Her bones had deteriorated from type 2 diabetes and crack-cocaine use. A nursing home in Medford took her in, with staff members teaching her to manage her condition and embrace healthy living. They helped Hill abandon the diapers and gradually regain her ability to walk.

Hill credits the staff for saving her life at Servant Living Center — a place no longer open as Oklahoma nursing homes financially struggle to attract and retain employees amid a growing aging population.

“If I didn’t have them, I wouldn’t be here today,” Hill, clean and sober at age 58, said from her Muskogee home where she now lives with her husband.

Servant Living closed in mid-2021 after management exhausted efforts to keep the doors open — even trying but ultimately failing to draw in dozens of nurses from overseas.

At least five Oklahoma nursing residences have closed in 2022, including a large one in Sapulpa that specialized in patients on ventilators and three small ones in Vinita, according to state records.

Sector experts and insiders say other closures could follow soon. Like Hill, more patients would be displaced from their homes and possibly relocated farther from their family and community.

Some individuals are being turned away because of staffing shortages — not a lack of beds — with hallways or entire wings closed. Staff members are eschewing lower pay, longer hours and difficult — albeit rewarding — work to job hop for sign-on bonuses and travel to other states on lucrative temporary contracts. Some have found employment outside health care amid the nation’s wage restructuring ushered in by the COVID-19 pandemic.

The nursing home sector says it’s handicapped in the marketplace by Medicaid reimbursement rates set by government that don’t cover the cost of care and employees to provide that care.

The government and long-term care providers appear to have differing perspectives on how best to boost the future of nursing homes as a potential fiscal cliff looms.

Sector shortcomings

Steve Buck, president and CEO of Care Providers Oklahoma, said financial analysis suggests the state’s Medicaid reimbursement rate — about $180 to $190 per resident per day depending on performance — is about $43.50 short of covering the actual cost of care. Buck said an additional $35 to $38 in COVID-19 supplemental payments are “pretty darn close” to bridging that gap but will expire at some point, potentially in March.

Care Providers Oklahoma is asking the state to find an approach that tightly binds the Medicaid reimbursement rate to audited cost reports — an estimated additional $58.0 million to $63.8 million investment annually from the state — to maintain the workforce and provide high-quality, dignified care for long-time contributors to the community.

On the other hand, the Oklahoma Health Care Authority — which manages the state’s Medicaid program — is looking to shift reimbursement more toward performance measures rather than costs of care to incentivize and reward better outcomes while strengthening provider accountability.

Medicaid, called SoonerCare in Oklahoma, is a health insurance program jointly funded by states and the federal government for low-income Americans. In Oklahoma, the federal government provides about $2 for every $1 the state invests.

Federal data show Oklahoma ranks 49th lowest in the U.S. for adjusted registered nurse staff hours per patient and is the second highest in nursing staff turnover rate. Lee Enterprises’ Public Service Journalism team analyzed the most recent data, as of August, from Centers for Medicare & Medicaid Services.

A shortage of staff nurses was reported in 34% of Oklahoma nursing homes at the end of May, compared with 23% nationally. Similarly, a shortage of aides was reported in 35% of nursing homes in the state, with the U.S. at 24%.

Buck, whose organization represents 19,000 professionals in long-term care settings, said Oklahoma could be best served by providing a robust reimbursement that allows employees to earn more for staying with the same employer.

OHCA CEO Kevin Corbett said now is the time to rethink the system structure of nursing residences and identify key drivers that need additional investment.

For example, Corbett said, the cost of care varies widely among the state’s 300-plus nursing homes — from $130 per resident per day up to nearly $400 — and isn’t necessarily an indicator of quality. He is interested in pursuing newer models that offer people better support to stay in their own homes when appropriate through home- and community-based services at a lower cost than a nursing home.

Corbett said a key question is determining the appropriate quality or outcome measures for nursing homes, and perhaps even one type of provider versus others.

“I think this is a good time to ask that question even though there is a pretty strong demand to say, ‘We’ve incurred significant cost; can we just fill the hole?’” Corbett said. “I think we should not lose the opportunity to kind of re-evaluate what is our nursing structure today — in light of the work that’s been done a few years ago — and what we perceive is going to be the future.”

