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Nursing Care Expected To Worsen As California Ages

Laura Wenus
Berenice Palmer in her room at the San Francisco Campus for Jewish Living.

Advocates warn that people who need nursing care may increasingly be sent far away from San Francisco in a developing shortage of affordable nursing home bedslinked in part to the cost of doing business and the cost of living in the Bay Area

Berenice Palmer shows me her room at the San Francisco Campus for Jewish Living, formerly known as the Jewish Home. She’s lived there for two years. She’s now 102. 

To someone who hasn’t been in a nursing home before, it feels almost like a dorm room. Tight, but comfortable. There’s her keyboard, for practicing piano. A TV stacked on top of a desk. Pictures taped to the big closet door. But the bed is a hospital bed. There’s a nurse’s station down the hall and a call bell in the room. 

Berenice Palmer’s daughter Terry Palmer tells me Campus is one of the best nursing homes in the city. There are activities nearly every day. We talk in the café that’s downstairs, where her mom has a tab she can charge coffee and pastries to. She’s still able to walk around on her own.

Berenice Palmer is lucky to have this room. 

“The reason the bed was available was because there was a roommate that liked to watch TV all night,” Terry Palmer tells me. “But my mother is very deaf and we both agreed that that wouldn't be a problem. And it did turn out actually to be somewhat of a problem. But my mother was able to tolerate it and we put her on the waiting list for a private room and after a year at the Jewish Home, she got a private room. And she's happy as a clam right now.”

The nursing home beds in California are mostly full, most of the time, and that’s been the case for a long time. In San Francisco,reports have warned of a shortage for years. Terry Palmer has been calling for the city to track how many patients are being discharged from hospitals to nursing facilities outside of the county. Another obstacle is the cost. 18.5% of California seniors live in poverty. But even for someone who has assets, nursing care is expensive. Around a hundred thousand dollars a year in the Bay Area — more than the median individual person in San Francisco makes in a year.

“A lot of the small residential [...] care facilities that would be run by a family [...], the property is worth so much. Now, when they retire, they sell the house and they go out of business,” Palmer says. “And so in San Francisco for instance, which is an expensive world-class city, we've got a shortage of Medi-Cal nursing home beds and we've got a shortage of small residential care facilities.”

Nursing homes get paid less, generally speaking, for patients who stay long-term than for people who just need short-term rehabilitation. So advocates say it’s especially hard to find long-term care, which is for people who won’t likely be able to manage things like eating and hygiene on their own, or who need an intensive degree of medical care, indefinitely. 

Providers say it’s due to a lack of capacity and that at any given time, the majority of beds in nursing homes are occupied by long-term patients.

“Currently we are probably one of the highest utilized beds across the United States. And so most of our facilities run in the 80% occupied area,” says DeAnn Walters, Director of Clinical Affairs for the California Association of Health Facilities. The association represents nursing facilities across the state. 

Walters says that because, by definition, long term patients don’t move out as quickly, that limits space available for additional long-term patients. Plus, younger people are now needing nursing homes more often.

“With the increase in the senior population and the fact that more people have access to skilled nursing care even before they become seniors then we were definitely going to see an impact on availability for anyone,” she says. “We see it in some areas right now where it's very difficult to get a bed. And so that will only increase as the population increases.”

Rather than growing to accommodate an aging population, Walters says nursing home capacity is actually shrinking. 

“It is quite a challenge for operators to build new skilled nursing facilities because of the regulation the time that it takes to get certified and just the cost that goes into it,” she says. “So we don't see a lot of new buildings being built. In fact, it's really slow and we see more where buildings are being taken offline because they are older and a lot of cases and so they don't meet current standards and so then some facilities are actually closing.”

In the Bay Area especially, advocates see a crisis brewing. Dr. Liz Halifax, who has always specialized in nursing care, sees a crisis brewing. She volunteers with the local long-term care ombudsman program. 

Dr. Halifax works as a gerontological nurse researcher at UCSF. She warns that in impacted areas like around San Francisco, the only option for someone needing nursing care may be at a distance. 

“I'm 58 now. So in ten years’ time when this crisis is really at its worst and I need a nursing home bed, the likelihood of me getting a bed within five miles of my home is going to decrease quite dramatically,” she tells me. “And it's possible that I'd be sent out of county or even out of the Bay Area as the issue is pretty much the same in the Bay Area. To go to a nursing home, which would obviously cause a lot of isolation, from my family and my social circle.”

The United States Department of Health and Human Services estimates that about a third of seniors nationwide get care at a nursing facility at some point and that the average stay is about a year. As the shortage builds, according to Dr. Halifax:

“People will get sent far away from their homes their families and their other social networks when they are sent to a nursing home.”

A lack of capacity in places like the Bay Area can make the task of finding good long-term care for a fragile senior extremely daunting. 

This story is the first in a series on accessing nursing home care in California. It was produced as part of the USC Center for Health Journalism’s California Fellowship.