Vermont's long-term care homes are desperate to move past a ruinous year. Step one: Fill empty beds.

Some homes that previously had waiting lists are taking the unusual step of advertising openings, a reflection of the stress that COVID-19 has placed on the eldercare sector. Now that most caregivers and residents are vaccinated, the vacancy light is lit.

The nonprofit senior housing provider Cathedral Square, accustomed to wait lists for the assisted living apartments in its downtown Burlington high-rise, has brought on an extra employee to help boost move-ins. At one point during the pandemic, 12 of the 40 apartments were empty, operations director Kathrynn Titus said.

"This is by far the largest number of vacant apartments we've had in the last 10 years," she said.

The huge long-term care industry, already struggling with staffing and quality problems, was turned upside down by the pandemic. Residential facilities were the site of an estimated one-third of the nation's COVID-19 deaths in 2020, according to the Atlantic's COVID Tracking Project. Long-term care residents make up about 1 percent of the nation's population, according to the project.

While Vermont's numbers were relatively low, long-term care residents accounted for 61 percent of COVID-19 deaths as of March 8. Nursing homes were hit hardest, in terms of cases, outbreaks and deaths, Vermont Department of Health data show.

At times, the pandemic halted new admissions to long-term care facilities and prompted homes to reduce their capacity because of staffing or social distancing constraints. When admissions were possible, some would-be residents stayed away, fearing infection or the highly restrictive environment. Some of those on Cathedral Square's wait list, for instance, had second thoughts when their names were called.

"A lot of people who we spoke to really didn't want to give up access to their visitors," Titus said.

The drop in occupancy rates across the industry has been stark. About 28 percent of Vermont's nursing home beds were empty in January, according to state data, compared to 16 percent in January 2019.

National industry groups have suggested that record-low occupancy, coupled with higher COVID-19-related costs, could cause more than 1,000 nursing homes to close this year.

Vermont has not experienced a wave of closures, though a few small care homes have shut down. The future, however, may depend on how well homes are able to lure back residents and workers.

Family First

The pandemic prompted family members to step in as caregivers, sometimes because residential care wasn't available. Others felt it would be safer to stay at home. 

As a board member for Age Well, a nonprofit that helps people understand their aging options, St. Albans resident Liz Gamache had an advantage when it came to navigating the landscape.

But Gamache, the former mayor of St. Albans, found it difficult to help her parents after Gov. Phil Scott declared a state of emergency in mid-March of last year. The pair, then both 83, had planned for more than a year to move from their Burlington home to an assisted living facility in April; some of their furniture had already been shipped to their new apartment. The home halted their move as a result of the pandemic, and with no options available, Gamache said goodbye to her husband and two children and moved in with her parents for two months to help them.

Gamache, then the interim director of the Preservation Trust of Vermont, occasionally visited her family outdoors, due to concern about infection. 

"We didn't know what the future would hold or how long this would go on," said Gamache. "It became a 24-7 thing for me."

The pandemic pressed millions of people into caretaking roles for family members. Gamache was glad to have that time with her parents and feels fortunate that she could continue working remotely while she was quarantined at their home. She knows not everyone had those options. Gamache stayed with her parents until a spot opened up for them in assisted living.

Move-in delays such as this led to a serious financial hit for the industry, as did the need to quarantine patients upon their arrival, according to Vermont Health Care Association lobbyist Laura Pelosi.

Nursing homes in particular faced another problem. Many offer short-term rehabilitation stays for patients to recover from surgery or illness. Some rehab patients sought to avoid nursing homes and instead turned to in-home nursing services.

Dane Rank, who runs Thompson House in Brattleboro, fears that a wariness of nursing home settings lingers. Outbreaks have drawn renewed scrutiny of the industry and raised questions about why homes were so susceptible. Investigative reporting by the New York Times exposed flaws in the federal five-star system for measuring quality, and Congress has held hearings on the harmful effects of private-equity ownership.

Rank's 43-bed, nonprofit nursing home has not logged any COVID-19 infections, and it had one of the highest occupancy rates, 89 percent, in the state in January. Still, he said, Thompson House has experienced a significant decrease in patients admitted from hospitals: They're continuing to opt for in-home services, even when their care needs are intensive.

At this point in the pandemic, Rank suggested, the growing "stigma" around nursing homes "is causing far greater risk to our older population than did the virus."

