Earlier this year, the Boundary Waters Care Center was in danger of closing.
Through a concerted push for funds, the center raised $60,000 in community donations and is still operating — but Executive Director Adam Masloski is fighting every day to overcome operational and financial challenges, and he is deeply concerned about the potential devastating effects of a federal staffing mandate.
That outpouring of financial support from the community may be a testament to how important Boundary Waters Care Center is to the town of Ely, Minnesota. The nonprofit nursing and rehabilitation facility employs 50 people with a $2.5 million payroll, and is the only nursing home within a 50-mile radius.
Boundary Waters’ struggles are emblematic of so many rural nursing homes, which are serving a special purpose of keeping residents close to their loved ones.
Since the Biden Administration’s proposed minimum staffing mandate landed in September, Skilled Nursing News has been reporting on the struggles of rural nursing homes, with sector leaders likening the situation to an approaching tornado if the mandate goes through.
The staffing proposal is untenable given that it fails to provide funding for its staffing stipulations while many rural nursing homes are at the brink of financial collapse, Masloski told SNN.
“I would hate for more and more rural nursing homes to close because of these funding gaps. I think that would [accelerate] the downfall of some of these rural communities,” he said, pointing out that Boundary Waters’ downfall would be devastating to the Ely community.
Wages remain the “biggest barrier” to greater workforce stability, Masloski said. And when faced with financial trouble as the facility’s occupancy continued to decline amid a labor shortage, Masloski also turned to ramping up advocacy efforts and reaching out to hospital systems in the area and city council members, in addition to seeking community support for private funds.
And while Boundary Waters escaped shutdown, Masloski said private funding is not a permanent solution.
The federal government needs to correct delays in reimbursement, provide more money for staffing and operational costs rather than for capital expenditures, and consider ditching the federal staffing proposal, he said.
Mandate seen as worsening wage pressure
Past federal regulations worsened the labor crisis, and rural nursing homes can’t afford more trouble on the staffing front, Masloski said. Already labor is not only hard to come by, but supplemented by expensive agency workers. Masloski said he is competing with hospitals and critical care settings for agency workers who have sometimes demanded as much as $200 per hour. Currently, about a third of Boundary Waters’ staff is comprised of agency workers.
And the mandate will make the need to fill in positions through agency workers even worse.
“I agree that we should have this level of care but [the federal government] has given me no way to implement that. And that’s what I think is the biggest struggle,” said Masloski. “Take the issue of requiring RN coverage, 24/7 in a nursing home. I think that that’s great. Our old people deserve that. But … where are these nurses going to come from and how do we attract them to work in long-term care?”
Being in a rural community, nursing homes compete with other sectors for workers, he said. And hospital systems often win in attracting clinical workers because nursing homes cannot afford to match wages.
“Our folks don’t get paid enough,” he said. “We do lose nurses to hospital systems. We do see a lot of folks that see a stop here in the nursing home as a stepping stone to a hospital career and ICU career. And one of the reasons for that is that we cannot compete with the wages that hospitals are giving.”
Boundary Waters’ reimbursements – and its ability to pay workers well – are also impacted by delays in payments for value-based care and the set up of funding models.
“In the state of Minnesota, our reimbursements are value based. And they’re dependent on our cost reports that are done each year. Through the pandemic, and even recently, the delay in cost reporting has been around 21 months to when we actually get our rates,” Masloski noted. “So not only is there a delay, but we are basically getting reimbursed on what we spent two years ago – and it’s hard to manage that from a budgetary standpoint when you have an already tight budget and you’re looking to increase wages to compete [better].”
Rescue through private funds isn’t permanent solution
Masloski is handling the situation by continuing his advocacy efforts with state legislators and community fundraising efforts, which the facility plans to turn into an annual drive. But he is aware that private funding isn’t enough, nor is it reliable.
He has suggested to state lawmakers to change the nature of the funding from being tied to capital expenditures – such as improvements in building, equipment and infrastructure – to funding that helps operational costs. The state earlier this year struck a deal to fund about $300 million in nursing home construction projects over four years.
“When I’m worried about keeping the doors open, I’m a lot less concerned about what I can invest in because none of that’s going to matter if I can’t keep the place open and running,” he said.
A critical access nursing home program has been funded by the legislature and is awaiting federal approval, which Masloski said will help the bottom line — but none of these moves is enough to alleviate the month-to-month struggle in trying to maintain a positive net income.
And so, Masloski is hoping that the state can assist with more workforce grants. A small grant recently was useful in giving bonuses out to individuals, but nursing homes need more such programs, he said.
“We have to address the fact that wages are the issue at this point … we need to attract people into wanting to work in long-term care,” he said.
Aside from creative fundraising and advocacy efforts to get more funding for operational and staffing expenses, Masloski said his team is engaged in intense training methods.
“We do all we can to grow from within. I have a nurse educator that will take someone off the street and train them to become a CNA. We’ll get them on site. We train them, get them through the program and pay for it every step of the way. I encourage all of my CNAs if they want to go to nursing school to do that, and we provide scholarships for that,” he said, noting that “numerous” workers at Boundary Waters have gone through the career development pipeline to go from CNA to LPN or even RN.
Another workforce solution to retain workers is to keep them engaged and motivated, Masloski said. He said he routinely allows nurses to step away from their day-to-day tasks on the floor to work on an area of interest such as infection prevention and wound care. Such work ultimately drives improvements in the center’s quality measures.
“So I’m kind of tailoring people’s full-time jobs to their interests so that we can see some traction in the quality of care that we’re providing,” Masloski said. “And I think that more workers these days, they want to find some fulfillment in their job. So finding those interests from folks and utilizing them has been key to our success and our quality measures.”
In the meantime, Masloski says that plans are being put in place for another fundraiser. The first fundraiser was tied to the urgent message about imminent closure, but whether this will translate to future success in fundraising remains to be seen.
“I don’t anticipate each year raising to the tune of $60,000 – I can hope, but hope isn’t that great of a strategy,” he said.
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