Belknap County nursing home staff told county officials the facility is operating at roughly 59% occupancy and faces persistent staffing shortages and reimbursement constraints that complicate efforts to increase census and balance the budget.

The nursing homeadministrator, Shelley, told commissioners the facility needs roughly 12 registered nurses, 13 LPNs/med techs and 30 licensed nursing assistants (LNAs) to staff at full capacity and that current agency staffing and contracts partly cover open shifts. "We could fill this building with residents, but how are we gonna staff it?" Shelley said during the meeting.

The county discussion focused on three linked problems: lower occupancy, the cost of agency staffing, and Medicaid reimbursement levels. Shelley said Belknap Countyexpects its Medicaid daily rate to rise to $283 on Jan. 1 and described long delays in Medicaid payments for some residents. She also presented a spreadsheet comparing county and peer facilitiesshowing lower census and high agency use across the region.

Why it matters: county-run nursing homes rely on a mix of private-pay and Medicaid residents; when Medicaid reimbursement and staffing costs diverge, the facility can operate at a loss or require large agency spending to maintain services. Commissioners said they want a multi-year plan to improve recruitment and contain agency costs.

Shelley and nursing-home staff outlined existing recruitment and training efforts: tuition support and work-study arrangements for employees who enroll in LNA, med-tech, LPN and RN programs; local high-school clinical rotations; referral incentives; job postings on the county and nursing-home Facebook pages; and radio advertising. Shelley described partnership challenges with training providers and colleges, including canceled LNA classes when instructors or minimum enrollment were not available: "We have a program up at the college that's gonna be 6 weeks and it's January 27 and we have no instructor," she said.

Staffing and agency costs: the nursing home previously held more agency contracts (about 28 during the COVID period) and now uses about 13 companies under contract, Shelley said. She estimated that fully staffing the facility with agency personnel would cost multiples of current budgets and argued that relying on agency labor at current market rates would not be a sustainable business model.

Services and operations: commissioners and staff also discussed operational pressures that affect costs, including ambulance transports for skilled residents who require stretcher transport for specialty or imaging appointments (Shelley cited costs of roughly $800 to $1,000 per ambulance trip) and the effects of local hospital service changes on where residents must travel for care. The nursing home has privatized kitchen services under an annual contract with a vendor (referred to in the meeting as Glendale); commissioners expressed concern about contractor recruiting and continuity.

Training pipeline and credentialing: presenters said workforce pipeline problems are partly structural: community colleges and training programs lack instructors or minimum enrollments, and state credentialing requirements (the meeting referenced the New Hampshire Board of Nursing) can delay med-tech or LNA licensure. Shelley described internal incentives and return-of-service requirements: employees the county sponsors for nursing education typically must remain employed for a set period after graduation (Shelley summarized those commitments as one year for med-techs and LNAs, two years for LPNs and three years for RNs).

Commissioners asked staff for clarifications and additional data and discussed next steps. One commissioner framed the countyrole as supportive: "I think what the overall goal, Shelley, is try to find ways to assist the facility in reaching their peak," the commissioner said. Staff agreed to gather more detailed revenue history, turnover rates and agency-cost projections and to pursue a five-year staffing and recruitment plan for presentation to the board.

No formal vote or ordinance was recorded during the discussion. The meeting concluded with commissioners requesting follow-up materials and a tour of the facility.