2024 OREGON LONG TERM CARE STATE REPORT Improving lives by advancing quality care in Oregon since 1950
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Long Term Care 101 A Continuum of Care Oregon Leads the Nation in Providing High-Quality Long Term Care Oregonians in Need of Long Term Care Nursing Facilities and Post-Acute Care Compliance Oversight and Quality Initial and Continuing Training Requirements Staffing Requirements Oregon Care Partners Trainings Economic Impact, Affordability, and Workforce Long Term Care Financing Oregon Medicaid LTSS Clients Policy Priorities Endnotes TABLE OF CONTENTS 4 5 6 8 10 11 12 14 15 16 19 21 22 23
2024 Oregon Long Term Care State Report www.ohca.com 4 Long Term Care 101 Long term care is a continuum of services and supports, including health care, social services, and housing, provided to individuals living with chronic conditions or disabilities that affect their ability to perform activities of daily life. Oregon’s continuum of care is provided through settings that allow Oregonians to maintain their dignity, independence, and autonomy within safe environments while receiving the health care services and/or support they need. The care continuum includes in-home care, senior retirement housing, assisted living and residential care communities, memory care communities, and long and short stay skilled nursing/rehab communities. The Continuum of Long Term Care Services and Supports In-Home Care fIn-home health supports and services f Supplemental family support and companionship fHealth care services f Support with some activities of daily living (bathing, laundry, etc.) Independent Living/Senior Retirement Housing fApartment-style settings fRecreational activities fAmenities such as housekeeping and dining services Assisted Living/Residential Care fCommunity-based and home-like settings f Assistance with activities of daily living and instrumental activities of daily living such as bathing, transferring, and medication management Skilled Nursing fPost-acute rehabilitative care fIntensive, skilled nursing services Memory Care f Specialized care and support for people living with Alzheimer’s disease and other dementias fSecure settings f Staff trained to care for residents with Alzheimer’s disease and other dementias and provide specialized services
www.ohca.com Oregon Health Care Association 5 A Continuum of Care Licensed facilities that provide 24-hour skilled nursing for short-term post-acute rehabilitative care or long stay services that are needed due to ongoing and indefinite cognitive or physical impairment(s). Skilled Nursing Facility (SNF) Residential Care Facility (RCF) Licensed 24-hour home and community-based service settings that serve six or more residents. Rooms can be shared by up to two individuals. Different types of residential care include 24-hour residential care for adults and specialty memory care communities. A licensed nurse must be regularly scheduled for onside duties and available for phone consultation. A registered nurse must be available to complete RN assessments, such as assessments for significant change of condition, and nurse delegation. Assisted Living Facility (ALF) Licensed 24-hour home and community-based service settings for six or more residents in individual, private apartments. Services are comparable to residential care communities. Assisted living facilities have the same nurse requirements as residential care settings. Adult Foster Home (AFH) Services are provided in single family home-like settings that are licensed for five or fewer individuals who are not related to the foster home provider. Adult foster homes provide a range of care and service needs. Memory Care Community (MCC) These secure settings care for individuals with Alzheimer’s or dementia. Each setting is licensed by the state as a residential care, assisted living, or nursing facility. Memory care communities are required by the state to train staff to care for residents with dementia and provide specialized services. Independent Living (IL)/ Senior Retirement Housing (SRH) Communities organized to provide housing and services to senior households. In general, these communities do not provide health care or assistance with activities of daily living. Often, they offer recreational opportunities, dining, laundry service, and other similar amenities. In-Home Care Agency (IHC) Agencies that employ, assign, and schedule caregivers to provide personal care assistance and/or companionship for clients in their homes or, sometimes, in community settings. Home Health Agency (HHA) Agencies that provide skilled care services in individuals’ homes. These services are largely funded by Medicare. Foundational to the long term care system in Oregon is a commitment to communitybased care, where care is provided to individuals in community settings with an effort to have a home-like feel, such as assisted living, residential care communities, and adult foster homes. Community-Based Care (CBC) Housing with Services (HWS) An entity that coordinates two or more health and social services for older adults and people living with disabilities, who reside in publicly subsidized or private congregate settings.
