Balancing community needs with budget pressure for the county nursing home

LACONIA — Medicaid funding reimbursement is one of the new challenges facing the Belknap County Nursing Home, whose staff is already dealing with continued staff recruitment struggles.

County Commissioners Peter Spanos (chair, District 1), Glen Waring (vice chair, District 2) and Stephen Hodges (clerk, District 3), in their proposed budget, recommended $15.8 million in total expenditures for the nursing home. The nursing home is public, operated by the county, and provides services to a mix of Medicaid and private-pay residents.

And, according to the commissioners’ budget projections, the nursing home is expected to take in more than $11 million in revenue in 2026, leaving a deficit to be shouldered by the taxpayers of about $4.3 million.

“Right now, the nursing home expenditures are $15.7 million, the offsetting revenues to that is $11.4 million,” County Administrator Debra Shackett said. “The cost to the taxpayers is $4.3 million.”

Shackett relayed the information to the county delegation’s Budget Review Committee during a meeting on Jan. 22. That committee comprises state Reps. Harry Bean (R-Gilford), Steven Bogert (R-Laconia), Mike Bordes (R-Laconia), Matt Coker (R-Meredith), Juliet Harvey-Bolia (R-Tilton), Lisa Freeman (R-Tilton) and Charlie St. Clair (D-Laconia).

The Belknap County Delegation is made up of the region's Statehouse representatives. Bordes also serves as the city's mayor, and Bogert as councilor for Ward 5.

Friday was Shackett’s last business day in the position ahead of her retirement, effective Jan. 31. Carina Park, formerly the town administrator in Lincoln, was tapped to replace her.  

“We had 14 private pay, we usually have about seven, eight private pay,” Nursing Home Administrator Shelley Richardson said at the meeting. “We were very lucky with the private pay, however, the rate went up Jan. 1. It’s $400 now, but private pays that are in the facility now are grandfathered in, at $350.”  

And there’s empty beds at the nursing home, 36 of them, with the census generally floating between 58 and 62 residents of late. There’s a roughly six-month waiting period for new residents, though in some circumstances, people can be admitted sooner. 

“The 36 beds, again, is it a staffing problem still?” St. Clair asked. 

“Correct,” Richardson said. “We have 31 open positions, and we have seven agency positions. So we would need to actually have 38 positions filled to run at full capacity, 94 beds.”  

Richardson said it would cost in the neighborhood of $8 million in spending to capture $4 million in revenue, under present conditions.

“And that’s when the Medicaid rates were high,” Richardson said. “We just had a Medicaid cut. We’ve gone down $7 a bed. And I don’t know what’s going to happen in July. I’m sure you probably heard in Concord, we were going to lose $17 a bed, because the Medicaid prices have gone down, the reimbursement.”

Medicaid reimbursement changes create additional challenges for county nursing homes, staffing challenges aside. 

“It’s going to get harder, because the providers that are out there with Medicaid Advantage plans, and doctors and hospitals are not picking up the Advantage plans, so people do not have a provider to come somewhere,” Richardson said. “So we don’t have orders, we don’t have somebody to follow them for their care, or their insurance isn’t accepted. They can only go to a facility that their insurance or Advantage plan will cover.” 

“It’s just getting more expensive, I would say, and so it will come down to how much is the public willing to pay to keep the nursing home, through tax dollars,” Shackett said. 

St. Clair said he’s received calls from constituents who aren’t able to get their relatives into the county nursing home, some who've waited six months to a year. 

Richardson said it's a similar situation throughout the community, and staffing is the prime culprit. They’re still required to follow federal COVID guidelines, handed down in 2023. 

“When we had a COVID outbreak, I had 10 employees out. So 10 employees out for 10 days, how can you take care of residents? We mandate staff to stay, we have to pay extra for staff to stay, it’s just very difficult,” Richardson said. 

“There’s no financial benefit,” Bordes said in confronting the deficit. “We’d actually lose money by having a full nursing home.” 

Shackett said the county has to balance several considerations when looking at the money. 

“That’s why the cost is so high, because we’re not going to hire 38 employees — we’ve been trying that — so they would have to be temporary staffing agency employees, which costs a lot,” Shackett said. “Then they’re coming and going, it affects the quality of care, it’s all sort of a losing proposition right now. Then that’s balanced against the need in the community, and there is a waiting list.”

Coker asked Richardson if the county nursing home is competitive among private-pay residents, who pay higher fees than Medicaid patients.

“We have to take care of people who have the fewest resources,” Shackett said. 

“It’s not really the mission of the nursing home to take private-pay residents, it’s to take people who have no money, which would really affect these numbers.” 

The county nursing home resident split is somewhere around 80% to 85% Medicaid patients, Richardson said, and the waiting list is something like 25 people.

“The fact in my mind is that, in spite of what people like to think, by living we’re costing other people money. It’s just the way it is. It comes down to: what’s important and what’s not important?” St. Clair said. “Is it important for the county to provide the services for the nursing home? Is it going to cost more? I guess so. Is that cost being pushed off to something else that we’re not seeing here? I don’t know. It just seems like poor stewardship for the county not to provide the service of the nursing home for our residents, to the maximum that it can be.”  

“I think that’s what they’ve been stating here, is the fact that, to get to the 60-plus beds, it’s costing an extra $4 million. So clean level, at the moment, in order to provide excellent service, based on the facts that we don’t have enough employees that are trained within the county that would love to come to work in the nursing home to add the extra beds,” Bogert said. “I think that with the amount of money, the amount of revenue, they are providing an optimal service level, based on a $4 million deficit.”