- [Announcer] This is a production of South Dakota Public Broadcasting.

(light music) - We got the email on a Friday, it was a late Friday afternoon and so I talked to my mom that Sunday.

- [Theresa] They were calling a meeting.

She was just sure they were going to close.

Well, I spent the next two days praying and hoping that it wasn't so.

But, it was.

- [Melissa] You know, I always thought a nursing home was a safe place to work because there's always going to be elderly.

So, where are these people gonna go?

- The uncertain future of nursing homes, on this episode of South Dakota Focus.

(light upbeat music) Welcome to South Dakota Focus.

I'm Jackie Hendry.

It's estimated that 2/3 of Americans will need long-term care later in life.

Deciding to move into an assisted living or a nursing home can be really difficult.

But in South Dakota, there's an added layer of uncertainty.

Rural nursing homes are closing at a fast rate.

And as they do, entire communities feel the loss.

Tonight we'll learn about some of the factors driving nursing homes to close, and hear from the people facing this uncertain future.

Starting with one of this year's latest losses.

- [Jackie] Clear Lake is a town of about 1,300 people in north-eastern South Dakota.

That's where Mary Bruinsma worked as a cook, and where she raised her children.

In 2020, just before the COVID-19 pandemic, she moved into the assisted living wing at the Deuel County Good Samaritan Society.

She lived there for just over two years.

- I thought I was set for life.

I would go out in a basket, so to say.

Well, Theresa came one Sunday and shut the door and, "You can't say anything about this for two days, mother, okay?"

They were calling a meeting.

- [Jackie] Mary's daughter is Theresa Schake who works with the Friends of SDPB.

Theresa got an email from the Good Samaritan Society on a Friday afternoon in May.

- And it basically said, "Don't ask the administration any questions, we'll explain everything for the reason for the meeting when you come on Tuesday."

And I said to my mom, like, "I'm pretty sure this means they're closing.

And I just want you to think about it.

We don't have to decide today, but where would you like to move to?"

- Well, I spent the next two days praying and hoping that it wasn't so.

- [Jackie] Mary wasn't the only one.

The staff at the Deuel County Good Samaritan Society had watched as other long-term care facilities close their doors.

Nurse Denise Eversma didn't realize just how bad their situation was.

- Just basically a month beforehand is when a few of us was like, "Things aren't adding up."

And part of that was when we had referrals, but yet national campus was telling us not to take any more referrals.

- [Jackie] Melissa Kloos had been working at the facility since she was a teenager.

- It was devastating.

It was hard.

We were told stuff with Medicare funding.

Our building needs work.

They, I believe they said it was like 1.25 million worth of work done to it.

Staffing, which, staffing is hard at every nursing home.

- [Jackie] Like many small-town nursing homes, this building is more than 60 years old, a testament to the community's initial investment.

Theresa Schake used to work in fundraising for the Deuel County Good Samaritan Society.

- Clear Lake raised $60,000 They raised $1,000 a bed in the '60's, which was a lot of money back then, to build the facility.

- [Jackie] That leaves some wondering why a similar investment wasn't possible today.

- We definitely could have done some fundraising to help with some of that.

And that's one thing that, in that meeting, when they announced that they were shutting down, that they never really had an answer for.

It was just basically brushing underneath the rug and then it went into the whole Medicare reimbursement and the expense of COVID.

Well, everybody's had COVID, everybody's had the expense of COVID.

So I felt like that was more of an excuse.

- [Jackie] But that's now how things looked to the leaders of the Good Samaritan Society, it's a nation wide non-profit long-term care provider based in Sioux Falls.

The organization manages more than 200 facilities across the country, including 18 in South Dakota.

Nate Schema is the CEO.

He says many of their facilities are more than 50 years old.

But raising money for building repairs doesn't solve issues like poor state and federal funding or chronic under-staffing.

- Sometimes we're in a position to say, "Look, the money is not enough.

A one-time check is not enough.

We need long-term sustainable investment."

And while we've been so grateful for the support that we've received from communities like Clear Lake, you know, we just didn't see a path forward in Clear Lake.

And if, not to be too prideful about ourselves, but if we can't do it in a position like this, where 70% of our locations are in deep rural communities, we're not sure, we were not sure there was a sustainable future for that community without significant investments or significant changes.

