[Senate Hearing 118-230]
[From the U.S. Government Publishing Office]
S. Hrg. 118-230
THE STATE OF
VETERANS' LONG-TERM CARE IN MAINE
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FIELD HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
SECOND SESSION
__________
JANUARY 26, 2024
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
54-781 PDF WASHINGTON : 2024
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SENATE COMMITTEE ON VETERANS' AFFAIRS
Jon Tester, Montana, Chairman
Patty Murray, Washington Jerry Moran, Kansas, Ranking
Bernard Sanders, Vermont Member
Sherrod Brown, Ohio John Boozman, Arkansas
Richard Blumenthal, Connecticut Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii Mike Rounds, South Dakota
Joe Manchin III, West Virginia Thom Tillis, North Carolina
Kyrsten Sinema, Arizona Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire Marsha Blackburn, Tennessee
Angus S. King, Jr., Maine Kevin Cramer, North Dakota
Tommy Tuberville, Alabama
Tony McClain, Staff Director
David Shearman, Republican Staff Director
C O N T E N T S
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January 26, 2024
Page
SENATOR
The Honorable Angus S. King, Jr., U.S. Senator from Maine........ 1
WITNESSES
Panel I
Scotte R. Hartronft, MD, MBA, FACP, FACHE, CPE, Executive
Director, Office of Geriatrics and Extended Care, Veterans
Health Administration, Department of Veterans Affairs;
accompanied by Annette Beyea, DO, MPH, Associate Chief of
Staff, Geriatrics and Extended Care and Community Living
Centers, Togus VA Medical Center............................... 2
Panel II
Sharon Fusco, Chief Executive Officer, Maine Veterans' Homes..... 13
Colleen Hilton, President, Northern Light Home Care and Hospice.. 15
Mike Pooler, Army Veteran........................................ 17
Steven SanPedro, National Council Member, Maine Veterans of
Foreign Wars................................................... 18
Joy Barresi Saucier, RN, MHA, FACHE, Executive Director,
Aroostook Agency on Aging...................................... 19
Paul Saucier, Director, Office of Aging and Disability Services,
Maine Department of Health and Human Services.................. 21
Kathleen Swinbourne, Family Caregiver............................ 23
APPENDIX
Prepared Statements
Scotte R. Hartronft, MD, MBA, FACP, FACHE, CPE, Executive
Director, Office of Geriatrics and Extended Care, Veterans
Health Administration, Department of Veterans Affairs.......... 41
Sharon Fusco, Chief Executive Officer, Maine Veterans' Homes..... 48
Attachment--Maine Veterans' Homes: The VA Small Home Model..... 51
Colleen Hilton, President, Northern Light Home Care and Hospice.. 53
Mike Pooler, Army Veteran........................................ 56
Steven SanPedro, National Council Member, Maine Veterans of
Foreign Wars................................................... 58
Joy Barresi Saucier, RN, MHA, FACHE, Executive Director,
Aroostook Agency on Aging...................................... 60
Paul Saucier, Director, Office of Aging and Disability Services,
Maine Department of Health and Human Services.................. 64
Kathleen Swinbourne, Family Caregiver............................ 67
THE STATE OF
VETERANS' LONG-TERM CARE IN MAINE
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FRIDAY, JANUARY 26, 2024
U.S. Senate,
Committee on Veterans' Affairs,
Augusta, Maine
This field hearing was held pursuant to Notice of Hearing
on January 26, 2024, at the University of Maine at Augusta,
Richard Randall Student Center, Fireside Lounge, 46 University
Drive, Augusta, Maine beginning at 2:00 p.m., Hon. Angus S.
King, Jr., presiding.
OPENING STATEMENT OF HON. ANGUS S. KING, JR.,
U.S. SENATOR FROM MAINE
Senator King. This is a field hearing of the Senate
Veterans' Affairs Committee. In other words, this is a real
live hearing just like you see in Washington, only it's
happening here in Augusta, Maine, and I want to publicly thank
the chair and co-chair of the committee, Jon Tester of Montana
and Jerry Moran of Kansas who facilitated our ability to do
this and are supporting this--our ability to do some listening
and talking, and I'll talk about what the topic is in a minute.
But I want to thank Jon Tester and Jerry Moran as well as the
staff. I want to thank my own staff, Teague Morris and Rowland
Robinson and the staff of the committee here. Behind every
senator is a very able staff rolling their eyes, just so you
know. And I also see some friends. This is always dangerous
when you start recognizing people in the audience because
there's someone you forget. I used to always miss legislators,
it was awful. But I have to recognize Tracye Davis and Ryan
Lilly. Tracye is the head of VA Maine at Togus. Ryan is her
predecessor who is now in VISN for New England. And then also
Dave Richmond, the head of Veterans Affairs for the State of
Maine. So we've got lots of people here with lots of knowledge.
And here is the topic: Long-term care for veterans.
Why are we talking about that subject? I can answer that
question with two numbers. Seven minus seven and 31.
Over the next 10 years, the veteran population in Maine is
projected to decline by 7 percent. However, the population--the
veteran population in Maine above age 85 is projected to
increase by 31 percent. That really tells you why we're here,
because we are facing a very serious surge of veteran--of
veterans needing and being prepared for some type of long-term
care. And what we're gonna try to talk about today is the
multiplicity of programs, what's available, how do veterans
access those programs, how do they know what's available and
are there ways that we can improve that access, particularly as
we're dealing with a population that's aging, that may not be
as technologically engaged so a website or an e-mail may not
always be the answer. So that's the challenge that we have
today, to be talking about how do we deal with the needs of
these wonderful veterans who are going to need more and greater
services as they age. So that's really the plan that we're
talking about today.
We have two panels. The first panel is VA oriented. We have
Scotte Hartronft.
Is that good enough, close enough?
Dr. Hartronft. Yes.
Senator King. Scotte came up from Washington to be with us.
He is the Executive Director of the Office of Geriatrics and
Extended Care. So he's the big guy from Washington on this
subject. With him is Annette Beyea who is his counterpart here
in Maine. She's the Chief of Staff--Associate Chief of Staff,
Geriatrics and Extended Care and Community Living Center at the
Togus VA Medical Center so we're going to talk with them for a
while.
And then we have a second panel that involves providers
here in Maine and veterans, and veterans' families who can talk
about the process and where the gaps are.
Why are we doing this? It's to help me and the committee
know what we need to do to help. How do we make the system work
better? And quite often, people in my business feel that the
work is done when the bill passes. The truth is, the work just
begins when the bill passes. And one of my favorite sayings is,
implementation is as important as vision. You can have a good
idea and a good bill. If it's not adequately implemented, it
doesn't meet the intended purpose. So the whole idea today is
to give me ideas which I can then take back and the staff take
back to the committee to inform our ongoing work in this
particular area.
So let's start.
You have opening statements.
I'm going to impose a rule that we have in Washington which
is five minutes because we do have a number of witnesses and--
by the way, in Washington, when you see these hearings, what
you don't know is that we have a little digital clock in front
of us and we have five minutes. And I once asked Senator Tester
when should I stop when the clock says five minutes? He
suggested in the middle of the word ``if''. So we want to
enforce these rules. But, in any case, we're delighted to have
you with us.
Dr. Hartronft, please go.
Dr. Hartronft. Thank you, sir.
PANEL I
----------
STATEMENT OF SCOTTE R. HARTRONFT ACCOMPANIED BY ANNETTE BEYEA,
DEPARTMENT OF VETERANS AFFAIRS
Good afternoon, Senator King. I appreciate the opportunity
to discuss veterans' access to long-term care in institutional
and non-institutional care settings.
I'm accompanied today by Dr. Annette Beyea, Associate Chief
of Staff for Geriatrics and Extended Care at VA Maine.
As an agency dedicated to serving those who served our
nation, VA recognizes the importance of ensuring that our
veterans have access to the care they need, especially as they
age and require long-term support. We are committed to
delivering compassionate, person-centered care that meets the
unique needs of each veteran we serve.
Aging and older veterans make up a significant proportion
of VHA enrollees, with veterans over the age of 65 representing
about 50 percent of all VHA enrollees. Additionally, 55 percent
of current enrolled rural veterans are ages 65 and older.
Between fiscal year 2023 and 2035, it is projected that the
number of enrollees age 85 and older will increase by 73
percent across the country. And the number of VHA women
enrollees aged 85 and older will increase by a projected 127
percent during that same period.
VA, similar to the broader U.S. healthcare landscape, faces
significant challenges in preparing for the growing population
of older adults and their anticipated health care needs. Some
of the biggest known challenges include ensuring an adequately
trained and available workforce, addressing gaps in geographic
coverage of care, particularly in rural areas, and providing
specialized care for conditions like dementia and behavioral
issues.
The majority of Americans prefer to age in place either in
their homes or in the least restrictive setting possible.
Supporting aging veterans is a priority for the VA. To fulfill
this commitment, the VA provides a range of programs designed
for the care and support for veterans of all ages across a
range of care settings.
Currently, VA is undertaking one of the largest multi-year
expansions of home and community-based services. The expansion
includes programs such as veteran-directed care, medical foster
home and home-based primary care programs which are all aimed
at enabling veterans to age in place with necessary support and
services.
VA has many multi-year projects dedicated to addressing the
needs of aging veterans. These projects include pilots,
initiatives and expansions that are either currently active or
anticipated. The VA location in Maine is particularly active in
this regard. These projects aim not only to expand access to
services, but to ensure that our staff and facilities are well
prepared to provide best care for aging veterans.
Some active or anticipated projects specifically related to
the VA Maine include the Institute for Healthcare Improvements
Age-Friendly Health Systems initiative, geriatric emergency
department accreditation, multiple expansion sites of home-
based primary care teams, an expansion of the existing Veteran-
Directed Care Program, virtual geriatric specialty care
services for rural veterans, an active pilot site for VA
provided homemaker home health services, anticipated virtual
mental health services, and we're also anticipating Redefining
Elder Care in America Project pilot.
So a lot is going on, and many other things are anticipated
here at VA Maine.
VA's various long-term care programs provide a continuum of
services for aging veterans designed to meet their changing
needs over time. The level of care is unmatched outside of the
VA. Together, these programs greatly improve the well-being of
veterans even during times of crisis.
These achievements would not be possible without the
consistent commitment of Congress, both in the terms of
attention and financial resources.
It is critical that we continue to build on the current
momentum and preserve the gains made so far. The challenges
mentioned earlier will require continuous innovation,
assessment, adaptability, and allocation of resources. Your
ongoing support is crucial in order to provide high-quality
care for our nations' veterans and their families.
Senator King, this concludes my testimony. My colleague and
I are prepared to respond to any questions you may have.
[The prepared statement for Dr. Hartronft appears on page
41 of the Appendix.]
Senator King. Thank you.
Dr. Beyea, do you have a separate testimony?
Dr. Beyea. I do not have a separate testimony.
Senator King. Okay, thank you.
The first question is one that I think is going to come up
over and over today which is workforce.