As a former Agency of Human Services director for Grand Isle and Franklin counties, Pam McCarthy might have been better prepared than many people to help her family members. She's also president and CEO of the Vermont Family Network, which helps families of children with disabilities and special health care needs.

McCarthy said she often hears that Vermont is ahead of other states in its system of care for people with disabilities and the elderly. But she said the system is fragmented and difficult to navigate, even for those skilled in weighing care options.

McCarthy studied dozens of options as she considered moving her mother to Vermont last year from a nursing facility in Delaware. She even considered consulting a professional, who quoted her a rate of $100 per hour for the work, to help her decide.  

"It might have been a worthwhile investment," McCarthy said. "I could go the extra mile and pay for that navigation, but not everybody can. The people who need it the most don't have the ability to pay or the time in their own lives to do all of the phone calls and hunting and paperwork it takes to make a good and well-informed decision about a placement or living situation."

She ultimately decided her mother would be happiest where she already was.

Help Wanted

The long-term care industry's recovery will require more than deft marketing. The pandemic dealt a blow to a workforce that was already considered in crisis. Nurses and qualified caregivers were hard to find and retain pre-pandemic. COVID-19 made recruitment even harder — and, in a few cases, seemingly impossible.

Bradford Oasis, an 11-bed residential care home in Orange County, permanently closed in January due to a staffing shortage and its close cousin: burnout. The home, which relied largely on Medicaid reimbursements, was on the edge before COVID-19 arrived, having cut caregiver pay to balance the books, even though its beds were mostly full.

A couple of staffers quit early in the pandemic, former manager Teresa Hemingway said, and she couldn't find replacements. As the year wore on, Hemingway said, she and others worked extremely long hours. Eventually she decided the situation wasn't tenable.

"We were just exhausted," she said.

Of the eight small residential care and therapeutic group homes that decided to close in the past year, Bradford Oasis is the only one to cite workforce pressure as the reason, according to Monica White, interim commissioner of the Department of Disabilities, Aging and Independent Living. But many homes are grappling with it.

"The pandemic has exacerbated this problem," she said, "with health care staff report[ing] significant burnout over a grueling year of long shifts and extraordinarily difficult work."

The industry is pushing the state to intervene through programs and funding to train more nurses, while homes that rely on Medicaid want to see a boost to the reimbursement rate, money they could use to raise wages. Growing the state's health care workforce will be a "key focus" as the pandemic subsides, White said.

Observers are optimistic that if more workers enter the industry, it can recover. Like most other businesses, long-term care facilities got a large infusion of cash last year to tide them over through the COVID-19 shutdown. Financial pressures should continue to ease in the months ahead, in parallel with visitation restrictions. Cathedral Square is aiming to fill its handful of market-rate assisted living apartments within the next three months.

One of the most dramatic shifts is already under way. Last fall, the largest nursing home operator in Vermont, Genesis HealthCare, moved to offload five of the state's biggest facilities, which collectively house about 18 percent of licensed nursing home beds.

The struggling national operator has proposed to sell them to a private buyer group that already began managing the homes last fall. The group is spearheaded publicly by David Gamzeh, Akiva Glatzer and Akiko Ike, who have purchased distressed homes throughout the Northeast.

The state Agency of Human Services is reviewing the proposed transfer.

The Genesis sale isn't unusual in an industry largely controlled by massive corporations and private investors.

Some advocates say the pandemic has presented an opportunity for changes — in how homes look, run and work together as a system of care.

Such considerations are especially relevant in Vermont, which has one of the most rapidly aging populations in the country. Long-standing programs, including a state Medicare program called Choices for Care, have already enabled more Vermonters to age in their homes. It's possible, but far from certain, that the pandemic will accelerate that trend.

Gamache's experience during the pandemic has prompted her to think more deeply about the process of aging. Her mother caught and survived COVID-19 last spring but passed away at the end of the year. The virus killed her mother-in-law; her father-in-law died of different causes months later.

"Isolation and loneliness is one of the takeaways from this experience," she said. "How detrimental it is for anybody, but especially seniors."

To Gamache, that's reinforced the importance of aging in a place with connections to friends and family. But she's not sure what that should look like.

"The future of aging provides so much uncertainty," she said. "It can be really hard to know how to plan."