Tag Archives for Maureen Maigret

Shortage of direct care professionals a local and national concern

Published in RINewsTdoay on April 22, 2024

Last week, at  the Senate Dirksen Building, Room SD-562,  Chairman Bob Casey, of the U.S. Special Committee on Aging, (D-PA), showcased S. 4120, legislation that he introduced with U.S. Senators Tim Kaine (D-VA), and Tammy Baldwin (D-WI). The Long-Term Care Workforce Support Act, introduced during the 118thCongress, would ensure that direct care professionals have a sustainable, lifelong career by providing substantial new funding to support these workers in every part of the long-term care industry, from nursing homes to home care, to assisted living facilities.

The Senate Aging Committee details a number of statistical findings showing the need for Congress to address the nation’s severe ongoing direct care professional workforce shortage. “A recent survey revealed 92% of nursing facility respondents and nearly 70% of assisted living facilities reported significant or severe workforce shortages.

In 2022, a survey of nursing facilities showed more than 50% of the facilities were limiting the number of new admissions due to staffing vacancies or shortages.  Another recent survey of Home and Community Based Service providers showed that all 50 states were experiencing home care worker shortages, and 43 states reported that some HCBS provider groups have closed due to worker shortages,” says the fact sheet.

Addressing the cause

By improving compensation, benefits, and support systems, S.4120  would ensure the United States has a “strong, qualified pipeline of workers to provide desperately needed care for older adults and people with disabilities.” notes a statement announcing the introduction of Casey’s legislative proposal.  

Specifically, S. 4120 would increase the number of direct care professionals, especially in rural communities.  It also would provide pathways to enter and be supported in the workforce for women, people of color, and people with disabilities.

S. 4120 would also improve wage compensation for direct care professionals to reduce vacancies and turnover.  It ensures that direct care professionals are treated with respect, provided with a safe working environment, protected from exploitation, and provided fair compensation.

The legislative proposal also documents the need for long-term care, identify effective recruitment and training strategies, and promote practices that help retain direct care professionals. It also would strengthen the direct care professional workforce in order to support the 53,000,000 unpaid family caregivers who are providing complex services to their loved ones in the home and across long-term care settings.

At press time, S. 4120 is endorsed by 50 organizations, including Domestic Workers Alliance, SEIU, AFSCME, Caring Across Generations, National Coalition on Aging (NCOA), Justice in Aging, National Partnership for Women & Families, National Council on Independent Living (NCIL), and the National Disability Rights Network (NDRN).

And a companion legislative proposal was introduced in the House by Congresswoman Debbie Dingell (D-MI).

Senate Aging Committee puts spotlight on Direct Care Staffing Shortage 

The April 16th hearing entitled, “The Long-Term Care Workforce: Addressing Shortages and Improving the Profession,” examined the challenges currently facing long-term care workers who are often underpaid and overworked, leading to widespread worker shortages that threaten the availability of care for those who need it.  

“It’s a crisis that stems largely from a lack of support for and investment in our caregiving workforce,” warns Casey in his opening statement. “Between 50 to over 90 percent of long-term care settings and providers report significant staffing shortages, affecting their ability to provide services, accept new clients, or even to remain open,” he says.

Casey noted that many direct care professionals have to work multiple jobs or overtime just to be able to support themselves and their families.  In 2022, their medium wage was just above $15 dollars an hour, well below what is paid for warehouse and convenience store jobs, per Casey.

“The direct care workforce, the majority of whom are women of color, are more likely to live in poverty compared to the general public,” notes Casey.

“Cumbersome federal regulations, requirements, and protections” and a “one-size fits all approach” won’t fix the direct care staffing shortage, responds Ranking Member Mike Braun (R-IN).

“To grow the long-term care workforce, the federal government should make it easier for people to enter by removing barriers,” says Braun, in his opening statement, calling for “productive approaches to build and grow the care professions.”

Overworked and not enough money

Nicholas Smith, a direct support professional at SPIN, a Pennsylvania-based organization that provides lifespan services for over 3,000 people with intellectual disabilities and autism, came to testify. “I work nearly 65-70 hours a week… due to my work, I have missed family events, nieces’ and nephews’ recitals, and school functions… a lot of people are leaving this field to make more money,” said the Philadelphia resident who has worked in the long-term care industry for over 25 years.