We can have all of the great programs in the world. If we
don't have the people to staff them, it ain't gonna work.
Where are we in terms of workforce? And one of the concerns
the committee has is the amount of time it takes to onboard
somebody in the VA.
Talk to me about workforce.
Dr. Hartronft. Well, the VA faces significant challenges,
both geriatrics and palliative care due to the--not only the
workforce, it's a supply and demand issue in the overall health
care market. But we also are in competition with local health
care agencies and organizations for the same small supply of
resources when it comes to those workers.
So, something that we are doing is competitive marketplace.
So, what we're doing is trying to provide things such as
retention, recruitment bonuses. We're doing the debt reduction
programs. So, there's many things our human resources have been
really doing as well as the PACT Act had many additional
resources for the VA to implement.
Senator King. I would suggest there's two ways to tackle
this. One is what you were just saying in terms of incentives
and loan forgiveness and those kinds of things, pay and
benefits, but also the process itself. The length of time--the
data we have at the committee is to get hired at the VA,
something like 28 boxes have to be checked. To be hired at
Northern Light Health, something like eight boxes needs to be
checked. So that's something that's within the control of not
your office but we--you're not going to be able to hire
somebody no matter what the pay is if you say, oh, you gotta
put your life on hold for nine months. We're not gonna get
those people. So, I hope that's something you can take back and
begin to address.
Dr. Hartronft. Yes, sir.
Senator King. We may get into this later. You're aware of
the CMS rule about staffing ratios?
Dr. Hartronft. [Nodding.]
Senator King. My concern about that--and we'll talk to
others about it--this is a rule that the--CMS is the federal
agency, it's the Center for Medicaid and Medicare Services. It
basically issues the rules and the regulations for health care
facilities that receive federal funds. So they have a great
deal of power. And they recently have promulgated a new rule
about staffing ratios in nursing homes which no one can argue
with that you have a good staffing ratio, that's patient health
and well-being, it's all good, except there's nobody to hire.
And my problem with the regulation is it's the best being the
enemy of the good because if the result is closed nursing homes
and fewer beds, we haven't gained anything. We're not helping
veterans if we have--if beds disappear.
And, by the way, 833 nursing-home beds have disappeared in
Maine in the last 10 years. Almost a thousand beds have
disappeared as our population is aging. And my concern about
the staffing memo or the staffing rule is that it could have
that further effect unless it's--unless it takes a cognizance
of the workforce shortage.
Your thoughts on that subject.
Dr. Hartronft. Well, of course when it comes to the VA
owned and operated community living centers, it won't be an
effect because we currently have staffing that exceeds that.
But one thing that we'll have to do is--it's really kind of
hard to predict in each market, of course, how it will have an
impact, especially with the mix of orality and the already
existing low number of potential facilities in the area. So,
what we would have to do in the VA is to really maybe expand
the number of facilities in response to what we do see an
impact. We're lucky in the State of Maine, we have great
partnership with the State veterans homes. And, actually,
there's more numbers of veterans being treated on an average
daily census in our state homes than are in our community
nursing homes or even our CLC. So, Maine specifically----
Senator King. Well, I think that's--that's something that
you're going to have to be thinking about because it ties back
to the workforce problem.
Dr. Hartronft. Yes.
Senator King. If you can't--if you can't get enough people,
you're not going to be able to meet the staffing ratios which
could mean a loss of capacity rather than a gain for the
veterans.
How about home health? I used to travel with my DHS
secretary in a room and say, how many of you want to go to a
nursing home? Nobody answered. So the question is: What can we
do? What can we do to expand and support home health services
which I think everybody, including veterans, would prefer and
really ramp that up. Talk to me about how you view that as part
of the overall toolkit.
Dr. Hartronft. Yes, the VA has really started the
initiation with, you know----
Senator King. Can you move a little closer to the mic,
please?
Dr. Hartronft. Oh, myself? Okay.
Really--we've really started the initiative of aging in
place, and part of that is the multi-year expansion that I
mentioned with Veteran-Directed Care, home-based primary care
as well as medical foster home. But we're also expanding in
many other areas including making sure that we have a broader
net when it comes to other services like HHA. We're also doing
those----
Senator King. Could you define expansion? Are we talking
20, 30 percent, 40 percent? I mean----
Dr. Hartronft. Like Veteran-Directed Care, we're
practically doubling the number of sites. There was only about
70 VAs prior to our expansion that had it, and then by the end
of 2024, they're going to have medical--have Veteran-Directed
Care at all VAs. And then such as Maine in this--we already had
a Veteran-Directed Care, but we are currently providing
additional funding and initiative to expand the existing
program they already have here. And then we've expanded a
couple of home-based primary care sites in addition, but
there's a lot going on, and I'll let Dr. Beyea give us some
specifics.
Dr. Beyea. Yes. We've been very fortunate at VA Maine to
expand our home-based primary care program. Specifically, we've
added three additional teams in Caribou, Bangor and Augusta. We
now have eight teams covering eight territories across the
state. And just to put this into perspective, in FY '22, we had
a hundred referrals to home-based primary care. In FY '23, we
had over 400 referrals to home-based primary care. We now have
over 300 veterans enrolled, we have 80 referrals pending so
that program is growing.
As Dr. Hartronft mentioned, innovation is also imperative
as we think about how to support age-friendly care at a
population level in the oldest state in the nation. We are very
fortunate at VA Maine to also receive funding to pilot a
Homemaker Home Health Aide Certified Nursing Assistant program
that will allow us to imbed certified nursing assistants as
part of our home-based primary care teams, so they will be
functioning as part of the team.
Additionally, we're expanding medical foster homes. We've
allocated a coordinator to that program and actually have five
homes with six veterans enrolled.
Furthermore, we acknowledge the important role of
noninstitutionalized care community resources and programs, and
have intentionally aligned resources and care coordination
through subject matter experts who truly collaborate and work
together to be able to meet the veterans' unique needs, whether
it's homemaker home health aide or perhaps Veteran-Directed
Care. For example, we're aware that we will be participating in
a Veteran-Directed Care respite pilot that will allow veterans,
through the caregiver support program, to receive supplemental
funding and not have a reduction in their Veteran-Directed Care
hours, so really aligning and coordinating across those
programs and services to meet a Veteran's needs is important.
Additionally, acknowledging that we have 3,700 geriatricians,
the projected need is 12,000 by 2030 and there are less than 50
in the State of Maine, so, we need to get innovative.
Senator King. I'm sorry, 3,700 in the whole country?
Dr. Beyea. Correct. With an estimated growing need of
12,000 in 2030. So, the majority of age-friendly care is going
to be delivered in primary care. So, what we're establishing in
Portland is a geriatric patient-aligned care team that includes
a true interdisciplinary, interprofessional team that will
allow us to provide primary care to a cohort of veterans to
establish best age-friendly practices so that we can, in a
phased and strategic approach, disseminate those practices both
in Portland and then to our more rural CBOCs.
Additionally, we acknowledge the need for telehealth to be
a part of this hub and spokes-type model.
In FY '23, we received funding to establish a telehealth
interdisciplinary model of care to extend age-friendly
specialty services to our most rural veterans. We have
successfully done that in Bangor.
Senator King. It would be nice to have WiFi in the CBOCs;
[Laughter.] just saying. Just a little parenthetical. Go ahead.
That's not your problem.
Dr. Beyea. So, again, really from a multi-modal perspective
and approach, figuring out how can we meet the population need
of aging veterans in Maine. And there is not just one solution,
it's multifaceted.
In addition, we talked about recruitment. We know, in our
CLC, we're approaching a 50 percent vacancy for our nursing
assistants so we are working intentionally to create innovative
programs like Grow Your Own where we can actually employ those
in training to become nursing assistants and pay them
simultaneously. So, there are lots of things that we're doing
internally----
Senator King. It's kind of an apprenticeship model.
Dr. Beyea. Right.
The other is with respect to the shortage of geriatricians.
We really prioritize our academic affiliates. And, so, with
Maine Medical Center and Northern Lights, we are actually a
primary teaching site for palliative medicine fellowship
trainees. Also, with Maine Medical Center, we provide clinical
training for Internal Medicine and geriatric residents at our
Portland CBOC as well as geriatric medicine fellows.
Additionally, 15 minutes down the road from Togus is a
geriatric medicine fellowship program with four accredited
fellowship positions. We also serve as a training site for
those fellows as well.
So, in thinking about recruitment, we see that fellows
come, they train at the VA, and they want to stay at VA Maine.
They see the priority and commitment to true interprofessional
collaborative practice and interdisciplinary approaches to
care.
Senator King. And can I assume that the mission is also
attractive?
Dr. Beyea. Very, yes.
Senator King. That's a big part of----
Dr. Beyea. That's the primary attraction, yes.
Senator King. Well, thank you. That was great, and a lot of
good information.
One of the things that jumped out at me though is the
complexity of the system and all of the various programs and
how does a veteran know what's available? First question is
knowledge, and the second question--we were talking about this
with the students--is do we have sufficient people I would call
navigators, whether they're in the VSOs or--who can help a
veteran say no, you're not--you're Montgomery or you're post-9/
11. Where do you fit? What are the programs, home health--do
you see what I mean? All of the programs in the world don't
help if you don't know what they are and if the family can't
find out what they are. How easy is it for a veteran to know
the various options?
Dr. Hartronft. I guess we can never over-communicate the
availability, what resources are available. I, myself, when I
left the service, I worked with the VSO to get involved--you
know, the VBA and other things. So, we--this really does take a
lot of people, and working, strong relationships with other
organizations such as VSOs or community partners. But also
internally, there have been many things to where we try
improving our care coordination. Intensive case management are
the terms that we want to use, and incorporate more practices
with interdisciplinary between nursing and social work. So,
it's really difficult because we have a lot of programs, but
many veterans need more than just one program to help them stay
at home. They may need adult day health care, they might need
some respite, they might need some homemaker home health aide.
So, it's not a single one-size-fits-all for veterans. So many
times if the veteran is not in the VA; we want to encourage
them and help them find the resources to get enrolled. And then
after that, it's really making sure that they establish with
their primary care team to coordinate with their social worker
and their physician or provider to get what services they need
based on that individual veteran since we can't really paint
with a broad brush what will individually affect others. So,
there's always room for improvement, I think----
Senator King. And the VSOs have an important role to play
here it seems to be. They're representatives that can act as
that navigator buddy system for an individual veteran.
A particular topic--this is sort of a narrow topic but one
that I'm interested in is falls.
One out of four people over 65 have a fall in a year. And
falls are often the beginning of the end and lead to a broken
hip and hospitalization. What--are there--what can we do to be
much more active in terms of fall prevention? I mean I would
think that ought to be a sort of basic--somebody comes into
your system, the first thing, are there grab bars in your
shower? I mean talk to me about that.
I've told my staff I want to be the falls senator; without
falling.
[Laughter.]
Dr. Hartronft. Yes, sir, I understand, sometimes you don't
want to be that kind of subject matter expert.
