As America’s population ages, access to long-term care is becoming an increasingly urgent issue, especially in rural communities. In this episode Lauren chats with Dr. Hari Sharma to discuss the growing challenge of nursing home closures in rural America and what those closures mean for patients, families, and communities. While nursing homes have always opened and closed over time, recent years have seen an overall decline in the total number of facilities nationwide, creating new concerns about access to both post-acute and long-term care services.

The views and opinions expressed in this podcast are solely those of the student hosts, guests, and contributors, and do not necessarily reflect the views or opinions of the University of Iowa or the College of Public Health.

Lauren Lavin:

Hello everybody and welcome back to Plugged In to Public Health. As America’s population continues to age, access to long-term care is becoming an increasingly important public health issue. Today, more than 58 million Americans are aged 65 or older and that number’s expected to continue growing over the coming decades. For many families, that means navigating questions about nursing homes, rehabilitation services, and long-term care for aging loved ones. But what happens when those services aren’t available nearby? In rural communities across the country, nursing homes have been closing at an increasing rate. Since the COVID-19 pandemic, the total number of nursing homes nationwide has declined and rural communities are often hit the hardest because they have fewer alternatives available.

When a nursing home closes, it doesn’t just mean fewer beds. It can mean longer travel times, fewer options for post-hospital rehabilitation, increased social isolation, and difficult decisions for families trying to keep loved ones close to home. To help us understand what’s happening, we’re joined by Dr. Hari Sharma. Dr. Sharma studies long-term care in nursing homes and healthcare access in rural communities. In this conversation, he explains what’s driving rural nursing home closures, how researchers measure access to care, and who is most affected by these changes, and what solutions might help communities adapt moving forward.

I’m Lauren Lavin, and if it’s your first time with us, welcome. We’re a student-run podcast that talks about major issues in public health and how they are relevant to anyone, both in and outside the field of public health. So let’s get Plugged In to Public Health. Plugged In to Public Health is produced and edited by the students of the University of Iowa College of Public Health, and the views and opinions expressed in this podcast are solely those of the student hosts, guests, and contributors. They do not necessarily reflect the views or opinions of the University of Iowa or the College of Public Health.

Thank you, Dr. Sharma, for being on the podcast today. I’m so happy to have you here and we’re going to talk about nursing homes and rural communities and yeah, we’ll start with that.

Hari Sharma:

Thank you for having me.

Lauren Lavin:

At a high level, I just want you to orient our audience. What’s been happening with nursing home closures in rural communities?

Hari Sharma:

We’ve always had nursing home closures, so that’s not a new thing. But recently what we’ve realized is it’s having impact in terms of access for both post-acute care and long-term care services for people. We’ve seen slightly higher percentage of nursing homes and rural areas close, but more recently since the pandemic, it’s seen absolute reductions in nursing homes. So in the past, what used to happen is nursing homes close in one area and then nursing homes would open up in another area. So there’s still a challenge with respect to access, but recently we’ve seen nursing home absolute numbers go from over 15,500 or so to below 14,800 or so. So there’s been absolute reductions and that’s been a challenge, especially in rural areas because they don’t have access to a lot of the other alternatives. And I expect this to continue. So the challenge for us is what do we do about it? How do you go about fixing it?

Lauren Lavin:

How do you get data on nursing home closures?

Hari Sharma:

So there’s a few different ways of doing it. So we have Medicare provider services file that lists all the providers that have been authorized to serve Medicare patient. So that’s the key data source that we use to identify nursing homes that have closed over the years and it documents going way back, so it allows us to go back as much as we want. But then we also sometimes realize there are some data issues, some stakes sometimes. So we verify those closes with two other data sets. One is care compare that list the quality and types of nursing homes available across the country. And then there’s also another dataset that’s built by Brown University LTCFocus that also documents nursing homes over time. So we verify that these places have closed using two other data sources.

Lauren Lavin:

Trust, but verify, right?

Hari Sharma:

Correct. And for the most part, they’re just fine. It’s just a few cases where the dates might be off or they’re closed but not quite close because after a certain time point they’re opening up again. So sometimes those things can happen too.

Lauren Lavin:

Is there a lag in the data or how many years does it take before it gets published?

Hari Sharma:

So the Medicare provider services file is pretty up-to-date, so it’s updated pretty frequently. We’re not too worried about the lag time per se. If you get 2023 data, then you can probably feel pretty confident about looking at closes in 2022. But if you allow around six to 12 months, I think that’s a decent amount of time.

Lauren Lavin:

Yeah. What motivated you to actually study this issue?

