Sherri Parker, assistant director of nursing at Caribou Rehab and Nursing, recalled a woman who came to her facility and was so sedated by the prescribed antipsychotic medication she had been taking at home that they couldn’t keep her awake for therapy because “she’d fall asleep in front of you.”

Parker, who handles gradual dose reductions at the nursing home, said she worked with a doctor to wean the woman off the medication. By the time the resident transferred back home two months later, “she was a completely different woman,” Parker said — able to eat on her own and be home alone while her husband went to work.

“I’ve seen a stopped antipsychotic medication on many people and sometimes I’m like, ‘Wow, they’ve actually done really well.’ That just goes to show me that it really wasn’t necessary to keep them on that,” Parker said.

But in recent years, she has seen an increase in these medications. At the end of last year, while reading referrals from the hospital for new residents, Parker said nearly every one had a prescription for an antipsychotic medication. She said it’s likely they were prescribed the medication while living at home or when they went to the hospital before ending up at her nursing home.

Statewide data shows the percentage of Maine nursing home residents receiving antipsychotic medication is increasing.

While the rate for short-stay residents, like the one Parker recalled, is relatively low, Maine’s rate for long-stay residents is higher than the national average. Short-stay residents are in a nursing home for less than 100 days, often recovering from surgery or being discharged from a hospital, according to the U.S. Centers for Medicare and Medicaid Services.

In the years after federal regulators cracked down on rates of antipsychotic medication given to long-stay nursing home residents, Maine became a success story, dramatically reducing its rate between 2011 and 2017 from 27 to 17 percent.

But since then, Maine’s rate has crept back to 20 percent, higher than the national average of 14.7 percent and the sixth-highest across all states, according to the U.S. Centers for Medicare and Medicaid Services. Among all American adults, the rate of antipsychotics was less than 2 percent. 

Antipsychotics are a type of medication, including Risperdal and Seroquel, designed to manage psychosis and delusions. They’re often given to patients with a diagnosis of schizophrenia or bipolar disorder. The side effects can be severe, including tremors, heart and circulatory problems, high cholesterol and sedation. They can be particularly problematic for older adults, even potentially shortening the lives of nursing home residents by increasing the risk of drowsiness, confusion and falling, said several experts.

CMS data on nursing home rates of antipsychotics exclude people diagnosed with schizophrenia, Tourrette’s Syndrome and Huntington’s Disease.

“Antipsychotic medications are especially dangerous among the nursing home population because of their potentially devastating side effects, including death, and the use of antipsychotic medications among nursing home residents is an indicator of nursing home quality,” a CMS spokesperson told The Maine Monitor.

Treating an episode, not a behavior

Dr. Susan Wehry, associate clinical professor at the University of New England in Biddeford and a board-certified geriatric psychiatrist, said there are times when antipsychotic medications are necessary to prevent a resident from harming themselves or others, but those occasions are rare.

“I understand an acute need for using a chemical restraint, but call it what it is: This is not treating a behavior; this is treating an episode of agitation that you can’t figure out how to address another way,” Wehry said. “You’re basically sedating the person.”

Wehry said what is often depicted as challenging behaviors from residents with dementia is actually the resident trying to communicate an unmet need. They may not have the language to say what they want, so rather than sedating the resident, it’s important to find out the cause of their frustration, she said.

Parker, with Caribou Rehab and Nursing, said she’s seen residents come off these medications and become more alert, social and talkative. And sometimes there’s no change in behavior, which she said begs the question why the resident needed to be on the medication in the first place.

As of this month, roughly 19 percent of Caribou Rehab and Nursing residents were on antipsychotics, slightly below the statewide average. Parker recalled when their rates were 5 percent and how proud she was, but said the numbers can fluctuate as admissions come in with pre-existing prescriptions.

“I tried really hard with my antipsychotic numbers to be down, and then just slowly they crept up again as we took admissions,” Parker said. “I would love to see my numbers come down and I know those are some things we have to work on.”

Multiple experts and advocates point to a number of explanations for Maine’s rising statewide average, such as staffing shortages and reliance on temporary agency staffing, diminished attention to the problem, MaineCare underfunding for nursing homes, and the all-consuming nature of the COVID-19 pandemic, which demanded more attention on infection control.

Staff who are overwhelmed with duties or haven’t had time to build relationships with residents may turn to medication rather than spending time on de-escalation techniques when residents have challenging behaviors.

“It’s a disappointment to see the rates have increased because I know we can do better,” said Brenda Gallant, Maine’s long-term care ombudsman who advocates for nursing home residents and their families.

Gallant was part of the coalition in 2012 that led the effort to reduce Maine’s rates of antipsychotics, with Wehry and numerous other advocates, providers and organizations.

Multiple people involved in that effort said the success was due to the commitment of a broad coalition that involved statewide trainings, workshops, mentoring programs, grants for innovative programs like Music and Memory, and resources such as a handbook for providers.

The guidance urged providers to take a holistic approach to treating dementia patients, which included education for family members on the risks associated with the medication, staff training programs that identify specific areas of competency and a collaborative transition process with hospitals.

“Initially, we were leaders,” Gallant said, adding that at one point Maine was ranked the seventh-most improved state in 2016, according to federal data cited at the time by the Maine Partnership to Improve Dementia Care in Nursing Homes.

Nationally, the rates during that time decreased from about 24 percent in 2011 to 14.3 percent in 2019, while Maine’s crept back up. But this data also can lag slightly: the collection period for the current data on this quality measure was Oct. 1, 2022 to Sept. 20, 2023.

“The tip of the iceberg”

In recent years, some experts have become concerned about an overreliance on medication for older adults, including Dr. Jabbar Fazeli, who has served as medical director for multiple nursing homes and assisted living facilities in Maine. He said antipsychotics could be the “tip of the iceberg,” and that facilities also use mood stabilizers and sleeping pills as a way to sedate residents.

Fazeli served as co-chair of the Maine Partnership to Improve Dementia Care in Nursing Homes and has been outspoken about reducing overreliance on medication for older adults. Before the federal government decided to focus on the issue, it was difficult to push back against a “pervasive” culture of using antipsychotic medications, Fazeli said.

Durgin Pines in Kittery, where Fazeli served as medical director for more than a decade until last month, maintained a rate of antipsychotic medication that was always below 5 percent, he said. Currently the facility has a rate of 4.2 percent, according to the Centers for Medicare & Medicaid Services. Fazeli said the success was dependent on a joint effort with the director of nursing, assistant director of nursing and the administrator to try all other options before resorting to an antipsychotic medication.

In recent years, lawmakers and the federal government have also become concerned about nursing homes “erroneously” claiming residents had schizophrenia as a way to “mask the facilities’ true rate of antipsychotic medication use,” the agency said in a release last year. CMS conducted onsite surveys to look at schizophrenia diagnoses and conducted audits of how nursing homes coded these residents.