According to Smith, the national average for direct service professional wages is only $15.43 in long-term care. “We spend time training new hires only to lose them because they cannot make a living wage,” he says, noting that other industries are offering more money.

“While people want to stay in this field, they cannot make ends meet. Pennsylvania has a long waitlist for home and community-based services, and this is due to the workforce crisis,” he says.

In her testimony, Brooke Vogleman, a licensed Practical Nurse with Huntington, Indiana based TLC Management, stated:  “I’ve seen what happens when long-term care facilities lack workers, resources and government support, like during the pandemic. Many of my colleagues got burned out and left the profession, forcing facilities to rely on costly temporary staffing agencies.”

Vogleman called on federal policy makers, including members of the Senate Aging Committee, to address the challenge through “targeted investments, not blanket mandates.”  

For instance, she told the Senators that LPNs are integral to the facility’s interdisciplinary team. “Staffing mandates that do not include our contributions to patient care or recognize us as nurses are very concerning to me and will have unintended consequences on residents,” she says.

Staffing mandates will force facilities to depend more on expensive staffing agencies, warns Vogleman. “Personally, I’m concerned they will actually increase staff burnout, as current caregivers will be stretched thin and working longer hours in order to comply with these impossible standards,” she says.

Matthew Connell, Ed.D., of Ivy Tech Community College of Indiana, came to share the work and achievements of his community college in addressing the shortage of healthcare and long-term care workers in Indiana.

According to Connell, serving more than 190,000 students at 19 campuses and 26 satellite locations as well as on-line, graduates more associate level nurses in Indiana.  Nearly half of these students are pursuing college credit while in high school. Ivy Tech is the nation’s single largest provider of dual credit.

Ivy Tech’s programs are especially designed to help graduates enter the workforce quickly and provide critical services for the state’s long-term care population at a tuition rate that is the lowest in the state, he notes. “One in three Registered Nurses [in Indiana] is an alum. More than 90% of its nursing graduates choose to remain in Indiana, working in hospitals and care settings,” he adds.

The last witness, Jasmine L. Travers, assistant professor at New York University’s College of Nursing,  concisely summed up how to fix the nursing shortage.  She suggested: “To improve access to and quality of long-term are, we must ensure that all direct care workers receive a living wage, a safe, respectful work environment, opportunities for advancement, adequate training, and accessible benefits to maintain their health and well-being.  Only when we recognize that these workers are critically important, hardworking processionals, can we begin to improve equity and health outcomes for staff and patients alike.”

Putting the spotlight on Rhode Island’s Direct Care Staffing Shortage

According to John E. Gage, MBA, NHA, President & CEO, of the Rhode Island Health Care Association (RIHCA), the Covid-19 pandemic had a dramatic impact on the healthcare sector across the country and especially in Rhode Island, and a disproportionate impact on nursing facilities. On a national level, in February 2020 nursing facilities workforce totaled 1,587,000. Today, it is 1,462,800, down by 124,200 or 7.8%. In Rhode Island, it is more dramatic. Pre-pandemic RI nursing facility workforce was 9,797 (2/2020). Current BLS data shows the most recent number of workers in RI nursing facilities is 8,300 – down 1,497 workers or 15.3%.  This is just about double the rate of loss of workers post-pandemic in RI compared to the national statistics.

“There are some local efforts to attract workers back to RI nursing homes,” says Gage, noting that there is a need to be laser-focused on workforce development efforts. 

Gage calls for RI Medicaid to increase reimbursements to nursing facilities to cover today’s actual cost of care, not on facility costs from 2011 (13 years ago!) with minimal average inflationary increases in the 11 years since the price-based reimbursement methodology began in 2013.  According to Gage, RI nursing facilities need an adequate, sustainable reimbursement system to foster continued high-quality care and services and provide nursing home with rates that enable them to retain current workers and recruit more caregivers.

RIHCA, a non-profit trade association representing more than 80 percent of the nursing homes in the state, and its parent organization, the American Health Care Association (AHCA) support the legislative efforts of Senator Casey’s Long-Term Care Support Act. “We support all efforts to increase Medicaid rates to enable facilities to regain and grow their workforce – both direct care and ancillary staff, to enhance the quality of care and quality of life for our nation’s and RI’s most frail elder citizens today and for the years ahead,” he says. 

