Nursing shortage hurts home care

An acute nursing shortage in Nevada is hitting home.

One agency that provides nurses for in-home care had to discontinue serving a young mother whose child needed care. It didn't have enough staff.

Another reports a turnover rate of more than 50 percent.

A woman who uses a third agency to care for her three home-bound children says the problems are so severe she may be put in the position of having to choose between potentially life-saving surgery for herself and the health of her children.

There is a huge gap between the number of nurses the state needs and the number on the job. According to a recent study done for the state Legislature, there should be 256 nurses per 100,000 Nevadans. The state has only 155 for every 100,000. By 2006 Nevada is expected to need 760 additional nurses a year.

That gap is felt most painfully among those who need nurses to come to their homes to provide care.

Home health care is among the lowest-paying jobs for skilled nurses, and state restrictions on Medicaid continue to cut into the funding available for those services.

In addition, greater paperwork requirements make the job less appealing to nursing professionals who have many other options.

A great need

That leaves people such as Nancy Harris with some difficult choices.

Harris, 49, is the mother of three children with medical conditions that require among them 16 hours of home health care every day, seven days a week. Formerly a licensed vocational nurse in the Army, Harris was medically discharged in 1988 because of heart problems and is disabled.

"The stress from dealing with the system is speeding up the deterioration of my heart," she said.

She took in the children, Lisa, 18; Raphael, 16; and Anisha, 14, in New Jersey through a program that provides in-home health care for homes in which special-needs children are placed. Harris, a single mother, adopted Raphael and is guardian to Lisa and Anisha.

She moved the family to Las Vegas two years ago hoping the dry weather would improve the children's upper respiratory problems and to be closer to family and friends.

Harris immediately found herself fighting for care for the children.

All three are mentally handicapped and have other major illnesses. All are tube fed through their stomachs. None can speak, though they communicate in other ways.

Raphael, 4-feet-1 and 40 pounds, gets around by scooting on the floor. He has chronic upper respiratory problems and must be on oxygen at night. He relies on a bag placed on his side for his bowel movements and has no spleen, leaving him susceptible to infections.

Anisha, who is bedridden, has cerebral palsy and disphasia, an ailment that prevents her from swallowing properly and makes her susceptible to pneumonia.

Lisa, also confined to a bed, suffers from Rhette syndrome, a neurological disease similar to cerebral palsy.

Harris said Nevada Medicaid authorities tried to cut care for the children to nine hours a day from the 16 hours a day that New Jersey provided. She said she fought and got Medicaid to authorize a total of 16 hours a day -- just over five hours per day per child.

Now the problem is finding nurses to work those hours.

Kasandra Jackson, a registered nurse with Colonial Home Care, is the only nurse who regularly comes to care for the Harris children.

She is paid $18 an hour, Jackson said, compared to $26 an hour she could make at a hospital.

To make matters worse, she used to be paid double time to care for the three children by another, now-defunct agency. But Medicaid doesn't allow extra pay for extra children.

"Normally in home care, it's one on one, one patient and one nurse," Jackson said.

"The workload here has tripled for the same pay," Harris said. "We have a hard time getting nurses and keeping them. We've been through five or six."

Jackson continues to take care of the Harris children because she has grown to love them, she said. "But I've got a life, too. I can't stay here 16 hours a day, seven days a week."

When Jackson is not available, Harris relies heavily on family and friends because it is so tough to attract more nurses.

Nurses interview Harris to see if they want to work for her rather than vice versa.

"The nurses pick and choose their assignments because they are in demand," Jackson said. "And taking care of three kids is more than they want to do. If they are desperate, they will do it for a while, but because of the shortage they don't stay long."

That leaves Harris in a predicament as she ponders what to do about her own failing health.

Her heart condition is hereditary -- the same ailment killed her father at age 42 and plagues a brother, sister and uncle.

