Texas’ nursing homes are missing something: nurses

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LUBBOCK — Robert Lozoya started a recent shift as a nurse manager for Carillon, Lubbock’s biggest senior home, at 7 a.m.

For the next 12 hours, he triaged his duties, picking up the slack for the nurses who did not show up for work. He made sure patients didn’t choke on their lunch, treated wounds and fielded a myriad of calls to doctors, families and pharmacies.

By the time Lozoya left, well after 7 p.m., he was exhausted. And he knew tomorrow would be more of the same. He and his team will adjust to being understaffed, as they’ve had to do so often in recent years.

“We’ll do it one way or another,” Lozoya said. “We’ve worked it out so far, so it’s been OK, it just hasn’t been ideal.”

Texas does not have enough nurses for its senior care facilities. The shortage is fueled by a number of factors. There is a growing apathy burning through the nursing industry, and the COVID-19 pandemic only fanned the flames. Baby boomers are both retiring from the nursing profession and needing care themselves. Nursing homes have been hit particularly hard by this crisis due to financial constraints and medical students wanting jobs in more prestigious fields.

In the backdrop of the staffing crisis is another troubling trend in Texas: Nursing homes are closing. A report from Texas Health and Human Services shows that from 2018-22, at least 60 nursing facilities in the state — 2% — have lost the battle to inflation, low Medicaid reimbursement rates and other financial burdens.

For Texas elders and their families, the dearth of new health care professionals in aging populations is dire. At best, they are waiting longer to find beds and paying more when they do. At worst, they are deserted, forced to navigate their last years without the sort of support an aging facility can provide.

“We’ve seen over time that individuals are sicker by the time they get in nursing homes and need a higher level of care, and providers don’t have the trained staff to take that type of patient in,” said Kevin Warren, president of the Texas Health Care Association.

Finding a home where elders can live out their lives safely and with dignity is hardest for families that live in the empty stretches of rural Texas. Nearly two-thirds of the nursing homes that have closed since 2018 were in rural areas. And seven were in the High Plains, the region that stretches from Lubbock to the top of the Panhandle.

“In rural areas, it’s common for the next closest nursing home to be 30 miles away or farther,” said Alyse Meyer with LeadingAge Texas, an advocacy organization that works with 200 aging-service providers across the state. “There are other factors that are important to families when forced to choose a new nursing home for their loved one.”

A costly short-term solution

Carillon is the most decorated nursing home in Lubbock — a critical piece in the city’s claim as a medical hub, which draws patients from all over the region. But for all of Carillon’s accolades, it has not been able to attract enough staff.

“It’s the worst that I have seen it as far as staffing goes,” said Pamela Roddy, executive director at Carillon. “It’s amazing to me that we can stay afloat, but we have people picking up extra shifts.”

LVN Robert Lozoya at the Lubbock nursing home where he works on Oct. 31, 2022. First: From left, Claudia Cera and Jo Ann Cisneros, both certified nursing assistants, talk with Lozoya at Carillon’s accelerated rehab department. The senior center is understaffed, and Lozoya said of hiring traveling nurses at higher pay rates: “It’s like you put a Band-Aid here, but you still have a bleed there.” Credit: Mark Rogers for The Texas Tribune

Compared with 2019, there is an 18% decrease in registered nurses employed in Texas nursing facilities, according to data from the U.S. Bureau of Labor Statistics. The nursing shortage has forced some facilities to deny patients from hospital discharges, Warren said, which causes a ripple effect.

“That puts pressure on the hospitals, and it adds stress to the family trying to figure out where to take their loved one,” said Warren, president of the health care association.

Faced with shortages, facilities often hire temporary travel nurses through agencies, paying at least 50% more per hour than their full-time staff.

The use of traveling nurses can be fraught for staff morale. The pay discrepancy caused tension among the staff at Carillon. Some questioned why money could be spent on agency nurses who get paid $45 an hour or more, but not on raises for regular employees.

“I promise them it’s because agencies are a short-term deal, it’s not forever,” Lozoya explained. “But if we use them, we can open more space. It’s like you put a Band-Aid here, but you still have a bleed there.”

Meyer, vice president of advocacy at LeadingAge Texas, said the majority of its members have had to deal with increased costs amid the shortage.

Oftentimes, agency nurses are drawn from long-term care, enticed by promises of travel, higher pay and shorter weeks — a seductive way of living that most nursing homes can’t compete with.

“They cost more for the nursing facilities, sometimes two or three times more than what they would pay a full-time nurse,” Meyer said. “On top of that, it impacts resident care because nurses are coming in and out, but this is their home.”

Glamour and money keep nurses away 

What concerns Tara Strawn, the nursing program director at South Plains College in Levelland, is that there are few new nurses coming up who might someday ease the strain. She sees nurses build their careers from the ground up, and she said they’re not going to nursing homes for a simple reason: They want what they see on TV.

While nursing homes may not be considered glamorous enough for a young student’s “Grey’s Anatomy”-esque fantasies, working in the emergency rooms or the intensive care unit could live up to expectations.

“Those areas don’t have as big of a deficit because that’s where they all want to work,” Strawn said.

She would like to see the state develop a path for student loan forgiveness that encourages nursing students, which could help the dire situation. Four other states — Kansas, Minnesota, Missouri and Oregon — offer state-funded forgiveness for medical students.

“We need to be investing in our young people so they’ll want to become nurses and because they have a heart for it,” Strawn said.

But part of what’s keeping students away from the profession is what’s pulling nurses away from facilities now — money. About 62% of Texas nursing home residents rely on Medicaid to pay for their services, but facilities don’t get enough from Medicaid to stay afloat for long.

“Texas is in a difficult position because historically, we’ve had really low Medicaid reimbursement rates,” said Meyer, with LeadingAge Texas. “The financial constraints are compounded, so you can’t really have a conversation about fixing the staffing shortages without talking about reimbursement.”

Meyer said many nursing facilities in rural Texas can’t afford to compete with more metropolitan areas that pay more. Until they can get help balancing the books, the shortage will continue to be a problem.

“It’s going to be an uphill battle for us,” Meyer said. “It’s going to be difficult to attract nurses specifically because there are so many options, and those options, nine times out of 10, will offer higher pay than nursing facilities.”

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.

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