Statistics on the burgeoning growth of the population of older people and their likely need for future care are frequently trumpeted. In 2019, the US population aged 65 and over was 54.1 million people and is projected to reach 94.7 million by 2060. Another: 70% of them will need some type of long-term care in their lifetimes — and those lifespans are increasing.
But paradoxically, nursing homes — the traditional though often last resort as providers of such care — are also closing their doors at an alarmingly increasing rate: voluntary closures more than doubled in the 1990s, and the trend shows no signs of slowing.
This means that care and housing is tenuous for many of the 1.4 million people currently living in the nation’s 15,600 nursing homes, and uncertain for those in future need. Added to this uneasy mix are drastic cuts recently proposed to the Medicaid program, which currently foots the bill for about two-thirds of the nursing home residents in the country, making more facility closures inevitable.
Whither They Goest
In the recent past, nursing home closures were rare. Facility owners, many of whom established their nursing homes as a family business, rarely shut down voluntarily. Most closures that did occur were caused by a nudge from on high — prompted only by rare catastrophic reports by state or federal authorities charged with performing periodic inspections or by gross financial mismanagement requiring the owners to close their doors. Even then, there were usually plenty of prospects waiting in the wings to take over as new owners. Nursing homes were big, and usually profitable, businesses. But as consumer protections and preferences have changed in the last decade or so, so have the rescue scenarios.
Some of the factors behind the change:
- Tightened controls on Medicare and Medicaid reimbursements to owners, which some complain make it impossible to operate at a profit, or even within a budget;
- Heightened consumer preferences to age in place, which more often than not means living at home or in a homelike setting rather than a more impersonal facility;
- Changing land use needs and trends, which in some areas of the country, make it much more profitable for real estate owners to dedicate the facility property to an alternative use, such as commercial hotels or businesses or residential developments; and
- Generational differences in owners, making it less likely that the owners’ children will step in and carry on the business once their parents retire.
Left in the Cold: The Residents
Even before a closing occurs, whether voluntary or ordered by authorities, the possibility sets off a flurry of activity by local, state, and federal agencies. As such agencies are wont to do, they require facility administrators to complete mountainous sheaves of paperwork, including detailed “closure plans.”
The laws and regulations mandating such plans are intended to protect residents living there and ensure they are smoothly transferred to another facility. At a minimum, they require that residents be given at least 60 days notice before a nursing home closes. But residents are commonly given short shrift in notice and other practical matters as facility owners and operators focus instead on finalizing finances and dealing with media inquiries. Often, too, the residents are given only grudging attention by staff members who may also be miffed at the prospect of being out of work.
And from a practical standpoint, a facility forced to close its doors because it’s no longer financially feasible to keep them open lacks the bandwidth and resources needed to meet residents’ needs to find suitable new homes.
Snafus occur in what authorities later label as “unsuccessful closings.” Residents’ belongings get packed up and are trashed or mislabeled. Medical history charts and medication orders get lost, resulting in dangerous delays in getting new medication orders. Family members aren’t notified in advance where a resident is moved; or a resident is not aware of an impending closure because notice was sent only to distant family members. Residents are placed in facilities in distant communities — in one reported instance, an eight-hour drive from loved ones. Or residents are told, in violation of the law, that they must accept the first place offered to them as their new home.
As a result, many residents often suffer from a combination of maladies common enough to be isolated and labeled as “transfer trauma” or “relocation stress syndrome.”
Symptoms may include:
- Increase in withdrawn behavior
- New deficits in self-care — such as washing, dressing, and getting to the bathroom independently
- Weight loss
What Can Be Done
While some nursing home closures are preventable or inevitable, much more can be done to help make them humane for residents who are, in effect, being evicted. And some states are now taking active steps to make that happen.
Wisconsin, for example, now has a program in place aimed at eliminating Transfer Trauma also known as Relocation Stress Syndrome. Thomas LaDuke, who holds the title of Ombudsman Relocation Specialist within the state’s Board on Aging and Longterm Care, emphasizes that informing residents and family members well in advance of a closing is key. He says that for most people, location is most important. “We ask residents what town or people they need to be near in the new location,” he says. “Nursing homes often pressure people to make decision quickly. We want the opposite of that — slow and mindful.”
LaDuke also encourages staff at the original nursing home to keep detailed notes on each individual resident — and to discuss those notes in person with nurses at the transfer facility. And ideally, he says, someone from the closing nursing home should accompany the resident to the new facility and help him or her unpack and settle in there.
Ohio has also instituted a progressive program for nursing home relocations. Erin Pettegrew, Deputy State Long-Term Care Ombudsman with Ohio’s Department of Aging, also emphasizes that the notification process should start early — and that the transitional team should carefully explain what’s happening to residents and discuss all possible options with them. She also stresses the importance of having follow-up visits with residents, being certain to ask them whether they feel better off in their new facility than they did in the former one.
Resources for Help
While the sources emerging for help in reducing Transfer Trauma are mostly focused on facility owners and staff, a few may be invaluable for family members and residents facing a nursing home closure.
- Know Residents’ Rights During a Nursing Home Closure
- A Checklist on Transferring Personal Items, helpful in stemming common complaints about property lost or destroyed during transfers, and
- Nursing Home Closures Kit, while intended for ombudsman and advocates, it can also be a helpful resource for others who want to ensure closures are conducted according to the rules.