“It is heartening to see the Senate Committee on Aging and leading members of Congress addressing the care worker crisis in long term care including supporting our many thousands of unpaid caregivers who provide a significant portion of long term supports and services,” says Maureen Maigret, policy advisory of the Senior Agenda of RI (SACRI). Multifaceted solutions are needed, adds Maigret that include supporting training programs for nurses and paraprofessionals, career ladders and providing adequate Medicaid provider payments as Medicaid is the primary payer for long term care.

According to Maigret, in homecare alone, 75% of persons referred for subsidized home and community care through the state Medicaid or the Office of Healthy Aging Home Cost Share program are waiting two months, and often longer, to get services. “Our nursing homes are challenged to recruit the nursing staff needed to provide resident-centered quality care. Federal funding during the pandemic brought some funding in to support worker wages but that funding has ended,” she says.

“The state Healthcare Workforce Initiative led by the Executive Office of Health and Human Services and the Department of Labor has been looking at needs across the healthcare system and addressing some of the training and education issues,” says Maigret, noting that advocacy groups, such as the SACRI, support the Medicaid reimbursement rate increases as recommended by the Office of the Health Insurance Commissioner. “These rate increases are necessary to reduce service wait lists and provide livable wages for direct care staff many of whom are women and women of color,” she says. 

Over 23 years ago, in his weekly commentaries in the Pawtucket Times, this writer reported on the crisis of a direct care staffing shortage and inadequate reimbursement being paid to  nursing facilities to care for Rhode Island’s fail seniors. Isn’t it finally time for the Rhode Island General Assembly to come up with the necessary funds and strategy to fix these problem once and for all?

To watch the Senate Aging Committee hearing held on April 16, 2024, go to https://www.aging.senate.gov/hearings/the-long-term-care-workforce-addressing-shortages-and-improving-the-profession

The legislative wish list of Rhode Island’s groups on aging

Published in RINewsToday on April 15, 2024

The Rhode Island General Assembly’s 2024 session kicked off on Jan. 2, 2024, scheduled to adjourn on June 30, 2024.  According to LegiScan, over the last three months 2,164 bills have been thrown into the legislative hopper.

“The state budget will likely be voted upon by the House Finance Committee in late May or early June.  Then a week later it is considered by the full House of Representatives, followed by votes by the Senate Finance Committee and the full Senate, and the final step would be consideration by the Governor. That process is usually completed  by mid-June to late June because the new fiscal year begins on July 1.” says Larry Berman, who has served as House Communication Director for 22 legislative sessions.“

According to Berman, the Senate and House both focus on their priorities within their own chambers first, and once those bills pass, then discussions take place between the leadership teams of both chambers to finalize bills for passage in both chambers before sending them to the Governor.  That time period will be May, and well into June. 

Legislative Wish List

Aging advocates are pushing for their legislative agenda’s to be included in the House budget.  They also are carefully monitoring the status of bills that have been introduced, specifically those that will have an impact on programs and services delivered to older Rhode Islanders.

Maureen Maigret, Policy Advisor, of Senior Agenda Coalition of RI (SACRI) puts the passage of H 7333 and S 2399 on ita priority legislative list to assist financially struggling seniors and persons with disabilities on Medicare. “As many older adults are struggling financially, SACRI is prioritizing H7333 (by Rep. Karen Alzate) and S2399 (by Senator Sandra Cano) to expand the Medicare Savings Program eligibility up to $28,000. These bills would put more money in the pockets of lower-income persons not on Medicaid by covering the Medicare Part B premiums that amount to $2,100 a year and also help them with prescription drug costs,” she says.

To provide financial help to our many unpaid caregivers we also support S2375 (by Rep. Linda L. Ujifusa) and H7490 (by Rep. Susan Donovan) to create a state tax credit up to $1,000 for half the costs incurred to care for an older family member needing supports and S2121 (by Sen. Valarie J. Lawson) and H 7171 (by (by Rep. Joshua J Giraldo) to increase the Temporary Caregiver Insurance program from six to 12 weeks.

According to Maigret, there are a number of bills addressing housing issues that SACRI also supports including those to promote ADU development, funding for affordable senior housing and incorporating accessibility features into new housing.

H. 7062, sponsored by Rep. June S. Speakman has passed the House. This bill would boost hosing production by helping Rhode Islanders to develop  ADUs has been identified by as a high priority this year for House Speaker K. Joseph Shekarchi (D-Dist. 13, Warwick).

