As baby boomers age and the workforce shrinks, experts fear there will not be enough people or money to care for all our elders. In many ways, that reality has already arrived in Vermont.
In recent years, dozens of Vermont seniors have ended up waiting in hospitals after being turned away from nursing homes. According to officials at hospitals across the state, many Vermonters wait months for placement in a nursing home. Some wait a year or more.
These seniors usually have a couple things in common: their financial needs qualify them for Medicaid, and their health conditions require higher staffing ratios than other patients. Most often, these seniors suffer from dementia.
That was the case for Robert Bousquet, an 85-year-old former mechanic and construction worker.
Compared to other dementia patients, Bousquet was lucky. His wait at North Country Hospital was only two months long: short, compared to many.
Still, Robert’s wife Joan Bousquet said the experience was a nightmare.
“I’ve never cried so much in my life,” said Joan. “I would leave him to go home, and sob the whole way home.”
Joan initially brought Robert to the hospital from their home in Irasburg because of a bladder infection and dehydration. Joan said the hospital treated both ailments within a week.
But Joan felt she couldn’t care for Robert at home any longer.
Robert had been refusing to eat or bathe. Often, Joan said, he would wander outside in the middle of the night. His Alzheimer’s was getting worse.
A hospital case worker helped Robert apply for Medicaid for long-term care, then began daily phone calls to nursing homes in about six Vermont cities. Every day for two months, Joan said, the nursing homes turned Robert down.
During that time, Robert wasn’t allowed to leave the third floor of North Country Hospital — not even to accompany his wife to a cafeteria on the first floor. Joan said his only activities were short walks in the hallway, and counting cars in the parking lot outside his window.
The state does not keep track of hospital waits for nursing homes. Monica Hutt, commissioner of the Department of Disabilities, Aging and Independent Living said her department hears about it “from time to time,” but not on a regular basis.
But Steven Grant, head of care coordination at UVM Medical Center, called the trend “a real problem.” Grant said on any given day, between 25 and 40 people face barriers to discharge for some reason. “The most common barrier we find,” said Grant, “are seniors with cognitive disorders, specifically dementia, who need long-term care placement.”
Grant said the problem appears to be getting worse, not better.
Jane Suder, who heads up patient management at Northwestern Medical Center in St. Albans, said six of her hospital’s 34 inpatient beds were recently taken up by patients in Robert’s position. That situation, she said, can lead to overcrowding, and waits for other patients who need the hospital’s services.
At times, both hospitals have housed seniors in search of long-term care for a year or more.
Vermont’s nursing home waits are “atypical,” according to Eric Carlson, directing attorney for the national nonprofit, Justice in Aging. He said in some parts of the country, people do have to wait for access to a nursing home. But, he said, “the level of difficulty that you’re talking about in Vermont is far above what I think the average is.”
Eventually, Robert Bousquet did get placed in a nursing home: Bel-Aire Center, in Newport. Joan Bousquet figured the long wait was the result of a shortage of beds.
In fact, many of the facilities turned Bousquet down despite having empty beds. According to a recent census from Vermont's Agency of Human Services, some of the facilities averaged dozens of empty beds throughout January. Statewide that month, the nursing homes averaged 474 empty beds each day.
According to the nursing facilities, however, staffing shortages mean those beds can’t be filled.
Laura Pelosi handles policy issues for the Vermont Health Care Association, a nursing facility advocacy group. She said VHCA's informal survey of 23 Vermont nursing facilities found that about a quarter of registered nurses and licensed practical nurse positions are vacant this year. Licensed nursing assistant positions were down 16 percent.
“We need a lot of nurses,” Pelosi said, “to meet the needs of our aging demographic.”
A 2017 report from the University of Vermont Area predicted demand for RNs in nursing homes and residential care settings will increase by 69 percent by 2030 to serve a ballooning population of seniors.
Vermont’s long-term care ombudsman, Sean Londergan, said there's more to it than the workforce shortage.
“They’re a business,” he said of nursing homes. For them, choosing patients for admission is a business decision.
Patients with private pay don’t usually have trouble getting into nursing homes, whatever their conditions. The same is often true for people with Medicare funding for rehab. But 60 percent of Vermont nursing home patients have Medicaid for long-term care. Medicaid pays the least.
Nursing homes prefer take the Medicaid patients who require the least expensive care.
That leaves people like Robert Bousquet - people who both qualify for Medicaid and have complex needs- left behind.
Joan Bousquet visits Robert every day at Bel-Aire Center in Newport. She said she's thrilled he has a safe place to live, people to talk to, and activities to choose from. But while Londergan and Pelosi both support increased Medicaid reimbursements for complex patients like Robert, others said the best solution is outside of a nursing facility.
At UVM Medical Center, Steven Grant suggested Vermont open some specialized facilities just for dementia patients. Officials with the state’s Medicaid program, Choices For Care, wondered if Vermonters know they can get wrap-around support for their loved ones at home.
And Jane Suder at Northwestern Medical Center said one state program has offered an alternative to patients waiting at her hospital more than once this year: something called Adult Family Care.