On January 15, 2019, Dr. Alyse Williams, John Osse, Interim CEO, Mary Litzel, DON, and Brenda Gorm, DON travelled to Cheyenne to present this information to the Committee considering the placement of a long term skilled nursing facility for our Veterans. The following is a letter that was presented by Dr. Williams, which is also signed by the entire medical staff in Johnson County.
Transportation, Highways, and Military Affairs Committee Regarding: HB0082
Dear Members of the Committee,
Through my medical education and training I have had many mentors, one of which taught me the art of medicine. He instilled in me the values that in addition to altruism, as physicians we must practice in such a way that we do what’s best for the patient as well as the healthcare system. There has been much talk about a VA Skilled Nursing Facility being located in Buffalo. Much of the focus has been on the impact on our local economy, some of the concerns have focused on the impact this will make on our current work force. What I have realized is that no one has taken a step back to ask if this is the right thing for Veterans and our current healthcare system. As a medical doctor who currently provides care for our Veterans, I am here to voice my opinion. As the newest provider at Johnson County Health Care Center I have the largest panel of patients from our current Veterans Home located in Buffalo. While these are some of the more medically complex patients I see, I enjoy caring for them and am grateful for their service to our country.
As mentioned previously these patients are medically complex, they require several sub-specialists that we simply do not have consistently in our community. Through the current VA system if I want to refer one of these patients to a specialist it takes weeks to even months to get them the care that they need, and oftentimes they still have to travel out of our county, usually to Sheridan or Casper, for their care. I do not think we can guarantee that these specialists will continue to take new patients, and again it is not guaranteed the VA will allow these Veterans to see the specialists who serve our community. I do not understand how this is good for the patent or our current healthcare system. In my mind it is an unnecessary burden to already overworked nurses and other support staff as it is their responsibility to transport these patients.
My second concern with the nursing facility being placed in Buffalo is who is going to provide the medical care for these patients? Are they going to have an in house medical doctor? Not one person who has lobbied for this facility has asked the current medical providers in Buffalo how they feel about this. They assume we will see all of these patients either in our clinics or in the emergency room. What people do not realize is our emergency room is covered by a solo provider for 24 hours. That means if we are inundated with multiple patients in the ER, someone is going to have to wait. We do not have the leisure or convenience of multiple providers and support staff in the ER to help coordinate care and transfers. This directly affects patient care and experience.
In my time working in Buffalo I have contacted our local VA hospital regarding patient transfers, I have been told it is not their responsibility to cure a Veterans homelessness when I asked about placement for an uncontrolled diabetic who was living out of his car. I have called asking about transferring a patient with a fairly cut and dried respiratory issue and was told they are only a detox facility. I could go and on, however, at the end of the day, placing this facility in Buffalo only puts a greater wedge in the continuity of care for these patients. I question if individuals know what continuity of care means? Others have testified that bringing this skilled nursing facility to Buffalo would only increase continuity of care and I find this disconcerting. The continuity of care starts with a primary care provider. They act as the gatekeeper for the patient and help to coordinate specialist visits as well as therapeutic and diagnostic procedures. For example, if a patient requires dialysis, this is not something we offer in our community. This would mean visits to a dialysis center three to four times a week. Again, creating an increased cost for our healthcare system resulting in these Veterans having to go outside of our county for medical care. If this facility is truly going to be a skilled facility that means they will need higher level nursing staff who are comfortable with higher acuity patients as they may require intravenous infusions daily, more complex wound care as well as additional support staff to provide rehabilitation services. These are services that are not currently offered to our Veterans. I also do not believe some members of our community understand the ramifications of placing Veterans with psychiatric and behavioral issues in our community. There are no psychiatrists in our community or on our current medical staff. Our hospital is not equipped with a locked unit should they end up in our emergency room or hospital. I only see this causing significant burden to the healthcare system, requesting additional nursing staff as often these patients require one on one supervision. There also typically ends up being an additional cost to the county when these patients have to be “titled” in order to get accepted into psychiatric facilities
I ask that you consider a physician’ s perspective on this matter. I choose to be a physician not only because I want to help people but I want to do what is right for our current healthcare system. Placing a skilled nursing facility in a community with already limited resources does not accomplish that goal.signed,
Alyse Williams, MD, Mark Schueler, MD, Brian Darnell, DO, Jennifer Rice, MD, Blaine Ruby, MD, Ryan Ludwig, MD, Hermilo Gonzalez, MD, Lisa Mullen, MD
The following is the letter that JCHC submitted to the county residents in November.
Johnson County Residents,
We want to share with all of you why Johnson County Healthcare Center is opposed to the VA Skilled Nursing Facility being in Buffalo.
We at Johnson County Healthcare Center fully support a new Veteran’s Skilled Nursing Facility in Wyoming, but don’t feel Buffalo is the best place for it.
