good Samaritan Center in Tripp has had little turnover and a wealth of long-term employees - including a certified nurse assistant whose wage has crawled up to $11 an hour after 30 years of service. The agency considers such employees a blessing, but their loyalty does expose another matter.

"They're not going to work forever," says administrator Stacy Kern.

Employee shortages throughout the industry are troublesome in light of population trends.

"We're just about ready to see the pig coming into the python," Fosness says from Sioux Falls. "I'm 49. When the baby boomers gear up and need nursing home care - it's frightening."

Inadequate reimbursement

Labor pool and employee retention are only half the equation for nursing homes gauging their future. The other half is the government reimbursement rate for eligible residents.

In the Good Samaritan Center in Tripp, for example, 35 percent of residents use their own money to pay for their stay and 5 percent qualify for Medicare because of time in a hospital. The other 60 percent are eligible for Medicaid because they have paid their personal wealth down below $2,000, Kern says. With the Medicaid reimbursement rate $107 per resident per day in Good Samaritan centers across the state, compared to actual costs of $122, the agency must find a way to cover the $15 gap.

The Medicaid program leaves nursing homes $3.5 billion short nationally and $24 million short in South Dakota, according to an analysis by accounting firm BDO Seidman. The federal government provides about two-thirds of Medicaid's funding, and the state pays the rest.

For each Medicaid resident in South Dakota, nursing homes lose $16.63 daily, according to the study. That's among the 10 highest shortfalls in the country.

Providers cover the red ink in a variety of ways: cutting services, carrying fewer employees, converting some beds from nursing home care to assisted living. Some use savings in the bank from days when private payments were the norm. But now, with Medicare residents in the majority, that source also is strained.

The new obstacle is that the Medicaid gap itself has become a moving target, with the Bush administration proposing budget cuts that would save the federal government money by widening the gap between nursing home costs and reimbursements. Congress has not yet had its say on the issue.

White River's example

The White River nursing home has 45 patients, most of them older than 70. Most have roots here, a community of 600 people 240 miles west of Sioux Falls, and they'd just as soon live here as Rapid City, Pierre or another city with more options for care.

Rural nursing homes put about two-thirds of their budgets toward covering staffing expenses. And most pay registered nurses - the most extensively trained - the going market rate or better. RNs in White River earn $18 an hour right out of college. That's on par with nurses in Sioux Falls and Rapid City. 

But there is little money left for certified nurse assistants, who help patients bathe, eat, exercise and so on - taxing work that often involves night and weekend shifts.

In White River, nurse assistants start at $6.75 an hour. Fast-food restaurants in nearby Winner and Pierre pay more for jobs that involve less stress and responsibility.

"It's a struggle," says Susan Comp, head of nursing in White River.

Money is so short that some homes can't pay for new equipment or building repairs. Homes in Parker, Dell Rapids and Letcher have closed, as have Prairie Crossings centers in Brookings, Aberdeen and Huron.

"The costs just keep going up, and the Medicaid reimbursements don't," says Mark Dickerson, spokesman for the Good Samaritan Society, which co-owns the three Prairie Crossing facilities. "So at some point, you just can't sustain them anymore."

In towns such as White River, nursing home leaders say they will stay open as long as they can.
White River residents say the community's economy depends on it. Along with the school, the nursing home is the largest employer in town.

Comp, who grew up here, says closing the home would cripple the local economy and quicken the town's demise.

Theresa Stands, 75, lives in the White River nursing home. She says much of her family and friends live within 20 miles. 

"I sure don't want that to change," she says. "Not at my age."

Butte, the 74-year-old ranch worker, doesn't think a quiet room in his hometown is too much to ask for. 

He points to a 60-year-old picture above his bed that shows him alongside his high school basketball teammates.

"That's who I know, what I know," he says. "I don't want to go off somewhere and try something new at my age."