Wisconsin nursing home crisis: where will we find staff and how will we pay them?

By LeAnn R. Ralph

COLFAX  —  It is turning out to be the perfect storm.

Well — perhaps “perfect” is not the right word to describe what is most definitely a storm.

The combination of Medicaid reimbursement rates that do not cover costs, a stringent training program, waiting lists for training programs because there are not enough facilities and instructors, a shrinking labor pool and wages that are so low, employees sometimes qualify for public assistance programs — have combined to create a crisis for nursing homes in Wisconsin.

And the Colfax Health and Rehabilitation Center is no exception.

Residents and staff at CHRC met with state Senator Terry Moulton January 30 to discuss the problems associated with staffing and to find out if there might be any help on the horizon.

Senator Moulton (R-Chippewa Falls) is the senator for the state’s 23rd Senate District which includes state Assembly Districts 67, 68 and 69. 

Colfax is located in the 67th Assembly District.

Medicaid

Part of the problem with finding enough staff to work at CHRC is that Wisconsin has the lowest Medicaid reimbursement rate for nursing homes in the United States. 

Because the Medicaid reimbursement rate is low, that means CHRC has less money to pay staff members better wages, said Jill Gengler, CHRC administrator.

“We are competing with other industries, gas stations and factories, that are paying higher wages, that are paying more than our staff are making who have been here ten or 15 years. Our rates are not allowing us to pay them more to keep them here. It’s really becoming a struggle,” Gengler said.

“I’ve heard that from many nursing homes around the district, especially concerning CNAs,” Senator Moulton said. 

Certified Nursing Assistants (CNAs) must go through a training program and become licensed as a CNA in order to work at a nursing home in Wisconsin. 

According to “Long-term Care Workforce Crisis: A 2016 Report” one in seven direct caregiver positions in Wisconsin’s nursing home and assisted living facilities are currently vacant. The survey discovered there are as many as 11,500 job openings in long-term care facilities across the state. 

The report was produced by the Wisconsin Health Care Association/Wisconsin Center for Assisted Living, LeadingAge Wisconsin, the Wisconsin Assisted Living Association and the Residential Services Association of Wisconsin. 

According to the report, the average Wisconsin facility is losing $55.89 per day for each Medicaid recipient. The report notes there are 16,490 Medicaid recipients residing in nursing homes, which would amount to a daily loss statewide of $921,626 — or nearly $1 million per day. 

“The combination of heavy reliance on the Medicaid program and the insufficient funding of that program severely limits a nursing home’s ability to compete in a tight labor market,” the report states.

Why?

CHRC resident Bess Jackson wanted to know more about why Wisconsin has such a low Medicaid reimbursement rate.

“That’s because of the reimbursement from the federal government. It’s not that the state of Wisconsin has decided to keep the money. The reimbursement we get from the federal government for Medicaid is lower than most other states,” Senator Moulton said.

“It is based on a formula. All states are based on the same formula. You could compare it to school aid. It’s in the same vein. When the public school aid formula was set up, some of the rural school districts were very conservative (in their spending), and they are now struggling because they are getting lower revenue (that was based on previous spending levels),” he said. 

Senator Moulton said he was hoping that Wisconsin would get more Medicaid money in the form of a block grant if the federal government decides to disburse Medicaid funds in a block grant form.

“Maybe with a block grant, we will have more flexibility about what we can do with that money,” he said.

Senator Moulton said he thought maybe the federal government would be acting on a block grant within six months.

According to information from LeadingAge Wisconsin, Wisconsin Medicaid nursing home funding for fee-for-service payments has decreased by more than $100 million since 2012.

There is no guarantee that if the federal government distributes Medicaid funding as a block grant that Wisconsin would get more money than the state receives now, and Senator Moulton did not elaborate on where Medicaid funding might be cut in order to shift more of the money to nursing homes. 

The current Medicaid rate is $198 per day, Gengler said. 

“Our rate to cover costs is much higher than that. Our private pay rate is $255 per day. There is a very big gap,” she said. 

“We have to cover our costs somehow … we can’t pay our bills and pay our staff unless we have money coming in the door. We also have some people on Medicare,” Gengler said.

Medicare covers a better portion of the cost, but Medicare only covers short-term stays, she said.

According to a fact sheet distributed to the Neighbors of Dunn County committee earlier in 2016, the average pay for Certified Nursing Assistants in Wisconsin is $13.32 per hour.

In addition to the decline in Medicaid reimbursement rates, Medicare reimbursement also is declining because of the federal sequestration

An austerity fiscal policy, the federal Budget Control Act of 2011 which went into effect in 2013, reduced Medicare payments by 2 percent per year. 

The federal Bipartisan Budget Act of 2015 extended Medicare sequestration until 2025 and continues to decrease Medicare provider and plan payments by 2 percent each year.  

Training hours

The number of training hours required for a CNA in Wisconsin is about double the number of hours required in Minnesota, Gengler said. 

The difference in training requirements means that people who might be willing to come across the border to work in Wisconsin are having trouble getting certified, she said.

