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Time to resolve RI’s ongoing Nursing Home staffing crisis

Published in RINewsToday on April 18, 2021

The latest release of AARP’s Nursing Home COVID-19 Dashboard shows that both cases and deaths in nursing homes declined in the four weeks ending March 21. Although these rates are improving, chronic staffing problems in nursing homes—revealed during the COVID-19 pandemic—continue. In Rhode Island, 30% of nursing homes reported a shortage of nurses or aides, which is only fractionally better than the previous reporting period. 

AARP has come out swinging to fight for enhancing the quality of care in Rhode Island’s 104 nursing homes.

AARP Rhode Island, representing 131 members, calls for the General Assembly to ensure the quality of care for the state’s nursing home through minimum staffing standards, oversight, and access to in-person formal advocates, called long-term care Ombudsmen. The state’s the largest aging advocacy group has urged lawmakers to create a state task force on nursing home quality and safety and has pushed for rejecting immunity and holding facilities accountable when they fail to provide adequate care to residents.  It’s also crucial that Rhode Island ensures that increases in nursing homes’ reimbursement rates are spent on staff pay and to improve protections for residents, says AARP Rhode Island. 

Last December, AARP Rhode Island called on Governor Gina Raimondo to scrap Executive Order 20-21 and its subsequent reauthorizations to grant civil immunity related to COVID-19 for nursing homes and other long-term care facilities. The aging advocacy group warned that these facilities should be held responsible for providing the level of quality care that is required of them for which they are being compensated.

Rhode Island Lawmakers Attack Nursing Home Staffing Crisis

During the legislative session, the state’s nursing home staffing crisis caught the eye of Senate Majority Whip Maryellen Goodwin is a policy issue that needs to be addressed. They knew that Rhode Island ranked 41st in the nation in the number of the average hours of care nursing home residents receive, according to data from the Centers for Medicare and Medicaid Services.  The state also has the lowest average resident-care hours per day of any New England state.

On Feb. 2, the Rode Island Senate approved S 0002, “Nursing Home Staffing and Quality Care Act” sponsored by Goodwin and nine Democratic cosponsors to address an ongoing crisis in staffing nursing homes that has been exacerbated by the COVID-19 pandemic.  The bill had passed unanimously in the Health and Human Services Committee, and ultimately, the full Senate gave its thumbs up to the legislative proposal by a vote of 34 to 4.  Only one Republican senator crossed the aisle and voted with the Democratic senators.

“There is a resident care crisis in our state. Staffing shortages and low wages lead to seniors and people with disabilities not receiving the care they desperately need. The pandemic, of course, has exponentially increased the demands of the job and exacerbated patients’ needs. We must confront this problem head-on before our nursing home system collapses,” said Sponsor Senator Goodwin (D-Dist. 1, Providence).

The legislation would establish a minimum standard of 4.1 hours of resident care per day, the federal recommendation for quality care long endorsed by health care experts including the American Nurses Association, the Coalition of Geriatric Nursing Organizations, and the National Consumer Voice for Quality Long-Term Care. The bill, which the Senate also approved last year, has been backed by Raise the Bar on Resident Care, a coalition of advocates for patient care, and the Rhode Island’s Department of Health (RIDOH).

The bill would also secure funding to raise wages for caregivers to recruit and retain a stable and qualified workforce. Short staffing drives high turnover in nursing homes. Not only does high turnover create undue stress and burnout for remaining staff, but it also diverts valuable resources to recruit, orient, and train new employees and increases reliance on overtime and agency staff.  Low wages are a significant driver of the staffing crisis. The median wage for a CNA in Rhode Island is less than $15, and $1/hour lower than the median wage in both Massachusetts and Connecticut.

The legislation would also invest in needed training and skills enhancement for caregivers to provide care for patients with increasing acuity and complex health care needs.

At press time, the companion bill (2021-H-5012), sponsored by Reps. Scott A. Slater (D-Dist.10, Providence) and William W. O’Brien (D-Dist. 54) was considered by House Finance Committee and recommended for further study.