An oversight organization said this does not appear to be a problem in Maine. The nonprofit that provides quality improvement organization services in New England, Healthcentric Advisors, said it has “thoroughly analyzed” Maine data and determined the state is not seeing an increase in schizophrenia diagnoses.

Fazeli added that in his 26 years in geriatric care, Maine is better than most other states, including those he worked in like Missouri, Massachusetts, Connecticut and New Hampshire.

But after a lot of initial energy in Maine, attention on the issue slowed, especially during the pandemic, Gallant said.

Many said the pandemic was all-consuming for nursing home providers, making it difficult to keep the focus on reducing antipsychotics while keeping up with evolving regulations and caring for residents who were forced to be quarantined.

Wehry, the geriatric psychiatrist, said it was understandable for rates to climb back up in the first months of the pandemic, but “that’s no longer an adequate excuse.” She said a lot of nursing homes reverted back to institution-centric care that forces residents to conform to their environment rather than create an environment that works for them.

“I think it’s broader than just the individual person who’s getting the antipsychotic. I think the culture change, which people worked so hard to introduce, also backslid in the pandemic,” Wehry said.

Ruta Kadonoff, who worked for the national nursing home industry group during the 2012 effort to reduce antipsychotic medication, and traveled across the country providing education on the issue, said Maine’s biggest challenge is workforce shortage.

Staff need adequate training on how to “get inside the world of a person with dementia,” time to work with a resident who is upset or struggling to communicate a need, and support to provide person-centered care that allows them to build relationships with residents. None of that is possible in a facility that is understaffed, has high turnover or relies on temporary agency staffing.

“Until we address that, I don’t think it’s realistic to think we’re going to address other quality issues,” Kadonoff said. “It’s a bandaid to try to address other things without dealing with the underlying fact that we just don’t have the people to provide this care and to do it well.”

Healthcentric Advisors, the quality improvement organization, said it has been meeting with the long-term care ombudsman and the Maine Health Care Association, which represents the state’s nursing homes, about refocusing attention on this issue. They plan to update and reintroduce training modules that condense the most useful tools and resources, which will be rolled out in late fall.

The Maine Department of Health and Human Services said it has identified the increasing use of antipsychotics in nursing facilities and encouraged the stakeholder group to reconvene along with nursing facilities administrators and medical directors. In January, DHHS published a stakeholder group report, Improving Quality in Maine’s Nursing and Residential Care Facilities, and noted that “this metric is likely to be among those tied to reimbursement as part of nursing home payment reform,” spokesperson Lindsay Hammes said.

Gallant, the ombudsman, said it’s important to return attention to this problem “if we want to make progress and get back to the place that we had initially in terms of really being leaders. I think that should always be our goal: to do the very best that we can for residents in our nursing homes.”

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The state will establish two new public defender offices covering Aroostook, Piscataquis and Penobscot counties, and change the name of the Maine Commission on Indigent Legal Services to the Maine Commission on Public Defense Services. 

Gov. Janet Mills signed the emergency bill, L.D. 653, into law Thursday after it passed unanimously in both houses. The legislation creates positions for 10 new public defenders and 12 other staff members, bringing the total number of public defenders in Maine to 25. 

“This legislation creates new public defender positions across communities in rural Maine and advances my commitment to improving the delivery of legal services to low-income people to ensure their constitutional right to counsel,” Mills said in a statement. 

The state’s first public defender office opened in Augusta late last year; it covers Kennebec County and will expand to include Somerset County when staffing levels increase. It followed the establishment of a Rural Defender Unit that has five trial attorneys who travel around the state.

The commission hopes to open four more offices in the next two years. One would cover Hancock and Washington counties; one covering Androscoggin, Franklin and Oxford counties; one covering Sagadahoc, Lincoln, Knox and Waldo counties; and one covering Cumberland and York counties. 

The public defender offices have been designed to handle about 30 percent of adult criminal cases in a given region, employing somewhere between three and eight attorneys with support staff. Their work will be supplemented by private lawyers in a hybrid system. 

Until recently, Maine was the only state with no public defenders, instead appointing private lawyers overseen by the Maine Commission on Indigent Legal Services to represent poor defendants. 

A nine-month investigation by The Maine Monitor and ProPublica published in October 2020 found that the commission repeatedly hired attorneys with criminal backgrounds, including a registered sex offender who was convicted of possessing child pornography, and a lawyer who exposed himself to a client.

The investigation found that the commission did not have enough money or staff to supervise these lawyers, many of whom had been disciplined for professional misconduct.

The ACLU of Maine sued the state in 2022 on behalf of poor defendants, claiming that the commission was failing to provide them with adequate counsel and thus violating their constitutional rights. 

The case is ongoing, and two attempts by the parties to resolve the matter have been dismissed by a judge. Last month, Superior Court Justice Michaela Murphy rejected the second proposed settlement agreement, saying it failed to address the constitutional crisis of individuals going without legal representation. 

Maine is facing a critical shortage of defense lawyers who will accept new indigent cases, and there are hundreds of people awaiting court-appointed counsel across the state, many of whom are in jail. 

“Standards and accountability mean very little when very few attorneys, or no attorneys at all, have been made available by (the commission) for judges and justices to appoint,” Murphy said when she denied the settlement.

She scheduled a trial to begin in late June.

In a State of the Judiciary address to lawmakers last month, Maine Supreme Judicial Court Chief Justice Valerie Stanfill said the courts have made progress in shrinking the pandemic-induced backlog of cases, but not enough, pointing to the lack of available lawyers on the commission’s roster. 

“We have people sitting in jail every day — frequently a dozen or more in Aroostook County alone — without an attorney because there is no one to take their cases,” she said. “I hope that adding some public defenders will help, but it will be a while before we really see results. And in the meantime, I fear the system will indeed collapse.”

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A typical day for Doug Edinger begins at 8:30 a.m., when he opens the doors to Seaside Pharmacy in Stonington, on the southern tip of Deer Isle.

The Ohio native moved to the Hancock County town with his family nearly 20 years ago. For the last decade he has owned and operated Seaside Pharmacy as its sole pharmacist, with his wife, Lydia, and daughter, Allison, assisting as pharmacy technicians.

Edinger, 69, regularly puts in 12-hour days, working well past his pharmacy’s retail hours. With the next-closest pharmacy 23 miles away in Blue Hill — a trip that requires crossing the length of Deer Isle and two bridges to get to the mainland — Edinger said he serves most of the island’s year-round population of nearly 900.

In the summer months, when the population swells, he often works even longer days.

“It’s quite a challenge on the old body,” Edinger said, “but we make it, and you know, we’re doing OK.”

