Eight years ago, the Nehalem Bay Health District board decided to terminate the relationship with Prestige, a skilled nursing facility (SNF) owner and manager that had managed the care center poorly for many years. The board took back responsibility for the care center. The first priority was to find a new management company who would be dedicated to improving the quality of care and the physical facility. After a statewide search, the board hired Aidan, a company that had a reputation for rehabilitating existing SNF’s.
The Health District formed an LLC (limited liability corporation) to make the Care Center an independent entity and to avoid making the district liable for damages incurred by the Care Center. Also, the board wanted to maintain a separation from PERS while providing a good benefit package to employees. The Health District board retained responsibility for the structure which was then leased to the Care Center.
Aidan assigned a very senior member of their company to create a new management team and establish priorities for improvements to be paid for out of profits. Despite the commitment of Aidan, the Care Center has continued to struggle to meet its goals. What are the barriers to improvement?
Under Prestige, the Care Center developed a horrible reputation. Failure to maintain the facility, poor staff training and performance, all decisions made from afar while maintaining a figurehead manager on-site, lack of coordination between admitting physicians and the attending doctor at the facility were among the reasons for the bad reputation. Aidan, with the board’s support, set out to correct the problems. New management was hired, staff training was intensified, many improvements were made in the facility, and still the problems remain.
The location of the Care Center in a rural area with a lack of affordable housing makes recruitment and retention of staff a major challenge. There has been frequent turnover in senior positions, particularly in the executive director and director of nursing slots. Frequent free classes to train certified nursing assistants (CNA’s) have not produced enough graduates who will take a job with the Care Center. And, the few that do rarely last very long because the wages they earn do not enable them to live close to the facility. Weather and car problems add to the difficulties. CNA’s do not have glamorous jobs, and these disincentives do not make the job any more attractive.
In order to make a profit which could be used to make the needed improvements, the census in the facility has to be maintained at a certain level. The Care Center is a 50-bed facility, but only 40 beds are actually available for use. A census of around 35 or more produces enough income for a small operating margin. Even if the center had enough referrals, state regulations require a mandated level of care givers per patient. If there aren’t enough, then either the referral has to be refused admission or temporary agency employees must be used. The center then faces loss of revenue or greatly increased costs.
Despite the fact that the care center is the only SNF in Tillamook County, its reputation has made referral sources reluctant to recommend the facility. Despite improvements, the center has a low quality rating.
The State of Oregon is trying to drastically reduce the number of SNF beds to save money. Whether intended or not, the State’s draconian quality indicators and punitive inspection processes do nothing to help struggling facilities. The State agencies work to improve conditions in the SNF’s using punishments as their primary approach. Rather than inspecting with the goal of educating and supporting improvements in performance, they levy heavy fines for infractions. This is not going to change, and the anxiety these practices create do not help improve the morale of the employees which is critical for good patient care.
The nearest SNF alternative is the Clatsop Care Center in Astoria. It has received a half million dollars a year from Clatsop County for many years. The Nehalem Bay Care Center receives no support from Tillamook County of from our local governments. While money isn’t the sole answer to NBCC’s problems, more money would not be amiss.
To summarize the problems:
• Bad reputation combined with low quality ratings
• Difficulty recruiting and maintaining sufficient staff levels
• Frequent changes in senior positions
• Low census resulting in slim to negative operating margins
• Property tax assessment and timber revenues contribute next to nothing
• Lack of affordable housing
• Transportation to work problems
• Hostile State regulatory agencies
• Lack of local government support
The current Nehalem Bay Health District Board (which is also the Care Center board) has four members. Three of the members are new, and the board is still searching for a fifth member. They face daunting challenges, not only with the Care Center, but also with the old hospital building. They deserve community interest and support.