Actually for us, that's one of the reasons why we're----
Senator King. By the way, I got a great piece of advice.
Someone asked Buckminster Fuller, the famous architect, for
advice on how to live a long life. His answer was ``always use
the bannister.'' [Laughter.] That's a pretty good rule, I
think.
Go ahead, I'm sorry.
Dr. Hartronft. Definitely.
Basically, I think a lot of it is that, you know, many of
it is prevention and practice, but one reason why we're
incorporating an age-friendly health system from the Institute
for Healthcare Improvement is you start imbedding that and
weaving it across settings because it's--it's not a one-time
assessment by one care setting. Because over time, a veteran
goes to the hospital and they get deconditioned, they need to
be assessed again. So, we're trying to make sure that every
point of care that they come in contact with, that someone can
have the mobility--either they're afraid of falling, or they
are assessed for fall risk, and then they're able to be
prescribed or put into physical therapy and other evidence-
based practices. And a lot of times social isolation can happen
because someone's just afraid of falling. Sometimes just a
single fall can really impact someone's life to where they're
afraid to do any other activities. So, it really is part of us
making sure that at every point of contact within the VA, from
primary care to inpatient, that they're assessed, and then we
take that into account. With Age-Friendly, one of the ``M's''
is ``What Matters.'' So, we want to find out what matters for
that veteran, that's our first key. And then another ``M'' is
mobility which includes falls and making sure that we're kind
of proverbially ``buffing them up'', to help them to do----
Senator King. There's a big prevention piece here.
Dr. Hartronft. Yes.
Senator King. The cheapest health intervention is the one
that doesn't happen.
Dr. Hartronft. Yes, sir.
Senator King. The one that doesn't have to happen. And to
the extent we can prevent falls--we know there's an epidemic of
falls in this country. So I hope that that's something that VA
nationwide would think about in terms of prevention of--we're
all conscious of costs and costs to the system. So keep that in
mind, please.
Dr. Hartronft. Yes, sir.
Senator King. Assisted living. Again, we're talking about a
continuum, and people don't necessarily need all of the
services of a nursing home, but they need some level of
services. Is assisted living a gap? Is that something we need
to be thinking about and developing larger, greater capacity?
Because that strikes me that doesn't really fit into the VA
system very well.
Dr. Hartronft. You're correct. Assisted living is a care
setting that we currently aren't authorized to provide room and
board and other services. So--that's one reason why we've been
really hyper-focusing on aging in place in the home itself. And
then we have to kind of go over to more of the long-term care
facility. But one thing we've been incorporating is for those
veterans who do go to assisted living is making sure that we
incorporate some of the home care services even into that
setting, when possible.
Senator King. Well, it seems to me that's an area that we
should be talking about in Washington.
Dr. Beyea, do you agree?
Dr. Hartronft. The VA has issued support for the one bill
that you mentioned, of course with available resources.
Dr. Beyea. Yes, I do agree. Given the rising prevalence of
neurocognitive disorders and need for memory care which often
requires residential level of care or Adult Day services to
remain in the community. Access to these services would be
incredibly helpful to delay nursing home placement and
institutionalized care----
Senator King. Right. Every day that you delay a nursing-
home placement, the veteran is happier and the taxpayers are
happier.
Dr. Beyea. Absolutely. And in the interim period, as Dr.
Hartronft pointed out, we really are investing in home care and
community-based services for that subset of the population.
Senator King. VA Maine is doing home care.
Dr. Beyea. Correct. In addition to the expansion of home-
based primary care, with our alignment and care coordination
through care programs like Homemaker, Home Health Aide,
Veteran-Directed Care, and Adult Day we are able to provide
Veterans and caregivers with additional support and some
respite----
Senator King. And respite is----
Dr. Beyea. Correct, yes.
So, as we expand home-based primary care, we acknowledge
that the need for respite will also increase. And so, in our
community living centers we're actually developing capacity to
provide more respite care. Additionally, we look forward to
that Veteran-Directed Care respite pilot which will allow us to
provide caregivers respite when appropriate and needed so they
can get away and see loved ones and do the things that refill
their cup.
Senator King. Everything we talked about still comes back
to workforce, doesn't it? Home-based care, respite care. It's
all having the people. Let's go back to that. We talked about
incentives--by the way, I recently learned that no one in the
Federal Government can make more than the President. That's
true, isn't it?
Dr. Hartronft. Yes.
Senator King. Well, that means you're asking a cardiologist
to take about a 70 percent pay cut to come work for the VA. I
think that's something we have to figure out how to waive or
something. And that is not necessarily what we're talking about
today, but it is--it's one more barrier if you're talking about
high-level specialties. But I do want to push you on--and I
realize you're not the one, but go back and say there's this
senator up in Maine that's sort of half crazy about this human
resources function and how long it takes. We've really got to
work on that because it would be awful to have somebody who's
ready, wants a mission, wants to do it but they can't wait for
nine months or a year. So I hope that's something you can push
on when you get back, and we'll push on it at the VISN level
too.
Interagency cooperation, do you--how does the VA coordinate
with CMS, for example? Because a lot of these placements are
combined financing. Medicare, Medicaid, VA. Is that a seamless
operation, or is that a bureaucratic nightmare? How is that?
Dr. Hartronft. Well, I think part of it too is really the
choice or preference of the veteran as to which authority they
want to use. Because, of course, many may have TRICARE, many
may have Medicare, some have other avenues, but many times of
course the VA is the primary payer in many cases. But I think
there is an area for continued collaboration and improvement to
make sure that veterans over age 65, especially--we're seeing
the larger picture. Sometimes if they're on Medicare, we don't
always see some of their care if they're on another or using
another authority. So, I think that is an area that we could
continue to improve. We do meet with them; we do have a lot of
interagency cooperation and collaboration groups, but I think
that's just the nature of it, if people are--it would be the
same case of somebody who is seeing multiple primary care
providers or--you know, just trying to keep everything
coordinated. It adds a little more complexity to try and
coordinate care across those different agencies.
Senator King. Dr. Beyea, help us out here. In your
observation, are there gaps that we should be filling? In other
words, like assisted living or payment for caregiving which I
know is an available program, but what--now is your chance.
What should we be attending to in the next round of VA and
veterans' legislation?
Dr. Beyea. Yes, I would most certainly advocate for
assisted living facility level of care. I think in terms of the
non-institutional care piece, we're very well equipped in
growing and expanding programs and services as well with
institutionalized care. We have great partnerships with our
community contracted nursing homes and with our state veterans
homes----
Senator King. Certainly that's important. You have what
amounts to a nursing home at Togus.
Dr. Beyea. Correct--our community living center.
Senator King. But you also contract with private sector
nursing homes for veterans' care.
Dr. Beyea. We do because often veterans want to remain
close to their loved ones and close to home. And so, we want to
create versatility and opportunity for them and to support what
matters most to them. And with respect to the state veterans
home, we recently hired a coordinator who is really
facilitating that partnership between the management at the VA
as well as the state veterans home, is providing education to
the staff at the veterans home as well as the VA, supporting
sharing agreements like with mental health. So in terms of our
partnerships with respect to long-term care and
institutionalized care, I think they're growing and we're very
fortunate. Also, we have been very successful in terms of the
non-institutional care programs to help veterans age in place,
which is often what matters most to them, but an opportunity is
certainly expanding access to assisted living facility care.
Senator King. That's good.
Now, one of the things we haven't touched on or we should
have talked about at the very beginning, only certain veterans
are qualified for nursing home care, that you have to have--
combat-related disability to a certain level or various rules,
but a peacetime veteran, maybe 20 years, doesn't necessarily
qualify for these services. What services do they qualify for?
Dr. Hartronft. Well, the nice thing is the home-care
services aren't dependent on service connection----
Senator King. So that doesn't have----
Dr. Hartronft. Home care----
Senator King. Okay. So that's available to any--to all
veterans?
Dr. Hartronft. As long as they meet the clinical needs,
obviously, they need assistance with activities of daily living
and they meet the clinical need. But when it comes to VA-paid
nursing home and community--it is, you know, as you said,
specifically tied to service connection or specifically to what
winds back to needs of a nursing home care, and it has to fit
back to their other plan. Otherwise, many of the veterans that
aren't qualified for like the VA, then they can go to the state
veterans homes where we provide per diem--which helps try to
provide part of the cost of care. So, they do have some avenues
to kind of work and--that's why it's such a great partnership
with the state veterans homes and other organizations.
Senator King. By the way, they must have prepared you for a
question from me about domiciliary care and the backpay that
you owe us. [Laughter.] We only passed that bill I think it's
two years ago this month. Could you speak to Brother McDonough
about that for me?
Dr. Hartronft. I'll make sure we'll find out.
Senator King. That's sort of an--it's not an in-joke, it's
an in-irritation. That's something we need to attend to.
Sort of wrap-up comments. How would you--wave a wand and
what would you like us to tackle in the committee?
Dr. Hartronft. Well, I think the continued support that
you've already provided with us with resources and timely
attention----
Senator King. It would help if we had a budget, not a
continuing resolution.
[Laughter.]
Dr. Hartronft. No comment. And then--but, yes, I think just
having y'all's support has been critical. And, again, it will
continue to be critical for your continued support and
attention really as we--because we're gonna have to continually
adapt and evolve to meet these needs as veterans so there's not
one answer that fits all the problems, but we definitely
continue your support----
Senator King. Well, the best news I've heard so far is the
expansion of the home-based care. I think that's really
important because this is one of those things where we know a
wave is coming at us, and shame on us if we're not ready for it
because it's totally predictable. This isn't a surprising event
like the storm two weeks ago. This is--those numbers are--you
know, the actuaries will tell us what we're facing. So I think
that we really need to do some hard thinking about what the
gaps are, how we can help fill them. And, of course, the
workforce issue applies across the board, not only for
retirement.
Well, thank you both very much for being here, thank you
for coming up, and I hope you listen in. And I do want to--what
I always say at the end of a hearing, any ideas, pass them
along online or offline. I can forget where I heard things, but
you are in a position to help us, and we're all on the same
side here. We're all in the same--have the same goal which is
improving the lives of our veterans and particularly in this
case, what we're talking about today, this population that is
going to be more and more in need of these services. So thank
you.
We're going to take a five-minute break which really will
be a five-minute, and then we'll come back with our second
panel.
Thank you all very much.
[Applause.]
[RECESS]
Senator King. We now have the second panel. I'm going to
ask each of our guests to introduce themselves and then--why
don't we go down the row and introduce yourselves, and then
we'll go back and have your testimony.
PANEL II
----------
Ms. Fusco. Good afternoon, everyone. My name is Sharon
Fusco, and I'm the CEO at Maine Veterans' Homes.
Ms. Hilton. Good afternoon, I'm Colleen Hilton. I serve as
the senior vice president for continuum care for Northern Light
Health, and I oversee, as the president, home care and hospice.
Mr. Pooler. Mike Pooler, Afghan vet.
