Strafford County officials say bed caps and Medicaid funding shortfalls limit nursing-home capacity at Riverside

Strafford County commissioners and state representatives spent a special-committee meeting outlining why Riverside Nursing Home is operating well below its licensed capacity and how state and federal funding rules have constrained local long-term-care options.

County officials said Riverside’s current daily census is about 170 residents even though the facility’s licensed capacity is roughly 215 beds. The county’s representative on the call described staffing shortages, reimbursement limits and a statewide cap on nursing-home beds as the primary causes of the lower census. “We’re the last resort,” the county commissioner said, describing Riverside’s role in taking residents private facilities cannot manage.

The discussion centered on three policy constraints county leaders said have reduced capacity: a moratorium that froze the number of nursing-home beds statewide, weak funding for the state’s Choices for Independence (CFI) home- and community-based services program, and Medicaid reimbursement rules county officials say leave facilities underfunded. County officials said the original intent when the bed cap was negotiated was to shift care dollars into community-based services, but the CFI expansion was not funded at the level planners expected.

County officials and representatives described how the Medicaid funding flows complicate local budgeting. According to the meeting record, federal funds cover roughly half of Medicaid costs while the remaining share is borne by the state and ultimately by counties; counties now pay collectively for about $135 million in CFI-related expenses, the commissioner said. The county commissioner also described a “budget neutrality” factor that has reduced actual Medicaid payments to facilities by about 28–31% in some years.

Committee members discussed policy and operational options that are constrained by federal and state rules. Committee members asked whether unused licensed beds could be sold or transferred; the commissioner said beds cannot be simply transferred between facilities though an owner could sell a facility, and that low Medicaid reimbursement makes such purchases unattractive to private operators. The group also examined whether assisted-living licenses or conversions might absorb unmet demand; the commissioner said assisted living generally requires a different license and, under current CMS rules, assisted living and nursing-home beds cannot occupy the same building unless grandfathered or waived.

Members noted there are at least two vacant assisted-living facilities in the county (one identified in Farmington) that nonetheless have no admissions; county staff said some private assisted-living operators refuse CFI payment because it reimburses at a lower level than private pay or Medicaid nursing-home rates, and CMS rules forbid counties from subsidizing Medicaid/CIF payments directly.

Committee members raised the operational impacts on hospitals. County officials said patients who cannot leave the hospital because there are no appropriate nursing-home or alternative placements create backlogs at hospitals such as Wentworth-Douglass, and that hospitals sometimes house patients for months while awaiting placement. The commissioner described coordination with hospitals and said Riverside intermittently receives transfers when private facilities cannot manage high-acuity patients.

The committee discussed financial and capital constraints on Riverside itself. Officials said Riverside has little or no depreciable capital value compared with newer private facilities and therefore receives little capital-related Medicaid reimbursement, which reduces its per-resident revenue relative to newer facilities that can claim a capital component in their rate.

Members agreed to continue fact-finding and to schedule facility site visits, naming Sullivan and Merrimack counties as examples to review recent renovations and additions before the committee considers capital or programmatic proposals. The county commissioner promised to provide additional documents requested by representatives prior to the next meeting.

Ending: The committee did not take any formal votes at this meeting. Members scheduled field visits and asked staff to supply follow-up documents and counts on vacant assisted-living units, current Riverside census and detailed budget impacts of the recent state reimbursement changes.