Hari Sharma:

I’ve been doing nursing home work for a long time.

Lauren Lavin:

Yeah, you can give us a little bit of backstory if you want.

Hari Sharma:

I’ve been working on nursing homes for over a decade now since my grad school days, but I’ve never thought about access challenges from a rural perspective. And I was always focused on these policies at the national level, thinking about quality of nursing homes more broadly. When I was evaluating dissertation papers, rural would be just one sentence in tables and that was it. But since I came to Iowa, I got to see the importance of rural and what it means to have a nursing home in rural areas. And I talked to Keith about, “Hey, we should do a project around nursing home.” And thinking about access to both post-acute care and long-term care services in rural areas. And we started looking into this and ever since we’ve been doing a lot of projects around access to nursing homes or other services that provide either post-acute care or long-term care services.

So that’s the backstory to why we got into this. Since we worked on this particular topic, we started identifying more and more issues with it. So we’re continuing to expand our work in this space, especially through the RUPRI Center.

Lauren Lavin:

I’m sure as soon as you proposed this to Dr. Mueller, he was like, “Yeah, let’s go.” And you’ve done a number of things with him since then too.

Hari Sharma:

Yeah. I’ve had I think a project for the last four years or so focused in some ways to nursing homes or access to post-acute care or long-term care services and we continue to work on it.

Lauren Lavin:

Why are nursing homes or long-term care services so essential in rural communities specifically? And then I guess the follow-up to that is like, then why are the closures urgent now?

Hari Sharma:

So as you get older, and a lot more people are getting older now, we’re living longer, which also means we’re staying healthy longer too, but as you start hitting your 80s and 90s, there will be a time when you’ll start to need help with respect to your daily activities of living, so we need that long-term care services at some point. And a lot of us, as you get older again, we fall, we have a surgery, we get hospitalized, we need some sort of therapy, and post-acute care becomes important at that point. Over time we’ve been trying to rebalance the way we pay for care or the way we provide services to people and for both of these things. We’ve gone more towards non-institutional care. So if we can provide care at home, let’s go for it. If we can provide care in a more community-based setting, let’s go for it. Those are cheaper.

But then the challenge in rural is we don’t have that many of those services available, even with the national policies that are meant to expand rural access to home and community-based services or assisted living from the state side, those are not going to work in rural the same way they work in urban areas. So in rural, nursing homes still are very critical in that sense because we don’t have the alternatives to provide the same level of services.

Lauren Lavin:

And rural populations tend to be older and if a nursing home closes in that area, they have to travel a much farther distance to then get to one either for their family or they’re separated from their spouse or they have to relocate to somewhere that’s not their hometown.

Hari Sharma:

Exactly. And that’s important, especially for older individuals. A lot of these individuals are suffering from ADRD, maybe have some cognitive issues at that point. It’s hard to recognize people. Anything that seems familiar to them becomes that much more important at that point. And imagine having someone from Iowa City go to a nursing home in Cedar Rapids, it feels completely new at that point. You may not know anybody that’s in there, but if it’s a nursing home here, you might feel a little bit more comfortable and for kids to visit their parents within four or five miles, six miles, 10 miles, might be much easier than having to travel 20, 25 miles away or even worse more than that.

Lauren Lavin:

Right. Yeah. You’re definitely not driving to see your parents every day if they’re that far away.

Hari Sharma:

Exactly.

Lauren Lavin:

You already talked about the data sets, but then how did you approach measuring changes in access to care in these communities?

Hari Sharma:

So it’s measuring access is challenging. So we looked at it from the perspective of potential access because figuring out realized access would need claims-level data and we didn’t have access to that data at that point. So we started thinking about, “So how can we really measure access if we don’t have the detailed data?” So we started thinking about, “Okay, let’s think about potential access. And if there is challenges with potential access there’s probably more challenges with respect to actual access.” So we started looking at, one, availability of providers that provide post-acute care and long-term care services in rural areas. So that would be thinking about nursing homes, thinking about home health agencies, thinking about hospitals with swing beds that can provide both post-acute care and long-term care services.

So one is, do these things exist for people in rural areas? And two, if they do exist within 100 miles, and that was our way of restricting the data set, more manageable data set, so if they do exist, how far are they from the ZIP code of individuals? So since we didn’t have individual-level data on this, we looked at the ZIP code level. So we can look at for people that are living in a ZIP code, let’s say 52246, how far do they have to travel to get to a nursing home that can provide post-acute care and long-term care services? If there’s no nursing home nearby, what else is available for them? If they need home health agency, how far do they need to travel to get to that?