Mr. SanPedro. Steve SanPedro, I represent the VFW, and I
also am the vice chair of the Maine Veterans' Home Board of
Trustees.
Ms. Barresi Saucier. Hi, I'm Joy Barresi Saucier, I'm the
executive director of the Aroostook Agency on Aging based in
Presque Isle, Maine.
Mr. Saucier. I'm Paul Saucier, I'm director of the Office
of Aging and Disability Services at Maine Department of Health
and Human Services.
Ms. Swinbourne. I'm Kathleen Swinbourne, and I'm a family
caregiver to a Navy Veteran and a Vietnam vet.
Senator King. Wonderful.
Sharon, why don't you lead us off. Do you have some
prepared thoughts?
Ms. Fusco. Of course.
STATEMENT OF SHARON FUSCO, CHIEF EXECUTIVE OFFICER, MAINE
VETERANS' HOMES
Well, thank you for the opportunity to speak with you again
today, Senator King; it's my pleasure to do so.
We've heard a lot today about workforce, and I'm going to
get right to the bottom line because my written testimony is
very detailed, and I don't want to read it to you.
Senator King. The practice is you say, I move that my
written testimony be submitted for the record.
Ms. Fusco. There you go, I move that. [Laughter.] So--but I
do want to give you sort of the bottom line up front. It's also
what I'm known for.
So very bluntly, the nursing home industry is in crisis. We
are on a precipice of collapse, and the reason for that is very
simple. Yes, we have workforce issues, and I'm not going to
underplay the importance of them, but more than that, our
reimbursement rates fail to cover the total cost of care. We
simply cannot afford to continue to steal from the future of
our homes to pay for our present. And that happens because--
again, it doesn't matter what rate we're talking about, whether
we're talking Medicaid, Medicare, VA, all of them fail to fully
cover the cost of care.
Senator King. What's the gap? Could you put a number on it?
Ms. Fusco. I can tell you that last year it was $17.1
million for the Maine Veterans' Homes.
Senator King. What's that as a percentage?
Ms. Fusco. It's about 15 percent of our budget.
Senator King. In other words, if the cost of care is 100,
what are you getting?
Ms. Fusco. About 15 percent is the gap.
Senator King. Fifteen percent is the gap?
Ms. Fusco. Yes. And we don't have unlimited investment
resources or capital replacement funds. I've got about a 36-
month runway.
Senator King. So that's compounded by additional
regulations that increase cost but don't provide any additional
funds; is that correct?
Ms. Fusco. That is absolutely correct.
And so when we think about that, and as the executive
charged with taking this organization into the future, I'm also
thinking about, well, what comes next and how do I prepare for
that? You're gonna hear today about wonderful collaborations
that are bringing organizations together into partnership to
address social determines of health such as transportation,
social isolation, food insecurity; but are they adequately
funded? And the answer is no. We've heard about great pilots
and we're so proud to be a part of them, but are they
adequately funded to help us think about the innovation we need
to our programs to serve the next generation of veterans? And
the answer is no. And my favorite, and I promise not to get on
a soapbox, is technology. Technology will fundamentally change
what it means to have a disability and to care for somebody
with a disability. Technology for the person who can't see and
helps them see. You talked about falls. What if we could
predict them? Guess what? That technology is here today, but I
don't have the investment funds available. I don't have the
funding available to prepare my infrastructure to take
advantage of that, and our veterans deserve that. So funding is
the primary issue. You put a number on it, but I'd like to put
a face on it.
I want you to envision Bart. Bart is a young man that's in
his late 80s. He's one of the first veterans I met, was very
proud to take me and show me his uniform and the whistle he
used to translate commands from the captain to the crew. He's
got his photographs, all of those memories that he's so proud
of, but his memories are on a wall for a reason. Bart has
dementia, and he needs 24/7 care that is just not possible in
the home. He's not acute so he's not going to end up in a
hospital. We need that step in between, and it needs to be
funded for folks like Bart, and we need to do it in a way that
honors them.
The rest of Bart's story is that about three weeks ago, I
was in the home the day Bart died, and what I saw was
absolutely heartwarming. I saw people who were visiting other
residents come out of the hallway. I saw staff, who weren't
addressing immediate care needs, come to the hallway, and as
Bart's body came down that hallway, flag draped over the body,
they stood at attention, they saluted, they put hands over
hearts and then they got into cadence behind that body and they
walked him out to the hearse for his final trip to his resting
place. Now, isn't that the care that we want to be providing
for our veterans? We need a sustainable system of care. And if
we want that sustainable system of care, we have to fund it.
Our veterans deserve it.
Senator King. Could you not be so indirect?
Ms. Fusco. Read my testimony.
[The prepared statement of Ms. Fusco appears on page 48 of
the Appendix.]
Senator King. Sharon, thank you. That's powerful and on
point. I really appreciate it.
Colleen from Northern Light.
Ms. Hilton. Sure. Do I need to say that about the previous
testimony--the testimony that I've submitted being read into
the record?
Senator King. Yes, if you want it in the record----
Ms. Hilton. Can I make that motion for everybody up here?
STATEMENT OF COLLEEN HILTON, PRESIDENT,
NORTHERN LIGHT HOME CARE AND HOSPICE
Good afternoon, Senator King, and I appreciate the
opportunity to participate today in this important hearing.
I want to mention, I also serve as the president for the
Home Care and Hospice Alliance of Maine which includes all of
the home care and hospice providers across this great state.
I've been a registered nurse and have dedicated my career
to caring for patients in the home and in community-based
settings. Our nurses, therapists and hospice clinicians care
for patients throughout the State of Maine in both urban and
rural settings. We have traveled 3.5 million miles last year to
deliver that care. We are also a unique home care organization
providing a number of public health services including
vaccinations, homeless shelter nursing services and
transportation of fresh food to patients at home addressing
Maine's food insecurity challenge. As we know Maine is the
oldest--has the oldest population in the country, and this
includes our aging veterans.
Veterans receive their home care and hospice through a
number of different benefits: Medicare, Medicaid as has already
been stated, and through the VA Togus Medical Center. We cared
for 489 veterans last year through the VA process. Our home
health services focus on recovery, quality of life,
independence with the goal to reduce emergency room visits and
hospital readmissions. The number of patients cared for every
day across Maine exceed all of the bed capacity in our local
hospitals. I want to say that again. We care for more people in
the home than all of our hospitals across the State of Maine.
The level of acuity is also rising as more and more medical
interventions are happening on an outpatient basis or a
surgical procedure that once resulted in a prolonged hospital
stay are now discharged on the very same day. Hospice care is
also growing in Maine, and that is good news where once we were
lagging in utilization in 2021, we ranked 13th. Maine has four
inpatient hospices across the state, one in Presque Isle,
Rockport, Auburn and Scarborough. I'm especially pleased to
report that we have housed veterans whose families needed
respite at our hospice houses. Using respite allows families
and caregivers enough support to enable the patient to return
home to live out the remainder of their life surrounded by
their loved ones.
I am deeply concerned that the home care services for
veterans and all individuals in need is at risk due to the
significant payment reduction that CMS started in 2020 when a
new payment model was implemented. Congress charged CMS with
ensuring budget neutrality and give the agency authority to
change payment rates in this model. The ongoing threat to home
health payments is exacerbated to MedPac's annual
recommendation to Congress for continued cuts. In January,
MedPac voted to recommend to Congress that they reduce Medicare
coverage for home health by 7 percent in 2025; 7 percent.
We're stuck in a vicious cycle----
Senator King. Your costs didn't go down? Your cost didn't
go down----
Ms. Hilton. Our cost went up, wage escalated, everything
escalated, medical supplies escalated and reimbursement went
down, as a recommendation.
This is just causing industry instability, payment
reduction proposals that threaten access to care.
In the Senate, there is a bill titled Save the Medicare
Home Health Program. The goal is to stop CMS from imposing
certain cuts and direct MedPac to consider their analysis, the
impact of all payers on access to care, for the home health
benefit.
We anticipate that veterans, patients and families will
experience historic access challenges to home health care. And
it's not because there isn't a need or a demand for these
services but rather due to the workforce crisis--and it is a
crisis--high inflation impacting cost and Medicare payment
reductions, they impact our ability to hire and retain staff.
Maine continues to struggle with the statewide shortage of
RNs, currently projected to be more than 2,000 by 2025. One
solution to resolving this nursing shortage is supporting nurse
faculty, and I know that your office is working with Lisa
Harvey-McPherson and working on this issue.
We already have regions in Maine with minimal or no access
to home care services. In responding to payment rates below the
cost of providing care, providers have reduced services to
distant geographic regions and/or reduced the actual number of
patients that they will accept in due care.
Due to the rural nature of our service area, we invested 15
years ago in the use of telehealth and remote patient
monitoring to broaden our reach to serve seniors across the
State of Maine. On any given day, we are caring for 500
patients from Fort Kent to Southern Maine who are taking
advantage of this technology. Using this technology, we can
support----
Senator King. Do you find--excuse me. Do you find the
patients are receptive to using telehealth?
Ms. Hilton. Very receptive. Eighty years old, 90 years old,
they know how to use the equipment and it's easy to use.
Using this technology, we can support people suffering from
chronic disease, and I believe that the pandemic truly
demonstrated the value of using this technology in the home.
When we were able to--when we were in the midst of the global
pandemic, telehealth with video capability was incredibly
beneficial. In 2023, we cared for 260 veterans to enable them
to age in place with the support of telehealth.
I urge this committee to focus on the impact that Medicare
and Medicaid payment policy is having on veterans' access to
post-acute care services.
Thank you.
[The prepared statement of Ms. Hilton appears on page 53 of
the Appendix.]
Senator King. Thank you, Colleen.
Mike?
Mr. Pooler. Yes, sir; my written testimony into evidence,
please.
STATEMENT OF MIKE POOLER, ARMY VETERAN
Good afternoon, Senator King. I appreciate the opportunity
to discuss veterans access to long-term care. And I really have
to apologize to you up front, sir. As you can see here by this
panel, I have the face for radio and the voice for print so
bear with me for a while, and we'll get through this.
Senator King. People have told me that too so----
[Laughter.]
Mr. Pooler. I know you work with Bernie Sanders, sir, so
I'm sure you're used to it.
My name is Mike Pooler. My wife Sue was a resident of the
Augusta, Maine Veterans' Home from October 2016 to April 2023.
I'm also extremely fortunate to be on the Maine Veterans' Home
Board of Trustees.
My wife Sue was diagnosed with dementia in 2013 at the age
of 48 and needed full-time professional memory care by
September of 2016.
In between these dates, I was fortunate to be able to
privately hire caregivers to come to our home and look out for
Sue during the day. These people, along with Sue's sister,
provided daytime and some weekend care while I was working for
the Maine Army National Guard. I had the night shift and
weekends while I continued to work. During this home caregiving
time, I never looked into any support from the VA for Sue's
caregiving. I have a 90 percent disability rating from the VA,
and my understanding is that there's no caregiving support for
spouses of veterans.