2024 Oregon Long Term Care State Report www.ohca.com 6 Oregon Leads the Nation in Providing High-Quality Long Term Care For nearly 50 years, Oregon has been a national leader in providing quality care and services to older adults and other Oregonians living in long term care settings. Oregon’s innovative efforts to provide aging services in the home and in home-like settings, and our commitment to fund these services for lower-income Oregonians, enable those in need of care from all socioeconomic backgrounds to receive some of the highestquality care in the country. Long term care is the continuum of services and supports that includes health care, social services, and housing for individuals living with illnesses, acquired injuries, or disabilities that affect the ability to perform activities of daily living. Today, more than 40,000 Oregonians reside in licensed long term care settings and more than 10,000 Oregonians receive services and supports in their own homes provided by licensed inhome care agencies. Oregon’s nearly 700 licensed assisted living, residential care, and skilled nursing communities, as well as 200 licensed in-home care providers across the state, are primarily operated by local or regional organizations that have served Oregonians for several generations, many of which are headquartered within our state. This local organizational leadership means that jobs, tax revenue, and economic impact are largely retained within our communities. Long term care continues to face many challenges, including continued recovery from the impacts of the COVID-19 pandemic and the resulting workforce and cost containment challenges that came with it. Due to #7 Oregon ranked 7th highest in the nation for high performance in long term care services and supports– AARP State Scorecard Ranking.4 #2 Oregon ranked 2nd highest in the nation with 4.83 Total Nursing Hours per Resident Day (Skilled Nursing Facilities).1 Oregon ranked 3rd highest in the nation for RN Annual median wage ($110,940).2 #3 Oregon ranked 3rd highest in nation in the PHI Direct Care Workforce State Index.3 #3
www.ohca.com Oregon Health Care Association 7 unprecedented inflation within the global economy and particularly to the healthcare sector generally, the cost of providing care and services continues to climb. Additionally, competition to recruit and retain caregivers and health care workers impacts facilities’ ability to maintain access and affordability, especially in rural communities. Addressing these challenges has never been more important for our state as demand for long term care services in Oregon is rising sharply as our population ages. It is critical that the state renew and enhance its commitment to long term care services and supports, including workforce supports and professional development and growth.
2024 Oregon Long Term Care State Report www.ohca.com 8 Long Term Care Providers & Oregonians Served PROVIDER TYPE NUMBER OF SERVICE PROVIDERS NUMBER OF OREGONIANS SERVED Adult Foster Homes6 1,329 5,316 Nursing Facilities7 129 6,491 Assisted Living/ Residential Care8 575 22,485 Independent Living9 200 12,000+ In-Home Care Agencies10 200 10,000+ Home Care Commission Workers11 16,000+ 19,000+ TOTAL 18,400+ 75,100+ Oregonians in Need of Long Term Care More than 75,000 Oregonians receive long term care services across the state each day, and that number will grow as Oregon’s population continues to age. In 2023, an estimated 877,131 Oregonians were 65 years of age or older, and, of that, 85,316 were over the age of 85—the age group most likely to need some form of care and support.5 By 2030, there will be an estimated 110,343 Oregonians over the age of 85, a 29% increase over the next eight years. POPULATION Oregon’s Population–Current & Future Projections12 65+ AGE 80,000 320,000 240,000 160,000 400,000 480,000 560,000 640,000 720,000 800,000 880,000 960,000 1,040,000 1,120,000 1,200,000 (Percent Increase—15.1) (Percent Increase—59.7) 2030 2023 85+ 136,276 1,010,001 877,131 85,316 Sources: Oregon Health Authority (2024), Oregon Health Care Association (2024); Tunalilar et al., (2023), Tunalilar et al., (2024). Source: Oregon Office of Economic Research (2024).
www.ohca.com Oregon Health Care Association 9 Oregon County Level Population Estimate of Total County Population, 2024—Age 85+ and 65+13 COUNTY COUNTY COUNTY COUNTY Baker Douglas Lake Sherman Benton Gilliam Lane Tillamook Clackamas Grant Lincoln Umatilla Clatsop Harney Linn Union Columbia Hood River Malheur Wallowa Coos Jackson Marion Wasco Crook Jefferson Morrow Washington Curry Josephine Multnomah Wheeler Deschutes Klamath Polk Yamhill 85+ 65+ 415 4,589 1,704 17,904 8,400 85,413 824 10,444 972 10,960 1,639 18,302 518 6,704 702 8,516 3,564 43,914 85+ 65+ 2,987 29,624 79 651 266 2,322 213 1,941 439 4,368 4,895 51,854 363 5,194 2,402 23,972 1,212 15,749 85+ 65+ 173 2,160 7,614 80,838 1,136 16,223 2,231 25,242 559 5,637 5,433 57,974 171 2,042 10,949 119,064 1,781 17,160 85+ 65+ 68 474 579 7,719 1,395 13,459 590 5,582 185 2,203 570 5,816 8,705 89,961 76 554 2,001 20,660 Source: Population Research Center (2024).
2024 Oregon Long Term Care State Report www.ohca.com 10 Nursing Facilities and Post-Acute Care With 129 licensed skilled nursing facilities, Oregon has one of the lowest numbers of nursing facility beds per capita in the country.14 Nursing facilities typically provide care for individuals in need of rehabilitation following a serious health complication or hospital stay. While some individuals may reside in nursing facilities for a long period of time due to more intensive ongoing skilled care needs, often nursing facility stays are short in comparison to those receiving care and services in other types of long term care settings. Therefore, length of stay in Oregon nursing facilities is highly compressed and reflects our state’s intentional emphasis on home and community-based services rather than institutional care settings, lowering costs for the state since nursing facility care is more costly than community-based options. The median length of stay in 2023 was 22 days.15 Median length of stay increased in 2020 and has continued to slowly rise over the last three years because of the impacts of COVID-19. This is likely due to serving a higher proportion of individuals with higher acuity and complex care needs. Median Length of Stay: Oregon Nursing Facilities 25 18 19 21 22 23 24 20 17 16 15 NUMBER OF DAYS 201716 201817 201918 202019 202120 202221 202322 Source: Luck et al., 2021–2024 and Mendez-Luck et al., 2018–2020.