It’s not that they go to a home health agency, but then the staff would go from their homes to wherever the patient or residents are. So that kind of gives us a proxy for whether they have access to, or potential access, to home health agency services. And same thing goes with hospitals with swing beds.

Lauren Lavin:

If our listeners aren’t familiar, what is a swing bed in a hospital?

Hari Sharma:

Swing beds are these beds that the hospitals can use for not just the care needs they have on a regular basis, but they can also use them for post-acute care or long-term care services. So there’s this flexibility in terms of how they can use those beds and it’s important in rural areas because in many cases they may not even have a nursing home at all nearby. So hospitals can provide acute care and then transition them to post-acute care with these swing beds. So it’s more of the beds themselves are not changing, but they can get reimbursed for that additional care that’s not acute care through these reimbursement mechanisms. So that’s how they get access to those.

Lauren Lavin:

Can’t you use Medicare to pay for swing beds? If you’re not familiar as listeners, Medicare does not pay for nursing home care typically for most adults.

Hari Sharma:

Correct.

Lauren Lavin:

So that’s another probably distinction is that older adults are probably using these swing beds or find them easier to access because you don’t have to meet the Medicaid income requirements. So with all of that, did you find that a majority of people had access to long-term care facilities within 100 miles?

Hari Sharma:

So within 100 miles, most of the people would have access to something.

Lauren Lavin:

But 100 miles is pretty far. That’s two hours driving.

Hari Sharma:

Exactly. And I think the bar for us shouldn’t be that. We wanted to put a restriction at some point and 100 miles was our limit based on some of the other studies that have used that same approach. We wanted to be exhaustive in the sense that, “Okay, let’s cover as much as we can,” but then we also wanted to have it a little more manageable in terms of the data analysis we need to do. So 100 miles was kind of that switch spot in, “Okay, let’s stick to it and see if we can get something within that range.” And rural individuals have access to something, it’s just that it’s not available nearby and that’s where the challenge is because older individuals want something close to their home. If they’re going for post-acute care services, they’re going back home after that, so staying 25 miles away is not what they want or need because they probably want their kids to visit them often as they are recovering from whatever illness they’ve had.

And if they’re transitioning to long term care, which is that they’re going to stay there on a longer term basis, typically over 100 days, then they still want their kids to visit them sometimes, even if that’s not every day, maybe once or twice a week, that would make them feel much more comfortable. But if it’s 25, 30 miles away and their kids have their own families to take care of and their jobs, it’s much harder. So that’s why I think it’s important for us to think about if there is access, if there is access within let’s say 25 miles or not.

And what we found is there’s a lot of ZIP codes that don’t have anything. And when I say anything, no nursing homes, no home health agencies, no hospitals with swing beds within that distance. So I think in our research we found around I think 6% or so didn’t have access to anything in places that had nursing home closures and if we looked at places or ZIP codes that didn’t have nursing homes at all, that percentage goes up to around 15%, 16%. So 15%, 16% of ZIP codes in rural don’t have anything within 25 miles. So that means-

Lauren Lavin:

And that’s anything, anything. Yeah.

Hari Sharma:

Exactly. If you think about people that are living in urban areas, that’s 0%. So they all have pretty much something within that range. So that means you can see that difference in access, or potential access, and I’m continuing to say potential access because a lot of the times, even if you see that there is a place available, they may not take you because of different reasons. They may not take you because you’re Medicaid or they may not take you because they don’t have enough staffing to take care of you. So there could be different reasons for them to not take additional people. So our measure was whether it’s possible for them to take you, which is a low bar.

Lauren Lavin:

Yeah. It’s just, is there a building that operates as a nursing home or hospital or whatever?

Hari Sharma:

Right. Exactly.

Lauren Lavin:

And there’s way more nuance to that, especially if you think about a nursing home serving a variety of counties, they’re probably going to be pretty full. And if they offer any type of specialized care like memory care, those tend to fill up way faster and you’re going to be waiting months.

Hari Sharma:

Yeah. When I look at nursing home occupancy rates, it’s much lower in rural areas than in urban areas, but then when I talk to people about whether they have had difficulty finding a nursing home, almost everyone says they’re waiting in line.

Lauren Lavin:

Yeah, that’s the rhetoric I hear.

Hari Sharma:

Then we see this mismatch of what we’re seeing in the data in terms of, “Hey, there are empty beds, why don’t we just fill them up?” But then the challenge is, one, these places may not want Medicaid individuals because the cost are more than revenue for at least some of them, or they actually may not have the staff to take care of individuals. So that’s why they’re binded in this position where they have empty beds but they can’t fill because they don’t have people to take care of the older residents.