As a significant number of Maine pharmacies have shuttered in the past decade, businesses like Seaside Pharmacy have had to carry a larger load.

In 2013, there were 314 pharmacies in the state. A tenth of those have closed.

In rural areas, the decline has been even steeper, with some counties losing more than a fifth of their pharmacies in the past decade.

Growing gaps in pharmacy access

There are currently 283 pharmacies in the state, according to the Maine Department of Professional and Financial Regulation.

Of those, just 20 percent are independently owned, like Edinger’s; 79 percent are owned by chains such as CVS, Walgreens or Hannaford. The rest are specialty retail pharmacies, such as those serving long-term care facilities or veterinary pharmacies.

A Maine Monitor analysis of pharmacy licensing data found that since 2013 the number of pharmacies has decreased in 11 of the state’s 16 counties.

The greatest declines were in Washington and Somerset counties, where the total number dropped by 31 and 22 percent, respectively. Per capita, Waldo, Somerset, Oxford, Sagadahoc and York counties have the fewest pharmacies — ranging from 1.3 to 1.6 per 10,000 people.

A 2021 analysis by researchers at GoodRx found that in every Maine county except Cumberland, York and Sagadahoc, at least a third of residents live more than a 15-minute drive from the closest pharmacy.

Access was the worst in Washington County, where 84 percent of the county’s 31,000 residents lived more than 15 minutes from the nearest pharmacy.

The Monitor’s analysis found the number of pharmacies in Washington County has decreased from 13 to 9 in the past decade. Two of the remaining locations are within tribal health clinics, and the rest are in Calais, Machias, Milbridge and Eastport.

Today there are 28 fewer independent pharmacies statewide than in 2013, the Monitor found.

Most counties saw a significant drop in independents over the past decade. In York County, for example, the total dropped from seven independent pharmacies to just one.

Feeling the squeeze

Lee Ohmart, a retired Brewer pharmacist, got his start working for his father, who owned three independent pharmacies, Ohmart and Hinckley Pharmacies, in the Bangor area. One night, Ohmart recounted, while “struggling to pay bills, my father looked at me and said, ‘You better really like owning a business. With the way chains and the insurance companies are squeezing us, you will work more hours than your chief pharmacist and you will end up being paid less.’”

Independent pharmacies are getting squeezed by pharmacy benefit managers, middlemen that negotiate pharmacies’ reimbursement rates with insurance companies and manufacturers, said Emily Dornblaser, an associate professor at the University of New England School of Pharmacy, in an interview with The Maine Monitor last fall.

Some pharmacy benefit managers are owned by insurance companies that also own the retail pharmacies. For example, the health insurance company Aetna, pharmacy benefit manager CVS Caremark and CVS Pharmacy are all subsidiaries of CVS Health Corporation. Aetna will often give customers preferential drug pricing at CVS pharmacies, or only cover prescriptions filled at a CVS.

The system leaves independent pharmacies without access to drug discounts the big chains get and with worse reimbursement rates, Dornblaser said.

“That has really been one of the reasons that independent pharmacies have been gutted, because they cannot actively compete with such large, organized health-care system entities that span insurance to distribution,” she said.

But the large chains have had their own problems, and have closed a number of stores across the state in recent years.

Rite Aid, which filed for bankruptcy last fall, closed three Maine locations in 2018 and sold the remaining 76 to Walgreens. Since then, Walgreens has closed 21 stores, including some still operating under the Rite Aid name.

Just last week, Walgreens shut down a store on Main Street in Lewiston. CVS closed two stores in 2020. Both chains announced hundreds of closures nationwide last year.

“The mantra was like: a pharmacy on every corner. And you used to see corners where there was a Walgreens and the Rite Aid or CVS like directly across from each other. And now that’s definitely not the case,” Dornblaser said. “I think the companies are recognizing that there’s not a lot of volume at those stores, and the cost to staff them is not worth it and that’s why they’re closing.” 

Many chain locations across Maine appear to have had staffing trouble.

One Washington County resident said they drive 24 miles one way from their home in Addison to the Walgreens in Machias to pick up prescriptions, and often find that even when submitting refill requests days in advance, one or more of their prescriptions aren’t ready when they arrive.

“What ends up happening is after I’ve started to go home, halfway home I get a notification on my phone that the other prescription is ready and I can’t turn around and go back,” the resident said in response to a Maine Monitor survey conducted last week.

“They don’t have enough people to cover the pharmacy. I waited one day for a half an hour, and I never got waited on and so I walked out.”

Maine law says a pharmacy must have a pharmacist in charge working and must be open at least 40 hours a week, or it must notify the Maine Board of Pharmacy, which licenses and regulates pharmacies, pharmacists and technicians.

In 2022, Walgreens — the state’s largest pharmacy chain — paid more than $68,000 in fines after the Board of Pharmacy found that 10 locations, including the one in Machias, failed to have a pharmacist in charge or reduced its hours without notice.

“We continue to meet, and in most locations exceed, the Maine Board of Pharmacy’s requirement for retail pharmacies to be open 40 hours per week,” a Walgreens spokesperson said in an email, noting there is “a shortage of pharmacists across the country, which has led to some adjusted pharmacy operating hours or temporary closures, including those in Maine.”

As the Monitor reported in the fall, this nationwide shortage of pharmacists has led to sudden closures and irregular hours at chain locations across the state.

In the mid-2000s, a wave of new pharmacy schools opened to meet the shortage of pharmacists. But then the 2008 recession hit, and as more people were entering the profession, fewer were retiring, Dornblaser said. By the late 2010s, jobs had become more competitive and wages had stagnated or dropped, leading pharmacy school enrollment to drop. 

Then came the pandemic and the COVID-19 vaccination rollout, which added a new dimension to pharmacists’ jobs. Last fall pharmacy staff at some CVS and Walgreens locations across the country walked off the job to protest what organizers said were untenable working conditions.

Independent pharmacies a beacon in rural communities

When Audrey Parks opened Western Maine Pharmacy in Kingfield in 2011, she said there hadn’t been another pharmacy in the town for at least 50 years.

According to licensing records, Mt. Abram Regional Health Center is the only other pharmacy Kingfield has had. But newspaper clippings reveal the pharmacy did not fill its own prescriptions and instead outsourced that work to now-shuttered pharmacies in Farmington and Madison. The health center withdrew the pharmacy license in 2011.

Parks’ pharmacy serves a huge swath of northwestern Franklin County that runs west past Rangeley to the New Hampshire border, and north on Route 27, past Carrabassett Valley and Eustis all the way to the Canadian border.

Betty Ann Listowich, who lives in Freeman Township in Franklin County, said before Western Maine Pharmacy opened, she had to travel 20 miles to Farmington to get her medications. Now her drive is only four miles.