www.ohca.com Oregon Health Care Association 11 Compliance Oversight and Quality Oregon’s long term care system continues to evolve and has recently implemented new federal and state standards to improve the quality of care. In 2017 and 2018, the Oregon Legislature passed legislation that enhanced training requirements for caregivers, increased civil monetary fines, required professional licensure and oversight of administrators, and launched the nation’s first set of quality measures for communitybased care settings (assisted living facilities, residential care facilities, and memory care). In 2019, the legislature passed legislation to enhance the infectious disease prevention and mitigation requirements for community-based care providers. Breadth of Oversight Licensed long term care providers are subject to thousands of pages of federal and state rules and regulations. They are also scrutinized by a wide range of oversight and advocacy agencies. Providers are required to meet federal, state, and local compliance standards for resident care, safety, and quality of life. Government Oversight By Licensed Setting in Oregon SKILLED NURSING ASSISTED LIVING (ALF) RESIDENTIAL CARE (RCF) MEMORY CARE (MC) ADULT FOSTER HOMES IN-HOME CARE HOSPITALS U.S. Centers for Medicare & Medicaid Services (CMS) DHS APD Safety, Oversight & Quality Unit DHS Adult Protective Service Investigators DHS Compliance Surveyors DHS Complaint Surveyors DHS/AAA Case Managers DHS Criminal Background Check Unit DHS/APD Contracting Requirements Long Term Care Ombudsman Fire & Safety Officials OHA Licensing OHA Certificate of Need TOTAL 11 9 9 9 9 5 5
2024 Oregon Long Term Care State Report www.ohca.com 12 Initial and Continuing Training Requirements Oregon has comprehensive training requirements for caregivers, clinicians, staff, and administrators in long term care service settings. For many long term care positions, Oregon has some of the highest training requirements of any state. These requirements include pre-service trainings as well as annual in-service continuing education. For example, certified nursing assistants (CNAs) in Oregon’s skilled nursing facilities are required to complete 105 hours of initial training. This includes 65 hours of classroom instruction and 40 hours of supervised clinical experience and a competency exam and additional, continued training required on a quarterly basis. The initial training requirement is more than the federal minimum requirement of 75 hours of initial training for CNAs in these settings. Assisted Living and Residential Care Communities The state exercises robust regulatory control over training requirements in all assisted living and residential care communities, which include memory care. Each facility must have a training program in place—and are held accountable for meeting training requirements through the state survey process—that includes methods to determine competency of direct care staff through evaluation, observation, or written testing as well as documentation of direct care staff’s demonstrated competency. Knowledge and performance that must be demonstrated within the first 30 days of hire by direct care staff that include: • The role of service plans in providing individualized resident care • Providing assistance with the activities of daily living • Changes associated with normal aging • Identification of changes in the resident’s physical, emotional, and mental functioning, as well as documentation and reporting on the resident’s changes of condition • Conditions that require assessment, treatment, observation, and reporting • General food safety, serving, and sanitation If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. Further, pre-service dementia care training is required which must include the following subject areas: • The dementia disease process • Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including reducing the use of anti- psychotic medications for non-standard uses • Strategies for addressing social needs of persons with dementia23 Specific aspects of dementia care and ensuring the safety of residents with dementia, including: • Identify and address pain • Provide food and fluids • Prevent wandering and elopement • Use a person-centered approach All staff must also undergo a preservice orientation, which includes these topics: • Residents’ rights and the values of community- based care • Abuse and reporting requirements • Infection control • Fire safety and emergency procedures
www.ohca.com Oregon Health Care Association 13 In addition, all staff must have: • Twelve hours of annual continuing education in topics related to the provision of care for persons in a community-based care setting, including training on infectious diseases outbreak, infection control, Home and Community Based Services (HCBS), and dementia training. Beginning January 1, 2025, training on LGBTQIA2S+ rights and protections will be required biennially.24 In-Home Care Agencies All in-home care staff are required to participate in four hours of initial orientation that includes multiple care-related topics. In addition, all staff must have:25 • Eight hours of initial training • A further four hours of basic, non-injectable medication training for caregivers who provide medication services must be obtained prior to providing medication services • Six hours of annual continuing education; if providing medication administration, additional 1 hour related to medication administration Skilled Nursing Facilities In addition to adhering to all regulatory, compliance, and training requirements set forth on a national level by the Centers for Medicare and Medicaid Services (CMS), Oregon nursing facilities have strict requirements at the state level, including the following training requirements. All staff must have: • An orientation to ensure the safety and comfort of all residents is assured in accordance with facility policies which is to be carried out by a registered nurse Certified nursing assistants (CNAs) in these settings must complete:26,27 • An Oregon State Board of Nursing (OSBN) approved nursing assistant training program (105 hours) • Pass an OSBN-administered examination that qualifies them to obtain certification as a nursing assistant in Oregon • Twelve hours of annual continuing education (at least three per quarter) to include resident rights (LGBTQIA2S+ rights and protections required biennially), identifying/reporting abuse, dementia, preventing wandering, and emergency procedures/disaster plan Sample of Care Training Requirements by Licensed Setting LICENSED SETTING INITIAL / PRE SERVICE ANNUAL CONTINUING EDUCATION Nursing Facility (SNF) Certified Nursing Assistant (CNA) 105 hours and Exam 12 hours (3/quarter) Assisted Living/Residential Care (ALF/RCF) Direct care worker Demonstrate proficiency in multiple care topics 12 hours including 6 hours in dementia specific topics; Additional training is required for memory care endorsed facilities In-Home Care Direct care worker 4 hours orientation 8 hours training 4 hours medication (for staff providing medication) 6 hours; additional 1 hour for medication administration
