care in Massachusetts co-reported by the state's four diocesan newspapers:

The Pilot, The Catholic Observer, The Catholic Free Press and The Anchor.

By Father Bill Pomerleau

And Michael Cox

SPRINGFIELD - Connie Henning, the administrator of the Providence Care Center of Springfield was in a good mood Jan. 13.

Despite a worsening snowstorm, hundreds of people had come to an open house at the former Crescent Hill Nursing Home in this city's South End.  Only a limited number of visitors that day were family members of potential residents for the once-empty center which was completely refurbished by the Sisters of Providence Health System last November. But Henning seemed more pleased that dozens of nurses, aides and otherhealth professionals and para-professionals had stopped by to view her facility.

"I've only hired two new nurses since we moved here," complained Joan Jalandra, the medical director of the Springfield care center.

Most of the staff from the now-closed Spruce Manor Nursing home, which was also managed by the Providence system, transferred with their patients to the newer home, but filling the extra beds in the bigger place has been delayed as Ms. Henning and Ms. Jalandra struggle to expand their staff.  Ironically, only a few Catholic extended-care facilities in Massachusetts have even moderate occupancy problems, and none are threatened with closure because they cannot fill enough of their beds. This contrasts sharply with some non-Catholic facilities, which account for nearly all of the estimated 5,000 empty nursing home beds in the state.

But staffing-related issues are preventing a few homes from promptly filling all of their available beds, and driving up costs with no increase in patient care for many others.

Henning told the diocesan newspapers of Massachusetts that the final two units of her center will probably accept patients in April, once state regulators are satisfied that they have hired sufficient, permanent staff.  The Springfield facility, located a short bus ride away from several lower income neighborhoods, has been able to more easily recruit certified nurses assistants, food service workers, and other non-professional or para-professional workers.

But in more affluent Lenox, where the Sisters of Providence have also re-opened a nursing home, and in the tighter labor market of eastern Massachusetts, even unskilled workers are difficult to find.

"We're competing with McDonald's. There are better benefits at fast food places," admitted Tara Gregorio, the assistant director of government relations for the Massachusetts Extended Care Federation, an industry trade group of nursing home owners.

In a collaboration unthinkable a few years ago, Gregorio has been travelling the state with organizers from the Service Employees International Union and the National Association of Social Workers.  Banded together as the Coalition of Organizations to Reform Eldercare, both management and labor are now lobbying Beacon Hill for higher Medicaid reimbursement rates. The nursing home operators now also agree with labor that the state should mandate higher minimum  staffing criteria, since today's typical nursing home resident is more medically needy than a resident in the past.

They also share a concern about the rising use of per-diem employees hired through agencies.

"Pools" were traditionally used by health care facilities that needed occasional temporary help, such as hospitals opening more beds during a flu outbreak. But some operators today use them to hold down the salaries of, or even replace, unionized employees with benefit-less, unorganized temporary workers, the employees union charges.

Most operators are also wary of a growing reliance on pools, since it drives up their costs as the agencies take a cut of the higher hourly wages the nursing homes have to pay. Catholic nursing homes find it difficult to avoid the use of pools and other practices as they are forced to compete for employees. But they also see a clear moral dilemma as they struggle to provide compassionate care to residents at a competitive cost, while not exploiting their workers.

"We're employing the working poor. We're not paying them a living wage," admitted Susan McDonough, the vice-president for Elder Services at Covenant Health Systems, New England's largest owner and/or operator of Catholic extended care facilities.

Like the Massachusetts facilities owned by the Providence Sisters, other religious orders, and the Caritas Christi Health System, Covenant has avoided much of the turbulence of some for-profit nursing home operators in the region.

Unlike the bankrupt for-profit operators which now operate about a fifth of the nursing home beds in Massachusetts, Covenant facilities largely avoided the management turmoil in their industry. Most Catholic nursing homes, even with older buildings in less attractive neighborhoods, are still financially stable and full.

But they are not completely immune from market forces. Covenant was forced to close Cambridge's Youville Heath Care Center in Cambridge in 1998 when changes in Medicare and HMO reimbursements made its short-stay, sub-acute care units unviable.

In the same year, Covenant purchased a failing nursing home on Worcester's Queen Street. Today, system administrators admit that the conversion of the former for-profit Mariner Health facility into the non-profit St. Mary's Health Care Center was a calculated risk.

The facility was in dire need of renovations and patients, it had a spotty past that included seven name changes in recent memory, and was located in one of the one of the poorest sections of the city.

Added to its challenges was the continuing saturation of nursing homes in central Massachusetts.

" (Covenant) really stuck their necks out doing it, both financially and because the facility had been through so much turmoil in the past," said Christopher Lane who took over administration of the facility in April 1999.

At the time, 43 of 123 beds were empty. After a $1 million renovation, and a marketing plan stressing the home's Catholic identity, its census climbed to 103 beds.

Lane now believes that his facility has a solid local reputation for providing quality care in a spiritual environment. But he has still to fill his final 20 beds in a region that will likely see further closures in what he termed a cruel game of survival of the fittest.

"If we were still at 80 beds who knows if we'd still be here?" Lane wondered.

Catholic nursing home administrators stress that their current problems are not completely comparable to the struggles of Catholic hospitals, which may be making them more difficult for the average Catholic and others who need their services to see.

"There's a cumulative effect here. Things have been a mess for 15 years, but a failing hospital or HMO crisis gets more attention," said Carmelite Sister Pauline Ross, administrator of Marion Manor For the Aged and Infirmed in South Boston.