RIDOH’s Director Nicole Alexander-Scott, MD, MPH says the state agency “supports the thoughtfulness of the provisions included in the legislation and welcomes dialogue with its sponsors, advocates, and the nursing home facility industry regarding methods to sustain the necessary conditions associated with the intent of the bill.”

Alexander-Scott states that “RIDOH takes its charge seriously to keep nursing home residents and is supportive of efforts to update standards of care to better serve Rhode Islanders in nursing facilities, as well as increase resident and staff satisfaction within nursing facilities.”

Scott Fraser, President and CEO of the Rhode Island Health Care Association (RIHCA), a nonprofit group representing 80 percent of Rhode Island’s nursing homes, says that “staffing shortages are directly traceable to the chronic lack of Medicaid funding from past governors. Period.” 

According to Fraser, state law requires Medicaid to be funded at a national inflation index, usually averaging around 3%. “Up until this year, previous governors have slashed this amount resulting in millions of dollars in losses to our homes.  Thankfully, Governor McKee is proposing to fully fund the Medicaid Inflation Index this year,” he says.

RIHCA opposes the mandatory minimum staffing the legislation now being considered by the Rhode Island General Assembly, says Fraser, warning that its passage would result in facilities closing throughout the state. “No other state has adopted such a high standard,” he says, noting that the Washington, DC-based American Health Care Association estimates that this legislation would cost Rhode Island facilities at least $75 million to meet this standard and the need to hire more than 800 employees. 

Fraser calls for the “Nursing Home Staffing and Quality Care Act” to be defeated, noting that the legislation does not contain any provisions for funding.  “Medically, there is no proof that mandating a certain number of hours of direct care results in any better health outcomes.  This is an unfunded legislative mandate. If homes are forced to close, not only would residents be forced to find a new place for their care, but hundreds of workers would also be forced out of work,” he says.

Goodwin does not believe that mandating minimum staffing requirements in nursing homes will force nursing homes to close. She noted that the legislation is aimed at ensuring nursing home residents receive adequate care and that Rhode Island is the only state in the northeast without such a standard.

“There is an un-level playing field in nursing home staffing in Rhode Island,” charges Goodwin, noting that many facilities staff 4.1 hours per day, or close to it, while others only provide two hours of care per day. “In either case, the overwhelming majority of well-staffed and poorly-staffed nursing homes remain highly profitable,” she says. 

According to Goodwin, the lack of staffing and certified nursing assistants (CNAs) is due to unreasonable workloads and low pay. “RIDOH’s CAN registry makes it clear that retention of these workers is a big issue. This is in part because they can make as much money – or more – in a minimum wage profession with much less stress,” she adds, stressing that “The Nursing Home Staffing and Quality Care Act” directly addresses these staffing challenges.

One quick policy fix is to provide nursing home operators with adequate Medicaid reimbursement to pay for increased staffing.  Lawmakers must keep McKee’s proposed increase of nursing home rates pursuant to statute, requiring a market-based increase on Oct. 2021, in the state’s FY 2020 budget. The cost is estimated to be $9.6 million.

With the House panel recommending that Slater’s companion measure ((2021-H-5012) to be held for further study, Goodwin’s chances of seeing her legislation becoming law dwindles as the Rhode Island Assembly’s summer adjournment begins to loom ever closer. There’s probably no reason to insist that a bill be passed in order to have a study commission, so this could be appointed right away if there is serious intent to solve this problem.

Slater’s legislation may well be resurrected in the final days of the Rhode Island General Assembly, behind the closed doors when “horse-trading” takes place between House and Senate leadership.  If this doesn’t occur, either the House or Senate might consider creating a Task Force, bringing together nursing home operators, health care professionals and staff officials, to resolve the state’s nursing home staffing crisis. 

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Ramping up COVID-19 Vaccine Plans

Published in RINewsToday.com on January 17, 2021

As state health officials say they are clamoring for more doses of COVID-19 vaccine, just days ago, Health and Human Services Secretary Alex Azar said in an interview with NBC’s Lester Holt there is no “reserve stockpile” of COVID-19 vaccine doses left to release to states, and all vaccine has now been released to fulfill orders by the states. Azar’s comments come after his announcement on January 12th that the states no longer need to hold back a second shot because there is confidence that Pfizer and Moderna, manufacturers of the vaccine, could keep up with the demand.

