Battling multiple challenges

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New York’s nursing homes face many difficulties, in addition to keeping residents safe.

Peg and Larry Witmer were married for 63 years. High school and college sweethearts, they had dated for six years before they wed. 

After Larry Witmer retired as executive director of the Greater Rochester Community of Churches several years ago, they moved from their 19th Ward home to St. John’s Meadows, a senior living complex affiliated with the St. John’s Home skilled nursing facility.

Then, Peg Witmer began to show symptoms of Alzheimer’s. As her dementia advanced, the cottage she and Larry were renting became too much to handle. Peg Witmer had bouts of confusion and was restless at night.

The couple moved to an apartment within the senior living facility’s Brighton complex. By this time, their son, Jim, and his husband, Randy Meyer, whose mother lives in Rochester, had relocated from Boston to Rochester to help care for their aging parents. 

Roughly two years ago, Peg’s difficulties were troublesome enough that they brought her to the Highland Hospital emergency room. When ER staff said they wanted to release her directly to St. John’s Home, Jim Witmer was relieved. He had hoped his mother could be placed in skilled nursing but feared they might have to overcome a series of bureaucratic hurdles to make that happen.  

Then came the COVID-19 pandemic, and as the outbreak progressed in lulls and surges, New York’s nursing homes became one of its flash points. Questions have almost entirely focused on a single statistic: the number of the state’s nursing home residents who succumbed to the virus.  How ready New York’s nursing homes might be to meet the needs of families like the Witmers, as they emerge from the pandemic, is a question yet to be answered. 

Like many families who have had to put loved ones into skilled nursing care, the Witmers have mixed feelings. Both father and son count the care Peg Witmer got as sometimes exceptionally good but at other times wanting. Still, both acknowledge, during the time Peg Witmer spent in the nursing home, no better alternative emerged.

After his wife moved into skilled nursing, Larry Witmer, who is in his 80s and dealing with an advancing case of Parkinson’s disease, gave up his apartment and moved into his son’s home. The 1940s-era, four-bedroom colonial sits near Highland Park midway between the nursing home and St. John’s Meadows. 

Living without the day-to-day contact of a wife he’d not been separated from for nearly seven decades was hard, Larry Witmer says. His wife’s dementia had advanced to a point that bringing her home seemed out of the question. 

One comfort for the family was that St. John’s Home was only a few blocks away, an easy walk from their home. After COVID hit, however, in-person visitation ceased and the nursing home might as well have been on another planet. 

Dealing with controversy

Locally, a nursing home controversy began to swirl in April 2020, when two Livingston County Republican state lawmakers called for the state to probe two COVID deaths at Hurlbut Care Communities’ 40-bed Avon Nursing facility. Hurlbut Care Communities CEO Bob Hurlbut at the time objected to what he considered to be unwarranted negative press coverage of his Avon facility. 

Hurlbut has since been somewhat vindicated after UR Medicine officials hailed him as a hero for opening up two of his nursing homes—free of the virus since May 2020—to recovering COVID patients as a measure to free hospital beds. UR Medicine Medical Director Michael Apostolakos M.D. publicly thanked Hurlbut profusely. 

Nursing home operators have largely blamed Gov. Andrew Cuomo’s late March 2020 directive ordering nursing homes to accept COVID-positive patients from hospitals for much of the virus’s spread in nursing homes. Cuomo has disputed the contention.

Mike McRae

Two of the first three COVID cases to appear at St. Ann’s Communities’ nursing homes came from hospital patients transferred there for rehabilitation, St. Ann’s CEO Mike McRae says. The third was a kidney patient who got weekly dialysis at on off-site facility. 

Through the summer, Cuomo insisted that the March order had little or no effect on nursing homes’ COVID infections and that the state’s nursing home deaths were relatively low. A July state Department of Health report and a statement by Special Counsel Beth Garvey released in the same month backed the governor’s statements.

In January, however, state Attorney General Letitia James released a report accusing the Cuomo administration of wildly understating New York’s nursing home deaths. 