Brenda Gorm, Amie Holt Care Center Director of Nursing, has shared with our legislature that Amie Holt “is a good place to work and we provide quality care for our residents, but we have struggled with consistently having adequate CNA staffing for as long as I can remember (over 28 years).”
Amie Holt offers CNA classes. Not only is the course free to students, but the facility pays an hourly rate for them to take the class and we pay all testing expenses.
Amie Holt would like to have more classes, but it takes months to find a few interested, qualified individuals who would like to become CNAs.
Amie Holt only has a 38% retention rate from our 2017 and 2018 classes. We have conducted exit interviews when these staff left and determined it is not a negative work environment that is causing them to leave. What we have found is that they left for the following reasons:
- Some left for less physically challenging work, such as assisted living or home care.
- Some left to pursue different positions outside of nursing home CNA.
- Some were terminated. Not everyone is cut out to be a CNA.
- Some go on to nursing school, as we pay the full tuition.
- Approximately 1/3 have moved from the area for personal reasons.
Amie Holt has managed by having our current CNAs working overtime and/or having less staff on duty than we would like.
Amie Holt has not seen anyone relocate for a CNA position. It is rare for someone to travel from out of town when they have ample opportunities close to home.
Amie Holt has had to freeze admissions at times including twice in the last year, because we didn’t have enough staff to care for residents of our community. Potential residents who need nursing home care in our community have had to go out of Johnson County for Nursing Home Care or stay in our hospital for months, waiting for admissions to re-open.
The Department of Health published a Wyoming Veterans’ State Home Needs Analysis. On page 19 of the report, Buffalo received high points for having a low median CNA wage of $12.16/hour.
During the Transportation, Highways & Military Affairs Committee meeting on October 23, 2018, the Administrator of Green House in Sheridan testified that they pay CNAs $15/hour, plus differential pay.
After we testified at the meeting a Senator was visiting with us and suggested that we should raise our CNA wages to $15/hour if we wanted to be competitive and keep staff, but offered no solutions of how to do so.
The new veteran’s facility will receive $417/day per Medicaid resident.
Amie Holt’s current Medicaid rate is $194/day. Our cost is $277/day. Medicaid is the main payment source for 60% of our residents. This $83/day difference for these residents totals an annual loss of $590,418 dollars that is subsidized by the facility.
If Medicaid rates don’t increase or Johnson County residents don’t want to pay more in taxes, the facility would have to absorb the cost of increasing CNA wages as well. Although our CNAs work very hard and we wish we could give them an increase of $3/hour as the Senator suggested, this would cost another $177,000 per year.
We are not sure we could sustain those costs indefinitely. Worst case scenario could be closing our nursing home. Alternatively we may need to look at reducing the number of residents that we serve at Amie Holt. Today we are at 100% occupancy. Any reduction would displace a Johnson County Resident to another community as there are no other options for Long Term Care in our community.
The new Veteran’s facility is projected to need 30-35 CNAs.
We understand that workforce issues are a concern throughout the state in every industry, which is all the more reason not to further challenge a community that is already struggling with its only Long Term Care Facility.
Consider the existing CNA workforce, and the likely impact of needing 30-35 more CNAs:
- Buffalo has 104 CNAs
- Casper has 861 CNAs
- Sheridan has 527 CNAs
The report published by the department of health describes the workforce impact like throwing a rock into a pond (thus disrupting a system). The larger the pond the smaller the ripples. Buffalo has the second lowest CNA labor pool out of the 12 locations initially considered. Buffalo’s pond is very small and thus the ripples felt by placing the facility in our community would be much larger.
The solution we’ve heard for Buffalo is to have Sheridan College amp up CNA programs, offering more in Buffalo. This still doesn’t provide interested, qualified individuals – the resource we are lacking.
Buffalo is a beautiful location, the cost to build the new facility would be lower here, and the current Veterans’ Home residents would have continuity of care as they moved into long-term care – we do not dispute any of these facts. But Buffalo doesn’t have a large enough workforce to support the new facility. If it is built in Buffalo, it will likely be at the expense of the residents of Amie Holt and those in the community that don’t qualify for the new Veteran’s Facility.
Residents have come to Amie Holt from the current Veteran’s Home for long-term care and have done well. In this way, they have been able to stay in their community.
Only 5 of our residents would qualify to live in the new Veteran’s facility. Since Amie Holt is the only long-term care facility in town, the rest would need to leave the community if our nursing home closed or reduced its capacity.
Johnson County Healthcare Center has always, and will always, care for our veterans – in the nursing home as well as in the hospital.
There are better alternatives in the state for the location of a Veteran’s Skilled Nursing Facility.
To learn more about the proposed facility or view the Level 1 & 2 Study completed go to: Veteran’s Home Study
Mark Schueler, Board Chair
Nicole Hobbs, CEO