‘Fiscal cliff’ ahead

Rep. Marcus McEntire, R-Duncan, co-authored Medicaid legislation — referenced by Corbett — that became law in 2019.

Senate Bill 280 raised the Medicaid core rate and installed incentives, with performance measures that track body weight, urinary tract infections, pressure sores and use of psychotropic drugs.

He said that legislation’s gains were wiped out by the pandemic, wage reset and inflation. Now nursing homes are losing money, he said, and banks aren’t keen to offer loans with the Medicaid reimbursement rate’s uncertain future.

In the near term, if the federal government lets the Public Health Emergency expire in January, then the COVID supplemental payments — $35 to $38 — would stop in March.

Corbett said OHCA has signaled its intention to plug that gap until June 30, the end of fiscal year 2023.

But it’s primarily up to legislators to work out a program or a mechanism in the upcoming session as a long-term solution, with input from experts such as OHCA, nursing homes and others, he said.

McEntire described the pending end of the COVID supplemental as a “fiscal cliff,” with the state and its taxpayers needed to come in and help nursing homes.

At some point, he said, nursing homes may begin prioritizing residents who have private insurance or Medicare — which pay better than Medicaid — and shut down Medicaid beds.

About 71% of nursing home patient days in 2021 were residents on Medicaid, according to state data.

“Let’s just pray that doesn’t happen — that’s what I’m trying to keep from happening,” McEntire said.

McEntire said it’s likely the Legislature revisits SB 280 to revamp and potentially add more to it.

“I hope politics aren’t played with this — because I just don’t see that happening,” McEntire said. “I think everybody’s on the same page. But if they get cute and try to do some reforms that the nursing homes aren’t into — man, it will be managed care all over again.”

Gov. Kevin Stitt has pursued private management of the state’s Medicaid program through contractors signed by OHCA, prompting a lawsuit from several health care organizations and objections from numerous legislators. The Oklahoma Supreme Court sidetracked Stitt’s effort for a while.

“There probably are going to be some tough decisions to make at the end of the day,” Corbett said. “But I think as long as we focus on what are the drivers that cause us to have to have this kind of conversation, I’m hopeful that we’ll come to certainly a reasonable conclusion.”

‘Never want to close’

On the day Kimberly Green had to announce Servant Living’s pending closure, she was down to only two nurses: her nursing director and assistant nursing director. Neither were able to be home much.

“You never want to close a building,” said Green, chief operating officer of Diakonos Group, which still has 25 buildings across Oklahoma. “Whenever you close a building and you move patients — residents — many of them die within the first year.”

Green’s decision to close came almost overnight. Eight months piecing together an operation had unraveled into an inability to continue providing care and heavy strains on what staff she had managed to keep.

Bonuses had been dangled for nurses to drive to Medford in north-central Oklahoma from other buildings. Hotel tabs were picked up if they would work the weekend.

She contracted with a firm that finds nurses overseas to bring in 50 from the Philippines, but the firm abruptly canceled four months later after filling only four spots.

Green said the firm reported that candidates loved her company but the pay wasn’t competitive with hospitals, home health and traveling companies — so there was no way it could fulfill the contract.

“It’s a waste of my staff’s time to keep trying to recruit for you,” Green recalled hearing on the phone. “And it just felt like a tidal wave.”

Hill, who was a resident at Servant Living for several years, recalls the special care and attention the staff offered her that forged lasting familial bonds.

Hill is Black, and she said they catered to her musical tastes with the likes of The Isley Brothers and Earth, Wind & Fire.

“They would play Black music to get me some push to get up and walk and sway to the music,” Hill said. “And that was really nice because they didn’t have to do that.”

Once her mobility was better, Hill at times would babysit in the dining room for a couple of hours to help nurses avoid losing any pay.

Hill didn’t want to leave Servant Living and misses seeing the nurses, though she keeps in touch with some. She said staff back then knew to check on her if they didn’t see her on her morning walk.

In that one regard, not much has changed.

“So now if they don’t see me on Facebook, they’ll text me like, ‘Hey, what’s going on? How ya doing?’” Hill said. “Or I’ll post on there that I’m not feeling good today. And they’ll text me like, ‘What’s going on? Have you taken your medicine today?’ Stuff like that.”

