Texas nursing homes, struggling during a pandemic that has ravaged their residents and decimated their workforce, are asking the state for $400 million in federal coronavirus relief to address a staffing crisis in the system that cares for the state’s oldest and most fragile residents.

Adding to the urgency is the fact that 40% of the state’s 100,000 nursing home employees aren’t vaccinated against COVID-19 and they could face a federal ultimatum to do so later this month.

Industry advocates fear the federal vaccination mandate could mean the potential exodus of tens of thousands of workers from facilities across the state before Halloween.

“We know we are going to lose additional staff when that vaccine mandate comes out,” said Becky Anderson, head of clinical operations for Focused Post Acute Care Partners, which runs 31 nursing homes and employs about 2,500 workers in Texas. “We just have some staff that are very adamant that they will not get the vaccine.’”

The federal rule comes at a time when the industry is already struggling with a shrinking workforce due to burnout, low pay, increased expenses related to the pandemic, and competition from other health care providers, administrators say.

Gov. Greg Abbott has vowed to fight any vaccine mandates in Texas.

According to recent surveys by the Texas Health Care Association and LeadingAge Texas, two nursing home industry groups in Texas, facilities across the state have seen a 12% decrease in their workforce in the last year. At least one-third of survey respondents are turning away new admissions due to staffing shortages, the survey says.

For the facilities, staffing shortages mean higher costs for overtime and an inability to grow or maintain patient population levels. Facility operators are also facing a pressing need for higher salaries and more money for recruiting tools, industry advocates said.

“The environment providers are operating in today isn’t sustainable,” said George Linial, president and CEO of LeadingAge Texas. “Texas cannot continue to kick this can down the road. A strong commitment and investment by lawmakers will pay huge dividends for the people we serve.”

However, it does not appear that help from Texas officials, either with emergency funding or staff, is imminent.

There is no bill filed in the current special session of the Legislature, which ends in just over two weeks, that would funnel any relief funds to nursing homes.

Texas has about $16.7 billion in American Rescue Plan Act money, and about $7.2 billion is marked in legislation to shore up the state’s unemployment fund, which was overloaded last year by record claims.

The funding request by the nursing homes includes $400 million to help recruit and retain workers, and an additional $350 million to pay for new infection-control measures and maintain them permanently for future crises.

For the remaining $8.5 billion available, requests from everyone else outside the nursing home industry amount to nearly eight times that much, budget officials say.

The nursing homes’ effort to get that funding has not gotten very far, sparking industry concerns that nursing homes will start shutting down.

Already, the nursing home workforce crunch is forcing admission caps, which is having a ripple effect on hospitals that are already at capacity with COVID-19 patients. With nowhere to transport patients well enough to leave a hospital but still too ill to go home, hospitals are now often required to house patients longer than they would have if they’d had a nursing home spot available, said Kevin Warren, president and CEO of the Texas Health Care Association.

It has also placed more burdens on families that may not be equipped to care for an aging relative much longer or older Texans whose medical needs are best met in a skilled nursing facility rather than through costly home care, he said.

“I am concerned that without additional funding necessary to recruit and retain current staff and develop opportunities to bring new employees into the profession, we will see continuously increasing access-to-care issues with expanding admission restrictions, closures, small independent owners being forced to sell, and bankruptcies,” Warren said.

Meanwhile, New York state lawmakers are considering sending medically trained National Guard members to fill vacancies in struggling nursing homes. So far, there are no similar plans underway in Texas to use the military branch to supplement staffing in any of the state’s 1,200 nursing homes.

A spokesperson for the Texas Division of Emergency Management, which oversees the state guard, referred questions about potential help for nursing homes to the Texas Department of State Health Services.

A DSHS spokesperson said that nursing homes with staff who are out sick with COVID-19 or that are overwhelmed with COVID patients can ask the state for help, but the facilities aren’t reporting high numbers of active cases.

While Texas has paid for thousands of relief workers this summer to send to hospitals that are struggling with a similar staffing crisis, Abbott has not announced a similar program for nursing homes.