“They know who we are and are extremely helpful,” she said.

A 2022 study in the Journal of the American Pharmacists Association found that in large urban areas nationwide, 63 percent of pharmacies were chains; in rural areas, 77 percent were franchises or independent pharmacies. 

Among the 79 people who responded to The Maine Monitor’s survey last week, many said they have had only positive experiences at local independent pharmacies, including Carroll Drug Store in Southwest Harbor, Harris Drug Store in Greenville, Wilson’s Drug Store in Bath, Belfast Drug Company in Belfast, and Mt. Blue Drug in Farmington.

Several also praised the locally owned chain Community Pharmacies, which has locations in Bucksport, Corinth, Cornish, Gorham, Hermon, Randolph, Saco and Waldoboro. 

A Camden resident who uses Jensen’s Pharmacy in Rockland said they prefer independent pharmacies “because of their ability to hear you.”

“There’s nothing we can do”

Those who rely on CVS and Walgreens reported a number of frustrations, including long waits, reduced hours — many are not open on weekends — and automated messages that told them prescriptions were ready when they weren’t.

Asked if they ever had trouble filling a prescription, a South Bristol resident said, “Yes. If it’s Friday, Saturday, Sunday or Monday.” 

They noted there are only two pharmacies in Damariscotta — a Walgreens and a Hannaford — and said one is closed on weekends and can take four to five days to fill prescriptions, while the other often has a line out the door. 

“Very hard for a single person to get prescriptions when sick,” they said.

Another respondent, from Islesboro, said, “Just Saturday I went to pick up a prescription and discovered that the pharmacy is now closed on Saturdays.”

In an email, a CVS Pharmacy spokesperson said, “We strive to ensure we have appropriate levels of staffing and resources in place at each of our pharmacies through a combination of staffing, labor hours, workflow process and technology.”

Several respondents mentioned they get some prescriptions by mail, but that’s not possible for drugs that need to be refrigerated.

One woman, whom the Monitor is identifying by her first name, Betsy, to protect her privacy, said she noticed her usual pharmacy, the Hannaford in Gardiner, falling more and more behind over the past 18 months.

It came to a head in December when she went to pick up her daughter’s prescription for mood stabilizers to treat bipolar disorder.

Betsy said she made the 21-mile drive from her home in Richmond, in Sagadahoc County, to Gardiner to pick up the prescription, as she has done for years. When she got to the pharmacy, she was told she could wait 40 minutes or come back the next day.

When she returned the next day she was told the same thing: wait 40 minutes or come back tomorrow. This continued for days. On the fifth day, she said she was getting agitated because her daughter had run out of medication.

“Now I’m getting angry,” she said. “But they’re just like, ‘You know, there’s nothing we can do.’ ”

She made the trip seven times in 10 days. After her daughter went two days without medication, Betsy borrowed a few days’ worth of pills from her son, who also has bipolar disorder and takes the same medication. It was Christmastime, stress levels were high and her daughter was going through withdrawal. Had her son not been able to help, Betsy said the situation would have been dire.

“I would have stood in the middle of the pharmacy and started screaming,” she said. “Honestly, I think I would have lost it.”

A Hannaford Supermarkets spokesperson said the company apologizes for any inconvenience customers may have faced. “When a prescribed medication is unavailable, we may require more time to fill a prescription while we work with the provider to identify a comparable alternative,” she said.

Despite the frustrations, several respondents said the pharmacists seem to be doing the best they can given staff shortages, and noted that having to provide vaccinations alongside filling prescriptions is a lot to manage. 

“The staff is doing their best but they are constantly overwhelmed,” said a Bath resident.

Edinger, the Stonington pharmacist, said even with the long days, he loves what he does.

“I wouldn’t be doing this if I didn’t,” he said. “It’s nice to be working with your family. And the customers are more like our neighbors and friends than they are customers.”

Edinger ended up in Stonington in the early 2000s because a local pharmacy had closed.

“It was a real hardship to the community. That’s how I got called to the island. One of the local businesses wanted to bring a pharmacy onboard inside their business and they asked me to come and start it for him. So that’s how I got here,” he said.

Asked what would happen if Seaside Pharmacy closed, Edinger said that’s not a possibility.

“The island needs a pharmacy,” he said. “There’s no option to close.”

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It would be hard to find two landscapes in the continental United States more different than the flat, arid desert of California’s Imperial Valley and the forested, stream-laced mountains of western Maine.

In late winter, while Maine’s ground is blanketed in snow, a patchwork quilt of irrigated fields covered with salad crops and hay stretch to the horizon in the Imperial Valley and to the Salton Sea, a 35-mile long, landlocked lake near the Mexican border.

But beneath the surface, western Maine and the Imperial Valley share something in common — nationally significant deposits of lithium.

It’s a strategic metal considered essential for batteries that power electric vehicles and the storage systems needed to support a global, renewable energy revolution.

News reports have highlighted the Maine discovery said to be one of the world’s largest deposits of lithium, locked in rock crystals on the side of Plumbago Mountain in Newry.

Meanwhile, lithium found thousands of feet underground in the superheated, salty water called geothermal brines is making global headlines.

There’s enough lithium contained in the brines around the Salton Sea for 375 million batteries for electric vehicles, according to a recent federal analysis. It’s enough to help the U.S. meet global demand for decades, the analysis says. 

Only 2% of the world’s lithium supply now comes from the United States. Most comes from Chile, Argentina, Australia and China, with much of the processing taking place in China. So there’s a huge effort to ramp up domestic production for national security and economic reasons. 

As America scrambles to develop a resource sometimes called the “new oil” or “white gold,” contrasts are emerging between what’s happening in western Maine and southern California. In a nutshell, Maine is moving cautiously to consider a single mine while California is well on the way to hosting a multi-billion dollar industry.

Maine has not been friendly to mining. The state’s metal mining laws, revised in 2017, are among the strictest in the country. No modern mines have been developed in decades, and no company has applied for a metallic mining permit from the Department of Environmental Protection since the law was passed. 

Wolfden Resources Corp., a Canadian company aiming to mine for zinc and copper near Pickett Mountain, was recently turned down by the Maine Land Use Planning Commission in its request for a rezoning, the first step before the company could apply for a mining permit. That is the closest any company has come to testing the state’s regulations.

But Maine may be more receptive to a lithium mine. On Wednesday, the citizen board that oversees the Maine DEP voted unanimously to adopt changes to the mining law that would exempt some metals from the state’s strict metallic mining regulations, provided developers can prove they won’t pollute nearby watersheds or cause other environmental harms.

Chemical processing would still be regulated under the metallic mineral mining law. The changes are expected to go back to the legislature for approval in the coming weeks.