- [Jackie] In Clear Lake, workers worried about their own uncertain future after the closing was announced in May.

But they stayed focused on the future for their residents.

- My main role after we got the news was finding placement for the 39, 40 people that we had living there.

So that was very hard for me to look at these people and, you know, most of them have been from this community their entire lives.

They were farmers here.

They were nurses here.

- Kloos helped some families with their relocation.

But other families took on that work themselves.

Michelle Gross's mother was a resident in assisted living.

As soon as they got back to her room after the announcement, they started talking about her options.

- "Do you want to move to Aberdeen or Sioux Falls, where you have some siblings?

Or do you want to move closer to one of your daughters?"

That kind of stuff.

I was trying to get her to be part of the decision so she didn't feel like she was just being shoved around.

- [Jackie] There was one facility near a relative in Minnesota, but it had a waitlist.

They eventually found an opening at the Avantara facility in Milbank, about a 50 minute drive north.

- My mom moved here to Clear Lake back in 2007 after my father had passed away, so she's been part of my daily life for 15 years that she was here in Clear Lake, so it's quite the change.

- [Jackie] It was a painful process for the staff, too.

- This is where some of them want to have their funerals back here.

That was some of their concerns.

It was like, "If I move away, how am I going to have my funeral?"

I literally had one resident that talked to me about that.

"Can I come back for that?"

It's like, "Absolutely."

- [Jackie] By the time the Clear Lake facility closed in mid-July, Mary Bruinsma had moved to Avantera in Milbank.

- I try to not get into the dumps.

Sometimes I stand on the edge and look, and don't want to go there, so.

The hardest part is the family is further away, and if they come to visit me, it takes them longer, so therefore they don't come as often, which okay.

They've got their lives too.

- [Jackie] But it's a different story when Mary thinks about the Good Samaritan Society's decision to close the Deuel County facility.

- I still have a little animosity, because they upset my life and many others because of their pocketbook.

I don't know.

I understand they've got to make money at it, but where does the charity come in?

- Stories like these are becoming more common in South Dakota.

We'll hear more from the Good Samaritan Society later in this program, but the issue is bigger than any one provider.

In the past five years, 10% of the state's long-term care facilities have shut down.

There are a few key causes, and none of them have easy solutions.

Mark Deak is the executive director of the South Dakota Health Care Association.

It's a lobbying organization that represents many of the state's long-term care facilities.

He says there is a range of challenges facing the industry today.

How has the rate of nursing home closures changed in the last, I don't know, even 20 years?

- Yeah, well, I can tell you, let's just start with the most recent.

In the last few months, as you know, we've had a number of closings.

Just recently, unfortunately, we heard that Armour is going to close.

Prior to that, we had Lennox, and Ipswich, and so that's just the last few months.

Now you go over the last few years, you have nursing home closures unfortunately in all types of communities, large and small.

You have a closure in Huron, Madison, Mobridge, Bryant, Tripp.

Just every size community, and you think about what that does to the community.

Oftentimes, it's their largest employer, that's the nursing home, and so that's no more.

Think about what happens to those residents when they have to move, and they're that much further from their loved ones to visit them.

It's just a very sad situation, and of course, the caregivers themselves that have lost their jobs and then have to move to a further location as well, and I think, you know, even from kind of a selfish perspective, the fact is most of us are going to need long-term care services at some point in our lives.

2/3 of us are, and so when you think about that, certainly we want that for ourselves, but we certainly want it for our loved ones and our family now.

- What seems to be driving these closures?

- Primarily, certainly there are a lot of factors depending on the community you're in, but primarily, it's the Medicaid rate.

- [Jackie] Medicaid is a medical-cost assistance program and a partnership between the state and federal government.

Like Medicare, there are certain age and income eligibility requirements.

Unlike Medicare, Medicaid covers nursing home care.

States reimburses care providers at a set rate.

But it's not a dollar-for-dollar ratio.

In South Dakota, nursing homes lose about $60 a day for every resident covered by Medicaid.

And when more than half of nursing home residents pay through Medicaid, facilities struggle to break even.

- South Dakota has underfunded Medicaid for many, many years.

In fact, for decades.

And frankly, we're kind of getting our comeuppance now.