2024 Oregon Long Term Care State Report www.ohca.com 14 Staffing Requirements Oregon has some of the most stringent regulatory requirements around long term care staffing in the nation. These requirements support our commitment to high quality care, but also drive the overall cost of care since labor represents the vast majority of costs to a long term care facility. Nursing Facility Staffing Requirements Both federal and state law regulates staffing standards in Oregon’s nursing facilities. Under current federal regulations, nursing facilities must have “sufficient nursing staff with the appropriate competencies and skill sets” to provide the required resident care and services. Nursing facilities are also required to have a registered nurse (RN) for “at least eight consecutive hours a day, seven days a week” and a RN must be designated to serve as the Director of Nursing on a full time basis. Oregon is one of a handful of states that also has state-mandated staffing ratios for nursing facilities. Oregon separately requires a RN care manager who is responsible for managing the nursing care of their assigned residents. Among other tasks, the RN care manager coordinates the nursing functions and tasks for their assigned residents and other health care providers and is responsible for verifying a resident’s care plan has been developed and documented. There are also minimum licensed nurse staffing requirements including the requirement to have a licensed charge nurse on each shift 24 hours per day with a RN serving as the licensed charge nurse for no less than eight consecutive hours between the start of the day shift and the end of evening shift, seven days a week. Furthermore, Oregon outlines the following minimum certified nursing assistant to resident ratios: • Day Shift: one nursing assistant per seven residents • Evening Shift: one nursing assistant per 9.5 residents • Night Shift: one nursing assistant per 17 residents Additionally, in April 2024, the Centers for Medicare and Medicaid Services (CMS) finalized a new rule governing minimum staffing requirements in nursing facilities. The staffing mandate: • Requires a minimum standard of 3.48 total nursing staff hours per resident day (HPRD), including 0.55 hours to be delivered by registered nurses (RNs) and 2.45 hours by nurse aides (CNAs). The remaining 0.48 hours may be filled by any combination of nurse aides, RNs, and licensed practical or vocational nurses (LPN/LVNs).
www.ohca.com Oregon Health Care Association 15 • Additionally, nursing facilities will be required to have a RN on-site 24 hours a day, seven days a week. Nearly all (97%) Oregon nursing facilities cannot currently meet the new 24/7 RN requirement. It is well documented that the country is facing a growing caregiver shortage as the population ages. Despite the staffing mandate’s phase-in implementation (urban facilities have 2–3 years; rural facilities have 3–5 years), Oregon has a severe nursing shortage that must be addressed immediately. Without more nurses, and funding to support those nurses, facilities will be unable to increase their workforce to comply with this new staffing mandate and serve aging Oregonians. Nursing facilities may be forced to limit admissions, downsize their facility, or ultimately, close altogether. Community-Based Care Staffing Requirements In alignment with industry best practice, Oregon’s community-based care facilities are subject to various staffing requirements set by the state government. In general, facilities must have sufficient, awake direct care staff to meet their residents’ scheduled and unscheduled needs 24 hours a day, seven days a week. A facility is required to use an acuity-based staffing tool (ABST) to help determine their staffing plan and ensure staffing levels are reflective of the overall resident acuity in that facility. Acuity-based staffing is widely viewed as the preferred model for staffing over staffing ratios for community-based care because each facility is unique in their services and resident population, which makes acuity vary significantly between facilities. Other factors that facilities must consider in developing a staffing plan include, but are not limited to, the number of residents in the facility, the physical plant and structural design of the facility, and the presence of residents who need two-person assistance. Oregon Care Partners Trainings Established in 2014 by the Oregon Legislature, Oregon Care Partners provides access to no-cost, high-quality trainings in all corners of the state. These trainings are offered in-person and online with timely, evidencebased curriculum, including Alzheimer’s and dementia care; medication management; challenging behaviors and communication; trauma-informed care; diversity, equity, and inclusion in long term care; and specialized training on Alzheimer’s disease for public safety workers. From January 2023 to May 2024, 47,835 unique individual caregivers completed 188,379 Oregon Care Partners in-person and online classes/webinars.28 The COVID-19 pandemic required Oregon Care Partners to completely reimagine its curriculum delivery. All classes were conducted via webinar, and online infection prevention training courses were developed in collaboration with the Oregon Department of Human Services (ODHS). Total number of caregivers trained 47,835 Total number of in-person and online classes 188,379 Caregivers Trained via Oregon Care Partners Source: Oregon Care Partners, 2024.