“In looking at the Governor’s State FY2025 budget we are advocating to add about $660,000 to the Office of Healthy Aging budget to increase funding to local communities to support local senior centers/programs to reach a level of $10 per each person age 65 and older in the city or town,” notes Maigret. SACRI calls for increased funding to implement the recommended increases for social and human services providers beyond the one-third level proposed by the Governor to help address the long wait list for accessing homecare services and provide more livable homecare staff wages. This is critical as the average private cost of home health aide services in RI is $36/hour, she notes.

“ As our industry continues to fight off the existential threats of inadequate funding and staffing shortages, our Association is staying laser focused on our homes receiving sufficient and sustainable financial reimbursements and supporting all initiatives to improve staff availability. Without substantive help from the General Assembly, we will continue to lose more homes and our ability to care for our most fragile RI citizens,” states John E. Gage, MBA, NHA, president and CEO of the Rhode Island Health Care Association. 

At AARP Rhode Island’s 2024 Legislative reception, State Director Catherine Taylor called for passage of H 7127 to provide an optional, voluntary Roth-IRA plan to the 172,000 Rhode Island employees who do not have access to a convenient, low-cost voluntary retirement savings plan through their employer.

The Secure Choice program, endorsed by Gov. Dan McKee and AARP Rhode Island, would be administered by the office of the General Treasurer, would see retirement savings accumulated in individual accounts for the exclusive benefit of the participants or their beneficiaries.  

The legislation has been referred to the House Finance Committee. A similar measure (S 2045) has been introduced in the upper chamber by Sen. Meghan E. Kallman.

According to Taylor, Secure Choice has been enacted in 18 states to date. In Connecticut, the program led to over 25,0000 workers saving over $19 million dollars in the first year of operation. These savings would not have been realized without Secure Choice.

Taylor also noted that Rhode Island is one of only 8 states that tax hard-earned Social Security benefits. “Our state tax on Social Security undermines the purpose of Social Security, which was designed to lift older adults out of poverty – not to fund state government,” she says.

AARP Rhode Island supports the efforts of Sen. Elaine Morgan (S 84) to completely eliminate the state tax on Social Security income and Sen. Walter Felag (S 246) to increase the thresholds to $ 110,000 for single, and $ 140,000 got joint filers, says Taylor.

“We would like to see the passage of S. 2556 [by Senators Lou Dipalma, Bridget Valverde, John Burke, and Pam Lauria] and H. 7493, sponsored by Rep. Scott Slater and Rep. Grace Diaz, that would establish a 20% add-on to the Medicaid per diem rate for nursing homes that have single-occupancy rooms and bathrooms,” says James Nyberg, executive director of LeadingAge RI.

According to Nyberg, there is a growing body of research that shows the benefits of single rooms on residents’ physical ad mental health and well-being, which was clearly exposed by the COVID-19 pandemic.  “There is also the simple fact that it promotes human dignity. Older Rhode Islanders should not have to share a bathroom and shower with strangers during a frail time of life,” he says.

“As for the budget, we want to ensure that the nursing home funding included in the Governor’s budget is maintained, and the Office of the Health Insurance Commissioner recommended rate increases be expedited, if possible, as well,” says Nyberg.

Just a Few More to Watch

Here is a sampling of other bills, of interest to aging advocates, thrown into the legislative hopper this legislative session:

Sen. Linda L. Ujifusa and Rep. Megan Cotter are sponsoring a bill (H 7208, S 2063) to provide relief to some of the state’s most vulnerable households by raising the eligibility limit and the maximum credit for the “circuit breaker” tax credit, which benefits low-income seniors and individuals with disabilities. The bills have been referred to their chamber’s Finance Committee.

The circuit breaker credit program provides an income tax credit to low-income Rhode Island homeowners and renters who are over 65 or disabled, equal to the amount that their property tax exceeds a certain percent of their income. That percent ranges from 3 to 6 percent, based on household income. In the case of renters, a figure representing 20 percent of their annual rent is used in the place of property tax in the calculation.   

The Senate approved S 2082, sponsored by Sen. Melissa A. Murray, to limit insured patients’ co-pays for supplies and equipment used to treat diabetes to $25 for a 30-day supply.