In September 2016, we were extremely fortunate to the--we
were extremely fortunate, the administration of the Augusta
home was very prompt in responding to our needs. All of the
stars aligned, and it took three to four weeks from the time I
called MVH until Sue was admitted in October 2016.
During Sue's stay, it was obvious from the start that the
staff at Augusta were and continue to be special people. One of
the nurses I met, as she was talking to Sue, stated that she
would never lie to Sue and would always tell her the truth. She
was not going to tell Sue something just to calm her down.
That's indicative of the dignity and respect the staff gives
each and every resident. The staff takes great pride in the
fact that they care for veterans and their spouses, many times
usually sacrificing higher wages at other places to take care
of them.
Over the years, and especially during the past three years,
there have been tremendous staff turnover. As you may be aware,
people with dementia need to see consistent faces to help them
alleviate stress. Also each dementia patient has a unique need
that staff learn during their time with the residents which
leads to higher quality of care. Over the years of visiting our
spouses--and we had a little coffee klatch of husbands there
that would talk to each other--the staff became a second family
to many of us. They would tell us how our spouses are doing,
any trends they see, what made them laugh, what's working for
them or any changes in behavior. Many weeks I spent more time
with the staff than the rest of my family. Sue passed in 2023.
Senator King, what you need to do: Stabilize the workforce.
This is directly tied to increased reimbursements, as you've
heard, which need to be tied to inflation. A most stable
workforce understands the residents better, notices things that
are off sooner which could lead to finding problems before they
cannot be resolved. These unresolved issues lead to worse
outcomes and a higher cost down the road.
There needs to be a way to have national guardsmen and
reservists who have not been on active duty or deployed to
become eligible for access to the state veterans homes. Absent
many more wars, this will only be the way to continue the
viability of the Maine veterans home system.
I look forward to your questions. Thank you.
[The prepared statement of Mr. Pooler appears on page 56 of
the Appendix.]
Senator King. Thanks, Mike.
Steve SanPedro, thank you for joining us. Steve is in my
office so often in Washington, the next time he comes, I'm
going to charge him rent.
Mr. SanPedro. I'll be there in March.
[Laughter.]
Senator, I'd like to submit my written testimony for
official record.
Senator King. So moved.
STATEMENT OF STEVEN SANPEDRO, NATIONAL COUNCIL MEMBER, MAINE
VETERANS OF FOREIGN WARS
Mr. SanPedro. Good afternoon, Senator King. It is my honor
and privilege to address you today regarding access to long
term care for veterans in Maine.
As a veteran myself, I have great concern for the future
care of veterans here in Maine. These men and women have served
their country and deserve to be cared for as the true heros
they are. The Maine Veterans' Homes' ability to do this is very
much in jeopardy due to today's rising healthcare.
Maine Veterans' Homes has a unique challenge of meeting
requirements from both the state and the VA, adding the need
for additional resources to cover expenses not incurred by
similar facilities. Inflation and the skyrocketing increases in
cost of goods have created a financial deficit that can't be
met causing great hardship.
Reimbursement rates no longer are in line with today's cost
of veterans' care. The current VA reimbursement rates are
$115.62 for per diem care, and $49.91 for domiciliary care.
These stipends in conjunction with Medicare, Medicaid,
commercial healthcare insurance and private pay are all used to
assist the veteran in paying for their care. However, funds
still fall way short of the cost to care for these veterans. As
a nonprofit entity, we are left to absorb this difference.
However, if you are rated at 70 percent or higher disabled
by the VA, your care is taken care of by the VA with no stipend
and at a lower rate of cost. The VA has set a price no matter
what type of care the veteran receives if they are rated at 70
percent or more. Long term, skilled and assisted living care do
not cost the same. There should not be a set rate.
Like many other things, the pandemic made an already
strained healthcare system even worse. Over the last three
years, we have seen a large increase of healthcare professional
leave the field not to return. Many seasoned professionals
chose to retire, others didn't want to endanger their families
and chose to switch careers in an effort to be safe. This
caused the medical field to see shortages like never before. As
a result of this, organizations like ours are forced to
participate in wage wars and hire more contracted nursing at
double and triple regional rates in an effort to fill very
necessary positions. A secondary effect of the staffing
shortages is the workloads that have been much more to bear for
the professionals----
Senator King. So it's a vicious circle. The workload goes
up, the staff burns out and leaves, and then you've got another
gap.
Mr. SanPedro. Yes, Senator.
That concludes my comments.
[The prepared statement of Mr. SanPedro appears on page 58
of the Appendix.]
Senator King. Thank you.
Joy. Thank you for coming from Aroostook.
Ms. Barresi Saucier. You're welcome, my pleasure.
Thank you for the opportunity to testify today, and I'd
like to submit my written testimony for the official record.
Senator King. So moved.
Ms. Barresi Saucier. Thank you.
STATEMENT OF JOY BARRESI SAUCIER, RN, MHA, FACHE, EXECUTIVE
DIRECTOR, AROOSTOOK AGENCY ON AGING
At the Aroostook Agency on Aging, we know that people want
to age in their home communities, and when they do so, they
fare better and they also make their community stronger. Our
core mission at Agency on Aging is to help this to occur.
Nationally, there are 622 Agencies on Aging funded in part
by the Older Americans Act. Agencies on Aging provide a variety
services and function as a national network with unique assets
and flexibilities that address many challenges faced by older
people including veterans.
All agencies serve as aging and disability resource centers
providing confidential, unbiased information and support to
older people, those with disabilities and their caregivers.
These agencies often act as the first and only responder to
those with questions or challenges that impact their ability to
live independently. The agencies intimately understand the
complexities of public programs, rural challenges and the
formal and informal community supports that exist at the local
level. In Maine in fiscal year '22, the Agencies on Aging
provided responses to over 291,000 requests for information and
assistance.
At the Aroostook Agency on Aging, through over 20 programs
and services that includes information, wellness--including
falls preventions in-home services and respite services. We
directly impact over 5,000 individuals each year, nearly 300 of
which are veterans.
With more than 25 percent of Aroostook County over the age
of 65, we're central to the well-being of our community----
Senator King. I saw that in your testimony.
Take note of what she just said. Twenty-five percent of the
residents in Aroostook County today are over 65. That's
extraordinary.
Ms. Barresi Saucier. We are where the nation is going. We
are already there.
A recent Community Needs Assessment by the Aroostook County
Health Improvement Partnership highlighted how several rural
disparities, just a couple that I'll mention, is that in
Aroostook County, the rate of disability is 25 percent higher
than the statewide rate. Alzheimer's disease is the highest of
any county in the State of Maine.
Nearly half of older adults living alone live outside of
the service health communities, and over half of the population
over 65 lack financial resources necessary to afford basic
expenses.
These factors linked with other factors, like lack of
access to primary and specialty care, limited access to public
transportation, older housing stock, fewer community supports
and the workforce challenges already mentioned.
We also, through this survey, gathered lived-experience
information including the following statements from veterans:
One said, ``if I don't get the help I need, I go without. We're
so isolated here. It's kind of hard if I need help or need to
ask somebody a question.'' Another shared, ``anytime you need
medical attention, we have to travel somewhere,'' and he
mentioned Bangor and Boston. A third commented, ``the financial
issues impact your psychological issues because you're worried
about, do I have enough money to pay the bills, am I going to
have enough food, am I going to be able to make my
appointments? ''
Due to the intensity of the challenges and the resource
limitations in rural communities, I believe it's imperative to
continue to leverage local assets and collaborations.
One excellent current example of such a collaboration is
the Veteran-Directed Care Program which is conducted by VA
Maine in partnership with three of the Agencies on Aging. We
see the benefits of these programs and how they empower
veterans to determine their own care plans as well as cover the
cost of other goods and services specific to their needs.
Although we've had limited referrals to this program in
Aroostook County, we believe it can be a good option. Some of
the barriers to participation include lack of awareness of the
program, difficulty identifying a worker and challenges with
managing the program on their own. Securing additional
resources for targeted outreach by both the VA and agencies
could improve the use as well as program revisions that would
allow utilization of technology to enable distant caregivers to
serve as authorized representatives may help.
In addition, there's a few other opportunities I'd just
like to mention, between VA and Agencies on Aging that could
happen that might strengthen navigation of community resources
and integration of specialty services.
Again, we're aging and disability resource centers. We
could leverage this resource to strengthen services for those
living in rural communities where formal VA supports are
limited.
In addition, we also could make connections with
specialized community services. In Aroostook right now, through
an ACL grant, we're developing a regional community-based
memory center to serve those with dementia and their
caregivers. I think this is an opportunity for a collaboration.
In closing, there are many other opportunities to address
these rural disparities. They are innovative, we are
innovative, the VA is being very innovative. The Agencies on
Aging stand ready to further partner with the VA to improve
awareness of services and access to these services, which are
issues that often prove challenging to those living in most
rural areas of America.
Thank you for the opportunity.
[The prepared statement of Ms. Barresi Saucier appears on
page 60 of the Appendix.]
Senator King. Thanks, Joy.
Paul?
STATEMENT OF PAUL SAUCIER, DIRECTOR, OFFICE OF AGING AND
DISABILITY SERVICES, MAINE DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Mr. Saucier. Good afternoon, Senator King, and thank you
for providing this forum to talk about this important issue for
veterans.
I will use the broader term, long-term services and
supports, to describe a continuum of services that includes
caregiver support, home care, adult day services, assisted
living, residential and nursing facilities.
MaineCare, Maine's Medicaid program, is the largest payer
of long-term services and supports in the state. This is true
nationally as well. In 2021, Medicaid paid for 44 percent of
national expenditures, and the VA paid less than 2 percent.
Many Maine veterans rely on MaineCare for long-term services
and supports including 42 percent of Maine Veterans' Homes
nursing home residents.
Although the federally administrated VA system and the
state administered MaineCare program operate independently from
one another, they face similar challenges in this post-pandemic
era. Attracting and maintaining a well-trained workforce is the
single greatest challenge facing long-term services and
supports in Maine. This is an area in which the Federal
Government can have meaningful impact through a substantial and
sustained effort in partnership with states and providers.
The need for long-term services and supports will continue
to grow as Maine's population ages, and the single biggest
constraint to growth is the availability of workforce. Maine
has invested more than $300 million with funding provided
through the American Recovery Plan Act, enhanced Federal
Medicaid match, Federal CDC grants and other one-time sources.
This federal funding has been put to good use and is greatly
appreciated, but Maine's structural workforce challenges are
not going away. This is a long-term problem that will require
sustained federal support over time.
Pay is certainly important, and Maine has made a
significant commitment to this area by adopting payment policy
that assures rates will cover wages for direct support workers
that are at least 125 percent of the State's minimum wage. The
State's minimum wage is indexed to inflation and as it rises,
so will Maine's LTSS rates.