2024 Oregon Long Term Care State Report www.ohca.com 16 Economic Impact, Affordability, and Workforce The long term care sector provides significant employment opportunities in Oregon, especially for women, who make up a majority of the long term care workforce. Yet, recruiting, training, and retaining the large number of professionals required to provide highquality care for Oregonians who need these supports is a major challenge. Sector leaders and stakeholders are working continuously to cultivate a pipeline of talent as demand for long term care services and supports grows. Providers in rural Oregon face particularly acute staffing challenges as populations in these areas have, sometimes significantly, proportionately more older adults in need of care than in urban and suburban areas of the state. However, the number of eligible workers is not increasing in these areas making it difficult for long term care facilities to find enough qualified caregivers and medical staff. More than 80,000 Oregonians are currently employed in the long term care sector. This includes approximately 55,000 Oregonians working in assisted living, residential care, and nursing facilities—a return to record levels of employment in this sector last seen in the years directly before the COVID-19 pandemic.29 The long-term care workforce will grow rapidly in the years ahead to serve Oregon’s aging population; however, significant efforts will need to be made to ensure the workforce is trained and available to support care needs. In particular, the demand for home health aides and personal care aides are both projected to increase by more than 25% by 2030.30 The total annual economic footprint of the long term care service sector in Oregon is nearly $10 billion.31 This figure includes direct, indirect, and what economists Oregon Nursing Facility and Assisted Living Facility Employment: 2014–2024 Source: Oregon Employment Department (2024).
www.ohca.com Oregon Health Care Association 17 call the ‘induced’ impact of the sector. Further, the sector generates more than $1.5 billion in combined federal and state tax revenue, which includes over half a billion dollars in state tax revenue per year.32 Further, the long term care sector contributes more than $1 billion per biennium in general fund revenue for Oregon. This also means that the sector provides significant employment opportunities and living wage jobs. Oregon’s long term care service providers create more than 84,000 jobs. These jobs represent diverse occupations such as nurses, personal care aides, social workers, cooks, and groundskeepers. Affordability of Care The affordability of long term care is an important equity and quality of life issue. Oregon has continued to support Medicaid increases over the last several years, which has enabled more access to long term care services for lowerincome Oregon seniors, however significant increases to the cost of care continue to drive up the cost of delivering that care to individuals not able to access Medicaid. These increases include inflationary costs to wages, food, medical supplies, and also significant technology, operational, and labor costs related to managing new regulations and improvements in care. Ultimately, most people who need long term care services and supports will rely on Medicaid at some point to help them pay for their care needs. However, stringent standards of eligibility mean that many middle-income Oregonians do not have adequate coverage or savings to fund their long term care needs and must spend down their savings to eventually meet Medicaid eligibility. As Oregon approaches one million adults 65 years of age and older, this raises many questions about access to care and affordability. DIRECT IMPACT $4.6 billion TOTAL IMPACT $9.5 billion FEDERAL TAX REVENUE GENERATED $1.05 billion STATE TAX REVENUE GENERATED $505 million TOTAL EMPLOYMENT 83,499 Economic Impact of Long Term Care Sector in Oregon Source: AHCA/NCAL Research Division (2024).
2024 Oregon Long Term Care State Report www.ohca.com 18 Oregon’s Nursing Environment and Pipeline Oregon continues to face a shortage of nurses and nursing assistants who are desperately needed to provide care within the long term care sector and hospitals and other health care systems in Oregon are dealing with the same shortage throughout the state. In 2022, there were an estimated 42,719 registered nurses (RNs), 3,540 licensed practical nurses (LPNs), and 13,477 nursing assistants employed in Oregon.33,34,35 However, supply is not currently keeping up with demand as there are a projected 2,926 RN and 2,212 nursing assistant job openings per year in Oregon.36,37 The lack of adequate numbers of practicing nurses means it is no surprise that the median annual wage of Oregon RNs ranks third in the nation at $110,94038 making the nursing profession a highly competitive occupation. RNs employed in nursing facilities, which have significantly fewer resources than hospitals, have an average annual salary of $92,872.39 The average hourly wage of certified nursing assistants (CNA) working in Oregon nursing facilities is $23.41 or $48,692 annually.40 The shortage of RNs is not based on compensation, but rather a lack of enough new RNs being trained to meet the demand. Oregon ranks last nationally in graduates from public nursing institutions and graduates the 3rd fewest nursing students if you include graduates from private institutions as well.41 This shortage will remain an issue as Oregon’s population ages and demand for RNs and other nursing professionals increases in the years ahead. REGISTERED NURSES $44.65 HOURLY $92,872 ANNUAL OREGON NATIONAL $38.69 HOURLY $80,475 ANNUAL LICENSED PRACTICAL NURSES $35.59 HOURLY $74,027 ANNUAL $30.09 HOURLY $62,587 ANNUAL NURSING ASSISTANTS $23.41 HOURLY $48,692 ANNUAL $18.91 HOURLY $39,333 ANNUAL Nurse Compensation in Skilled Nursing Facilities, Current Average Oregon and National Rates OREGON NATIONAL OREGON NATIONAL Source: Hospital & Health Care Compensation Services (2024).