While Maine cautiously considers a way to permit a lithium mine, pilot projects aimed at extracting lithium on a large scale are well underway by California’s Salton Sea.

Global investors and major automakers are spending billions on what they say will be the world’s cleanest, major source of lithium extraction. Some boosters have dubbed the area, “Lithium Valley.”

What’s happening in California could ultimately impact the future of lithium mining in Maine and other places by raising a critical question: If new, lower-impact technology can tease out global supplies of lithium from geothermal brine, is it better to leave rockbound deposits in the ground?

This question came to the fore because of activity at geothermal power plants at the southern edge of the Salton Sea. For more than 40 years, geothermal plants near the lake have pumped the 500-degree brine, using the steam to spin turbines and injecting what’s left back underground.

Today there are 11 power plants with a total generating capacity of 400 megawatts, enough to power 300,000 California homes, with more plants planned. 

But until recently, the millions of tons of dissolved lithium in the brine were pumped back into the earth, unused.

Now three operators are at various stages of extracting lithium from the salty water using technology known as Direct Lithium Extraction, or DLE, which they say could bring their pilot projects to commercial scale.

If they succeed and the methods are financially viable, proponents say the process could capture lithium with lower environmental impacts than hardrock mining, while generating clean, renewable energy. 

The projects, however, are not without controversy, in part because large volumes of water are used in extraction processes. An investigation by the Howard Center for Investigative Journalism, reported in February in USA Today, reviewed 72 proposed mine sites and found most would take billions of gallons of water from already stressed resources such as the Colorado River. That’s the largest source for Salton Sea projects.

There’s also pushback from residents in the impoverished Imperial Valley, who already struggle with elevated health problems. In January, the nonprofit Comite Civico del Valle announced its intent to sue to overturn permits for a proposed lithium production campus, citing concerns over water use and air pollution from construction and operations. 

Meanwhile, developers and investors are in a race toward commercial viability. Three major players are taking the lead.

Berkshire Hathaway Energy Renewables: This Warren Buffett-led company’s subsidiary runs 10 geothermal plants. It has worked since 2022 on a process to recover lithium at a demonstration plant and produce battery-grade lithium carbonate.

EnergySource Minerals: This company is developing Project ATLiS at the 55-megawatt John L. Featherstone power plant. It’s using a patented extraction process and is aiming to be in full operation in 2025. Last year it signed a supply contract with Ford Motor Co.

Controlled Thermal Resources: This company held a groundbreaking ceremony in January to launch its $1.8 billion Lithium Valley campus, billed as the world’s first fully integrated facility to extract and process lithium, possibly with on-site battery manufacturing and recycling plants.

The project is called Hell’s Kitchen and the company says fully realized, it could represent a $28 billion capital investment and support nearly 8,000 jobs. The company has entered into investment and supply agreements with General Motors, and has received $100 million from Stellantis, the parent company of Jeep and Chrysler, to advance development.

In late January, Biden administration officials were among those at a groundbreaking for the first phase of the planned Lithium Valley production campus.

“This administration supports the vision of Lithium Valley,” said John Podesta, Biden’s climate czar, during remarks at the event, “and it’s not just winning the (lithium) race, it’s about providing good-paying jobs.”

A game-changing technology

Direct Lithium Extraction isn’t a new process. But the latest techniques to filter lithium from the salty, mineral rich brine and create a sustainable industry in tandem with geothermal power plants, is a game-changer, according to Michael McKibben, a research professor at the Department of Earth and Planetary Sciences at University of California, Riverside. 

“We should never mine lithium from hard rock again,” he said.

McKibben, who contributed to the federal analysis, said the key issue is the economics of bringing the extraction processes at the Salton Sea to commercial scale.

“I think ultimately, if DLE can be scaled up successfully in many places, it will put hard rock mining out of business. It may take a decade, but I think the writing is on the wall.”

Not everyone agrees that the Salton Sea projects represent a disruptive technology.

“Do I think what’s going on at the Salton Sea will replace any or all lithium mining in this country?” said Corby Anderson, a professor and associate director at the Colorado School of Mines. “No, I don’t. It’s not a panacea. It’s an opportunity.”

Anderson said supporters downplay the technical challenges and costs of recovering lithium from a thick brine loaded with compounds and minerals. And he said public opposition to mining often is based on perceptions that linger from polluting practices no longer used. 

“Modern mining,” Anderson said, “it’s not like all the dirty pictures of the past.”

Is Maine’s lithium still worth mining?

Mining is cleaner than it used to be. But with so much potential and investment already taking place at the Salton Sea, is mining in Maine needed for the U.S. to develop sustainable supplies of lithium?

Yes, said Mary Freeman, the co-developer of the Plumbago North project.

“If mining can be handled in an environmentally responsible manner,” she told The Maine Monitor, “what is the value of excluding Maine from participating in a viable sector of the economy?” 

Freeman and her husband, Gary, are gemstone miners who split their time between Maine and Florida. They want to expand the pit they developed near Newry to mine lithium-bearing spodumene minerals from a deposit some experts estimated could be worth $1.5 billion.

They plan to ship it out of state for processing, which would avoid the waste products that could threaten Maine water supplies.

Freeman said their project is on hold, awaiting legislative acceptance of the proposed amendments to Maine’s mining regulations.

But she said development of additional domestic resources such as the Salton Sea doesn’t diminish the value of mining the spodumene at Plumbago North, which contains large crystals with both high lithium oxide and low iron content. These materials can be used for products such as scientific glass, used in computer and cell phone screens.

This sentiment reflects the notion that market competition will lead the U.S. to develop a range of domestic lithium sources. That’s likely, according to Patrick Dobson, a lead geological scientist at Lawrence Berkeley National Laboratory and chief author of the federal analysis done for the U.S. Department of Energy that characterized the geothermal resource and lithium potential at the Salton Sea. 

Dobson is aware of the Plumbago deposit and monitors efforts to extract lithium and other critical minerals from geothermal, hard rock and clay deposits. They include:

Silver Peak, Nevada: Albemarle Corp. has produced lithium from brine deposits for decades at what is, for the moment, the country’s only active lithium mine. Lithium is concentrated through evaporation in a series of ponds. The company plans to double production, even as opponents say it’s depleting the area’s aquifer.

Clayton Valley, Nevada: Canadian-based Century Lithium Corp. is working to advance a lithium brine project near the Silver Peak site. The Clayton Valley project is conducting pilot plant operations and has a processing operation elsewhere in Nevada.

Thacker Pass, Nevada: This mine, on the Oregon border, is at one of the country’s largest lithium deposits. Native tribes and environmental groups fought it but pre-construction has begun. General Motors is investing $650 million for rights to the lithium supply and now is the largest shareholder. It previously was owned largely by Ganfeng Lithium Group of China.