As chairwoman of the Extended Care Federation, Sister Ross supports state Senate Bill 2130, which would fund an immediate 10 percent wage increase for nursing home Certified Nursing Assistants, who provide much of the day-to-day care to residents. CNAs earn an average of $8-10 hour, and have a statewide job turnover rate of 93 percent.

Another bill would raise minimum staffing so that each resident would have 4.13 hours a day of direct care from a staff member. Together, the changes would eventually cost $300 million annually.

Half of the funding would be reimbursed from the federal government. But that still carries little weight with state lawmakers more concerned with hospital and HMO problems.

"Even legislators who agree with us are saying our proposal hasn't yet passed the laugh test," Gregorio said at a March 23 forum at the South Hadley Council on Aging.

SIDEBAR

 By Michael Cox

WORCESTER - Facing economic constraints, nursing homes have resorted to unique penny-pinching strategies to provide the best possible care on the smallest dollar.

Such is the case at Notre Dame Longterm Care Center where they have formed unlikely alliances with their competitors to bolster their purchasing power.

This (which is akin to Starbucks and Dunkin’ Donuts forming a coffee-buying partnership) and other economizing efforts are just some of the ways elder-care providers are trying to get the biggest bang for their buck in a field that is under-funded, under-staffed and over-bedded.

"We try to economize in areas that don’t affect patient care," laments Notre Dame’s administrator Katherine M. Lemay whose facility is part of Intercare Alliance, a group of local nursing homes who are involved in volume purchasing to try to decrease their expenses. "The more we can save on our supplies, the more we can spend on staffing."

While the Catholic facility on Plantation Street, owned by the Sisters of Notre Dame de Namur, has remained financially strong in recent years, others haven’t been so fortunate. One in six nursing homes in Massachusetts is currently in bankruptcy; 16 in central Massachusetts have gone into bankruptcy since 1998, according to the Massachusetts Extended Care Federation.

Economizing efforts aren’t enough, insists Mrs. Lemay, who says there needs to be more political debate about how best to care for the nation’s elders.

"If we had 16 banks that went out of business, you can be sure those bankers would have plenty of clout," she said. "Think of our population — old, frail and debilitated women. How strong a voice do they have? What’s their political clout?"

Mrs. Lemay is among a growing number of nursing home administrators who agree that the system needs a drastic overhaul. "It is a system that was designed without a design. It all just happened by default," she says.

The problem for administrators in a nutshell is this, she explains. The state’s low Medicaid reimbursement rates have resulted in a staffing shortage brought on by low wages in a booming economy.

In Massachusetts, more than 70 percent of the state’s nursing home residents are recipients of Medicaid, the state-federal program that pays for healthcare for the poor. And wages are directly tied to those Medicare rates, says Mrs. Lemay.

Therefore, if the state’s reimbursement rate is too low it becomes difficult to recruit and retain qualified health care workers. The Extended Care Federation says most homes lose $10 to 15 per Medicaid patient per day, according to a recent article in the Worcester Business Journal.

Meanwhile, the state has done little to address the problem, says Mrs. Lemay.

Gov. Paul Cellucci’s $69 million increase in Medicaid funding for next year amounts to a 3 percent increase statewide (it’s a 1 percent increase at Notre Dame), she says. But it will be spent mostly on staffing and is barely enough to effect any real change in wages, she points out.

Certified Nursing Assistants, who provide much of the day-to-day care to residents, make an average of $8-10 hour, and they have a statewide job turnover rate of 93 percent.

Thanks to a bonus referral plan and a reasonably flexible work schedule, the turnover rate at Notre Dame is at a relatively low 65 percent, says Mrs. Lemay.

"So even though we’re far lower than the state average, it’s still a struggle for us. And we work really hard to keep the people we have and to recruit others."

Turnover in staff and under-staffing in nursing homes statewide inevitably means one thing for the patients: more deficiencies, insists Notre Dame’s administrator. "There are three things that affect quality of care," she points out, "It’s staffing, staffing and staffing."

Notre Dame for its part has been able to remain in sound fiscal shape despite the industry woes of its competitors. It has also been able to provide a high level of care. Mrs. Lemay points to several factors for their good fortune.

Part of it is their reliance of private pay residents who offset the cost of Medicaid. Notre Dame is funded 70-75 percent on Medicaid and 20 25 by private payers. Some nursing homes rely up to 90 percent on Medicaid, she says.

In addition, the building is modern, well-managed and efficient, and Notre Dame’s reputation as a quality health care provider in the community has allowed its occupancy rates to stay full in a region that is unquestionably over bedded, she says.

Mrs. Lemay also points to the facility’s Catholicity as its mainstay. "I think it adds another dimension that has a tremendous impact on the quality of life."

Notre Dame’s rosy fiscal outlook notwithstanding, the administrator strongly believes that lawmakers have to take action before more nursing homes fall by the wayside. Or worse, residents are not cared for properly. But just how to fix the system is open for debate.

In the short-term, she says, it makes sense to increase the Medicaid rates and establish some minimum staffing levels to ensure the quality of care. But continuing to increase the rates year after year is only a temporary solution to a long-term problem.

Long-term solutions, she says, should include the purchasing of private insurance and tax credits for those who plan for their long term health care needs.

These are supposed to be the best of times, she points out. "What will happen when it inevitably turns?" And what will happen, she adds, when all the Baby Boomers, most of whom are around 50, get older? "Who will care for them?"