‘Seniors deserve better’

With a new roof, new floors and two renovated hallways, Ranch Terrace stands empty in Sapulpa after closing three months ago despite the upgrades to make it more competitive.

“The residents were heartbroken. ‘This is my home,’” Scott Rogers, a Ranch Terrace co-owner, recalled many residents saying. “It’s something I never want to go through again. It was like a death.”

Ranch Terrace provided regular long-term care but, importantly, it also specialized in patients who required ventilators. The community was one of a few in the state able to handle such high-level care.

The building, able to serve up to 85 residents, only had 30 in early June. Its ownership announced Ranch Terrace would close soon because its sparse staffing levels severely limited how many people could live there.

Rogers said 50 skilled nursing professionals would work there in a perfect world. Instead, he could field only 15 employees the prior month.

“We are dealing with human lives. The end users of our industry are the seniors of Oklahoma,” Rogers said. “Our seniors deserve better than this current situation. It’s not nuts and bolts; it’s lives. And it’s heartbreaking.”

Green, who has been in the nursing field for more than three decades, works out of Franciscan Villa in Broken Arrow for Diakonos Group.

She said she has more referrals than ever and could fill her beds. There just isn’t the staff.

In one particularly difficult week, Green said she had to turn away five people she knew.

‘Impending crisis’

About 100 Oklahomans turn 65 years old each day, according to a report published in November 2019 by a Long-Term Care Services and Supports Advisory Committee.

The number of seniors is estimated to grow 40% in the next 15 years. The report cites AARP data that project the 85-and-older demographic — the highest user of aging services — will continue to increase beyond the year 2050.

By 2030, the report says, seniors will outnumber children for the first time in history, setting the stage for an “impending crisis” in long-term care.

Don Blose, CEO of Spanish Cove Retirement Village in Yukon, emphasized to the House Public Health Committee that long-term care and aging services in Oklahoma have never had the resources to provide quality of care that seniors need.

Now the sector is competing against and losing employees to big-box stores, fast-food chains and convenience stores — not just with other health-care settings — for professional nurses, Blose said.

“We are so not ready for what is coming,” Blose said. “In my assessment, an aging crisis is coming, and it will likely be the next public health emergency outside of another pandemic.”

Buck, who served as secretary of human services in Stitt’s cabinet before he moved to Care Providers Oklahoma, emphasized the need for certified nurses aides.

CNAs are individuals most intimately involved in the care of residents, from helping them dress or bathe to turning them over to prevent bed sores. The ballpark wage for a CNA in Oklahoma is around $12-$13 an hour based on what Medicaid reimbursement allows, Buck said, which isn’t competitive to recruit them, much less keep them.

A key to quality of life for aging adults is their relationships with staff members, which Buck said high employee turnover rates diminishes.

“We shouldn’t forget those basic functions even below direct care in terms of pay. Your basic sanitation and housekeeping staff, your kitchen prep staff,” Buck said. “This salary dynamic has fundamentally changed the landscape. Companies are having challenges recruiting the most entry level of positions.”

‘No help coming’

Servant Living Center’s mix of residents made it special in Oklahoma before its closure.

As it offered psychiatric care, its residents suffering from mental health issues felt welcome when elsewhere they might feel out of place. The nursing home also took in individuals who have served out their federal prison sentences or aging inmates the feds no longer could care for behind bars.

Stephanie Skaggs was one of the final two nurses on board at the end after working there 14 years. Many residents told her they wanted to be among the last ones out.

“If we’d done that, we’d have never left,” said Skaggs, who was the assistant director of nursing.

For Skaggs, the shuttering was a chance to re-evaluate her career choice. Her personal life was nonexistent.

She missed kids’ events to shove food in her mouth, shower and sleep for five hours before making the 30-minute drive back to work. She was emotionally and physically exhausted. The routine physical demands of nursing forced her to get surgery on one shoulder; the other still needs treatment.

She decided to stick with nursing because she knew she had the work and got to stay within Diakonos Group.

Skaggs wishes there were more lifelines from the government to try to help prevent a nursing home from shutting down.

“There should be a system in place before a facility closes so that we ensure that they have had everything offered to them to help them before they have to do that,” Skaggs said. “I understand in our situation, there was no help coming to our rescue.

“But somewhere there’s got to be something so that people don’t have to do this.”

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