In the January 12th announcement, Azar noted several steps the states should take immediately, and the federal government was taking:

Expand groups getting vaccinated to include all those over the age of 65 – Vaccinate those 16-64 with co-morbidities – Expand channels to include those more familiar with people to reach them where they are, such as pharmacies – release all supply to order by states.

Azar encouraged states that are holding back “second shots” to not do so, saying, “Every vaccine dose that is sitting in a warehouse means another life lost…”

In response to the rollout of COVID-19 vaccines, Katie Smith Sloan, president and CEO of Washington, DC-based Leading Age and acting President and CEO, of the Visiting Nurse Associations of American, had some thoughts. “With COVID-19 death tolls topping 4,000 a day, it’s chilling to hear that vaccine stockpiles may have been misrepresented, and that older Americans who have been dying in record numbers might suffer as a result,” she said in a Jan. 15 statement.

Making it a Priority of Giving COVID-19 Vaccines to Seniors

“We hope these reports are not true. For weeks, state policy makers, distribution partners and aging services providers have been basing their vaccine allocations and strategies on vaccine stockpile estimates,” Sloan noted.    

“Because more than 265,000 people 65 or over have died of COVID, we have been pleased that many states have made the right decision to prioritize older Americans and their caregivers for immunizations, and that the process is underway in long-term care.  We hope this news is not a setback for those people, as well as others waiting for vaccinations in home health, hospice, PACE programs, adult day or other settings,” says Sloan.  

Rhode Island’s plan not changing

However, Rhode Island has chosen not to prioritize the distribution of it COVID-19 vaccine to older Rhode Islanders. The Rhode Island Department of Health (RIDOH) expects residents age 75 and older who reside in the community to be vaccinated in February or possibility March. Specifics as to vaccinating residents ages 50 to 74 have not been announced. While other states are beginning mass vaccination sites at stadiums, no such plans exist in Rhode Island.

AARP Advocates for those over 50

“Since the start of the pandemic, over 95 percent of the deaths from COVID-19 have been among people 50 and older,” AARP Rhode Island State Director Kathleen Connell and State President Phil Zarlengo said in a Jan. 8 letter to Gov. Gina Raimondo, urging the state’s top official to “ensure that Rhode Islanders age 50 and older are prioritized to receive a vaccine.”  (see Weiss Commentary printed here on January 11). 

AARP is fighting for older Americans to be prioritized in getting COVID-19 vaccines because the science has shown that older people are at higher risk of death.  On Jan. 11, the Washington, DC-based AARP sent a letter to HHS Secretary Alex Azar calling for his agency to take immediate action to address the issues that have slowed down vaccinations across the country.

RIDOH’s plans

On Jan. 15, in a Vaccine Update, Nicole-Alexander Scott, MD, MPH, Director, Rhode Island Department of Health, stated: “There was a lot of news this week about the federal government urging states to vaccinate people who are 65 years of age and older. We want to get vaccine to people older than 65, too. The limiting factor is not federal rules, or our approach in Rhode Island. The limiting factor is the amount of vaccine we are getting. We are getting 14,000 first doses of vaccine a week. There are close to 190,000 people in Rhode Island who are 65 years of age and older. It would not be honest or fair of us to say that all Rhode Islanders older than 65 can get vaccinated tomorrow, because we just don’t have the vaccine.” 

It is unclear if RI is holding “second shot” vaccine doses in storage. There is about a week’s lag from receiving the doses and distributing them. On January 15th, the state said they had administered a total (first and second shots) of 51,220 shots. On January 12th, the most recent report provided, the state says it has received 72,175 doses from the federal government.

Scott added:” We’ve seen the confusion and frustration that has resulted in states that have opened eligibility to groups that they did not have enough vaccine for. In Rhode Island, we are vaccinating older adults incrementally and thoughtfully. That means that when we tell you you can get vaccinated, you know that there is a real, physical vaccine waiting for you – not just that you fall into a broad category that is eligible to get a vaccine when we eventually have one. Please know that if we could, we would make sure that everyone got vaccinated immediately. But we’re just not getting enough vaccine right now, so we’re doing the best we can with what we have.”