Pay is not the only factor influencing the supply of direct
support workers. Availability and portability of training is
another key factor. To that end, Maine is adopting a universal
direct support worker credential that will enable workers to
apply their expertise across home and facility settings for
individuals with physical, intellectual or age-related needs.
This complements efforts in small house models and elsewhere
toward universal workers who engage with residents to assist
with multiple needs and preferences including personal care,
meal preparation, laundry and social activities. The approach
is more person-centered, efficient and satisfying to both the
worker and the resident which has been associated with higher
quality care. Green Houses, one specific form of small-house
model, had documented staff turnover rates that are half those
of traditional nursing homes. This is a very promising area to
which the VA could contribute with more research and
development from its own experience. The VA has funded the
construction of several small-house models across the country
including one right here in Augusta. We would all benefit from
understanding the outcomes and operational best practices
emerging from these homes.
Maine has also seen that self-directed care can be an
important part of the workforce solution by expanding and
providing more information about our self-directed home care
options. Maine has grown this option during and after the
pandemic. In most cases, self-directed care is provided by a
family member, but the use of non-related caregivers is also
rising. This is another area in which the VA can assist, and we
welcome the expansion and availability of its Veteran-Directed
Care programs.
I'd like to conclude with some thoughts about system
balance. The VA and Maine state long-term service and support
programs share an interest in ensuring a system that has a
necessary balance of home--and community-based services and
institutional services. Older adults have consistently
expressed an overwhelming preference for aging in their own
homes, which is reason enough to pursue more HCBS options. But
we also learned during COVID that having an appropriate balance
contributed to the resilience of our system. Maine's nursing
homes have not yet been able to return to pre-pandemic
occupancy levels. They're serving fewer people today than they
did before the pandemic. Fortunately for Maine, the story's
been quite different in the home care sector. To be sure, home
care has also experienced workforce challenges, yet Maine's
three largest home care programs grew by 17 percent during the
pandemic, serving nearly a thousand more individuals today than
they did at the pandemic's onset.
The VA has recognized the importance of balance, projecting
increasing growth of its HCBS options over time in a recent
government accounting office report. To date, the VA's current
balance lags Maine's and most states, and Maine welcomes a
significant increase in VA home care options.
Thank you for the opportunity to testify today.
[The prepared statement of Mr. Saucier appears on page 64
of the Appendix.]
Senator King. Thank you.
Kathleen. And, Kathleen, don't we know each other? Did you
go to Mt. Ararat?
Ms. Swinbourne. Uh-huh.
Senator King. With one of my sons, I think.
Ms. Swinbourne. James.
Senator King. James, James. That's Maine, isn't it?
Ms. Swinbourne. He and I were Senate Pages together----
Senator King. Oh, that's right, that's right.
Go ahead, Kathleen.
STATEMENT OF KATHLEEN SWINBOURNE,
FAMILY CAREGIVER
Ms. Swinbourne. Good afternoon, Senator King. Thank you for
the opportunity to participate in this Senate Veterans' Affairs
Committee field hearing on long-term care services for veterans
in Maine.
I'm from Topsham, I'm a registered nurse, licensed massage
therapist, long-time yoga instructor and previous business
owner. I'm here to share my experience as a family caregiver
for my father Clare John Swinbourne, an 85-year-old Navy
veteran with 20 years of service and three tours in Vietnam. My
dad was exposed to Agent Orange and suffers from Parkinson's,
dementia and PTSD.
In 2012, my dad was diagnosed with Parkinsonism systems,
and from the instruction of the family physician, he was
encouraged to apply to the VA for disability but was denied due
to the diagnosis ``Parkinsonism'' rather than Parkinson's
disease.
My active care began in 2019--I'm about to describe a fall.
At that point, my dad had been living with Parkinson's symptoms
for seven years. His gait was off, and he walked with a cane.
He was struggling with his executive function, and experiencing
intense mood swings and long bouts of depression. One day in
December of that year, he suggested we hang wreaths in the
front of my parents' home. We walked to the front, and he
gestured for me to walk ahead of him. He was often self-
conscious of his slow and laboring walk. I went ahead and in
moments, I was startled by his yells behind me. I turned to see
my dad lying on the ground with blood on his hand and knee. I
ran to help him. I could tell by the blood and shock in his
eyes had he had no warning that his body was going to give out
on him. He was embarrassed and apologetic, and I helped him to
his feet. I know not to do this now, but I put my arm in his
and aborted the wreath-hanging and led him inside so that I
could care for his wounds. We walked down the stairway--or,
excuse me--we walked down the driveway to the garage and took
one step in the door, and we both crashed down onto the cement.
My dad landed on the same bloody knee and hand. The fall
happened so quickly, I had no opportunity to brace myself or
protect him from falling. This time he was sobbing and in
shock. I held my dad for a long time as he cried. I can't say I
knew how he felt, but I realized with the Parkinson's disease
it was progressing, and the body he knew and trusted his whole
life was beginning to betray him.
I eventually got him to his feet. Inside, I cleaned and
dressed his wounds, and put him in his comfy recliner. All the
while he was apologizing to me still for falling. I told him it
wasn't his fault. And once I got him settled, I went downstairs
in a separate room and cried uncontrollably. I sat there for a
long time crying and praying because I knew I needed to figure
out how to care for him with this disease, but it was
overwhelming.
The next day I called his primary care doctor and put in a
request for an urgent referral for home care, and the next day
they sent Chan's, which was wonderful, and began with a social
worker who interviewed my parents and I about my father's needs
as well as needs of the home. And at the end, she pulled me
aside and said, we are more than happy to help you but because
he's a veteran, I really encourage you to apply for his
disability because he will be taken care of so well.
So the next day I got in touch with the American Legion,
and a representative at the health administration--excuse me,
the business administration side of the VA and she was
wonderful, and she gave me a long list of appointments and to-
dos that took me a little bit over a year and a half to
complete. Mind you, it was the start of the pandemic so we'd
have appointments scheduled and we'd show up and we weren't
supposed to be there, or it was canceled, or there was an
outside agency in Florida scheduling us in Maine and sending us
to Massachusetts. And I would try to reschedule and spend a
week trying to figure out who to talk to and how to change it.
During this time of pursuing the disability, which is more
of the administrative piece, I was also trying to figure out
how to teach my parents about the disease, and make sure that
we were having somewhat of harmony and support within the home.
And if anyone has been with someone whose mind is going
into dementia and Parkinson's, it's brutal. So I think during
the year and a half of the pandemic, I didn't really sleep
because I was awoken by night terrors and my mom wouldn't sleep
so I was always running on empty. So I'd call this poor woman
at the administrative side and cry and ask her, is there any
way that I could get help? And she turned me on to the 1-800
line, the VA, which I will tell everyone about, who can access,
because it's incredible. And I remember that conversation, she
calmed me down, and told me about the caregiver program up in
Maine and literally connected me while we were on the phone,
and that was a game changer. And they told me about the
program. The next day--that's my thing--the next day I applied
and in a few months, became part of the family caregiver
program so that I could get a small stipend, but I was more
interested in having the educational support and counseling so
that I was doing an okay job, if I could, in taking care of my
dad.
Also the help with the caregiver program, they told me
about handicapping the home. I pursued the HISA grant which was
similar to the disability process. It took me about a year, and
only because there was one hang-up in sending the right faxed
form from the outside occupational therapy practice to the VA.
But they had sent an OT team to our home to evaluate what my
dad needed, and then they sent the write-up back to the primary
care office. And then I would wait. And then I would call them,
did you send the form? Yes. Call the primary care at the VA.
Did you receive the form? No, we haven't. So that went on for
weeks and finally I was like, who is telling me the truth? And
I talked to the manager of the OT practice and she said, I know
someone at the VA, I'm going to figure out what the halt is,
and it was a specific form that they needed to fill out that
they didn't know. Finally got that through and within a year or
so, I handicapped the home. And I want to just give credit to
the VA and the prosthetics department. They're incredible. Just
like the business administration side, they gave me everything
I needed to do, it's just very time consuming.
Senator King. So the problem wasn't the service, it was the
time to get the service; is that correct?
Ms. Swinbourne. Yes, and doing the right steps and telling
the right people, yes.
Um--sorry. As I was getting this all figured out, we were
also realizing my dad's needs were increasing so I began the
process of applying for the re-adjudication of his benefits
when he was denied in 2012. And also the administrative side
helped me with the right forms to fill out. We submitted them,
and waited a long time for a response. And this poor
representative, I called her every week, what's happening, are
we going to find out? Because I was trying to plan for the
future, and I knew that we were going to use the money to pay
for the rest of the construction to handicap the home, and also
to pay for an additional caregiver alongside my mom and I.
So I reached out to your office, and that's when I
connected with your staff, and they were incredibly supportive
in helping me figure out and locate where the application was.
And within two weeks, we had the backpay.
So after that, I then applied for full-time status with the
caregiver program and I was denied. There wasn't, in my
experience, a lot of evaluation or assessment to why I was
denied, but we were denied, and the stress was increasing. I'm
just--I'm going to advance a little bit. The stress sort of was
coming from the progression of my father's disease. And we
realized this past summer, he probably needs to be in a home,
even though that's not something we wanted to do. So we moved
into the Maine Veterans' Home, which is beautiful, and we joke
in the family, it's the Hilton of elderly spaces. But his
dementia is so severe that he needs more intense observation
and care.
I was trying to collaborate with the primary care team at
the VA, and it was a little bit difficult to close that circle
in getting support in I guess you would say taking away his
rights to make decisions so that we could make sure he'd stay
there safely because he wanted to leave. Every day he was
calling me, ``Kath,'' and causing a lot of ruckus. And we
brought him home for Christmas, and he ended up not going back.
Very long story short, he's now at the long-term care at the
VA. We're very happy. One of the first things that he said to
me when I went to visit him is, ``I feel safe,'' and that's
important.
I'm here today to share this story of caring for veterans
for--to share this story so that other people caring for
veterans don't give up. I'm also here to share the things that
I feel need improvement at the VA. I'm so happy with the
benefits we've received, even though many times it felt like I
was trying to bust down a brick wall. But once the wall came
down, I was able to tap into the wealth of resources for my dad
and myself.
I wish I had a case manager or a medical social worker to
guide me through the appropriate channels and check points to
regularly evaluate my dad's conditions and needs, and to make
sure his medical records were alwaysup-to-date to help us move
through this stage from being at home to the nursing level of
care.
I know this is the intention of the VA to provide a medical
social worker. We were assigned one, but this wasn't our
experience. It was very difficult for me to connect to the
primary care team, and also with them to communicate with the
caregiver program. We often fell upon our next steps through
crisis, and I was regularly asking for help, but so often my
phone calls weren't returned. When my dad went into rehab, I
was undergoing extensive months of a long process to re-apply
for the full-time care, and also Vet Direct care. By the time
there was a decision, simultaneously my dad was in the hospital
and then ended up at MVH.
In an ideal world, veterans and families would benefit from
the medical social worker to educate them on the process of the
disease and its progression, to guide them through the proper
channels in moving from the home to the nursing home.