Lithium potential isn’t limited to the arid west. Piedmont Lithium is seeking to develop a project in North Carolina, in a forested area west of Charlotte that is more like Maine. The company describes the area as the “Carolina Tin Spodumene Belt.”

The company has asked state regulators for more time to conduct feasibility studies. The proposed open-pit mine faces opposition from Gaston County residents concerned with water pollution, groundwater levels and other concerns.

These and other projects illustrate the soaring demand for battery storage and political pressure to develop domestic supplies. But Dobson said it remains to be seen which ones come to fruition.

Whether Maine stays in the mix may be decided in the weeks ahead.

“Which lithium projects turn into actual commercial developments,” he said, “will depend on a variety of factors, such as local acceptance, environmental approvals and the commercial viability of each project.”

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With two legislative proposals now dead or unlikely to pass, Washington County leaders are eyeing one remaining plan to provide more funding for rural law enforcement patrols following the pullback of the Maine State Police from patrol coverage in the county last summer.

During a work session on January 8, the legislature’s Criminal Justice and Public Safety Committee decided not to recommend a bill, LD 630, that sought to fund more law enforcement officers in rural parts of state, including Washington County, although two committee members voted for an amended version of the bill.

Senator Marianne Moore of Calais, a co-sponsor of the bill, understands that the committee opposed the measure because of the proposed funding source.

With the reduction in state police patrol coverage beginning last July, Washington County Sheriff Barry Curtis says of his call for deputies, “We have quite a need for more people. The state police forced our hand to get more people to handle all of the complaints.”

Curtis estimates the sheriff’s office now will be handling about 3,000 additional calls a year that were previously covered by the state police.

In 2022, the sheriff’s office handled between 7,000 and 8,000 complaints; in 2023 the number increased to 9,557, with the state police helping to cover the calls until early July. This year Curtis expects the number will be well over 10,000.

“We have to pick up more people to cover the complaints,” said Curtis. The cutback in rural patrol coverage is “doing a great injustice to the people of Washington County if we don’t.”

Curtis said additional deputies would help the sheriff’s office provide more coverage and allow changes in the current scheduling to give more time off for the deputies.

Of the need for more law enforcement officers in the county, Chris Gardner, chair of the Washington County commissioners, noted in his testimony for the bill, “The rural drug issue remains our biggest fight. Criminals know we lack resources and have set up shop in rural Maine. So much so that recently the facility with the most people incarcerated for homicide-related offenses in Maine other than the Maine State Prison was the Washington County Jail.”

Gardner says the county has “consistently invested in our side of the equation.” While the proposed county budget in October would have increased the county tax by almost 20% to fund additional sheriff’s deputies and dispatchers, that amount was cut down in the budget that was approved to an 11.3% increase for county taxpayers, with funding for one additional deputy and two dispatchers.

“We invested, but where’s the state?” he asks.

In his testimony he noted that in the 1990s there was a 50/50 call sharing agreement between the state police and the sheriff’s office. That was reduced to one-third coverage by the state police a decade ago.

This past year state police rural patrols were diminished even more, although the agency does provide assistance with its specialized teams. LD 630 was meant to be a mechanism for “how the state could step up and help carry their side of the equation,” Gardner said.

However, after the bill was carried over during the last session, the Maine Sheriffs’ Association worked with the Maine Municipal Association to introduce a bill amendment to provide funding for the measure through a reallocation of the real estate transfer tax. Under the proposal, the amount the counties retain from that tax would increase from 10% to 20%.

“It was not a great idea,” said Gardner, as it would mean taking money from MaineHousing, a state agency that seeks to make homeownership affordable, which was a concern brought up by members of the legislative committee.

Taking money from affordable housing initiatives to fund rural law enforcement was not viewed favorably by the committee during the work session.

Gardner pointed out that increasing the amount retained by the counties from the real estate transfer tax would have meant an additional $84,000 for Washington County, while an additional sheriff’s deputy, including a patrol vehicle, can cost $150,000 to $175,000.

“The state police pulled out of Washington County, and we lost three bodies,” said Gardner. The proposal brought forth during the work session would have provided only $84,000 to the county “to replace three” state police rural patrol troopers, he notes.

Gardner also pointed out that under the proposal Cumberland County would have received over $1.4 million.

“How the hell is this a rural patrol bill then?” he asked rhetorically. “They turned a rural patrol bill into a taxation and housing issue.”

Gardner says the county commissioners did not want to raise taxes and promised to “take the fight to the state” for more funding for rural patrol. The plan, though, “went completely off the rails.”

Along with concerns about the source of the funding, others who opposed the bill saw it as an unnecessary expense. Michael Kebede, policy counsel at the ACLU of Maine, stated in his testimony that the measure would “expand a fundamentally flawed arm of state government.”

He stated, “Over the past few years, it has become increasingly clear that we have relied on the policing institutions in our state to solve challenges better suited to our healthcare, housing and educational systems.”

Kebede added that “by neglecting human services and instead investing in policing, Maine and other states have turned law enforcement into de-facto social workers, healthcare workers and investigators of minor traffic problems.”

Other funding efforts

A previous effort to provide more funding for Washington County law enforcement was also turned down.

Senator Marianne Moore had proposed bills to provide $200,000 a year for two county sheriff’s deputies and $400,000 a year for four dispatchers, but the proposals were rejected by the Legislative Council in 5-5 votes in November as it considered bills to be allowed for introduction during the second session of the legislature.

The additional positions were initially included in the 2024 budget proposal for the county, but the county budget committee had scaled back that proposal to fund only one additional sheriff’s deputy and two additional dispatchers.

An additional measure, LD 2109, has been proposed by Senator Jeff Timberlake of Turner that would direct the Maine State Police to maintain their rural patrol services in all counties of the state at no less than the 2020 staffing levels.

“I totally support this bill in hopes that Washington County could again have shared shift coverage by the state police,” said Senator Moore. Gardner says the county commissioners also will be supporting the bill, which has not yet been scheduled for a public hearing.

“The state has failed to fund the state police. Our problem is not with the state police, but it is with those who fund them,” Gardner said. “The road troopers are just as overworked as anyone else. There’s just not enough of them.”

He observed, “The state has a responsibility to fund rural patrol, and the only mechanism is the state police.”

However, the state has underfunded state police rural patrol for 40 years, with no increase in funding for patrol troopers since 1977.

Gardner said that, if the Maine State Police do receive more money from the state, those funds should go to rural patrol.

“We need a better funded Maine State Police,” he commented, but if funding is provided, he says the state should contract with the counties until the state police can hire more troopers to provide the additional rural coverage.

“The commissioners are going to continue to fight, because we have to,” the county commission chair said. “We have to address this. We can’t just keep putting this on the property taxpayer.”