And since then, some have questioned the governor’s explanations. A recent New York Times article suggests, for example, that Cuomo aides altered Health Department numbers as the governor’s book, touting his skillful handling of the pandemic, was being published, in an apparent attempt to make the death totals seem less drastic. 

That still-unsettled controversy has focused virtually all of the media’s gaze and much of the public’s attention on Cuomo’s count of fatalities. The state’s skilled nursing facilities’ pandemic-battered finances have drawn comparatively little attention. They could be turn out to be a concern of more lasting consequence.  

Some 12 months ago, when COVID began to seriously hit New York, Peg Witmer had been a St. John’s Home resident for more than a year. In March 2020, the state Health Department, which regulates all of New York’s nursing homes, ordered visitations to cease. As the pandemic waxed and waned, the no-visitor rule was alternately tightened and relaxed. But when in-person visitation was allowed, it was permitted only in facilities that had been COVID-free for 14 days prior, a standard that many including St. John’s Home were seldom able to meet.

St. John’s home is a member of the Alliance for Senior Care Communities, a consortium of five large Rochester-area nonprofit skilled nursing facilities. Other members are Jewish Senior Life, Episcopal Senior Life Communities, Friendly Senior Living and St. Ann’s. The consortium collectively accounts for some 2,000 nursing home beds, more than a third of the area’s total complement. 

Rising costs

As it has been with all health care professionals, learning how to deal with the virus as nursing operators was a matter of trial and error and learning by doing.

“I have never genuinely appreciated the saying building the airplane while it was in the air until we had to live through this,” McRae says. “The biggest challenge in the beginning was making sure of not getting spread from staff. Initial guidance was to let (COVID)-positive staff work with adequate PPE. Looking back now, why was that even allowed?” 

With the visitation shutdown, alliance members began a regimen of twice-weekly Zoom visitation for residents’ families. Staff also arranged window visits in which family members could stand outside of nursing homes and visit through an open window. 

Neither alternative was entirely satisfactory for him or his father, Jim Witmer says. Peg Witmer was often easily distracted. An aide with an iPad might seem of more immediate interest to her than the people on the screen.   

“We’re getting new or revised information all of the time—it seemed like every 15 minutes when the state’s restrictions were first announced,” McRae said last March. “I’d like to say that they were all consistent with one another, but that would be too much to expect in such an unprecedented environment. We are grateful for the help, but that’s been a challenge.”

In March and April, McRae says, “testing was not readily available. It was difficult to know that the person you’re working shoulder-to-shoulder with wasn’t infected. We could not get gowns to save our life.”

Creative thinking was called for. To solve the gown problem, the alliance partners turned to the Pennsylvania Dutch.

As McRae recalls, “some folks down in Pennsylvania, some Amish folks, converted all the work they were doing to making reusable gowns. We spent tens of thousands of dollars on reusable gowns. We went down and picked them up on the side of the road from a horse and buggy. We we’re doing everything and anything to move heaven and earth to keep our elders safe and to keep our staff safe.” 

While the nursing home consortium’s members managed to creatively solve their gown problem, they had no control over the skyrocketing cost of PPE.

“Before COVID, we could buy a box of 200 gloves, nitril gloves, for $7.15,” McRae says. “Today, we pay $37.14. That’s a 500 percent increase. It’s supply and demand. 

“And it’s not just that we’ve gone up 500 percent on the cost; our usage has gone through the roof,” he adds. “A (disposable) exam gown pre-COVID cost 20 cents a gown. Now it’s $1.89 a gown.  It’s not only the cost that’s increased; it’s the volume. Our expense line for supplies has gone through the roof.”

Falling revenues

While New York’s nursing homes’ cost of doing business has skyrocketed, their revenues have fallen. Some states like New Jersey upped their nursing homes’ Medicaid payments during the pandemic. New York cut its rate. 

Nonprofit and for-profit nursing homes alike have similar sources of revenue. Both see most of their payments come from Medicaid, a program to aid the poor whose costs are split approximately evenly between the federal government and states. 

