Home health care nurses in short supply
Recovering from vascular surgery at Beth Israel Deaconess Medical Center, the 78-year-old woman yearned to be home for the last days of Hanukkah. The good news came Tuesday when her doctor declared her medically ready to leave the hospital. But she's stuck there at least until tomorrow because no visiting nurse could be found.
"We called seven or eight agencies, but none had a nurse available for Christmas Eve or Christmas," said Lynn Wichmann, director of case management for the hospital. "The patient needs help with home IV antibiotics and twice-a-day dressing changes. There's no way she could get by without the home care."
Across the region, home health care agencies are turning away hundreds of patients every month because of a shortage of visiting nurses. The problem is particularly acute on holidays and weekends and has been growing as hospitals seek to send patients home quicker and sicker, and agencies struggle to fill nursing vacancies.
"It's a silent crisis," said Carolyn Markey, chief executive of the Visiting Nurse Associations of America in Boston. Silent because few patients complain publicly, afraid that would make it even harder to find care.
While no one has collected statewide data, area agencies reported turning away 30 to 200 patients a month.
The patients facing the greatest difficulty getting care are those who need it most -- patients like the 78-year-old, with complex home care regimens who require once- or twice-daily visits from a registered nurse. The majority are elderly, without family.
Earlier this month, a man in his 80s had to stay in a Worcester hospital for several extra days because he needed help with intravenous antibiotics twice a day.
"We couldn't commit to twice a day for six weeks," said Carol Premo, a regional director of admissions at VNA Care Network, which serves 210 communities in Greater Boston and well past Worcester. "He and his spouse were well into their 80s. They couldn't learn how to administer the antibiotic safely themselves and flush the line. So he couldn't go home."
Premo, who didn't know what became of the man after she turned him away, says the agency simply has not been able to hire enough nurses to keep up with increasing demand.
Statewide, the Home Health Care Association of Massachusetts estimates that 10,000 more Medicare patients will be served by home health workers this year than the 90,000 seen in 2001 and 2002. Medicare patients account for the bulk of the association's clients.
"Two years ago, we were turning away almost no one," Premo said. "Now, we're turning away up to 200 patients a month, or about 9 to 10 percent of referrals. And those are just the patients we know of. There's probably 10 times that, since every time you say we're full, they won't call you for the next few."
Hospitals, which account for the majority of home health care referrals, are working harder to line up home nursing for patients. Hospital discharge planners nationally told a Medicare advisory committee last year that they were having problems securing care for patients with wounds and other problems that needed daily attention.
In Massachusetts, hospital workers say they regularly start calling nursing agencies three or four days before a patient is actually ready for discharge. Often they need the beds for other patients.
On Wednesday, for example, patients at Beth Israel were lined up in the emergency room waiting for beds. But hospital officials say they won't send a patient home without the proper supports. Sometimes, patients end up going to a rehabilitation center or nursing home for a period, which can be more expensive and may not be the best solution for the patient.
"If they're well enough to be home, most people would prefer to be home," said Nancy Sullivan, director of case management at Massachusetts General Hospital. "Staying in the hospital is not a good thing if you don't need it. But it's a challenge [to line up home care], especially in the Boston area."
VNA of Boston is turning away 30 to 40 patients a month, as is Partners Home Care, which serves communities in Eastern Massachusetts.
"The demand has increased. People want to stay in their homes and, technologically, we can do things in the home we couldn't do before," said Marcia Reissig, president of Partners Home Care. "But we don't have the staffing."
American Hospital Association figures show there is a shortage of more than 100,000 nurses nationally in hospitals alone. Home health care agencies compete with hospitals and nursing homes for registered nurses, but typically cannot compete on salaries. Partners Home Care, for example, pays its nurses about 20 percent less than the major Boston hospitals. The recruitment problem is compounded by the need for home care nurses to have the experience and training to work alone.
Many of the home care agencies operate at a loss because of high costs and low reimbursement from private insurers and the state Medicaid program. Medicare, which funds the largest chunk of home nursing, pays better, but not enough to make up for the others, agency officials said.
Congress has cut Medicare payments for home nursing, most recently last year, deciding it was growing too fast. Federal spending dropped from a high of nearly $18 billion in 1997 to about $10.5 billion last year.
Agencies say they don't pick and choose patients based on how much they will be reimbursed by insurers, but those who have studied the issue say reimbursment is a potential problem.
"There are still incentives to avoid heavy-care patients because you're going to lose money on them," said Keith Lind, a senior policy adviser with the AARP's public policy institute. "If the shortage were easy to solve, it would have been solved by now."
To address the nursing shortage, VNA Care Network recently won a $810,000 federal grant to provide preceptors who will train nurses just out of school to function autonomously in the home.
Separately, Carol Ellenbecker, director of the graduate nursing program at the University of Massachusetts at Boston, received a grant last month to study factors that could increase job satisfaction for home care nurses and encourage them to stay on the job. She said cuts in government payments and the nursing shortage are forcing nurses to make fewer and shorter visits to patients.
"It's pretty bad now," Ellenbecker said. "Nurses don't want to come to home care as readily as they used to because the jobs are more stressful, and they're less able to establish satisfying relationships with the patients. I think it's only going to get worse."
Alice Dembner can be reached at Dembner@globe.com.
