Carmen León, a certified nursing assistant at Emmanuel Convalescent in Los Gatos, cares for Maria Ramirez.

Sick Pay

Healthcare workers say that low wages and long hours will continue to cause labor shortages in the state's nursing homes

By Oakley Brooks

Photographs by Paul Myers

Carmen Leòn is there in the morning to ease her patients out of bed, bathe them, help them into their clothes and feed them their breakfast. She's there at midday to turn the frail bodies of the bedridden--to avoid ulcers that form on the skin when too much pressure builds on one particular spot. She stretches stiff limbs for those in wheelchairs.

And on her longest days at the Emmanuel Convalescent Hospital--a skilled nursing facility in Los Gatos--she's there deep into the night, continuing to comfort those racked by Alzheimer's, strokes and depression.

And then she goes home to two kids fast asleep and with a paycheck that--after deductions for taxes and medical insurance--is barely enough to cover the mortgage and utilities. Overtime pay, she says, is what keeps her out of financial trouble, and occasionally allows her to send money to her mother, who lives in Colima, Mexico.

There are other nursing homes and hospitals in the area that would pay Leòn, 33, more than $11.50 an hour. But in the six years since she received her nursing assistant certification, she's only known the residents at Emmanuel.

"I really like my people here," she said recently in the staff kitchen at Emmanuel, turning her round face into a smile. "But sooner or later, I may have to fly away."

Leòn's predicament shows a snapshot of what's wrong and what's right with skilled nursing care facilities in the area and around the state.

The industry thrives on certified nursing assistants such as Leòn who act as personal attendants and leave most of the medicating and skilled care to nurses. Those assistants help build a familial atmosphere in facilities and will willingly work long hours to compensate for chronic understaffing. But even the most dedicated can only handle the low pay and draining work for so long. Since 1998, almost 20,000 nursing assistants have left the industry in California.


Leilani Balancio, a certified nursing assistant in San Francisco listens to the discussion of AB 1075 during the California State Senate Health Committee review of the bill on July 11 in Sacramento. More than 200 nursing home employees from the state attended the meeting to voice their support.




Leaders in the union that represents healthcare workers believe they have the answer: legislation that would dramatically increase the number of nursing assistants and trained nurses in skilled nursing facilities like Emmanuel. They think that more workers, along with steady wage raises, will greatly improve the conditions in care centers and make them more attractive to nursing assistants.

But it will cost the industry and the state--which reimburses the industry through Medi-Cal payments--dearly. Beginning in 2004, The industry would pay an estimated $191 million a year to increase staffing to a proposed level of one care giver per five patients during the day, and one per 15 patients on the night shift. The state would have to pay around $423 million per year to reach those ratios.

And leaders in the state Senate and the healthcare industry aren't sure that there are enough workers or potential workers available to allow an increase at nursing facilities. The proposed increases would require 9,000 new nursing assistants and 4,000 new registered nurses from a shrinking labor pool.

Leaders in Sacramento and in the industry are wondering if nursing facilities will truly get the boost they need from the proposed legislation--Assembly Bill 1075.

"Increasing staffing standards is only part of the solution," said state Senator Deborah Ortiz (D-Sacramento), who chairs the Senate Health and Human Services Committee. "This issue is closely tied with a number of other factors, including workforce availability and the system's reimbursement structure."


At Emmanuel Convalescent in Los Gatos, the Service Employees International Union has made inroads with the staff. The facility's owners are now allowing union employees to recruit at Emmanuel.




Before any increase in staffing, the industry's lobby, the California Association of Health Facilities, wants the state to reimburse facilities based on the level of care required by individual patients at those facilities. Currently, nursing homes in the Bay Area with low-income patients on Medi-Cal support are reimbursed on a flat fee: $125 per patient per day, according to association spokeswoman Kelly Queale. Queale says reforming the system might allow facilities to collect more money if their patients require more intensive care and higher staffing levels.

"We'd like to see this legislation amended to tie it to reimbursement reform," she said.

Despite the health care industry's quest to amend assembly bill 1075, it has continued to move through the state legislature in recent months.

The assembly passed the bill on June 6, in a 47 to 24 vote. Local Assemblywoman Rebecca Cohn (D-Saratoga) voted in favor of the bill and her chief of staff, Cris Forsyth, says that while it would bring increased costs to the state, the legislation is crucial to the well-being of nursing homes.

"There are a lot of bills that have to cross that funding hurdle," said Forsyth. "This one deserves to be funded."

When the legislation headed over to Ortiz on the Senate side, her committee approved the bill 8-1 on July 11 and pushed it on to a vote in the state Senate.

Over 200 nursing assistants from the Service Employees International Union say their presence at the Senate health committee meeting helped nudge the bill on. Many drove to Sacramento straight after their overnight shift and filled the balcony of the health committee meeting room. Donned with brightly colored T-shirts and some still bearing the stench of soiled sheets, the workers made their presence felt.