Lauren Lavin:

Have you done any research that looks at the staffing components of nursing homes and what that looks like in rural areas?

Hari Sharma:

So staffing-wise rural areas are doing okay when you look at the average staffing for the most part I think our RNs or LPNs, I think LPN is a little bit on the lower end in rural areas, RNs were doing just fine. I think the expectations for some of those is lower too, so the staffing that you need for nurse time per resident is pretty low, but then the issue is if that one nurse decides to move away, then it’s going to be harder for rural areas to find that additional nurse.

Lauren Lavin:

Right. Recruiting is difficult.

Hari Sharma:

Exactly. And one of the challenges we’ve seen, and it’s not in this paper, but another paper that we did a little while ago, was looking at the impact of nursing home closures on rural health sector employment, and what we’ve found is there’s a persistent decline in health sector employment when nursing homes close in rural areas, whereas in urban, people can move to different areas so that the total employment doesn’t really change, but in rural there is this reduction in health sector employment that’s pretty significant.

Lauren Lavin:

Interesting. Did you find that particular regions or populations were being disproportionately affected by these closures?

Hari Sharma:

In rural areas we tend to have a larger white population. So if you look at the data, you’ll see white population being affected by it. But when we dig deeper, it’s the low-income population that’s affected by it. A lot of people with Medicaid are being affected by this. When people say, “Is it the minority suffering from this?” Not necessarily. There are a lot of things that affect access to care and in rural it’s the low-income Medicaid residents that are being affected by nursing home closures.

Lauren Lavin:

Interesting. The question that’s probably on everyone’s mind as I listen to this is what are the drivers behind these nursing home closures? You talking that they’re happening, it’s affecting rural areas, but why?

Hari Sharma:

There’s a couple of regions and if you talk to providers, they will probably have more, but from my perspective, one, we are looking at low-occupancy rates and that’s a problem. So if you’re having occupancies in your 50s, that just doesn’t add up when it comes to financial sustainability of these places. You need to drive up that occupancy rate to 80%, 85% to make it viable in terms of covering those fixed costs of operating a facility like a nursing home that has high-fixed costs. Two, the reimbursement rates are not high enough for some of these providers to make up for it. So if you have low occupancy, [inaudible 00:21:29] rates are lower, that means you’re not getting that enough revenue. And third, I think workforce challenges are real challenges in some places if they can’t have enough of staff to get that occupancy rate higher to say 80%, 85%, even if people come in if they can’t take them, that means they’re not getting that revenue.

And the problem may not necessarily be, “Oh, we don’t have people coming in.” It may be that there are people coming in but they can’t take them because they don’t have staff to take care of them and burnout and stress are always there for workforce. When we really think about addressing this issue, it has to be multifaceted, but you can’t just focus on, “Hey, we’re going to pay you more.” That’s not sufficient because you also need to think about the workforce. Why do they not want to be here or where do they not want to work in nursing homes? Where we have an ongoing project where we’re looking at how much people are getting paid in nursing homes relative to other places and you go to Panda Express, you get paid $16, $17, $18 per hour. You go to a nursing home and work all day and you’re getting $14, $15.

Lauren Lavin:

And the work might be a little bit harder.

Hari Sharma:

It’s harder, it’s challenging, and sometimes it’s stressful when you see older individuals struggle with their daily activities and you’re constantly exposed to that and you’re trying to help, but at the same time, if you’re not valued or being supported, then it really affects your morale and your interest in working in these settings too. So all of those things are going to work to make this a bigger challenge than it is.

Lauren Lavin:

Right. There’s not one single solution is basically what that comes down to.

Hari Sharma:

Correct. Correct.

Lauren Lavin:

Did you look at any associations with the characteristics of nursing homes that are closing? Are they more likely to take Medicaid or any other characteristics that make them more likely to close?

Hari Sharma:

So typically the places that are closing are small places that have occupancy issues, they tend to have higher proportion of Medicaid. Again, this is all feeding into the challenges to, we’re seeing a lot of hospital-based facilities being closed because they’re not seeing the financial benefits of keeping these nursing homes as part of their arrangement, whatever the arrangement they might have. So the bottom line is if you’re heavy on Medicaid, you’re going to struggle. And if you’re relatively small-size facility, that means you probably don’t have the resources of a big chain facility, let’s say, where they could put some dollars in if you’re running short on something, hoping that you can actually get more revenue by expanding more resident population in the days ahead. So if you don’t have access to those things, then you’re going to close as well. So I think it’s all getting to that same idea of revenue being important but not having access to enough of revenue to continue services.