We dug a real big hole.

It's going to be very hard to get out of it.

I do need to give credit to the governor and to the legislature for making some significant strides over the last few years, but it's clear that a lot more needs to be done, and if not, I fear we're going to see more closures.

- What are the biggest concerns that you're hearing from the facilities that you work with?

- The biggest concern would be staffing, and that was an issue before the pandemic, and it's become that much more of an issue now.

Now I know you hear that in all areas, and I think it's true that many areas are impacted by staffing shortages, but I have to say that unfortunately long-term care is unique that way, even when compared to other medical areas.

We have a thousand less long-term care staff than we did prior to the pandemic, so prior what we did two and a half years ago.

If you look at other health care providers, you look at hospitals, home care, physician's clinics, they don't have that.

They're basically at the same level of staffing, so it's a huge issue that way.

Now, how do we change that?

It's hard, because particularly, I mean, frankly the job of taking care of frail people has always been difficult.

You know, you need to feed, you need to bathe them.

It's 24/7 care.

Well, how much more difficult is it in a pandemic?

Folks are burning out.

They're tired of it, and the least we can do is try to pay them something more so we can attract and retain them.

- That thousand, that's shocking to me.

I hadn't heard that number before.

Medicaid reimbursement and staffing challenges were very real for long-term care providers before the pandemic, but rising costs and low wages have made the problem worse.

Facilities may look to travel nurse agencies to fill the gap in staffing, but this can also be cost prohibitive.

The Walworth County Care Center in Selby is an anomaly.

It's a rural long-term care facility with no traveling staff.

It's independent from major healthcare providers.

And it survived after the Good Samaritan Society announced it would shut down the facility four years ago.

Selby is a small town in north-central South Dakota, about 20 miles east of Morbidge and the Missouri River.

Dan Biel is a local business owner and president of the Walworth County Care Center's board of Directors.

He remembers when the Good Samaritan Society announced plans to pull out of the community in the fall of 2018.

- We talked to Good Sam about it, and then they made us a deal that if we raised, like, $400,000, they would run it for another year.

- [Jackie] The community had just three months to raise the money.

Dan Biel and others called a community meeting in the school gymnasium.

- And we probably had 200-some people there, I would say, and they wanted to keep the nursing home, and some people, I don't know how we came up with the money.

We just said, "We got to raise $500,000 to keep our facility open," and we started getting checks that night.

- [Jackie] People like Patti Baumann and her brother Mike Schanzenbach recognized the need.

- I don't consider myself elderly yet, but I'm getting there, but there was people that live here that were older that I were, and they were there and I suppose they're looking at the future, too.

You know, "Where am I going to go?"

- And when you live in rural America, farther away is quite a ways at times, you know.

It just makes it harder on not only the individual but the family members as well.

- [Jackie] After multiple community meetings and fundraisers throughout the county, Selby managed to reach the half-a-million-dollar fundraising goal.

- We started negotiating with Good Sam and told them what we need, and they told us what they need, and eventually it turned out that our town had built this facility and gave it to Good Sam for one dollar back in the '60s.

So that's what they decided to do with us.

They gave it back to us for a dollar.

So that was a big start for us.

We had a facility, but we had to buy pretty much everything in it.

- [Jackie] The newly-named Walworth County Care Center took over operations on December 1st, 2018, the initial closing date the Good Samaritan Society had announced a few months earlier.

- We didn't know at that time if we would be open for a year or for eight months or two years.

And we were upfront with our employees.

We were upfront with our residents.

We said we're going to give it our best shot and most of the employees stayed.

Most of the residents stayed, and most of the employees are still here.

- [Jackie] One of those remaining residents is Patti Bauman and Mike Schanzenbach's mother.

They'd originally wanted her to stay in the facility in Mobridge, where Patti lives.

- When she was able to and could drive, she was over here every day.

She was visiting her friends that were in, and it was just something for her to do after my dad passed away.

We asked her, you know, "Would you like to go to Assisted Living?

They have a nice facility in Mobridge," but she wanted to come here.

- She definitely wanted to stay in Selby.

Yeah, no doubt about that.

(laughs) Pretty clear!

- [Jackie] And it turned out to be the right choice.

- Mobridge got their notice about two or three months after we were going, which was a bad, bad thing.