Rhode Island’s report

After listening to the state’s reports on plans for getting out the vaccine to the group the Centers for Disease Control and Prevention is recommending, those over 65, and those under 65 with underlying medical conditions, there seems to be an overall lack of urgency in ramping up for this new directive, said Nancy Thomas, Publisher of the RINewsToday.com, who was on the update webinar this week, with other reporters. “There are no plans – or none they are willing to announce – for how people will register, or sign up, for when the 65 and over category is ready to go. Questions about how people will identify themselves at the site also were yet to be determined. When asked about mass vaccination sites, officials said they may consider schools, but had no plans for using McCoy Stadium or other large sites. We’ve seen states all around us opening up stadiums – many of whom are still vaccinating medical workers – but ramping up to do as many as they can until supplies are exhausted for that day. Massachusetts even has swag – pins, wristbands, and banners – to build up the sense of excitement, which also builds compliance. We have asked RIDOH about public education campaigns and they say they have a campaign coming.  

With such a large percentage of seniors in Rhode Island, are we ready to ramp up? Some states are vaccinating 24/7, with appointments at 2am and such. I guess a sense of frustration weighs on me and on others who do not see big plans, forward looking plans in the near future. Meetings with the public focus more on reporting of what has been done and where we’ve been, rather than where we’re going,” Thomas said.

Biden Releases COVID-19 Vaccination Plan

President-elect Joe Biden, speaking a day before he unveiled his COVID-19 Vaccine Plan on Jan. 15 in Wilmington, Del, unveiled a $1.9 trillion “American Rescue Plan” to combat COVID-19 and to shore up a wobbly economy. The emergency vaccination and relief package combine funding to reduce the economic impact of the pandemic (including direct stimulus payments of $1,400 per person, extending unemployment compensation, raising the minimum wage, continuing eviction and foreclosure moratoriums to increasing the Child Tax Credit) with strategies to fight to combat the virus itself.

About $400 billion of Biden’s “American Rescue Plan” is directed to controlling the virus by setting up mass vaccination centers, funding more sophisticated scientific analysis of new strains and creating teams of local health workers to trace the contacts of infected people.

President-elect Joe Biden’s Jan 15 press conference, lasting a little more than 19 minutes, warned that “We remain in a very dark winter. He noted that COVID-19 infection rates are creeping up 34 percent, COVID-19 related hospitalizations are increasing, and 3,000 to 4,000 people are dying every day of COVID-19.  “Things will get worse before they get better,” he said.

When releasing his five step COID-19 Vaccination Plan, Biden stated, “This is the time to set big goals and to pursue them with courage and conviction because the health of the nation is at stake.”  His strategy of getting 100 million Americans vaccinated during his first 100 days in office relies on the following steps: encourage states to vaccine more people age 65 and over including front line workers; creating thousands of community vaccination centers at gyms, sports stadiums and community centers; activating local pharmacies to give vaccines; ramping up supplies of vaccines by triggering the Defense Production Act and distributing vaccines quickly; and regularly updating state and local officials as to how much vaccine they are getting and when to expect the delivery.  Biden promised to give regular updates pertaining to the meeting of his goals, “both the good news and the bad.”

Mask Mandate – Wear that mask

During his first 100 days, Biden will be issuing an executive order to require masks for federal workers, on federal property, and on interstate travel, like trains and planes.  He is also urging governors to require masks in cities and states.

“I know masks have become a partisan issue,” says Biden, stressing “it’s a patriotic act.  Experts say that wearing a mask from now until April will save more than 50,000 lives, he noted.

Biden called on Congress to make his COVID-19 Vaccination Plan happen. “I’m optimistic. I’m convinced the American people are ready to spare no effort and no expense to get this done,” he said, stressing it “will take many months to get where we need to be.”