The legislation would apply to private insurers, health maintenance organizations, nonprofit hospital service or medical service corporations and the state employee health insurance plans that cover such supplies. Under the bill, beginning Jan. 1 (or, for state employees, the next time the health plan contract is purchased or renewed by the state), co-pays for insulin administration and glucose monitoring supplies shall be capped at $25 for a 30-day supply, or per item when an item is intended to be used for longer than 30 days.

During this legislative session, S 0089 and H 5417 were introduced by Senator Meghan Kallman and Rep. Evan P. Shanley and take their savings with them when they change jobs. The legislative proposals have been referred to the House Finance and Senate Committees for consideration.

For more details about legislation being considered by the Rhode Island General Assembly, go to https://legiscan.com/RI/legislation/2024.

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Regulatory approval can make a belated Christmas miracle happen

Published in RINewsToday on April 8, 2024

A belated Christmas miracle may truly happen, if state and federal agencies allow the Linn Health & Rehabilitation to convert one of its floors into affordable assisted living specializing in memory and dementia care. If this happens, says the facility’s management and its Board of Trustees it will keep the East Providence-based nonprofit facility from closing, preventing the displacement of residents and staff. 

Faced with rampant inflation, rising food and utility costs, high temporary staffing agency fees, and very low state Medicaid reimbursement rates that haven’t kept pace with increasing costs in over a decade, Linn Health, established over 52 years ago, publicized its financial troubles over four months ago.   

The Best of the Best 

When the news broke about Linn Health & Rehabilitation’s financial crisis over four months ago, the facility had just been named a 2024 ‘Best Nursing Home’ and ‘High-Performing’ short-term rehabilitation home in the nation by U.S. News & World Report, states Jamie L. Sanford, LNHA, LCSW, administrator of Linn Health & Rehabilitation.

“Here we are, one of the elite nursing homes in the United States, and we are finding it difficult to stay afloat like six other homes in our local market who have gone out of business, and three others who have declared bankruptcy, and one other who recently had to downsize by 50 beds,” says Sanford.

“It’s sad that Rhode Island families who deserve an affordable 5-star nursing home like ours don’t have the option because of inadequate Medicaid reimbursement. The struggle is real,” says Sanford.

Together with Aldersbridge Communities and its volunteer Board of Trustees, Linn leaders launched a savvy PR move, calling it a “Hail Mary” effort, to find its Christmas miracle donors and funding to prevent it from closing or forcing the displacement of 71 residents and the laying off of 150 staff members. A clever twist on the message resulted in a story on Rhode Island television stations, talk radio, and pick up by other media outlets.

“Our tireless pleas for funds to keep us afloat until a slight Medicaid reimbursement rate increase is expected to take place later this year were heard, but didn’t result in us receiving any emergency gap funding. We did receive charitable contributions from generous donors in earnest, but the amount was nowhere near enough to cover our losses of $100,000 per month,” states Richard Gamache, MS, FACHCA, chief executive officer of Aldersbridge Communities. With revenues dwindling, Linn leadership came up with a solution: convert one floor of the nursing home into affordable assisted living, specializing in memory and dementia care”, he notes. 

Submitting the Application

According to Gamache, its application for recertification was submitted last month and he expects the license to be approved by the RI Department of Health soon. “Obtaining our certification so that we can bill the Centers for Medicare & Medicaid Services is a bigger obstacle, because the federal government is involved,” he says. But, it could take “one or two months to get the facility’s licensing and certification approved by the RI Department of Health and Human Services (RIDHS) and CMS.  

If approved and certified, Linn Health & Rehabilitation will operate “The Loft at Linn” – a new assisted living memory care unit featuring 22 private studio apartments on the second floor of the building. The third floor will remain a licensed nursing home, albeit smaller now with 33 beds.

According to Gamache, the RIDHS has recertified Linn residents currently receiving long-term care to qualify for assisted living-level memory care, enabling them to continue to live at Linn and have the same caregivers they are used to and know. 

Meanwhile, grant funding from the Rhode Island Foundation, the Ruby Linn Foundation, and other sources are being used to pay for the apartment renovations; and to re-educate and train certified nursing assistants to become certified medical technicians so they can remain on staff working at the assisted living memory care program.