A lot of their residents went west, or at least half of them, and then we got some of theirs, the ones we could handle and then got some of their staff.

- [Jackie] When the Mobridge care center closed, that made the Walworth County Care center the only nursing home in the county.

But Dan Biel isn't sure if the story would have the same ending today.

- One thing that I think helped us a lot is that we could get the building and use it as a healthcare facility.

A lot of them, I'm hearing now, they might sell them the building or give them the building, but they can't use it as a healthcare facility, which I think in the overall scheme of things is very, very bad for the state.

- [Jackie] The Walworth County Care Center is still up and running, but there are familiar challenges.

Trista Bates is the home's administrator.

- Staffing is a huge issue for, I think, not only our facility, but for the whole entire state.

The whole entire nation.

I think there's just a lot of travel positions out there.

We are fortunate that we do not have any travel staff in our facility.

We've been able to do that because the staff here just pick up shifts.

There are shifts that become open, they pick them up.

Our goal is to have our own staff.

They know our residents.

They love our residents.

They know the plan of care, so they're just dedicated to working those extra shifts.

I would like to see the travel industry maybe have some regulations.

I think we are all at risk of losing our staff to travel because they can get paid twice as much.

I could have the same staff member live in town and work for travel agency and still come to work here, and get paid twice as much.

- Some members of congress want to investigate how travel nursing agencies determine their rates.

The American Health Care Association has even petitioned the Federal Trade Commission to put a cap on what those agencies can charge.

Mark Deak works with the South Dakota Health Care Association says in an email that a state-by-state approach risks losing travel agency services altogether.

But there's something else that keeps Dan Biel awake at night, and it won't come as a surprise.

- I'm worried about Medicaid reimbursement.

You know, I'm worried about all the restrictions they put, try to put on small nursing homes as far as staffing and hours, that kind of thing.

It's hard for a small facility.

- [Jackie] It's a topic he pushes every year during the state legislative session.

- That's one of the things that we really want to get pushed up some.

If there's extra money, and there's never extra money, but if there is money, we definitely need money, because we take care of the poorest of the poor, and take care of them just like the private pay and just like the insurance pay.

They all get treated the same, whether they pay or not.

- In Deuel County, the shut down of Clear Lake's nursing home has made some people angry.

They blame state lawmakers, and the Good Samaritan Society.

In some ways, the loss is even stronger because of the community's long history with the organization.

The Good Samaritan Society opened its doors in North Dakota nearly 100 years ago.

Its now national reach has created a long history in rural communities like Clear Lake.

And Scottie Hagen's family has a long history with the Good Samaritan Society.

- My mom first got a job there two years after the Good Samaritan center opened up, and then her dad followed and became a janitor.

As years went by, every single one of us, there were seven of us kids, and then of course my mom and dad, my dad worked there for 33 years as a maintenance guy.

I worked in the kitchen and my daughters all worked in the kitchen.

- [Jackie] Hagen's mother-in-law, Alice, worked in the facility as a CNA for more than 20 years.

She was also a resident until the Good Samaritan Society closed it down in July.

Hagen says the meeting with family members and residents when the shut down was announced was emotional, including some frustration at Governor Kristi Noem.

Deuel County is close to where Noem grew up.

- People were angry.

Some were yelling, "Well, does Kristi know?

Does Kristi know, Krisi Noem," you know.

And I said, "You bet she knows, she knows."

"Well, I can't believe she didn't do nothing to stop it," and I said, "Well, it's just the way it is right now."

If you don't expand Medicare and Medicaid, you're not going to keep these rural places.

- Just to be clear, even if the governor did know a particular nursing home was in danger of closing, the contributing factors of that closure are way more for any single policymaker could solve.

The headquarters of the Good Samaritan Society is in Sioux Falls.

Nate Schema is its CEO.

He says the long-term care industry is up against significant challenges, and funding is just one of them.

- While we're really grateful for some of the ways that Governor Noem has infused some dollars into our sector, it's just a start.

Right now, we have South Dakotans driving 20 miles across the border into Minnesota and taking care of Minnesotans because they can see 3 to $7 more an hour.

- [Jackie] South Dakota's low Medicaid reimbursement rate is exacerbating staffing issues that have only worsened since the pandemic began.