She was scheduled for bypass surgery in San Diego earlier this year, Harris said, but her condition has worsened to the degree that doctors now are considering a heart transplant when her heart reaches a certain level of deterioration.

She does not know when she might get a transplant. She is supposed to go to the veterans hospital in Los Angeles for an examination and second opinion, but with the backlog at VA hospitals, it could be months before she sees a doctor.

When it finally happens, she worries about what will happen to her children while she is in the hospital and while she is recovering.

"Medicaid wants me to put my kids in a nursing home," she said. "We're talking about seriously ill children who won't live outside their home environment. Anything short of their being at home won't get it. But my Medicaid worker is constantly telling me to go find a nursing home for my kids."

In her view if she has a heart transplant to save her own life, her children could die.

"If they go to a nursing home, it's like signing a death certificate. These kids were 'failure to thrive' to begin with," said Harris, referring to a condition in which children do not grow at what is considered a healthy rate.

Though privacy laws prevent Medicaid officials from discussing individual cases, the deputy administrator of the state Division of Health Care Financing and Policy said every effort is made to provide home care for those who are eligible.

A nursing home is a last resort.

"If it is at all feasible to remain at home, that is what we strive for," April Townley said.

"But if we reach a point where we can't find nursing care aides and the kids would not be safe, then we would have to look at the alternatives," she said. "For some people, they might prefer a nursing home. We don't try to impose our desires."

Feeling the pain

Local agencies that provide nurses, both to hospitals and home health care, are finding the nursing shortage no easier to deal with. And it's not just because of Medicaid policies.

At this time last year, Around the Clock Healthcare Staffing had 172 nurses on its registry, Connie Reising, the agency's director, said.

"Now I have 30," said Reising, whose company provides nurses for hospitals. "Even the hospitals are having trouble finding nurses."

Mary Sundblom, director of Home Care Plus, says it's getting tougher.

"We occasionally do Medicaid, but they don't want to reimburse for skilled care," she said.

Adding to the complex medical coverage system, she said, is the fact that there are no widely accepted standards. Rates vary from agency to agency, from insurance company to insurance company.

Her company doesn't do long-term, in-home care, but sends skilled personnel for hourly visits to do such things as change dressings and other services.

"The insurance companies, including Medicaid, are paying less and less," she said, making it difficult for private agencies to stay in business.

"It's not an equitable situation," Sund-blom said. "We have to pay our bills."

Chris Watson, administrator of Colonial Home Care, says her company has to turn clients away because of the nursing shortage.

"I worry about all the patients," Watson said. "I wonder who will care for them when we turn them away."

Roger Corbin, chief financial officer for Caring Nurses Inc., a company that specializes in providing home health care, says that while the turnover rate for his firm has eased somewhat since it was created five years ago, it is still close to 50 percent.

"In our first year we employed as many as 50 staff members," he said. "The second year we had as many as 35 or 40 turn over."

A lot of the problem, he said, comes from the tremendous amount of paperwork required by Medicaid and Medicare.

Time that should be spent caring for patients is spent learning new regulations and how to fill out new forms, which discourages nurses who might be considering entering the home health care field, Corbin said.

"If I was a nurse, I wouldn't want to do home health," he said. "The focus now is on a balance of care and good documentation skills.

"The key problem is paperwork -- a lot of paperwork is involved. Ten to 15 years ago nurses were already complaining about all the paperwork. Now it's four to five times as bad -- mainly for Medicare and Medicaid."

Gail Harper, office manager for Nurse Finders of Las Vegas, said her company -- which provides long-term, in-home care -- has the same staffing problems as the other companies.

"I just spoke with one of our clients we had to discharge," Harper said. The young mother's child needed care, she said, but "We just don't have the staff. And that's one of many."

Harper places some of the blame on Medicaid.

"It's become so difficult to manage these cases, nobody wants to do them. So people are on their own," she said.

To stay in business, Harper said, home health care providers can't afford to pay nurses as much as the nurses can demand in other markets, such as hospitals.