The story Funds sought for more rural patrol officers appeared first on The Maine Monitor.

Within the last decade, 23 nursing homes in Maine have closed, prompting long term care advocates, providers and industry leaders Wednesday to urge lawmakers to provide additional funding to prevent more closures.

“This is a call to action to address what has become a crisis in our long term services and support system resulting in the closure of nursing homes and residential care facilities across the state,” Brenda Gallant, the state long term care ombudsman, told a group of lawmakers Wednesday.

Since 1995, Maine’s number of nursing homes have decreased from 132 to 81, according to data presented to lawmakers.

There are currently no nursing homes at all in Hancock County and only one in northern Penobscot County. Half of the homes in Washington County have closed since 2014.

Gallant, whose ombudsman program advocates for long term care residents and their families, said nursing home closures force residents to relocate to other facilities, sometimes much further away.

She told a story about one resident in Aroostook County who could only find a placement in York County, 267 miles away, after her facility closed. The ombudsman program eventually found her a placement in Aroostook County, but only “after great difficulty,” Gallant said.

Nursing homes were the hardest-hit health care sector during the pandemic, said Anglea Cole Westhoff, president and CEO of the Maine Health Care Association, which represents about 200 nursing homes and assisted living facilities across the state. Maine lost 10 to 15% of its long term care workforce, and the primary reason they gave for leaving is stress and burnout.

To keep up with staffing minimums, nursing homes have turned to temporary agency staffing, but the “cost of temporary staff has just exploded and reimbursement doesn’t keep pace with that,” Westhoff said.

Mary Jane Richards, CEO of North Country Associates, which operates 23 nursing homes across Maine and Massachusetts, said their costs related to agency staff increased from about $7 million in 2019 to $39 million in 2022.

“We simply can’t sustain that,” she said.

North Country Associates had eight closures since 2018, including in Bar Harbor, Saco, Belfast, Ellsworth and Houlton, Richards said. 

The Department of Health and Human Services is currently looking at reimbursement rate overhaul to adjust how nursing homes are paid for the care they provide, but Westhoff said there has not been any updates on a new model or reimbursement methodology.

Current MaineCare reimbursement rates fall about $40 short of the cost of care per resident per day, Westhoff said. Since 2012, this annual shortfall in Maine has grown from $28 million to $43 million.

DHHS last month issued $19 million in one-time MaineCare payments to nursing homes for pandemic recovery. 

Without these supplemental support payments during the pandemic, the shortfall in 2022 would have been $96.5 million, Westhoff said. Without new investments or continued one-time payments, nursing homes will continue to close, she said.

“The status quo is really unacceptable. More facilities will be left with no alternative but to look at this path of closure or converting to a lower level of care,” Westhoff said. “This is harmful to the resident, to their families and to the communities where they live.”

Sen. Marianne Moore, who sits on the Health and Human Services committee, told The Maine Monitor before the press briefing the best approach to address these challenges is to address workforce shortages by preventing burnout and overtime.

“Throwing money at it is not the answer,”  said Moore, R-Washington.

Other solutions the advocates and providers discussed included expanding training programs, supporting family caregivers, expanding adult day centers and providing onsite daycare for direct care workers. 

Rep. Anne Perry told the Monitor another key solution is providing a pathway for immigrants to join the workforce earlier. 

“This is a long-term problem that’s going to require a long-term solution,” said Perry, D-Calais.

Nursing home beds in Maine have decreased from 10,000 in the mid-1990s to less than 6,400. The disappearance of nursing home beds pushed more Mainers with higher medical needs into less intensive residential care facilities, the Monitor found in a year-long investigation.

“As the state that has the oldest median age, and we are aging, this is a trend that if left unchecked could really spell disaster,” Westhoff said. “As Baby Boomers age, we will not have the capacity to adequately care for older adults who require long term care supports and services.”

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Maine nursing homes are closer to meeting the Biden administration’s proposed minimum staffing standards than their counterparts in most other states, but recent payroll data show that still fewer than one in 10 are meeting these proposed standards every day.

And while some long-term care advocates said the national standards should go further, nursing home industry leaders said it would be difficult for a rural state like Maine to find the workers to meet the required minimums, which could lead to more closures.

The Biden administration in September proposed federal standards that would require nursing homes to have a registered nurse on duty at all times, and establish minimum care hours per resident from registered nurses and nurse aides.

During the second quarter of 2023 — from April to June — Maine nursing homes met the proposed minimum care hours from both registered nurses and nurse aides an average of 59 out of 91 days in the quarter, according to analysis from The Maine Monitor, USA TODAY and Big Local News at Stanford University, the latest federal staffing data. The data is collected by the Payroll-Based Journal from the U.S. Centers for Medicare and Medicaid. 

Only Alaska was higher with an average of 88 days. The national average was 18 days.

However, only 8% of Maine nursing homes met both standards on all 91 days of the quarter. This still places Maine third in the country behind Alaska and Hawaii. (The national average was 1%.)

Part of the reason Maine nursing homes are more prepared to meet the standard could be because the state already has its own nursing home staffing requirements, including minimum staff ratios.

However, long-term care resident advocates and industry leaders said the biggest challenge for Maine homes would be meeting the proposed requirement for registered nurses on duty at all times.

Brenda Gallant, Maine’s long-term care ombudsman who advocates for nursing home residents and their families, praised the effort to establish national minimum standards. She viewed staffing as the most important aspect of quality of care in a nursing home. However, Gallant said, she would have liked to see the proposal go even further.

“Honestly, why is it taking the country so long to do the right thing, both by residents and staff?” she said. “We can’t expect people to want to do this work without sufficient resources and when there isn’t sufficient staffing.”

Studies have tied staffing to quality of care and called for the establishment of a federal minimum staffing standard.

The Maine Health Care Association, which represents 200 nursing homes and assisted living facilities across the state, has called the proposed minimum an unfunded mandate that could lead to more nursing home closures. 

In less than three years, the number of nursing homes in Maine has dropped from 93 to 83, some of which have cited staffing challenges as part of the reason. The federal payroll data included staffing information from 85 nursing homes for the second quarter of this year, but two more have since closed. 

Angela Cole Westhoff, the organization’s president & CEO, said Maine nursing homes are among the closest to meeting Biden’s proposal because the state already has some of the highest standards in the country and because Maine homes serve residents who often have higher care needs, which requires them to provide more staffing per resident.

But workforce shortages are already stressing the industry, she said, adding that there needs to be significantly more investment from policymakers to better train and pay direct care workers.

“Essentially, every single nursing home in Maine has multiple jobs posted,” Westhoff said. “We already want more staff. The issue is that Maine simply does not have the workers available to meet our needs.”

While Maine is comparatively better than most other states, the fact that other states are so low demonstrates there is a significant challenge to meeting this proposal, said Jess Maurer, executive director of the Maine Council on Aging.