“It takes us longer to get our aides certified, and we also do a lot of training on site. Our industry, as a whole, does not think we need that high of a training requirement,” Gengler said.

CHRC employs several different kinds of staff members to take care of residents.

Personal care workers are employed in the assisted living portion of CHRC (Sandy Ridge Apartments) and can be trained in-house with trainers who come in and do the training, Gengler said.

The CNAs need about three times as much training as the personal care workers, and they must take a CNA course off-site to be able to work in the nursing home, she noted.

CNA training programs are in short supply.

“It is difficult to get into certified nursing assistant programs. For many nursing students and physical therapists — the certified nursing assistant training is required as part of their school. But then they are never required to use it, or do not use it, in their field,” Gengler said.

“Those spots in the class are taken up by (nursing students and physical therapists). People who want to work in a nursing home have to find a class and get on a waiting list,” she said, adding that a shortage of trainers also is contributing to the problem.

Fewer hours

Gengler said that while she is advocating for requiring fewer training hours for CNAs, she is not advocating for less-qualified CNAs.

“When someone comes into the skilled nursing setting, there are a lot of medical needs that need to be addressed, and the training is something (the CNAs) need to be effective in that role,” she said.

“But when you look at the training requirements between Wisconsin and Minnesota, ours are higher than most. I could see the on-the-floor training hours being reduced, the class hours being reduced. They’d still have to pass the test and meet all of the requirements, but it could make people a little easier to get through the program and get them out on the floor working,” Gengler said. 

Quinn Nellessen, director of nursing at CHRC, pointed out that CNA candidates also are experiencing difficulty getting into the testing sites so they can take the required tests and become certified.

“More testing sites would help,” she said.

In the past, when the American Red Cross was administering the testing to certify CNAs, there were more testing sites available and candidates could get in sooner to be certified, Nellessen said.

Now the testing has been taken over by a company called Pearson VUE, fewer sites are available and waiting time has increased, she said.

Registered nurses

Recruiting registered nurses for CHRC also has become much more difficult, Gengler said.

“There are fewer of them to go around,” she said.

Access to nursing programs at the university level or the technical college level is now more restricted, with waiting times running two or three years for people who want to become registered nurses, Gengler said.

Not enough instructors are available to teach in nursing programs, and universities and technical colleges are not able to increase the number of sections they offer, she said. 

The state Legislature also has decreased state aid for higher education in recent years.

“There are lots of people who want to go that route, but they are having difficulty getting into a nursing program,” Gengler said.

“That’s a real barrier to us. It would be helpful to have more nurses in the market, more nurses to work in long-term care,” she said.

“And my understanding is that it will only get worse because of the retirements that will be taking place in the next few years,” said Barb Stobb, activity director at CHRC.

The industry is expecting to have quite a few more openings for CNAs and nurses in the coming years because older workers will be retiring, Gengler said.

One facility in Eau Claire is recruiting candidates in Puerto Rico and finding families to sponsor them here. Other facilities are closing down wings because they do not have enough staff for the whole building, and they are consolidating their residents. Other facilities are not admitting as many new residents so they can take care of the ones they already have, Gengler said.

“It is making me very uncomfortable about what our options are moving forward to provide quality care — because that’s our mission. We are not-for-profit. We are community-owned and community-run. Our goal is to provide the best care possible, and we are finding that to be more and more difficult (with the shortage of CNAs and registered nurses). It’s a challenge every day, and there doesn’t seem to be any relief coming,” she said.

Staff meeting 

After a tour of the facility, Senator Moulton sat down to meet with CHRC staff members.

“It used to be we would post a position and get at least three or four applicants. Now when a job opening is posted, it can go six months without any applicants,” Gengler said.

CHRC currently has seven staff openings.

“We’ve seen a huge increase in needing to find coverage for shifts, any shift and all shifts,” said Kenzie Galetka, who does the scheduling for CHRC.

“It used to be day shifts would be full, and you’d have a hard time with night shifts, but now it’s every shift where we are starting to struggle,” she said.

In the last quarter, CHRC had 862 hours of over-time, and in the quarter before that, the facility had a little over 400 hours of over-time, Galetka said.

“It has been a definite struggle. It burns out a lot of our staff,” she said.

All together, 862 hours of overtime in a quarter is the equivalent of nearly two-full time staff members and amounts to nearly 72 hours per week.

“We lose staff because they are burned out. They are working all of the time,” Galetka said.

“The money only goes so far. We don’t have that much to play with. We are finding if we pay a little more to get people (to work for CHRC) then what do you do for the rest of your staff who have been here for years? You have to pay them more, too. There is no way to keep up with the cost for the low supply,” Gengler said.

One staff member noted that sometimes, after people get their CNA certification and start working and see how much they have to do for the pay, they start looking around and will go to another facility where they can get paid more money but do not have to work as hard.