"We have to turn cases away because we just can't staff them. There just aren't enough people to go around," Harper said. "The few staff we do have can be picky, and they are."

Rougher waters ahead

John Packham, who did the study for the Legislature, said things are likely to get worse before they get better if a bill passes to set minimum staffing standards for nurses at a hospital for a specified number of patients.

"For the foreseeable future, the demand vastly exceeds the supply (of nurses) being produced," Packham said. "We will remain a net importer."

But it is hard to import a nurse who might make in the neighborhood of $30 an hour in a Nevada hospital but $112 an hour in New Jersey doing skilled nursing care in the home.

Ed Rogan, spokesman for the New Jersey Department of Human Services, said registered nurses who are reimbursed by the state to make a home visit to perform a skilled service are paid at the rate of $28 per quarter hour.

The money goes to the private agency that the nurse works for, and the agency pays the nurse after taking its cut.

He said private duty nurses who have a contract to go to a home every day for a set amount of time are paid at the rate of about $35 an hour and licensed practical nurses at the rate of $25.

Harris says the difference between care in New Jersey and Nevada is like night and day.

"New Jersey never gave me any problems. They always paid for the care. I never had to fight over the number of hours of care my kids should have," she said.

"In New Jersey they are concerned about the health of the caregiver, about my health. They didn't want me to get sick or burn out. Here in Nevada they don't give a damn."

Part of the reason for the frustration, Rogan said, is that the Northeast doesn't have Nevada's nursing shortage.

"This area, the New York-to-Washington corridor, has a lot of hospitals, a lot of teaching universities," he said. "A lot of health care services are concentrated here. We are producing more nurses than other areas."

Which comes as no surprise to Cynthia Bunch, spokeswoman for the Nevada Nurses Association.

"We're graduating less than half of what we need each year," Bunch said of the state's nursing school program. "Unfortunately, it's only going to get worse."

The profession isn't attracting the numbers of nursing candidates it used to, in part because of the bureaucratic changes in the industry over the past seven or eight years, she said.

Bunch said other contributing factors to the nursing shortage are burnout and the aging of the baby boomers who are retiring and leaving the profession but aren't being replaced.

"Most nurses feel we are adequately compensated," Bunch said. "The issue is working conditions.

"Because facilities have had reduced payments from insurance companies, facilities are cutting back on nurses which in turn increases the workload and liability of the nurses who stay."

Physicians, she said, face the same problem.

"They're leaving as rapidly as nurses," she said. "And it's for the same reasons."

Nursing aides, personal care assistants who do such chores as feed and bathe patients, are another expanding void in the health care profession.

"Most homebound patients need help bathing and that sort of thing," Bunch said. "But the pay is very low."

Assistants may earn $6 or $7 an hour, she said.

"There is a very high turnover rate. They can earn more working at a casino," she said. The work, she said, is "physically very demanding, very stressful."

Growing demand

The rapid growth of Southern Nevada is going to make the shortage worse because many of the newcomers to the Las Vegas Valley are older and need more health care, said Tammy McDermott, president of the Nevada Health Care Association.

"The demand has outstripped our supply," she said.

To attract more nurses, sign-on bonuses are being offered along with higher salaries and other incentives.

"But we can't wave the magic wand and make them appear," she said. "We're trying to work with the universities about admitting more students. And many of the larger companies and hospitals are even doing international recruiting."

The state is sympathetic, she said. "They are at a point where they're seeing there is a problem. But not enough has been done till now."

Her organization is starting a task force that will try to come up with solutions to the nursing shortage, which might include changes to licensing requirements and admission requirements to nursing schools.

"Nobody wants to relax standards to the point where we're just pumping out people with a bunch of initials behind their names," she said. "But the need is very critical.

"In long-term care construction, we have 800 to 1,000 beds opening up in the next three to six months in Las Vegas. The bricks and mortar are there, but once providers open the doors, are we going to have people to care for the patients?"

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