"The scuttlebutt was that we prevented amendments that would have weakened the bill," said union chapter spokeswoman Isobel White.

The chapter has been lobbying heavily in the past couple of months to drum up support for the legislation. One of the campaign leaders is Mary Magdalena, a former employee at Emmanuel Convalescent in Los Gatos, who was a nursing assistant for 15 years before her back finally gave out.

Now she's recovering from cracked and dislocated vertebrae. She says the repetitive lifting that care workers do in turning patients wore her down. The workers are taught techniques to lift patients and to use harness machines where possible to avoid injury. But Magdalena says even with proper training, it's just a matter of time before the physical nature of the job seriously affects nursing assistants.

"It's a heavy and sometimes dirty job, and that's why a lot of people don't go there," says Magdalena. "You cannot do what they're asking you do under current conditions."

Magdalena and local union leaders think that expanding the number of workers in each nursing facility will make the job less physically taxing for nursing assistants. The assistants do about 80-90 percent of the hands-on care at nursing facilities, according to a recent union report.


Carmen León (left) a nursing assistant, eats lunch with her co-workers at Emmanuel Convalescent in Los Gatos.




Union leaders also think that increased staffing levels will boost the level of care. Studies from the National Academy of Sciences' Institute of Medicine show a direct correlation between increased staffing and better care in nursing homes.

But neither the academic community nor the federal and California governments have settled on acceptable levels of care and staffing at skilled nursing facilities. While a national nursing home reform group recommends that each nursing facility give more than four hours of individual care to patients every day, the state currently requires that facilities provide an average of 3.2 hours of care to each patient per day.

The ratio of care givers to patients outlined by Assembly Bill 1075 would allow California nursing facilities to provide individual care of more than four hours per day.

To make that change, the union insists nursing assistants need to receive a legitimate bump in wages. Starting rates for nursing assistants in the area vary from $8.88 at Emmanuel in Los Gatos to $11.07 at the Saratoga Retirement Community.

Nearly $500 million of state money has been budgeted for nursing facilities over the last two years--much of it for wage increases. But a recent state audit suggested that as much as 30 percent of the wage money never reached its intended target: healthcare workers.

This year, for the first time, the state earmarked funds for nursing facilities that had entered into a collective bargaining agreement with its staff or had committed to a wage increase.


Maria Ramirez is one of many patients who require full-time care from certified nursing assistants.




Several local nursing facility administrators say they believe that both wage increases and a boost in staffing levels are needed to keep up with the cost of living and to retain workers.

"The workers do feel like they need more money, what with gas prices so high," said Saratoga Retirement Community Director of Nursing Harvander Sijher.

Sijher says she consistently has shortages in her staffing and lately she's been having trouble filling the overnight shift. To cover the holes, she uses nurses and assistants from the local nurse's registry, which provides a steady supply of temporary healthcare workers.

Ruth Hernandez, who recently left her position as Emmanuel's top administrator, says she relied on the registry to fill staffing holes as well. Hernandez adds that the Emmanuel facility continues to keep a ward of 29 beds closed because of inadequate staffing.

The improvements in staffing numbers and pay might add strength to an industry that's largely surviving on, as Hernandez puts it, the staff's "commitment from the heart."

Family members with patients at Emmanuel know the value of that commitment

Landra Linstrom, 64, of San Jose used to tell friends that her full-time job was taking care of her aging parents. Now, her father George Mooberry, 95, whose short-term memory was damaged by a recent stroke and who suffers from dementia, is under Emmanuel's care.

"We're very thankful that there are people that will do this," said Linstrom. "It takes a special breed."


George Mooberry, 95, sings along with Wynona Pratt, a volunteer who helps with the activities at Emmanuel Convalescent twice a month.




Mooberry, who once sang in church choirs and organized his own choral group in Stockton, now rolls his chair next to the piano in Emmanuel's common room when the morning music sessions start. Over the last four years, he's become close with several of the nursing assistants, though Linstrom said he can never remember their names.

Mooberry's interactions with Emmanuel workers aren't always sweet. Linstrom says he has a chronic problem with forgetting that the nurses have given him medication. And when family members arrive at the facility, he'll tell them the staff is withholding treatment, putting workers in an awkward position.

"Often, it's really hard for him to interact with people," said Linstrom.

Linstrom says that she would support improvements at Emmanuel in the number of workers and their pay.

It's that kind of popular support that the nursing assistants union is counting on as it continues to push for passage of Assembly Bill 1075.

As for Carmen Leòn, she's behind the union's push for more staffing and its continued effort to raise wages. But she's not holding her breath. She's been interviewing for a nurse's aide position at the Santa Clara Valley Medical Center. If she gets the job, she says she'll go.

"They have better benefits," she said. "I'll miss these people though."

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