Two things you should know about me before proceeding:
1) Like my friend and colleague Kathryn Knowlton, I have never before done a blog (well, she now has, but she confessed in her Dec. 19, 2018, blog – which you should go back and read if you missed it the first time around – that it was her first jaunt into the blogging world).
2) Though most of my practice is centered around clients in rural western Kenosha and Racine counties, I am hardly qualified to comment personally from a “rural” or perspective. I can’t nurture a growing vegetable for my life, and I have an unfounded fear of large animals that don’t say “woof” (cows and horses are really really big and could squash me).
In need of a topic, I turned to what I do know about my rural clients: when injury, illness, or infirmity leads to a need for long-term care, they are moving away. Away from their homes, away from their spouses and families, away from their friends and lives. Every skilled nursing facility (SNF) in Kenosha County is located in the City of Kenosha or its surrounding Village of Pleasant Prairie, which are far removed geographically, socially, and politically from the farms and pastures sprawling a few dozen miles west.
My clients’ spouses have limited choices when their partner is displaced: live apart from their spouse and dedicate substantial portions of their days to traveling to provide care and companionship, or sell the house/farm and move to town to be closer to their life’s love.
The options present a no-win dilemma for my rural clients in southeast Wisconsin, a local dilemma I wanted to write about on a local level. Until I stepped back from the map to put things in perspective.
Racine and Kenosha County, while respectively the fifth and eighth largest counties in the State by population, are geographically among the smallest. Several northern counties are in themselves two to three times the size of Racine and Kenosha counties combined. If relocation and separation are issues in our small corner, what does the situation look like for the ill, infirm, and injured in the vast north?
I started by familiarizing myself with the overall density of facilities throughout the state. Working with a map of Wisconsin and the Wisconsin Department of Health Services (DHS) Directory of Licensed Wisconsin Nursing Homes, I wasn’t shocked to observe that several geographically-large, yet rural counties are served by one or two SNFs, generally with a small number of beds.
Bryce A. Lehman, DePaul 2011, is an attorney with Edenhofer Law Offices, S.C., in Paddock Lake, where he focuses his practice in estate planning, probate and trust administration, elder law, and residential real estate.
Giving consideration to demand and the tenuous economics of maintaining a SNF, this was anticipated. To that end, I had confirmed what I had expected: a resident of Bayfield, Burnett, Sawyer, Washburn, Price, Forest, or Florence counties is going to be limited in their options for care, and will likely have to relocate dozens of miles within their home county. If there is an open bed in their county.
What was slightly startling, however, is that there are two counties – Vilas and Menominee – which are completely devoid of any nursing homes whatsoever. If a resident of those counties requires skilled care beyond that which can be provided in their home (which may be an overly optimistic prospect in itself, as internet searches for in-home care providers in these areas provided few results outside of distant urban areas), that person, and possibly a spouse, not only has to uproot from their home, but likely must vacate their county of residence altogether.
Given Wisconsin’s rich rural history of family and multigenerational land ownership, this probably means leaving the county in which they’ve resided their entire life.
But that was only part of the story. To get a picture of how many people are affected, other factors had to be considered. How many people actually reside in the respective unserved and scant-served counties? What percentage of those persons are elderly, blind, disabled? (For purposes of this effort, I focused solely on percentage of “elderly” persons, as defined for Medicaid purposes as anyone 65 years or older) Do adjacent counties have capacity for overflow?
The U.S. Census Bureau gives population estimates as of July 1, 2018, for all U.S. states, counties, cities, and towns with a population of 5,000 or more, including percentage estimates of persons 65 years of age and over. All population data herein is derived from the census bureau’s tables.
For a baseline, an estimated 16.5% of Wisconsin’s estimated 5,813,568 residents are age 65 or over – approximately 960,000 people. With 30,782 beds in 382 facilities per the DHS Directory, that is a statewide average of 31 persons for every available skilled care bed.
With citizens living an average of 18-20 years past age 65 (per the Social Security Administration’s Period Life Tables), and an estimated 35% of those persons requiring SNF care at some point in their lives (per the U.S. Department of Health and Human Services Administration for Community Living and LongTermCare.acl.gov), it isn’t hard to see why lack of available beds is often an issue even in average- and above-average served regions.
So how do our subject counties compare to the state averages? Are their neighbors situated to make room for their residents?
Vilas County has zero facilities – and happens to have the highest percentage of residents age 65 and over: 30.4%, nearly double the statewide average. With a population of approximately 21,938, that’s an estimated 6,669 people facing a 35% chance of having no choice but to leave their home county to receive adequate care. Vilas County is geographically large; many of those people are likely to be relocating far from home.
Vilas County is substantially contiguous with Iron County and Oneida County, and also abuts Price and Forest counties. Iron County, to the west, has the second-highest percentage of residents age 65-plus, at 30%. With a population of 5,676, this amounts to 1,703 persons. Iron County has two SNFs with 103 total beds. At 17 persons per bed, it is well below the state average of 31 persons for every available skilled care bed.
Isolating Iron and Vilas counties as a group – basically the entire north central part of the state – the two counties account for 8,372 65-plus residents and 103 beds, 81 persons per bed. Those beds are all located in the far-north outpost of Hurley, a good distance from most of Vilas County.
