Pinnacle Health & Rehab in South Portland. Maine’s long-term care facilities are struggling to operate amid a labor shortage. Ben McCanna/Staff Photographer

As the administrator at Pinnacle Health & Rehab in South Portland, Jeff Ketchum has a vested interest in hiring and keeping excellent, reliable workers.

It’s a critical part of providing quality care for the nursing home’s 60 residents and avoiding the much higher cost of bringing in temporary workers from outside agencies. And it impacts every aspect of running the facility, from administering medications, to preparing meals, to cleaning rooms.

Some of Ketchum’s employees have worked there for decades. But too often lately, workers come and go, which puts a strain on other staff members, makes it harder to maintain care standards, and keeps the facility from operating at full capacity, he said.

“It’s a revolving door sometimes,” Ketchum said. “There was a shortage even before COVID-19. The pandemic just made it worse and we’re one industry that hasn’t recovered.”

While filling positions is challenging for many employers in this tight labor market, it has become especially difficult for long-term care residences in Maine and across the U.S. Coupled with chronic government underfunding and other economic factors, the labor shortage is contributing to long waits for admission, diminished care and facility closures. And it comes at a time when new state and federal funding schemes and staffing requirements threaten to bring more closures.

Since 2020, about 20% of nursing homes nationwide have closed a unit, wing or floor because of labor shortages, contributing to a loss of nearly 63,000 long-term care beds nationwide, according to the American Health Care Association, which represents 14,000 facilities. Pinnacle in South Portland has 73 beds but can meet staffing requirements for only 60, Ketchum said.

At least 774 nursing homes have closed since 2020 – 15 of them in Maine – and about half of all nursing homes are currently limiting or have waitlists for new admissions, the national association found in a report released in August.

Ten years ago Hancock County had four nursing homes. Now it has none.

The labor shortage and closures come at an inopportune time for the nation’s oldest state, where the median age is just over 45. Maine’s population age 75 and older is projected to nearly double in less than two decades, from about 130,000 in 2023 to 251,000 in 2040, said Angela Westhoff, head of the Maine Health Care Association.

The overall staffing reduction in Maine’s nursing homes has been precipitous, from over 11,000 positions in 2005 to 8,062 today – 1,345 fewer just since the pandemic, according to the national association.

Staffing in Maine’s assisted-living facilities is down 241 positions since the pandemic, to 23,345. And Maine has a shortage of about 2,200 registered nurses across all health care facilities, the Maine Nursing Action Coalition and Maine Hospital Association reported.

“It’s the worst crisis we have seen in long-term care going back decades,” Westhoff said. “There just aren’t enough workers in Maine to meet all staffing needs. Access to skilled nursing is challenged now. As Maine continues to age, it’s only going to get worse.”

COMPLAINTS ARE RISING

Nursing homes provide round-the-clock medical care and support for seniors with serious health issues or rehabilitation needs. Assisted-living facilities provide moderate care for seniors who need help with daily tasks, such as taking medications and bathing, but still have some independence.

Jeff Ketchum, administrator at Pinnacle Health & Rehab in South Portland. Ben McCanna/Staff Photographer

The staffing shortage is having a negative impact on both, as well as the communities they serve, making it harder to find an available bed and receive quality care.

In the last two years, the Maine Long-Term Care Ombudsman Program has experienced a spike in complaints about diminished care, staffing and admissions, said Brenda Gallant, executive director. Data on admissions assistance is anecdotal, she said.

“The ombudsman program has received an increasing number of requests for assistance from older and disabled adults in getting admission to a nursing home or residential care facility,” Gallant said. “These are individuals who in prior years would have easily found admission.”

From fiscal year 2022 to fiscal year 2023, complaints related to inadequate care in nursing homes increased from 132 to 163, while complaints about inadequate staffing increased from 45 to 72, Gallant said. Complaints about residential care or assisted-living facilities declined slightly in the same period, from 111 to 91 complaints about care, and from 60 to 50 complaints about staffing.

Typical complaints include long wait times when residents ring call bells for assistance, Gallant said. One rehab patient waited over an hour for help needed to get to the bathroom with a walker. Ultimately, the response came too late and staff had to change the bed and help the patient shower.