“You could work at a grocery store and get comparable paychecks, compared to working on the floor and caring for residents. People will come here, and their stay is rather short, because once they are doing the duties, they realize how hard you have to work for the paycheck. Oftentimes, they don’t have a problem leaving,” said Caitlin Jewell, a CNA at CHRC.

Another staff member said it should not be about the money, but the reality is, all employees have bills to pay.

Demanding job

Staff members also noted that not only is the job of working in a nursing home physically demanding, but it is also mentally demanding.

Jewell said she has been a CNA for almost ten years, and the mental stress is the most difficult part of the job.

“I don’t mind working hard. I don’t mind a hard work load or to do the job of two people. But if you’re a resident, if you are seeking help and you have to wait ten or 15 minutes to get the help you need, the resident isn’t thinking, ‘oh, there is a shortfall in Medicaid funding for nursing homes.’ They reflect it back on you personally,” she said.

“They think you are not adequate at doing your job because it took you so long to come and assist them when in reality, you’ve been assisting other people. So no matter how much energy you spend helping other residents, you still feel, and the feedback you get from residents is — it’s not good enough. That affects you personally and your self worth,” Jewell said.

Staff members noted that if residents have to wait for assistance, it also becomes a safety issue. 

If the resident has to wait ten or 15 minutes because CNAs are working with someone else, sometimes the residents take it upon themselves to do what they need to do, such as going to the bathroom, and that can result in falls and injuries, they said.

Sign-on bonus

Senator Moulton noted that some facilities are paying sign-on bonuses.

“We have not implemented a sign-on bonus because I’m not sure it always pays off in the long run. Some are paying big chunks of money to get people to jump ship. The worker who is willing to do that is not always the highest quality,” Gengler said.

In some instances, employees will work at a facility long enough to get the sign-on bonus, then they leave for the next facility to get the next sign-on bonus, she said.

“Our resources are so limited we don’t have options like that. We are a stand-alone not-for-profit. We don’t have a large corporate umbrella or maybe a Grace Lutheran Foundation that backs us up. Or the County of Dunn to raise taxes. We don’t have anything. We have to be very careful about the dollars we spend. We have so few dollars to spend in a market that has become fierce and competitive,” Gengler said. 

One staff member noted that nursing homes can offer all the money they want for sign-on bonuses, but there just are not enough people available to work.

Complicated care

Staff members at CHRC said that the needs of people living in nursing homes have increased dramatically.

It is no longer a matter of Grandpa and Grandma just not wanting to stay alone in their home anymore, because in those situations, people have assisted living options, they said.

“What you are seeing here are complicated cares, more things going on, more acutely, more than just the rehab. Yes we have short-term rehab, but our long-term residents are more acute and require more care, but the funding just is not there. It’s the struggle of trying to provide that quality care because the residents deserve it,” one staff member said.

“Quality care costs money. Good people cost money,” Gengler said.

“People don’t work here for the money. But they do have to pay their bills,” she said.

“You don’t just come here to clock in and clock out. You have to care about the residents, otherwise there’s no way you can keep doing the job. One of the most important parts of the job is giving residents a good quality of life to the best of your ability,” Jewell said. 

Trust is an important part of the job as well. The residents have to trust that CHRC employees are going to take care of them, she said.

“But if you’re rushing, rushing, rushing because you’ve got five other people waiting, it inhibits their ability to feel connected and to be able to trust you. That’s got to be frustrating for the residents. They don’t understand the background — and they shouldn’t have to,” Jewell said.

Nursing home staff also see more reactionary behaviors from residents because the residents do not understand why someone cannot help them right now. 

“You see more behaviors coming out. They are getting more mad at us and not letting us do the cares, too,” said one staff member.

Senator Moulton asked if the nursing home staff sees an impact on family members.

“Yes. When we are in the room, a family member will say, ‘we know you’re so busy. But … now we need this,” one staff member said.

“Or it’s the opposite. They will say, ‘you’re not meeting the needs of my parent.’ And they don’t care if you’re busy or not busy, staffed or short-staffed, they expect the best care for their parent. And that’s 100 percent right. They should expect the best care for their parent. Oftentimes they do not recognize that you are busy with other residents to care for. That’s not their concern. It’s their loved one who needs the care,” Jewell said.

Many of the nursing home staff also are working with residents on Hospice, and end-of-life care takes its toll on staff members too. 

“The residents deserve the best quality of life they can get here. To do that we need quality staff. And we can’t afford the staff, so we’re over-working the good staff we have, and something is going to have to suffer. But they are all too important to suffer,” said Olivia Larson, an administrative assistant who also works on scheduling staff. 

“People worked their whole lives. And now they’re being told they have to wait. That they have to wait for the staff to come and help them,” said one staff member.

“And it’s important things. Like going to the bathroom. Who wants to wait ten minutes when you have to go to the bathroom?” said another.

Senator Moulton noted that while he has never worked in a nursing home, he used to work at a hospital in Chippewa Falls.

“I know where you’re coming from. Hopefully we can make some inroads on getting more reimbursement. It is not falling on deaf ears. I understand your situation completely. I will do whatever I can,” he said.