ELLSWORTH — Wednesday was a long day for Angie Hodson Slinker.
The Biddeford resident left her home in the early morning hours to drive nearly four hours to the Sonogee Rehabilitation and Living Center in Bar Harbor, where her mother has lived for the past three and a half years.
The meeting with Sonogee officials was for caregivers and residents of the facility, who had been asked to sign paperwork so that staff could release medical information as they scrambled to find placements for residents at facilities elsewhere.
The phone call from Sonogee officials on Monday that the organization would be closing its doors in April had stunned Slinker.
“I was completely floored,” she said, stopping for an interview on her way back to southern Maine. Slinker’s voice broke as she lamented the situation residents and staff had found themselves in.
“It’s become home,” Slinker said. “Having to uproot her and start over — my mom has Alzheimer’s dementia. It’s going to be a big change, transitioning all over again.”
Finding a bed anywhere in the state was a challenge several years ago, Slinker said. When they were first looking, her mother had spent a month in the hospital before the space in Bar Harbor opened up.
In an email, Mary Jane Richards, chief operating officer of Sonogee’s parent organization North Country Associates, declined an interview, saying: “As you can imagine, there are no staff available to be interviewed because we are focusing on finding placement for the individuals that live here.”
A press release from Sonogee officials cited low occupancy rates, a competitive job market, the increase in minimum wage and decreased admissions due in part to competition with the MDI Hospital Swing Bed program, a short-term transitional program between hospital and home that started in 2000.
Sonogee is not alone in its struggles. Maine has seen a spate of closures in recent years, having lost close to 3,000 beds since 1995, according to federal data.
And there are fewer and fewer residents to fill the beds that remain. Occupancy rates at nursing homes are down nationwide, with nearly one in five beds now going unused, according to the National Investment Center for Seniors Housing and Care.
Maine has a higher occupancy rate than the rest of the country (close to 89 percent) but that number has steadily declined in recent years, according to the Centers for Disease Control and Prevention.
How can there be empty nursing home beds with an aging population?
One of the most significant contributors to the paradox may be a change in the type of patients nursing homes are caring for, write authors of a 2009 paper funded by Centers for Medicare and Medicaid Services (CMMS).
In the mid-1990s, facilities began a “major shift in focus” toward short-term, “post-acute” rehabilitation rather than long-term care.
If a patient is admitted to the hospital for three consecutive days, Medicare will pay for a short-term stay in a skilled nursing facility, meaning these homes were reimbursed by Medicare for these short-term stays, at rates often much higher other reimbursement programs.
(Medicaid, known in Maine as MaineCare, pays for long-term care.)
But with the passage of the Affordable Care Act, hospitals began being penalized for patients who were readmitted. Because of this, many started labeling patients with the outpatient designation “under observation,” rather than admitting them, according to an article on the American Health Care Association website.
Medicare doesn’t cover skilled nursing care rehabilitation for these types of patients, which means not only that patients may wind up paying for rehabilitation out of pocket, but has also meant cuts to a revenue stream that nursing homes had increasingly come to rely upon.
There are also more options for care than ever before.
“You have increased alternatives, like assisted living, and other ways for people to stay at home,” Ruth Katz, senior vice president of public policy at Leading Age, told The New York Times last year.
“When people find community alternatives, they use them whenever possible.”
Federal funding has followed, and perhaps in part propelled, this shift.
In 1980, 99 percent of federal Medicaid dollars went to institutions, according to Medicaid reports. That number has declined to 43 percent, with the majority of Medicaid long-term care spending now flowing toward home- and community-based alternatives, due in part to lobbying from activists for exactly that.
And then there are the financial pressures associated with changing regulations, including a 2016 overhaul of long-term care facilities by Centers for Medicare and Medicaid Services.
The changes were the most comprehensive in nearly three decades, and regulators themselves acknowledged that complying with the new rules won’t come cheap.
Phased in over five years, the authors said they expect implementation to cost around $63,000 per facility for the first year and $55,000 for subsequent years.
Brenda Gallant, executive director of the nonprofit independent Maine Long-Term Care Ombudsman Program, said she sees the overhaul as positive, if pricey.
“We’re looking at the regulations as being a good thing and offering greater protection for a population that has changed over the last several years,” Gallant said.
But the mandate also required a number of new positions for facilities without an increase in funding, said Nadine Grosso, vice president and director of communications at the Maine Health Care Association (MHA).
“They’re requiring such things as an infection control preventionist, a chaplain. There’s this list of staff that in this environment is going to be really difficult to meet,” Grosso said.
Maine’s nursing homes are also smaller and caring for higher-needs patients, said Rick Erb, president and CEO of Maine Health Care Association, and more expensive to run. The average number of beds per facility, said Erb, is the smallest in the country, about 65.
“So when they make a requirement to add an infection control officer it’s the same for us as a nursing home that may have 200 beds,” Erb said.
“It is a challenge for us to meet these national standards when our facilities are much smaller,” Erb said. “Small facilities are what people want, but it’s expensive to run.”
There is also, of course, Maine’s tight job market.
“[Long-term care work] is very complex, difficult work and it’s very demanding,” Gallant said.
“In a good economy when there are other jobs available that pay more and are less demanding it’s difficult to attract staff.”
Maine also has higher staff-to-patient ratio requirements than many other states, which Gallant said could account for some of nursing homes’ high labor costs.
But all of this will likely do little to comfort Sonogee residents and caregivers.
Bud Smallidge’s wife, Barbara, has been at Sonogee for six years. He travels almost daily to visit her from his home in Seal Harbor — but if she’s moved farther away, those visits would likely become less frequent.
The closest facility she could be moved to would likely be in Ellsworth at Seaport Village, but there’s the possibility she could be moved farther — to the Bangor area or as far away as Camden, one of the facilities within 60 miles that accepts MaineCare.
“It’s going to change Bud’s whole routine,” said Ginny Norwood, a friend and one-time Sonogee employee who visits frequently to volunteer and was having her near-weekly lunch with Smallidge.
“Sonogee is like a home for Bud. This is going to affect his whole life.”