Lauren Lavin:

Yeah. Yeah, that makes sense. So then from a policy perspective, what options do you think are there to address some of these concerns and mitigate the problems?

Hari Sharma:

It’s a tough question. We see that these nursing homes are going to continue to close and that’s something we’re not going to be able to control, but a lot of these are private places, they’re going to continue to close. We can’t control that. What we can do is think about, is there something we can do to change that into something that’s more sustainable? For example, if a place is about to close and it’s mainly financial region that they’re struggling, then can we repurpose that nursing home into something more meaningful where we could provide some additional services?

So far, a lot of the times what we’ve seen is if it’s a nursing home, it’s a nursing home. But can we run a daycare in the first floor and have assisted living in one wing of the building and then post-acute care, long-term care services on the other side? So making sure that we’re getting at that fixed cost of operating these facilities and we’re getting the revenue from different sources. So one is to repurpose the nursing homes that are going to close no matter what we do. So that’s one. And two, I think we really need to think about investing in the alternatives in rural. So if it’s home health agency, what do they need to be successful in a rural area?

And I’ve talked to some home health agency providers, operators. And for them, they’re a small place and they don’t have the revenue coming in from outside investors. So anytime they struggle, that means they’re out. They just can’t sustain for a long time period. They’re not able to invest in the benefits of the workforce because if the revenue is not high enough and they just have four or five workers that are working for them and one decides to take off, then suddenly they have the patients they’ve been caring for but they don’t have the people to take care of them. So there’s this real struggle with some of these operators. So we got to think about how can we best support these small agencies that are working in rural areas so that they can sustain their operations even in these challenges.

And third, we got to continue to invest in small-scale assisted living and adult daycare centers as well so that we’re taking care of individuals from when they start to need a little bit of help to when they need all the help from the workforce. So having that transition phase where we have people that need a little bit of help are being assisted in daycare centers or assisted living and then through this transition to their care needs, we also have the workforce that’s available to address them.

Lauren Lavin:

Yeah. Some creative solutions to pretty complex problems.

Hari Sharma:

It is. It is.

Lauren Lavin:

Looking ahead and as we wrap this up, what concerns you most if these trends continue?

Hari Sharma:

The biggest concern for me is people not having access to post-acute care, long term care services close to their home and having to transition these people to places that are 40, 50 miles away where they don’t recognize anybody in there. One of the biggest advantages of being in a rural place that people often talk about is familiarity with the people that they are living with. And if we take that away from people, that’s going to be very stressful and mental health is a big concern when you look at depression rates and rural nursing home residents is much higher than in urban. Social isolation, that’s a big issue, and we realize through COVID that is a concern that we should take seriously.

So we know that nursing homes are going to close, but we got to think about, “So what are we going to do to make sure that people have access to both post-acute care and long-term care services nearby?” And for that we seriously need to think about thinking of nursing homes as these places where we can do multiple things, not just providing post-acute care and long-term care services, and also encouraging small home health agencies or adult daycare centers or assisted living in rural areas. We don’t need big ones, we just need small ones that are able to take care of people from their communities. And for that whatever flexibilities we need, we should be able to work towards that and that’s what we need I think in rural areas to fix this problem, or not fix, maybe help alleviate the problem a little bit.

Lauren Lavin:

That was a fabulous This way to end this, I appreciate you chatting with me today, Dr. Sharma. I learned a lot and I’m sure our listeners did too.

Hari Sharma:

Thank you for having me and I appreciate you taking interest in this particular issue because I think it’s very important for rural communities.

Lauren Lavin:

Yeah. Thank you so much.

Hari Sharma:

Thank you.

Lauren Lavin:

That’s it for our episode this week. A big thank you to Dr. Sharma for joining us today. One of my biggest takeaways from this conversation is that nursing home closures are about much more than buildings or bed counts. They’re about access, community, and quality of life. So for many older adults, especially those living in rural areas, staying close to family, friends, and familiar surroundings can make a tremendous difference in their wellbeing. When local care options disappear, that impact ripples far beyond the healthcare system.

This episode also highlights an important reality facing our country. We have an aging population and the demand for long-term care services is really only going to grow. The question isn’t whether communities will need these services. It’s how we can make sure people have access to them regardless of where they live. This episode was hosted and written by Lauren Lavin and edited and produced by Lauren Lavin.

You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts, and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team? You can reach us at cph-gradambassador@uiowa.edu. This episode is brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.