- That gap is roughly $60 or more short in these rural communities.

The math just doesn't work.

We're not able to pay our people, we're not able to compete with industries, manufacturing, all these businesses that continue to raise their rates.

I always compare to Jimmy John's.

When you go get a sub right now, you're gonna spend 12 to $15 to get a sandwich because they're passing those things on to pay their people.

Well, in nursing homes, I don't have the ability to change my rates like that because in many of our buildings, 60 to 70% of our funding comes from Medicare and Medicaid, which I don't have control over.

And so I think when you combine all of these pressures, these headwinds, the workforce, the struggle to find workforce, the rising inflation on everything that we do, the cost of food, the cost of supplies, the cost of delivering care, it really has reached an untenable situation in some of our rural communities.

- [Jackie] But for the people living and working in rural communities, it's a hard pill to swallow.

Denise Eversma lives in Clear Lake and worked at the Deuel County Good Samaritan Society for 13 years.

- I really wanna know why corporate didn't take care of us.

Why don't you try to find the help that your facilities need, the help with?

- I think in Good Samaritan society we have over 2,000 open positions.

And when you really break that down, that would mean that we need an additional 14 caregivers in each of our locations across the country.

- [Jackie] While the Walworth County Care Center in Selby has managed to survive independently, that's primarily because of a unique situation.

Good Sam sold the building to the community for $1.

And they can use it as a healthcare facility without any restrictions.

But these kinds of agreements are complicated because one organization is essentially turning over a facility to its potential competition.

What works in one place doesn't always work in another.

In Clear Lake, Michelle Gross attended the family meeting where that question came up.

- Okay, what are you going to do with the facility?

You know, what's going to happen to this building?

Knowing that the community was what brought Good Sam in back in the '60s with raising money per bed, and then throughout the years with all the fundraising and things the community has done.

Plus even Trinity Lutheran donating land, and if I remember right, their answer was basically "nothing."

Another question was, "Are you willing to work with any group on, you know, anything?

Even bringing in a different company or doing something with this building?"

And they were like flat out saying, "No."

- [Jackie] But there might be some room for compromise.

There are negotiations ongoing between Good Samaritan and Deuel Area Development, a non-profit economic development corporation dedicated to Deuel County.

The organization declined requests for an interview citing pending details.

But last month, the Clear Lake Courier reported Good Samaritan would give the building to the non-profit without any future use restrictions.

Deuel Area Development plans to hold a community meeting to discuss ideas for the space.

- In many cases we've seen communities come together and say hey we need some office space.

Maybe we need to move some city or county businesses together.

Maybe we need a daycare.

Maybe we see a different vision for Senior Living.

So ultimately we did come together with the leaders there in Clear Lake.

I do believe there's a plan there together.

Yes, there is something that I know that is well on its way in Clear Lake.

You know, I think about Selby coming together and doing everything they can to continue to support that community.

I think it's phenomenal.

I also know that there are some other external factors that came together about that same time, in a neighboring community in Mobridge, and so I look at it from the standpoint of you know in some of these communities, how do we bring our resources together, how do we consolidate them so we can make one really strong community?

And I know that's not always the most popular thing to say and do and you know, trust me, we're always looking for the opportunity to make it work.

- [Jackie] There are plenty of opinions in Clear Lake about what might have prevented the care center from closing.

But Scottie Hagen, whose entire family worked at the center, says there's a shared conviction that something needs to change.

- These people that are on Medicaid right now, they're the ones that have worked really hard.

I mean, like Alice, you know, 27 years she worked as a nurse's aide.

You're not going to get that much money put away, but what you do get put away, with being in the nursing home one to two years, it's all gone.

So you have no choice.

We really need help, you know, for these hard-working rural people.

- Are we comfortable with that as Americans to say, you know what, closest nursing home is 50 miles away.

You know, would we accept that in our schools?

Would we accept that in our hospitals?

And so I think we need long-term solutions to our funding, to our workforce crises that we're experiencing right now, so we truly have the healthcare that we need close to home.

- You can find ongoing coverage of nursing home challenges online at SDPB.org/news.

If you have questions about the future of elder care or if there's a story you want us to look into, email us at [email protected].

Until next time, I'm Jackie Hendry.

Thank you for watching.

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