Texas nursing homes were devastated by the coronavirus, which had an especially high death rate among the older population and killed 10% of the state’s nursing home residents in its first year.

In an effort to reduce the deadly impact of the virus, both state and federal governments imposed stringent safety mandates on nursing homes that changed daily, sometimes hourly, at the height of the pandemic last year.

The homes struggled to supply tests and personal protective equipment to staffers at their own expense, and some made extensive modifications to their air filtration systems, their building layouts and their staffing plans to respond to the health crisis.

Meanwhile, the cost to run a Texas nursing home has risen dramatically during the pandemic. Safety protocols and the ongoing staffing problems have meant budgets for Texas nursing homes have risen by 25% in the past 18 months, according to the survey released on Tuesday.

And even more trouble lies ahead. About 75% of Texas nursing homes are operating at a loss, the THCA/LeadingAge survey said.

Staffing challenges

These staffing challenges at nursing homes are not limited to lower-paying or entry-level positions. Every one of the 31 facilities run by Focused Care in Texas has openings, and the vacancies go all the way to the top, Anderson said. Three facilities have no administrator, and another handful are without a director of nursing, she said.

Bonuses for referring new employees and extra shifts can help attract and retain staff, but about 90% of nursing home residents use Medicaid or Medicare, which keeps budgets limited and pay for most entry-level positions between $10 and $15 an hour.

There is also a shortage of applicants for work that was already difficult and now that work comes with the extra safety requirements and gear needed to treat a COVID-19-susceptible population. Any new worker finds themself working longer overtime hours because of the hiring shortfalls and all of that contributes to employees quitting within a month or two of being hired, she said. The problem has gotten so bad that the company is updating its orientation program to find a way to better prepare new hires for the difficult environment, Anderson said.

The high turnover, especially among new hires, “is quite alarming,” she said. “It’s always been hard work, but it’s even harder now with everything going on, and just the exhaustion.”

Vaccine woes 

According to the U.S. Centers for Medicare and Medicaid Services, about 65% of nursing home staff are currently vaccinated nationally. A recent rise in cases among nursing home residents, both in Texas and across the country, driven by the highly contagious delta variant, prompted the federal agency to announce in August that all nursing home employees be vaccinated in order for their facilities to continue participating in the Medicare and Medicaid program.

Those rules are expected to come out later this month.

Anderson is casting an anxious eye on that moment, when potentially 40% of her workforce could become ineligible for employment.

About 62% of the staff and 81% of the residents in Focused Care facilities across Texas are vaccinated, Anderson said.

But while the rates of resident vaccinations are fairly high across the system, they range widely among the staff depending on the facility, state numbers show.

Statewide, the vast majority of nursing homes that have fewer than 40% of their staff fully vaccinated are located in rural areas — mainly east Texas, where counties have some of the lowest vaccination rates in the state.

By contrast, most of the nursing homes with more than 90% of staff vaccinated are in the Rio Grande Valley and in El Paso, which have some of the highest vaccination rates in the state.

Warren, the head of the nursing home advocacy group THCA, said that while administrators work every day to convince their staff to get vaccinated, it is a near-impossible task to move them off the belief system that causes them to reject or fear the vaccine even though it’s free and widely available.

Much of it, he said, has to do with where they live.

“There is that relationship between the vaccine rates within the community and within the facility,” Warren said. “When folks in these facilities are working 8, 10, 12 hours a day, on their days off, they’re spending time with their families and friends in the community. So if that same prevalence of concern and distrust of the vaccine is present in that community, it’s only furthering their own hesitation.”

Carla Astudillo and Reese Oxner contributed to this report.

Disclosure: LeadingAge Texas and Texas Health Care Association have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.

This article originally appeared in The Texas Tribune, a member-supported, nonpartisan newsroom informing and engaging Texans on state politics and policy.

Karen Brooks Harper, The Texas Tribune

Karen Brooks Harper is a general assignments reporter for The Texas Tribune. More by Karen Brooks Harper, The Texas Tribune

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