“It’s a statewide issue and all kinds of facilities are affected,” Gallant said.

SHORTAGES IN ALL JOBS

​The shortage includes long-term care jobs of all kinds, from nurses and personal care assistants, to food service workers and maintenance staff.

It includes the people who check vital signs, bathe residents and make beds; the dieticians, cooks and servers who plan, prepare and deliver meals; and the workers who keep facilities clean, mowed and operating safely.

Annual salaries range widely, from about $75,000 for registered nurses to $31,000 for housekeeping aides.

“There’s a shortage of help in all areas and there’s a lot of turnover, from administration on down,” said one resident of a large senior community in central Maine. “We didn’t have a cook for a while and we were served sandwiches a lot.”

As a result, many staff members at the facility are being asked to do more, often outside their job descriptions, which isn’t unusual in long-term care, according to the resident’s daughter. Both agreed to be interviewed if their names and the residence were withheld to protect the mother’s care and security. 

“Now they’re doing additional work all the time without being paid for it,” the daughter said. “In some cases, they could go work at McDonald’s and make more money. Unfortunately, some longtime staff members are leaving because of it.”

Crystal Facteau, kitchen supervisor at Pinnacle Health & Rehab, emerges from a walk-in cooler with sandwich fixings at the 60-resident nursing home. Maine’s long-term care facilities are struggling to operate amid a labor shortage. Ben McCanna/Staff Photographer

Ketchum and other long-term care administrators have responded by increasing pay, benefits and recruiting efforts with some success, but the struggle continues in a state where the number of nursing homes has plummeted as its older population continues to grow.

Concern mounted in April, when the Biden administration issued new federal rules for minimum staffing in nursing homes that will require at least one registered nurse to be on site at all times. Facilities in urban areas will have two years to comply; rural operators will have three years.

State officials have taken some steps to offset financial and hiring challenges that have plagued Maine’s long-term care facilities for decades, including an overhaul of the MaineCare reimbursement system starting in January, but providers worry that it won’t be enough.

“I’m not holding my breath,” said Gabrielle Herbig, president of Sweet Seniors, a family-owned, assisted-living residence in East Millinocket. Previous state funding increases and one-time infusions haven’t helped her 16-bed facility in rural Aroostook County very much, she said.

“We’re currently fully staffed, and we’ve been lucky we haven’t had to use agency staffing,” Herbig continued. “But when we do need to hire someone, it’s stressful because we don’t have a large workforce in a small community.”

And even when every position is filled, Herbig said, “it’s still very challenging if vacations and emergency staffing needs overlap.”

SHORTAGE BRINGS CLOSURES

There are 79 nursing homes in Maine, down from 132 in 1995, according to the Maine Health Care Association, which represents over 200 nursing homes and assisted-living facilities.

With the closure of 15 skilled nursing facilities since 2020, the number of nursing home beds in Maine is down 600 to 6,002, the association reported. In the same period, 16 residential care facilities have closed or converted to another level of care, reducing the number of assisted-living beds by 360 to 4,546, according to the association and the Muskie School of Public Service.

As a result of the closures, on any given day in Maine, about 200 hospital patients are waiting for a bed in long-term care, whether they need skilled nursing after heart or hip surgery or another form of residential care.

“Rural facilities are disproportionately impacted because of the lack of population and workforce,” Westhoff said. “Facilities in urban centers are competing with employers in the restaurant and hospitality industries.”

To meet staffing needs now, many nursing homes and assisted-living facilities regularly hire temporary nurses and other clinical workers through agencies, which costs two to three times more than permanent staff, Westhoff said.

Higher agency costs contributed to a $96 million annual deficit in MaineCare reimbursements to long-term care facilities, along with pay increases of 30% to 50% to help retain permanent full- and part-time staff, she said.

STATE AGENCIES TAKE ACTION

Recognizing the growing staffing challenges, Maine’s Office of Aging and Disability Services and Department of Labor are working together to increase pay and recruiting for jobs in long-term care.

Nursing home rate reform will take effect in January, updating how facilities get reimbursed through MaineCare, the state’s form of Medicaid. It’s a new, forward-looking payment system intended to increase permanent staffing and reduce agency hiring of nurses, medication technicians and other clinical positions.