Additionally, the medical social worker can bridge the
families to the providers for regular geriatric evaluation and
management and the caregiver program upon immediate diagnosis
of the war-related disease.
I feel the VA has all the big pieces that can help. It's
the little stuff connecting the dots between the programs where
I feel it falls apart.
I'm so grateful for your office, Senator King. I contacted
them again for assistance when I was unable to receive return
calls or clear guidance from the staff at the VA. I'm certain
the support of your office is what allowed me to experience
progress and momentum in my dad's care. However, I don't feel
veterans and families need to take it to this level. Calls
should be returned, guidance needs to be available, and the
application process is too extensive for aging veterans who
don't have a young family member or advocate who can give
them--who can give up their job to pursue their benefits and
care. For five years, I temporarily gave up my career and
income for my dad because I love him, and I believe in honoring
those who fought for our freedom, but I've greatly compromised
my financial, physical, mental and also emotional stability due
to the constant stress and time commitment.
If I had been compensated for the care for his full-time
needs, I may have felt differently or may feel differently, but
I was doing full-time work for part-time pay and also trying to
go to nursing school. It was an idealistic hope that I could
take care of him if need be.
I believe the VA is a wonderful organization with an
abundance of resources for families and veterans, and I'm
hoping that the refinement of better communication and
correspondence and leadership from the primary care team can
create positive change for veterans and families.
Thank you.
[The prepared statement of Ms. Swinbourne appears on page
67 of the Appendix.]
Senator King. Thank you. That was very moving and important
for us to hear. Thank you.
It seems to me to start with your testimony, as I
mentioned, the problem that you had with the VA wasn't with the
programs or the adequacy, it was the time, and I'm delighted my
office could help, but it shouldn't take that step to get that
help.
Was this--did you get the sense this was a lack of, again,
of workforce? Just too much burden on the people at the VA?
Ms. Swinbourne. Yes.
Senator King. I'm sorry nobody said we're not gonna return
these phone calls, it just didn't happen.
Ms. Swinbourne. Yes. I think it was a lack of staffing
which I feel very empathetic toward, yes.
Senator King. Let me move, Joy, to something that you
touched on very briefly. One of the concerns--and I've heard
this when I've met with their agencies, particularly in rural
Maine, is an epidemic of loneliness. Could you talk about that,
and the fact that so many of our seniors are isolated with very
little--I remember being in Washington County and there was a
lady there who said the only person she ever sees is the Meals
on Wheels driver. Talk to me about that problem. It doesn't
strictly relate to the VA, but I think it touches on what we're
talking about. There are certainly veterans who are in this
category.
Ms. Barresi Saucier. Yes, we definitely hear this in rural
Maine and nationally too. This is really becoming its own form
of an epidemic, the epidemic of loneliness. The rural community
Health Improvement Partnership project that we have just been
undertaking with some state funding brings 20 community
partners together to talk about social determinates of health.
And the needs assessment that we did found that this is not
only the issue of social isolation, but the issue of belonging
is a challenge in our rural communities. And so we've
prioritized that as one of the four areas that we'll be
focusing on in our Community Health Improvement Partnership.
In Aroostook County, a couple things we are doing, because
we do understand that with distance comes disparities. You
know, I tell people that driving from the top of Aroostook to
the bottom is like driving from Albany to Boston. It's very
hard to conceptualize that until you do it in a day. We all
have done it in a day before----
Senator King. I think Brunswick or Portland is halfway
between Madawaska and New York City. People don't realize how
tall Maine is.
Ms. Barresi Saucier. It's a big space. It's sparsely
populated, but yet we believe that no matter what community you
live in in Aroostook County, that you need access to services.
We recently received, through congressionally directed
spending, thanks to Senator Collins and Senator King, a project
called Access Points for Aging where we're collaborating with
20 communities in Aroostook County, these are primary and
secondary service-hub communities, to install an actual
footprint in that community, an existing community space, where
there can be a partnership between the community, age-friendly
community, municipality, Agency on Aging, healthcare, other
social service agencies to have a place where people can go to
access information. These are outfitted with technology. All 20
will be able to be linked together. So if you're in Danforth,
you can provide a Tai Chi presentation to Fort Kent.
Senator King. Will that access information include
information about VA availabilities?
Ms. Barresi Saucier. As I said in my written testimony, I
think this is a great opportunity to link the VA into that
network in our area. This isn't something that all AAAs have.
It really is a demonstration pilot. We expect that others will
want to follow suit, and already another agency is trying to
follow suit with this concept as well.
And then in addition, we have--related to social isolation,
I believe it was 2020, we were the recipient of a community
care corp grant which allowed us to develop and establish a
program called Friendly Volunteers. We have friendly visitors,
callers, helpers and techies. These are trained background
check volunteers, community volunteers, that we match to older
people that need a connection. It's a very, very popular
program. The challenge with this type of program though is that
that was one-time funding, that was one-time two-year funding
and now we're faced to try to--well, how do we piece this back
together without a full-time coordinator to do this work? This
is another great example of an existing resource that could be
tweaked to match veterans with veterans. The infrastructure is
all there. We just need resources to continue to make these
type of programs run.
Senator King. Thank you.
Steve, I noted you nodding during Kathleen's testimony. Can
the VSOs serve as navigators, helpers? Is that a function that
would be useful in the situation of the delays and the
unanswered phone calls?
Mr. SanPedro. You're referring back to Kathleen's
testimony?
Senator King. Yes.
Mr. SanPedro. I'm sure we can advocate.
Senator King. That's what I'm suggesting.
Mr. SanPedro. Absolutely. I don't know if we would change
it, but I mean I will tell you personally that Ryan, Tracy and
Jennifer, you guys do a tremendous job providing healthcare and
benefits.
Just two days ago----
If you don't mind me sharing, Jennifer.
--I reached out to Jennifer about a veteran that had an
issue with her claims process, and she felt she wasn't being
heard and she wasn't being taken care of. A different regional
team was looking into it. Jennifer's team took over it, and
long story short, this veteran walked away feeling like she was
heard and that she was cared for and she's very happy, and I
told Jennifer that before.
So I think we have--the overall thing that I hear from
veterans across the state is they do believe in that VA
healthcare, they do want to use it. The national VFW did a
survey, and overwhelmingly veterans want to use VA healthcare.
Is it perfect? No. But tell me a healthcare system that is.
I believe that we have leaders there that want to help us,
they care. They truly enjoy their jobs----
Senator King. For the record, I totally agree with that
statement.
Mr. SanPedro. Yes. What I would have done, if she reached
out to me or--you know, I would have reached out to them
because that's typically what I do. I don't--you know, I
don't--I know everybody doesn't have that access, but I do, and
that's what I do. I just say, Jennifer, can you help me? Here's
another one. This isn't the first time Jennifer has helped me.
And I've reached out to Tracy and when Ryan was here, I worked
with Ryan. They are great partners with the VSOs, and they
truly believe in taking care of veterans. So I simply would
have advocated for her, and I believe that it would have been
taken care of. However, there is a problem with some of the
processes. I mean they're labor intense.
You know, one of the things that I would have said, if you
asked about veterans, how do they feel, most veterans want to
stay at their home. But if they can't, they--a lot of them
prefer to go to Maine Veterans' Homes. Not because I sit on the
board but because that's true. However, a lot of them are not
close to a Maine Veterans' Home, and they want their families
to be able to visit. So the VA contracted homes, many people
don't even know about them. There's 10 of them in the State of
Maine, and most veterans don't know about them.
Senator King. These are the private nursing homes that are
contracted for by the VA?
Mr. SanPedro. Correct. But most of them don't know about
it, and who do they turn to, you know, and how do they learn
about it? So there's definitely an education problem. Not in
the State of Maine, in the whole Nation, on what the VA can do
for ya. Whether it's just getting out of the military or filing
a claim or getting your healthcare, a lot of people just don't
know what the VA has for them, and there's so many programs
that they provide for our veterans and no veteran should----
Senator King. So awareness is a big part of the issue?
Mr. SanPedro. Yes. And, you know, like thank you for
signing the bill that I came to you in September or sponsoring
the bill that I came to you in September about the TAP
program----
Senator King. The President signs the bills.
[Laughter.]
Mr. SanPedro. Right. We're working on it, right?
But that simple thing of allowing the VSOs to come in
during TAP, it costs the United States zero dollars. And you
take----
Senator King. TAP is the Transition Assistance Program?
Mr. SanPedro. Transition Assistance Program. You would
think that that would be a simple thing, but we have to get a
law to pass to let the VSOs to come in during TAP to show--to
help start the claim process.
Senator King. To make the contact?
Mr. SanPedro. Correct. So education to me, I think, would
solve a lot of our problems, and I do think that it would solve
Kathleen's problems.
Senator King. Thank you.
Paul, I want to talk a bit about reimbursement. What's
the--for MaineCare, which is a lot of what we're talking about,
what percentage of those dollars are federal, and what
percentage is state?
Mr. Saucier. So Maine gets about 62 percent federal these
days. And, as you know, that changes with economic conditions
in the state. Administrative costs are 50 percent federal and
50 percent state.
Senator King. So on a dollar to a nursing home, the State
of Maine puts up roughly 40 percent, the feds 60?
Mr. Saucier. That's right.
Senator King. Sharon, you said something, and we sort of
blew by it, and I want to get back to it. You said--I think you
said I have a 36-month runway. What did you mean by that?
Ms. Fusco. What I meant by that was that we are in a
situation where we have to use funds that we reserve for
capital replacement. Like rehabbing buildings, maintaining
buildings, keeping our infrastructure in good shape. Those
funds today are being used to pay for services today.
Senator King. So you're using capital to pay operations?
Ms. Fusco. Correct.
Senator King. Always a bad place to be.
Ms. Fusco. Yes. And understand that, you know, because we
are a private nonprofit, we're a little different as a state
veterans home. We are charged to do that. The state doesn't pay
for our buildings and our replacement buildings and things of
that nature. So we've done the right thing over the years,
right? We've invested that money so that we have a pool so that
when we need capital replacement, we can do it. But when we
have to make payroll and it's the choice between making payroll
or not.
Senator King. You're dipping into savings to pay the rent.
Ms. Fusco. Exactly. And that steals from our future, and it
also means I can only do that so long before I have to say, I
got to close the doors because I can't make payroll. And that
runway is 36 months. We've done what we can to extend it.
Senator King. So the 36 months is when you run out of
your----
Ms. Fusco. Yes, at current spend rates, yes.
Senator King. That's a scary thought, isn't it?
Ms. Fusco. It is.
Senator King. We don't have a representative on the panel,
the private nursing home industry, but, Sharon, you're in this.
Tell me your thoughts on the CMS staffing role.
Ms. Fusco. I think it's bad policy. And it's not because I
don't believe that, yes, if we had more staff and more people
available, that's great. But it's bad policy because, one, we
don't have the workforce, and if we learned nothing else
through the pandemic when we had a mass exodus of the workforce
from this industry, what we learned was we had companies
swooping in to save the day by charging us three to four times
for those nurses.