CDC: Rhode Island Hit with Widespread Flu

Published in the Woonsocket Call on January 6, 2018

The U.S. Centers for Disease Control (CDC) says it’s a no brainer as to what issue I should cover this week. Being homebound for three or four days, with the flu, and my submittal deadline looming, I pen my commentary on widespread flu activity now being reported in Rhode Island.

CDC’s Influenza surveillance (ending Week 52) reported widespread influenza “flu” activity in 24 states including Rhode Island. This CDC warning recently triggered a requirement by the Rhode Island Department of Health (RIDOH} to require unvaccinated healthcare workers in a variety of health care settings to wear masks when entering a person’s room, serving food, or participating with patients in group activities.

The masking requirement helps protect healthcare workers from catching the flu, and helps protects patients who are often dealing with other serious health issues,” said Director of Health Nicole Alexander-Scott, MD, MPH., in a statement released on January 2. “For people who have not been vaccinated yet, it is not too late. Flu vaccine is the single best way to keep yourself and the people you love safe from the flu. Getting vaccinated today will provide you with months of protection,” she says.

According to the RIDOH, typical flu symptoms include having a fever, coughing, a sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. Some people also may have vomiting and diarrhea. People may be infected with the flu, and have respiratory symptoms without a fever.

There are many types of illnesses or injuries even less severe cases of the flu do not require a visit to the emergency room, says RIDOH, noting that less severe cases of the flu will be treated more promptly by a primary care provider or in urgent care facilities. The department notes that going to an emergency room can oftentimes result in long waits because emergency room providers prioritize more serious injuries and medical conditions.

But, when do you seek out treatment for a nasty case of the flu? RIDOH says that difficulty in breathing or shortness in health, pain or pressure in the chest and having flu-like symptoms that improve and return with a fever and worse cough are clear warning signs to go immediately to an emergency room.

CDC expects that increased flu activity in the coming weeks, noting that the average duration of a flu season for the last five seasons has been 16 weeks, with a range of 11 weeks to 20 weeks. With significant flu still to come this season, CDC continues to recommend that anyone who has not yet gotten a flu vaccine this season should get vaccinated now. It takes approximately two weeks for the protection provided by vaccination to begin.

Although 480,000 Rhode Islanders were vaccinated last year, RIDOH, says that the flu sent 1,390 Rhode Islanders to the hospital and resulted in 60 deaths (compared to 1,216 hospitalizations and 33 deaths the previous year. The state saw more flu activity during the 2017-2018 flu season than during any flu season since the 2019-2010 season, when the state experienced the state experienced the H1N1 flu pandemic.

It’s Not too Late to Get Vaccination

In kicking off Rhode Island’s annual flu vaccination campaign last October, RIDOH Director Nicole Alexander-Scott, MD, MPH, said, “A flu shot is the single best way to protect yourself and the ones you love against the flu. When you get a flu shot you are not only protecting yourself, you are also protecting the people in your life by limiting the spread of the flu.”

So, if you have not been vaccinated, consider doing so. RIDOH recommends that children older than 6 months of age should be vaccinated against the flu. Others should, too., including health care workers, pregnant women, people over age 50, nursing facility residents and persons with chronic conditions (specifically heart, lung, or kidney disease, diabetes, asthma, anemia, blood disorders, or weakened immune systems).

It’s easily to quickly get a flu shot because of its availability at doctors’ offices and pharmacies throughout Rhode Island.

In addition to getting a flu shot, here are a few simple tips that can help prevent you from getting the flu.

Wash your hands thoroughly throughout the day, using warm water and soap. If you do not have soap and water, use an alcohol-based hand gel.

According to the CDC, the flu can spread to others up to about 6 feet away, by droplets made when a person cough, sneezes or talks. So, reduce spreading the flu, just by coughing or sneezing into your elbow or into a tissue.

Avoid touching your eyes, nose, or month because germs spread this way.

Get a good night’s sleep, be physically active and look for ways to manage your stress. Also, drink plenty of fluids, and eat nutritious food.

Keep surfaces wiped down, especially bedside tables, surfaces in the bathroom, and toys for children, by wiping them down with a household disinfectant.