Each state administers its own Medicaid program, setting rules for how beneficiaries like nursing home residents are paid. In New York, Medicaid pays less than the cost of care. That means for every patient on Medicaid, nursing homes lose money. They make up the difference by charging more to privately paying residents. 

Medicare, which has better rates than Medicaid but pays only for a limited number of days for rehab patients, also helps make up the difference. Long-term care insurance can also pay a better rate, but relatively few have such insurance and many companies that used to offer it have fled the market. 

St. Ann’s share of residents on Medicaid—86 percent—is typical. Such ratios make nursing home finances a tricky balancing act in the best of times.   

New York last adjusted its nursing home Medicaid rate in 2007. Facing its own budget woes during the pandemic, it cut rates further. On an annualized basis, McRae says, the cut reduces St. Ann’s Medicaid revenue by $400,000.

Falling nursing home occupancies also do not appear to bode well for New York nursing homes’ finances. Like all U.S. health care organizations, nursing homes need to do a minimum amount of business to stay solvent. 

Occupancy rates during the pandemic have declined. The average rate at Hurlbut Community homes currently sits at 70 percent, a double-digit drop from pre-pandemic levels, Bob Hurlbut says. Asked how St. Ann’s occupancy rates are holding, McRae doesn’t state a specific figure. Rates nationally have fallen to around 55 percent, he offers.

No one has determined why occupancies are so low, but the pandemic is a likely suspect. Reports of high death and infection rates arguably are discouraging some from choosing a skilled nursing option, if they can avoid it. Lack of visitation opportunities is another likely culprit. As the pandemic eases, McRae says, he hopes occupancy rates will increase. Still, he concedes, there is no guarantee that they will. 

Bob Hurlbut

New York’s tightly regulated nursing homes report to the state Health Department using the online Health Emergency Response Data System, HERDS for short. During the pandemic, the state added a new daily COVID report to nursing homes’ HERDS requirements.

While the data collected might help the state in some way, the daily COVID reports have no real benefit for nursing homes themselves and have significantly added to already overburdened nursing home staffs’ workload, operators say. The reports must be filed daily without exception by 1 p.m. St. Ann’s and Hurlbut homes have both been hit with $2,000 fines for filing reports as little as one minute late, McRae and Hurlbut say. Both organizations are protesting.

After James’ January report was released, the Assembly and Senate separately passed bills aimed at correcting inadequate nursing home staffing, a shortcoming identified in the report. At this point, the legislation’s final form and thus how it might affect the state’s financially fragile nursing homes is not clear. 

Both bills state they are to be implemented immediately. But each outlines a slightly different set of steps to be taken. Both leave details to be worked out when the legislation is promulgated by the commissioner of health. While both bills clearly aim to ensure that nursing homes devote a sufficient amount of revenue to resident care, nursing home operators fear that the measures could further financially hamstring their already stressed facilities. 

The Empire Center, an Albany think tank, recently released a report critical of the reform bills. It disputes James’ staffing conclusions and questions her finding that for-profit homes had worse COVID outcomes than nonprofits.

While their organizations’ future is uncertain, McRae and Hurlbut say that their facilities’ immediate picture is in brightening in some respects. More than 80 percent of both organizations’ residents have been immunized with COVID vaccines. Though not as quickly, vaccination of staff is also moving forward.

Still, says McRae, it would be foolish for the nursing home to let down its guard. 

“All it takes is one moment where an asymptomatic person spreads it that you’re vulnerable,” he notes. “We now have all the PPE we need. We now have people morning, noon and night making rounds and making sure PPE is appropriately applied. We’re constantly doing reeducation, doing our own infection-control surveys. 

“We have a lot of mechanisms and systems in place. Does that mean we will never have another positive case? I can’t say that. That would be like saying: Do you ever think you’ll have the flu in the building? I couldn’t say that.” 

In December, St. John’s Home told Larry and Jim Witmer that Peg Witmer likely had little time left and had been put into hospice care. Fearing that they might not able to see Peg Witmer before she died, they decided to take her out of the nursing home and move her into their own home. 

Peg Witmer died a few weeks later. As she faded, a parade of friends came to see her off.

Will Astor is Rochester Beacon senior writer.

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