Price County has two facilities, in Park Falls and Phillips – both geographically isolated from Vilas County. Forest County has one facility in Laona, located in the southern, opposite side of the state from Vilas County. Both counties (Price: 25.1%; Forest: 22.7%) are well above the statewide average of 16.5% aged 65 and over.
That leaves Oneida County. Oneida County ranks high in percentage of residents 65 and over, at 25.5%, accounting for 9,045 of its 35,470 residents. With 267 beds – 34 persons/bed – the county is slightly above the state average of 31 persons/bed. However, 195 of those beds are far to the south of Vilas County, in Rhinelander. Only 72 beds are in nearby Minocqua.
Breakdown: There are no licensed SNF beds/facilities in Vilas County, which has the highest percentage of residents aged 65 and over. The closest available beds are in Minocqua, but they are few, and are only “close” for residents in the southwestern part of the County. An injured, ill, or infirm Vilas County resident may be faced with a substantial relocation.
On the other end of the spectrum, Menominee County – also with zero facilities – has the state’s lowest percentage of residents age 65 and over: 12.7%. In a county of approximately 4,658, that’s 592 people who may have to relocate. Menominee County is relatively small geographically. Nonetheless, the necessity to find care in a neighboring county is certainly a burden.
Menominee County is bordered by Langlade, Oconto, and Shawano counties. By last count, 4,509 of Langlade County’s 19,268 residents (23.4%) are aged 65-plus. There is one facility with 136 beds (33 persons/bed) located in Antigo near Menominee County’s western border. Oconto County’s four facilities and 244 beds are spread throughout the county. Only Gillet’s 25 beds and Suring’s 50 beds are located near Menominee’s border, with 99 beds in Oconto Falls located a little farther east. No major roadways connect Menominee County to Gillet or Suring. Of Shawano County’s five facilities, four are located in Shawano, consisting of 271 beds a little south of central Menominee County. The 50 beds in Wittenberg are a bit farther away.
Overall, in these four counties, there are 701 beds and approximately 21,153 people 65 and over – resulting in an average of 30 persons per bed. Of these, 100 beds are located in Oconto (50) and Wittenberg (50), on opposite sides of their respective counties from Menominee County.
Breakdown: The situation in Menominee County is mildly better than in Vilas County. There are fewer residents, in a smaller geographic area, with proximity to an average number of beds in neighboring counties. Assuming availability of an open bed, an injured, ill, or infirm Menominee County resident may not have to relocate as far as a Vilas County resident, but will still have to leave their home county.
This blog focused on the raw numbers of two Wisconsin counties lacking licensed SNFs to provide in-county care for those counties’ residents. This problem is not on a path toward improvement. In fact, it is getting worse.
The New York Times – citing Cowles Research Group, which keeps annual statistics on long-term care and nursing homes – recently reported that over 440 rural nursing homes have closed or merged nationwide in the past decade.1
Wisconsin Public Radio recently detailed the state’s shortfalls in funding and available workers, which resulted in the closures of 27 SNFs in Wisconsin since 2016, and eight additional facilities announced their closures this year.2
As funding issues – particularly in terms of support of, or resistance to, Medicaid Expansion – are currently a hot political topic in our state, it is not my intention to expound upon those issues here. I mean only to drive home the point that there is a nursing home shortage in rural Wisconsin, the shortage is growing, and lack of financial resources is contributing to that growth.
My rural clients in southeastern Wisconsin are faced with grim options when presented with the necessity for long-term care near their homes. The prospects for local long-term care services in other parts of the state appear even less palatable.
At what point will an aging population, increased rates of disability, inadequate funding, and worker shortages hit the crisis point? Or has it already?
A Few Notes of Interest
Ashland County, to the west of Iron County, has the state’s lowest ratio of persons to beds at 8:1 – about 1/4 of the statewide average. Those facilities may catch overflow from Iron County, making more room for Vilas County residents. It’s also possible Ashland County also bears a heavy burden from neighboring Bayfield County which, while geographically one of the largest Wisconsin counties, has the fifth-highest percentage of residents aged 65-plus (26.8%), and with 65 beds for 4,031 65-plus residents, a 62:1 person-to-bed ratio – double the state average.
The highest person-to-bed ratio belongs to Waushara County, with 5,799 65-plus persons vying for 50 beds, a whopping 116:1 ratio. Nearby Waupaca owns a 9:1 ratio (second lowest after Ashland), but other adjacent counties – Portage (82:1), Adams (78:1), Marquette (74:1), Green Lake (48:1), and Winnebago (36:1) – have little available support.
Burnett County in northwestern Wisconsin has the second-highest person-to-bed ratio, at 86:1. Adjacent counties are Douglas (21:1), Polk (22:1), Barron (25:1), and Washburn (33:1).
After Ashland and Waupaca, Grant (13:1), Trempealeau (13:1), and Florence (15:1) counties round out the five lowest person-to-bed ratios.
After Menominee (12.3%), Dane and Milwaukee – Wisconsin’s most populous counties – are tied for lowest percentage of residents 65 and over, at 13.2 percent. Milwaukee’s 125,163 elderly residents vie for 3,698 beds (34:1), while Dane has 1,525 beds and 71,592 residents age 65-plus (47:1).
1 Jack Healy, “Nursing Homes Are Closing Across Rural America, Scattering Residents.” The New York Times, Mar. 4, 2019.
2 “Funding Shortfalls, Worker Shortage Stress Wisconsin Nursing Homes.” Wisconsin Public Radio, Feb. 12 2019.