www.ohca.com Oregon Health Care Association 19 Long Term Care Financing Source: Luck et al., 2024.42 Skilled Nursing Facilities 65% Medicaid 11% Traditional Medicare 9% Medicare Advantage 11% Private 4% Other Government Source: Tunalilar et al.,2024.43 Assisted Living Residential Care & Memory Care Source: Tunalilar et al., 2024.44 53% Medicad 47% Private 0% Other Payer Sources Public funds, primarily Medicare and Medicaid, are the main sources of long term care financing in the United States, including in Oregon. However, the level of public investment varies by program and care setting. For instance, nursing facilities see higher rates of Medicare and Medicaid funding than community-based care facilities, where private pay remains the largest payer source statewide. However, Medicaid is increasing as a payer source in community-based care communities with more lower income Oregonians requiring services. The growing differential between private pay rates and Medicaid rates places tremendous financial stress on providers who primarily serve Medicaid clients. This differential must be addressed with continued investments for access to be maintained for those needing care across the state. 42% Medicaid 58% Private <1% Other
2024 Oregon Long Term Care State Report www.ohca.com 20 Private Pay vs. Medicaid Rates Total Oregonians Enrolled in Medicaid Utilizing Long Term Care Services and Supports 35,81645 Source: Office of Forecasting, Research & Analysis (2024). *Private pay and Medicaid rates are average, monthly statewide rates for assisted living/residential care facilities and memory care “MCC” facilities.The rate for in-home care is 2023 data and is statewide average hourly data. Sources: Genworth Financial 2022,2023, and 2024; Tunalilar et al.,2022 and 2024; Oregon Department of Human Services, 2022 and 2024. *PRIVATE PAY46 MEDICAID RATE47 PRIVATE PAY48 MEDICAID RATE49 ALF $5,045 Level 1 - $1,922 $5,825 Level 1 - $1,830 Level 2 - $2,382 Level 2 - $2,268 Level 3 - $2,989 Level 3 - $2,846 Level 4 - $3,753 Level 4 - $3,574 Level 5 - $4,513 Level 5 - $4,298 MCC $5,99550 $4,480 $8,00051 $6,276 IHC $32/hr $29.90/hr $37/hr $38.08/hr Assisted Living Memory Care In-Home Care 2022 2024
www.ohca.com Oregon Health Care Association 21 Medicaid Long Term Care Clients by Care Setting52 767 Residential Care 842 Contract Residential Care 1,934 PACE 2,954 Memory Care 2,369 Adult Foster Homes 18,802 In-Home Care Oregon Medicaid LTSS Clients Total: 35,816 4,106 Assisted Living 4,042 Nursing Facilities Source: Office of Forecasting, Research & Analysis (2024).
2024 Oregon Long Term Care State Report www.ohca.com 22 Policy Priorities The Oregon Legislature must reassert its commitment to services for low-income older adults and people with disabilities by making investments in Medicaid long term services and supports in the 2025–27 biennium. In the wake of the COVID-19 pandemic, a workforce crisis, and mounting new regulatory requirements, providers are struggling to keep up with the rising cost of care, continue to raise caregiver wages and benefits, and address the needs of all Oregonians. Here’s what the Legislature can do to support the long term care agenda in 2025–27: Invest in Medicaid Long Term Services and Supports: Low-income older adults and people with disabilities rely on Oregon’s Medicaid program to get the care they need, when they need it, in the setting of their choice. Currently, reimbursement to long term care providers through Medicaid is underfunded and needs to be increased. � Approve cost-of-living-adjustments for in-home care agencies and community-based care facilities. This may also include reimagining underlying rate models for home and community-based services to ensure rates truly meet the rising cost to provide care statewide to increasingly complex and highneed residents. � Approve full re-basing of rates for nursing facilities in accordance with the Medicaid rate methodology in Oregon law. � Oregon has some of the highest direct caregiver wages in the nation, and the average caregiver wage is now 20% higher than Oregon’s standard minimum wage. We want to continue to grow wages for this valuable workforce and encourage the Legislature to help fund wage growth through wage add-on programs, which have been successful in the past in helping providers with fixed revenues afford ongoing wage growth. Improve State Systems to Advance Accountability and Efficiency: Removing systemic barriers to accessing affordable care, aligning the regulatory burden put on providers with what is needed for the best quality care outcomes, and ensuring state agencies have appropriate resources to achieve their core missions are the only way to ensure our system is able to meet impending demand. � Streamline and expedite the Medicaid application and eligibility assessment process. Oregonians currently wait too long and navigate far too complicated processes to receive Medicaid benefits. This exacerbates hospital discharge backlogs to post-acute settings and harms individual and families who need care. � Ensure providers are reimbursed on-time for care provided to Medicaid beneficiaries. Currently, some providers are not paid on time or at all for services, creating backlogs of unpaid bills, and putting providers in challenging financial positions. Address the Nursing Crisis: Oregon must address critical nurse workforce shortages and provide funding for increased nurse requirements to enable facilities to maintain capacity and access to care. � Increase nurse faculty salaries to reduce the discrepancy in compensation between educational and clinical settings and enhance incentives for nurses to work as instructors. � Better promote, fund, and support programs for clinical placements or nurse mentorship in long term care settings for nursing students. � Explore establishing loan forgiveness programs for nurses who pursue careers in long term care after graduation.