Shifting operations to assisted living and repurposing existing nursing home rooms will keep the facility’s doors open. “It’s not enough to solve our financial woes completely, as we expect the nursing home to continue to lose money – just not as much as we have been losing,” notes Gamache. “The irony is that we will save Rhode Island over $780,000 in a year because of the difference between what they will reimburse us for assisted living, versus a skilled level of care per Medicaid resident,” Gamache calculates. 

As a whole, because we’re going from a 42-bed skilled nursing floor to a 22-bed assisted living floor, the state is going to save $2.8 million per year in Medicaid dollars,” notes Gamache.

It is not surprising that Rick Gamache, who has years of experience managing nursing facilities, might have just found a way to keep his facility open,” says Kathleen Heren, Rhode Island’s Ombudsman. If the request of recertification is approved by state and federal regulators to offer assisted living with memory care, residents won’t be displaced and workers won’t lose their jobs, says Heren.

“It was never a viable option to sell Linn Health to an out-of-state nursing facility chain,” says Heren, noting that there is a need for assisted living facilities offering memory care. “There are high functioning people affected with dementia, with no medical conditions, who do not need to be placed in a nursing facility,” she adds.

Comments from the Sideline 

Like Heren, Maureen Maigret, policy advisor for the Senior Agenda Coalition and member of the RI Advisory Council on Alzheimer’s Disease Research and Treatment, holds Gamache in high regard. By converting a floor to needed assisted living with a memory care, staff will not be displaced, so residents with memory issues will not be losing staff who know them and who they are comfortable with.

According to Maigret, many assisted living residences strictly limit residents on Medicaid. A few years back, the state changed the Medicaid reimbursement for assisted living to one with three levels of reimbursement with a higher level of reimbursement to encourage more residences to accept persons with higher needs who are on Medicaid. ”We know that RI has many persons with diagnoses of Alzheimer’s and related dementias so such memory care programs are critical for those who cannot pay privately with monthly rates often over $6,000,” says Maigret.

Maigret notes that the state’s Health Department reports that 34 assisted living residences are licensed as Special Care/Alzheimer’s residences, but it is does not show which ones accept Medicaid. “And even those that do often limit the number of residents on Medicaid as they can get higher reimbursements from private paying persons,” she says.

According to Gage, in 2024, RI’s nursing homes are being paid rates by Medicaid that are based on their 2011 actual costs under the price-based reimbursement system that was implemented in 2013. Core principles of this reimbursement methodology are the statutory annual inflation adjustments and a Medicaid rate analysis every three years to determine whether rates are reasonable and adequate. “In the vast majority of years in the past decade, RI Medicaid has slashed or eliminated inflation adjustments, and they have never conducted a rate analysis/adjustment.  As a direct result, RI nursing homes are losing $50-75/day on each resident receiving care under Medicaid,” he says.

Gage predicts that Linn and Scandinavian Home will not be the last to make the difficult choice to downsize or close. “Just since the start of the pandemic, six RI nursing homes have closed and three were in receivership. Now, two nonprofit homes are forced to downsize their facilities,” he noted. “RI nursing homes must be adequately reimbursed by Medicaid under a stable and sustainable reimbursement system, and there needs to be bold action to recruit and retain frontline healthcare workers at competitive rates,” he warns, calling for the state to preserve nursing facilities. 

Demographics show a silver tsunami on the horizon. We need to ensure that there will be capacity for those who will need short-term or long-term care and services in the coming years,” states Gage.

As far as any potential Medicaid savings resulting from the planned conversion, Gage says that Linn would only be able to accommodate 33 nursing facility residents down from its former capacity of 87. By downsizing the nursing home by 54 beds and transitioning that floor into low-income memory care assisted living for just 22 residents, there will be a savings to the state, he says. due to the combined capacity of the facility decreasing by 32 residents, and those who remain in the memory care unit will be receiving a lower level of care and assistance than that provided in a skilled nursing home.

At press time, Gamache waits for the license from RIDOH and certification from the Centers for Medicare & Medicaid Services to be approved that enables the opening of the new assisted living memory care program. 

“There is no reason while this approval shouldn’t happen,” says Gamache. “We can comply with all the regulations, we’ve identified an overwhelming community need, and we are saving the state a lot of money,” he quipped. 

“After all, this is a win/win for the state, for residents, their families and staff to enable Aldersbridge Communities continue operating a full continuum of care,” states Gamache.