“(Agency hiring is) not only more costly, it’s very difficult to work on quality when most of the staff is cycling through on six-week contracts,” said Paul Saucier, aging office director.

Crystal Facteau, a longtime kitchen worker at Pinnacle Health & Rehab, prepares lunch for the 60-resident nursing home. Maine’s long-term care facilities are struggling to operate amid a labor shortage. Ben McCanna/Staff Photographer

The new system, proposed by the Mills administration and approved by the Legislature, will incentivize efforts to increase long-term care access, quality and safety by tying some portion of payments to staffing stability, clinical outcomes and surveys of resident/family satisfaction.

The improved rates are expected to support competitive wages and staffing levels that are significantly above both state and federal requirements, Saucier said. The new payment system starts next year and follows multiple rate increases and budget supplements, including nearly $20 million last year and $30 million this year.

The Labor Department also has stepped up health care career navigation and recruiting efforts, supported by pandemic recovery funding.

Last week, the department sponsored a health care job fair in Lewiston that included several long-term care providers, and it sent a wall calendar to high school guidance counselors across the state promoting professions such as certified nursing assistants and medication technicians.

“It’s an all-hands-on-deck situation,” Saucier said.

INCREASING PAY, RECRUITMENT

Not every long-term care facility is struggling.

Piper Shores is an exclusive, 425-resident senior community in Scarborough that includes independent, assisted, skilled nursing and memory care options.

Piper doesn’t accept MaineCare coverage, so it doesn’t face the same financial constraints that limit other facilities. CEO Phil Jean has been able to address chronic staffing shortages that previously forced Piper to hire agency workers for clinical positions and compete with Portland’s vibrant restaurant scene for food service workers.

Jean conducted a wage and benefits analysis of competing facilities and industries and responded by substantially increasing Piper’s pay structure and promoting a positive workplace culture for its 275 full- and part-time employees.

Piper also engages in strategic recruiting, regularly attending job fairs and seeking potential candidates even when it’s fully staffed. It recruits teens through local high schools to work as servers in Piper’s dining rooms and three restaurants. And it offers signing bonuses as well as bonuses to current staff members who bring in viable job candidates.

“Some of our best recruiters are our current employees who can speak highly of working here,” Jean said. “We’re basically always actively recruiting. And we’re no longer using agency staff.”

‘I LOVE MY JOB’

Back at Pinnacle Health & Rehab in South Portland, administrator Jeff Ketchum has taken similar steps to address the staffing shortage. But it’s a modest operation, with 53 of 60 residents covered by MaineCare, so his ability to compete with other facilities and industries is limited.

The company hired a recruiter four months ago, so Ketchum has been able to reduce the use of agency workers for clinical positions by half. He strives to pay competitive wages, increasing clinical staff salaries 33% since 2020.

He also has increased hourly rates for other jobs, but he finds that younger workers move on as soon as they find a job with even slightly better pay and benefits, and managing openings on his 75-member staff remains challenging.

“We can’t stay afloat relying on agency staff,” Ketchum said. “If someone calls in sick, others have to step in.”

He worries that the new MaineCare reimbursement system will lead to more closures. He believes state officials are needlessly concerned that facilities will turn a profit from increased state support when many are on the verge of shutting down. He fears that payment incentives tied to staffing stability, clinical outcomes and resident satisfaction surveys could become penalties.

“I’m hopeful (the new system) improves things, but I’m nervous,” Ketchum said. “Will it fix the problem? Will it be enough to stay in business? The incentives they plan to put in place could turn out to be more punitive than helpful.”

Ketchum is grateful for longtime employees like kitchen supervisor Crystal Facteau, 44, who has worked at the nursing home for 23 years.

Facteau, who lives in Buxton, said she’s satisfied with her salary, but she couldn’t afford to work at the nursing home if she didn’t get better health care insurance and other benefits through her husband’s employer.

Still, she said, her work is a lot more than just “a cooking job.” She loves the residents, she said, and she takes pride in the fact that good, healthy food is a critical part of long-term care.

“For some residents, food is the one thing they still have choice over,” Facteau said. “I love my job. This place is like my family.”