www.ohca.com Oregon Health Care Association 23 Endnotes 1. Kaiser Family Foundation (2023). Average Reported Nurse Hours per Resident Day in All Certified Nursing Facilities. Available from: https://www.kff.org/other/ state-indicator/average-nurse-hours-per-resident-day-in-all-certified-nursingfacilities-2003–2014/?currentTimeframe=0&selectedDistributions=total-nursing&sort Model=%7B%22colId%22:%22Total%20Nursing%22,%22sort%22:%22desc%22%7D 2. Gooch, K. (2024). “RN annual median wage for all 50 states.” Beckers Hospital Review. Updated April 23, 2024. Available from: https://www.beckershospitalreview.com/ compensation-issues/rn-annual-median-wage-for-all-50-states.html 3. Angell, S., Stepick, L., & Scales, K. (2024). Direct Care Workforce State Index: Mapping Workforce Policies and Outcomes. PHI. Available from: https://www.phinational.org/wpcontent/uploads/2024/07/PHIs-DCW-State-Index_report_web.pdf 4. Reinhard, S., Harrell, R., Blakeway Amero, C., Flinn, B., Houser, A., Lingamfelter, P., Choula, R., Caldera, S., Hado, E., & Alexis, J. (2023). Long-Term Services and Supports State Scorecard 2023 Edition. Washington, DC: AARP Public Policy Institute, The Commonwealth Fund, and The SCAN Foundation. Available from: https://doi.org/10.26419/ppi.00203.001 5. Oregon Office of Economic Research (2024). Oregon’s Annual Population Forecast. Population of Oregon: 1990–2033. Release June 2024. State of Oregon. Available at: https://www.oregon.gov/das/oea/Pages/forecastdemographic.aspx 6. Tunalilar, O., Dys, S., Carder, P., Jacoby, D., Elliott, S., Kim, M., Parsons, N.F., & Albalawi, W. (2023). 2023 Adult Foster Home: Resident and Community Characteristics Report on Adult Foster Homes. Portland, OR: Portland State University. Institute on Aging. 7. Centers for Medicare and Medicaid Services (2024). Nursing homes including rehab services. Data.CMS.gov. Available from: https://data.cms.gov/provider-data/topics/ nursing-homes 8. Tunalilar, O., Dys, D., Levchenko, Y., Jacoby, D., Kim, M., Albalawi, W., Carder, P. (2024). 2024 Community-Based Care: Resident and Community Characteristics Report on Assisted Living, Residential Care, and Memory Care. Portland, OR: Portland State University Institute on Aging. 9. Oregon Health Care Association (2024). Estimate of Independent Living Communities in Oregon. 10. Oregon Health Authority (2024). Health Facility Licensing & Certification. In-Home Care Agencies. Available from: https://www.oregon.gov/oha/PH/ PROVIDERPARTNERRESOURCES/HEALTHCAREPROVIDERSFACILITIES/ HEALTHCAREHEALTHCAREREGULATIONQUALITYIMPROVEMENT/Documents/ IHCList.pdf 11. Oregon Department of Human Services (2023). 2023–25 Agency Request Budget (ARB), Section 2. Oregon Department of Human Services. Available from: https://www.oregon.gov/odhs/about/pages/budget.aspx?utm_source=ODHS&utm_ medium=egov_redirect&utm_campaign=https%3A%2F%2Fwww.oregon.gov %2Fdhs%2Faboutdhs%2Fdhsbudget%2F 12. Oregon Office of Economic Research (2024). Oregon’s Annual Population Forecast. Population of Oregon: 1990–2033. Release June 2024. Available at: https://www.oregon. gov/das/oea/Pages/forecastdemographic.aspx 13. Population Research Center (2024). 2023 Annual Population Reports Tables, April 16, 2024. Population Estimates by Age and Sex for Oregon and Its Counties: July 1, 2023. Portland State University. Available from: https://www.pdx.edu/population-research/ population-estimate-reports 14. Luck, J., Scarborough, N., Kumbeni, M.T., Bahl A, & Yarbrough, M. (2024). The State of Nursing Facilities in Oregon, 2023. Corvallis, OR: OSU College of Health. 15. Luck et al., (2024). 16. Luck et al., (2024). 17. Luck, J., Scarborough, N., Kumbeni, M.T., & Bahl, A. (2023). The State of Nursing Facilities in Oregon, 2022. Corvallis, OR: OSU College of Health. Available from: https:// health.oregonstate.edu/sites/health.oregonstate.edu/files/2023–10/2022%20Oregon%20 Nursing%20Facilities%20Report.pdf 18. Luck, J., Zhang, W., Scarborough, N., Kaiser, A., Bahl, A., & Mendez-Luck, C. (2022). The State of Nursing Facilities in Oregon, 2021. Corvallis, OR: OSU College of Public Health and Human Sciences. Available from: https://health.oregonstate.edu/sites/health.oregonstate. edu/files/2023–10/2021-oregon-nursing-facilities-report.pdf 19. Luck, J., Zhang, W., Patil, V., & Kaiser, A. (2021). The State of Nursing Facilities in Oregon, 2020. Corvallis, OR: OSU College of Public Health and Human Sciences. Available from: https://health.oregonstate.edu/sites/health.oregonstate.edu/files/skilled-nursingfacilities/pdf/2020-oregon-nursing-facilities-report.pdf 20. Mendez-Luck, C., Luck, J., Zhang, W., & Kaiser, A. (2020). The