Senator King. These are the traveling nurses companies?
Ms. Fusco. And these are those traveling nurses. And what
happens in that situation is they are not committed to quality
as MVH defines it. They're fine individuals. If you're a
traveling nurse, this isn't about you. But what it's about is
that you don't know why we do things the MVH way. We got to
five stars as a CMS rated nursing home because we have quality
standards that we expect all of our employees to meet. And when
you're a traveling nurse, you're there for what; 60, 90 days?
You're not vested in my quality program. And you heard Mike say
how difficult it is to build a relationship with somebody who's
not vested in the mission. And you're creating a culture where
I've got some employees that I can pay my rate, and others that
I have to pay three and four times that rate. Imagine what it's
like standing next to somebody who's doing the same job as you
who's getting three times what you're being paid. It's
criminal.
Senator King. It's not exactly a morale booster.
Ms. Fusco. No, it's not. Now, I will say, we have done a
great job of working to eliminate temporary staffing in our
homes. But with work--if CMS comes down and says, ``hey, you
have to do this, you have to have this'', we will be right back
to temporary staffing. I mean those private nursing homes are
gonna be back to it.
Senator King. They're also going to be facing closure;
aren't they?
Ms. Fusco. They already are. And now CMS is going to impose
a staffing mandate that will increase their cost not just
because they have to hire more people, but because we're going
to be in this competition for people.
Senator King. Colleen?
Ms. Hilton. Yes, I'd like to add to that.
In Northern Light Health, we have eight nursing homes, six
we jointly own with another healthcare company. Prior to the
pandemic, we would advertise for a nurse in Lincoln, Maine;
three years not a single applicant. Three years, no applicant.
That nursing home eventually we converted to residential care.
Seaport in Ellsworth just closed. Deer Isle, during the
pandemic, right at the tail end of the pandemic closed. There's
now not a nursing facility or a skilled nursing facility in
Hancock County.
Senator King. I don't think there's one in Washington
County either.
Ms. Hilton. There's Milbridge right on the edge, but people
in Hancock County will now have to travel to Milbridge or to
Bangor. And so it is baffling at a time when five nursing homes
I think have closed since the pandemic, and you mentioned the
800 and something beds that have disappeared in the last five
years that we are----
Senator King. As the population ages.
Ms. Hilton. As the population ages, as the needs are
increasing that we are actually mandating 24-hour nursing care
when we can't produce it and we have a projected shortage, and
you can't fast track a nurse. You know, your wife's a nurse.
You can't fast track a nurse to fill that gap, and we're all
dealing with, in every sector of healthcare, those tough
questions of do we pull in that contracted labor for three
times the cost, or do we say to this family, this patient, we
can't provide care to you?
Senator King. Sharon, don't you have a whole wing at the--
we had a hearing at the Augusta home, and there was a part that
isn't open, right?
Ms. Fusco. Well, we have since, I'm happy to say.
Senator King. You staffed it up?
Ms. Fusco. We staffed it up, and we're actually near
capacity in that home, but it took us a year and a half to do
it.
Senator King. Well, I thought Mike made an important point
because we're all talking about hiring people but, Mike, you
made the point about stability and retention.
Mr. Pooler. Yes, sir. Yes, the folks that are there, great.
You know, with dementia patients, like I said, they need to
have that stability with the staff so they can, you know--
they're never gonna get better, but they're not--the decline
will be less. And if they can find issues sooner, they can fix
them sooner before they have to travel to the hospital for an
operation. So that stability from the family level is critical.
Senator King. If retention is the goal, one of the ironies
is that as you have gaps and you have longer hours and--that is
a vicious downward spiral because people burn out.
Is that your experience, Colleen?
Ms. Hilton. It's just a phenomenon of what we're dealing
with. And I think it did actually truly start right before the
pandemic, but certainly exacerbated by the pandemic. There
are--you know, there are significant needs across our state,
and people do chase money. And if they can go 30 miles over
here and increase their wage, I can't begrudge them for that.
But we've seen wage escalation, in some of the nursing homes,
up to 20, 30 percent, and it's still not enough to retain----
Senator King. To hold the people.
Ms. Hilton. To retain the people. Every one of us are
focused on retention. That's really where we spend the vast
majority of our time, but the workforce is very migratory right
now because of, I think, the socioeconomics and the workload
which is so intense and hard.
Senator King. The good is we have a historically low
unemployment rate, but that creates the question of the
migratory workforce.
I'm not going to make light of this issue, but I'll share a
story.
The first month that I was Governor, we had a retreat for
the cabinet where we went out to Newry, Maine where they had a
ropes course, and ropes courses do various things. It's to
build teams and those kinds of things. And part of it was to go
way up on a rope and have a rope around your waist and fall off
and have the person below hold you. It was, you know, trust and
all that. Well, it happened the guy who was holding me was a
guy named John Orestis who happens to be a nursing home owner.
And so I'm falling off and dangling 40 feet above the ground
and I had been down here for about a month and John said,
Governor, what do you think of nursing home reimbursement
rates? [Laughter.] I said, whatever you need, John, let me
down. [Laughter.] But it is--it is a serious problem. And
you're squeezed, you have increasing expenses and virtually no
increase in revenues. I mean that can't work for very long.
Ms. Hilton. No.
Senator King. Other thoughts before we conclude?
Thank you all. This has been wonderful testimony.
By the way, this is my favorite part of my job is hearings
and asking questions and learning and writing down ideas. I
have lots of things for Tester and Moran to work on when we get
back.
Other thoughts you want to be sure to get on the record?
Paul, you would like a greater increase of federal funds
for MaineCare?
Ms. Saucier. One of the very efficient ways to distribute
federal money is by providing a special federal matching rate
for targeted activities, and that's one of the things I would
recommend. It would be very efficient for CMS to, for example,
give a 75 percent federal match rate for any workforce related
activities and make that very broad. The workforce money that
we received through the recovery act and others has been put to
great use. That was a very large $130 million bonus program
here in Maine that went to all HCBS, Home and Community Based
Service providers, for example. Those--many of those are small
providers that are not in a position to write a grant or to
HRSA or, you know, otherwise directly receive federal funds.
But through the state, I think that could be very beneficial.
Senator King. I like the idea. In other words, additional
federal funds not generally but targeted toward workforce
retention?
Mr. Saucier. Targeted--right, right. Yes, I think that
would be one--one way to go with it. I mean just to give you a
sense of how big this problem is, senator, in the CMS proposed
rule that you've been asking about, there was notice that HRSA
would invest $75 million as part of the regulatory--the new
regulation. Maine invested $300 million, one small state, in
the last three years. My belief is that it helped stabilize the
workforce. It did not fix it, and that's just one state. So the
$75 million that HRSA would be offering is--I mean it's----
Senator King. For the whole country?
Mr. Saucier. For the entire country. Which is why I say, I
mean HRSA does certain things really, really well and----
Senator King. Define HRSA.
Mr. Saucier. Health Resource Service Administration.
They're the federal agency that focuses on the healthcare
workforce, and they're--especially larger providers can benefit
a lot from HRSA grants. The state has--you know, the universal
benefit--the universal curriculum, that I mentioned, was funded
with HRSA funding, but it's out of reach for a lot of these
small providers that we really depend on. Home care providers
sometimes are two employees. And so, you know, we really need
to be able to reach them.
Senator King. By the way, that's a problem across the
board. We had an Armed Services Committee hearing this week
about the inability of many small businesses to interact with
the Pentagon. It's just too much, too much paperwork, and we're
losing innovation and capabilities that we need.
Final point on that, it suggests itself. How about
innovation and technology? Are there ways to deliver services
more efficiently and effectively at the same or less dollars?
In other words, is that another way to approach this?
Colleen, you're nodding.
Ms. Hilton. Yes, I'd love to take----
Senator King. The record doesn't show when you nod. That's
why----
Ms. Hilton. Oh, sorry.
We invested, probably 15 years ago, in technology so we pay
for it. It's not reimbursed. It's not covered by the Medicare
benefit. There are small parts of--bits and pieces that they
may cover but we are--and, again, this was clear through the
pandemic when we couldn't get into some homes, we could drop
ship equipment to a home, and could get video eyes on people in
their home and do assessments as best we could. So it is a
helpful additive to what we do. It can't replace someone that
needs personal care assistance and toileting and those sorts of
things, but it's typically not covered by most of the
insurances. So for an organization like mine which has done,
over time, pretty well--we go from, again, Fort Kent to
Kittery, coverage. Last year we were 10 million in the hole, 10
million to the negative, a very efficiently run organization,
and we are gambling on our investments in technology because it
has to--reimbursement has to catch up with it because it is one
of the solutions to the workforce shortage.
Senator King. One of the things--during the pandemic, there
were rules waived for reimbursement for telephone and
telehealth, and they were--we've been fighting--we want to keep
that permanent.
Ms. Hilton. We do too.
Senator King. Because telehealth is a huge opportunity. And
as I think one of you mentioned, the patients are okay with it.
And I understand that there's a lower appointment-missing----
Ms. Hilton. Correct. For home visits and for behavioral
health, it's often preferred.
For us using it with chronic care disease management,
congestive heart failure, we can catch things early, treat them
early with preestablished protocols, and that person never goes
to the hospital, doesn't have to take up time in an office.
They can be treated at home and continue on their----
Senator King. Prevention, prevention, prevention.
Ms. Hilton. Prevention, public health.
Ms. Barresi Saucier. Can I add to the telehealth comment?
Senator King. Please.
Ms. Barresi Saucier. I just want to mention our evolving
memory care center in Presque Isle, is a collaboration between
the Aroostook Agency on Aging and Acadia Mood and Memory Clinic
in Bangor. And this model creates a comprehensive hub for
Aroostook County where we can do everything from work with
Acadia on early diagnosis and treatment through service
coordination, family caregiver support, community education,
and respite care. And the telehealth components are going to
allow us, with Dr. Singer who has a 600-person wait list, to
fast track one person from Aroostook County every week into his
program using telehealth. So we're really excited about this
opportunity to--as a community-based organization to be a hub
for a telehealth project.
And just my other comment, I'm so excited to hear about
everything that the VA is doing related to the community-based
programs, and I just want to remind about the fact that
Agencies on Aging have across the country these amazing assets
and established infrastructure that if we can partner together,
we can do great things so look us up across the country. There
are 622; it's just a great use of existing resources rather
than recreating resources when this network already exists so
thank you.
Senator King. I want to thank all of you. This has been
very informative. I've got lots of notes. As you drive home
tonight, when you think of oh, I should have said this, send it
forward. Be in touch with my office so that we can have the
benefit of your thinking.
It's wonderful to see all of you, most of you I know and
have seen before.
Kathleen, I will tell James I saw you.
And it's been very, very helpful and informative.
Thank you so much. Thank you all.
[Whereupon, the above-named hearing was concluded at 4:02
p.m.]
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