State of Nursing Facilities in Oregon, 2019. Corvallis, OR: OSU College of Public Health and Human Sciences. Available from: https://health.oregonstate.edu/sites/health.oregonstate.edu/files/ skilled-nursing-facilities/pdf/2020-oregon-nursing-facilities-report.pdf 21. Mendez-Luck, C., Luck, J., Mahakalanda, S.J., & Govier, D.J. (2019). The State of Nursing Facilities in Oregon, 2018. Corvallis, OR: OSU College of Public Health and Human Sciences. Available from: https://health.oregonstate.edu/sites/health.oregonstate.edu/files/ skilled-nursing-facilities/pdf/2019-oregon-nursing-facilities-report.pdf 22. Mendez-Luck, C., Luck, J., Larson, A.E., Dyer, & G.B. (2018). The State of Nursing Facilities in Oregon, 2017. Corvallis, OR: OSU College of Public Health and Human Sciences. Available from: https://health.oregonstate.edu/sites/health.oregonstate.edu/files/ skilled-nursing-facilities/pdf/2018-oregon-nursing-facilities-report.pdf 23. Oregon Administrative Rule. OAR 411–054–0070. Available from: https://secure.sos. state.or.us/oard/viewSingleRule.action?ruleVrsnRsn=314956 24. OAR 411–054–0070. 25. Oregon Administrative Rule. OAR 333–536–0070. Available from: https://secure.sos. state.or.us/oard/viewSingleRule.action?ruleVrsnRsn=306483 26. Oregon State Board of Nursing (n.d.). Oregon Nurse Practice Act. Available from: https://www.oregon.gov/osbn/Pages/laws-rules.aspx 27. Oregon Administrative Rule. OAR 411–086–0310. 28. Oregon Care Partners (2024). 29. Oregon Employment Department (2024a). Current Employment Estimates (CES) Industry History Data. Nursing and Residential Care Facilities. State of Oregon. Available from: www.qualityInfo.org 30. Oregon Employment Department (2024b). Occupation Profiles: Home Health Aides (311121), Oregon (All Counties). State of Oregon. Available from: https://www.qualityinfo. org/oprof 31. AHCA/NCAL Research Division (2024). Analysis of Nursing and Residential Care Impact for Oregon (2022), Personal Care Aides in Home Health and Individual Services Impact for Oregon (2022), and Home Health Care Impact for Oregon (2022). July 8, 2024. 32. AHCA/NCAL Research Division (2024). 33. Oregon Employment Department (2024c). Occupation Profiles: Registered Nurses (291141), Oregon (All Counties). Salem, OR: State of Oregon. Available from: https://www. qualityinfo.org/oprof 34. Oregon Employment Department (2024d). Occupation Profiles: Licensed Practical and Licensed Vocational Nurses (292061), Oregon (All Counties); Salem, OR: State of Oregon. Available from: https://www.qualityinfo.org/oprof 35. Oregon Employment Department (2024e). Occupation Profiles: Nursing Assistants (311131), Oregon (All Counties). Salem, OR: State of Oregon. Available from: https://www. qualityinfo.org/oprof 36. Oregon Employment Department (2024c). 37. Oregon Employment Department (2024e). 38. Gooch (2024). 39. Hospital & Health Care Compensation Services (2024). 2023–2024 Nursing Home Salary & Benefits Report. 40. Hospital & Health Care Compensation Services (2024). 41. Helligso, J. (2022). Postsecondary Healthcare Education Shortage in Oregon. Oregon Longitudinal Data Collaborative. Available from: https://www.oregon.gov/highered/strategyresearch/Documents/SLDS/STUDY-PostsecondaryHealthcareEducationShortageIn OregonFinal.pdf 42. Luck et al., 2024. 43. Tunalilar et al., 2024. 44. Tunalilar et al., 2024. 45. Office of Forecasting, Research and Analysis (2024). Monthly Caseload Forecast Variance Report. Oregon Department of Human Services. Adults and People with Disabilities. June 2024. Salem, OR: Oregon Department of Human Services. Available from: https:// www.oregon.gov/odhs/data/Pages/apd-data.aspx 46. Genworth Financial (2022). Monthly & Hourly Median Costs Oregon—State 2021. 47. Oregon Department of Human Services (2022). Rate Schedule— Effective January 1, 2022. 48. Genworth Financial (2024). Monthly & Hourly Median Costs Oregon—State 2023. Available from: https://www.genworth.com/aging-and-you/finances/cost-of-care 49. Oregon Department of Human Services (2024). Rate Schedule—Effective July 1, 2024. Available from: http://www.dhs.state.or.us/spd/tools/program/osip/rateschedule.pdf 50. Tunalilar, O., Carder, P., Winfree, J., Elliott S., Kim, M., Jacoby, D., & Albalawi, W. (2022). 2022 Community-Based Care Resident and Community Characteristics Report on Assisted Living, Residential Care, Memory Care. Portland, OR: Portland State University. Available from: https://www.pdx.edu/institute-on-aging/cbc-annual-reports 51. Tunalilar et al., 2024. 52. Office of Forecasting, Research and Analysis (2024).
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