The proposed rules for nurses and nurse aides would be phased in over three years for most homes, but rural areas would have five years to meet the new standards. The proposal also includes $75 million for staff recruitment and training.

Maurer said the proposal should include additional support and funding for rural communities where it will be hard to find the workers to meet these standards, especially in Maine because it is the oldest state and has among the lowest working-age population in the country.

“We’re the first in the country to deal with this, but we will not be the last,” she said. “We should be the canary in the coal mine. The Feds should be looking at how many nursing homes have closed in Maine and why and who is going to follow because they can’t meet these staffing ratios in small, rural areas.”

Best and worst performers

Even some of the nursing homes doing the best at meeting the proposed requirements were critical of the proposal.

Seven of Maine’s 85 nursing homes met both Biden requirements on all 91 days of the quarter. Among those were two Maine Veterans Homes, in Augusta and Bangor. Both locations have a five-star rating from the federal government based on staffing, health inspections and quality measures.

Rebecca Gagnon, Chief Operating Officer of Maine Veterans Homes, said the homes might have met the proposed minimum staffing requirements because they are “consistent with the unique VA regulations” they already are required to meet, such as round-the-clock presence of a registered nurse.

These existing requirements make operations more costly due to workforce scarcity, Gagnon said.

“Although Maine Veterans’ Homes assumes that the recent change proposed by CMS concerning minimum staffing requirements is prompted by a priority of ensuring care for nursing care residents, we are concerned that the mandate will have the opposite, unintended effect of complicating the availability of services for Maine’s seniors as the industry continues to struggle to meet staffing levels,” Gagnon said.

Cove’s Edge in Damariscotta also met both the proposed registered nurse and nurse aide hours on all 91 days of the quarter and has a five-star rating from the federal government. But MaineHealth, which owns and operates Cove’s Edge, said it had “serious concerns” about a national ratio.

MaineHealth is able to invest and subsidize staffing across all its facilities because it is the state’s largest health system, but it comes at a cost and stand-alone nursing homes may not be able to do the same, said Katie Fullam Harris, chief government affairs officer for MaineHealth.

The existing labor shortage, especially for nurses, is creating pressure across the entire healthcare system.

On any given day, MaineHealth hospitals have 60 to 70 people waiting to be discharged to a nursing home or rehab but there’s nothing available, she said. Cove’s Edge has an additional unit that is currently empty because reimbursements are too low to staff it, Harris said.

“If you mandate a staffing ratio for which there’s no justification, all you will do is put further pressure on a system that is already in crisis,” she said.

Four of the five nursing homes least prepared to meet the proposed standards are owned by Genesis Healthcare, which is one the largest long-term care providers in the country with nearly 250 skilled nursing homes and assisted living facilities in 22 states, according to the company’s website.

Cedar Ridge Center in Skowhegan met both of Biden’s requirements on one day of the quarter and has a two-star rating from CMS. Pine Point Center in Scarborough met both requirements on two days and has a four-star rating. Sandy River Center in Farmington met both on four days and has a one-star rating. Sedgewood Commons in Falmouth met the requirements on five days and has a three-star rating.

A representative for Genesis did not respond to requests for comment.

The proposal on the table

If Biden’s proposed minimum standards are implemented, nursing homes that accept Medicare and Medicaid would be required to provide residents with a minimum of 0.55 hours of care from a registered nurse per day and 2.45 hours of care from a nurse aide per resident per day. And a registered nurse would need to be on duty at all times.

Current standards require a registered nurse or licensed practical nurse to be on duty at all times.

Public comments on the proposal were accepted through early November.

Minimum staffing standards would improve safety and quality care in nursing homes, Xavier Becerra, secretary of the U.S. Department of Health and Human Services, said in a press release at the time.

“When facilities are understaffed, residents suffer,” Becerra said. “They might be unable to use the bathroom, shower, maintain hygiene, change clothes, get out of bed, or have someone respond to their call for assistance. Comprehensive staffing reforms can improve working conditions, leading to higher wages and better retention for this dedicated workforce.”

The Centers for Medicare and Medicaid has estimated that about three-quarters of nursing homes nationally would need to increase staffing to meet the proposal.

Maine nursing homes are already required by state law to have one direct-care staff member for every five residents during the day; one for every 10 residents in the evenings; and one for every 15 residents overnight.

These standards are very close to the three hours of care per resident from a registered nurse and nurse aides that would be required under the national standards, said Gallant, with the ombudsman program.

Gallant said she’d like to see national standards go even further and require 4.1 hours of direct care for each resident. This number comes from a 2001 study by CMS into quality of care, which recommended that registered nurses, licensed practical nurses and certified nurse aides provide a total of 4.1 hours per resident per day. (This recommendation included a standard for LPNs, but Biden’s proposal does not.)

On average, Maine nursing homes met the nurse and nurse aide minimums recommended by CMS in 2001 on 14.5 days of the quarter, according to the analysis of payroll data.

The ombudsman program has conducted focus groups with direct care workers across the state to hear about concerns. In these discussions, Gallant said she’d heard from workers who felt like they couldn’t call in sick because there was no one else to come in.

“There’s not a choice about providing sufficient staffing. Period. There’s just not. That’s what facilities exist to do: take care of people,” she said. “People want to do a good job. If you don’t have sufficient staff, it becomes impossible.”

The primary challenge in a rural state like Maine would be meeting the requirement to have a registered nurse on duty at all times, according to both Gallant and Westhoff, with the industry group representing Maine nursing homes.

“The Feds should be looking at how many nursing homes have closed in Maine and why and who is going to follow because they can’t meet these staffing ratios in small, rural areas.”

Jess Maurer, executive director, Maine Council on Aging

Nearly a quarter of Maine’s nursing homes — 20 out of 85 — met the proposed minimum registered nurse hours on every single day of the 91-day second quarter, according to the analysis of payroll data. This ratio is higher than all other New England states. Nationally, only 6% of nursing homes met this proposed minimum on every day of the quarter.

According to an analysis from the American Health Care Association, about a third — 28 out of 85 — Maine homes would currently meet a 24/7 registered nurse requirement, Westhoff said.

Low MaineCare reimbursement and workforce shortages are driving nursing home closures, Westhoff said, which causes a ripple effect across healthcare as hospitals and other facilities absorb the backlog of patients.

Rather than regulations and obligations, there should be a focus on innovation and solutions, said Maurer with the Maine Council on Aging. For example, it might be a better use of time to regulate staffing agencies, which are expensive for nursing homes and are intended as a stopgap during an unforeseen staff shortage but are increasingly becoming the norm.

And it’s long overdue to increase reimbursement rates for this work, she said. 

“We should be talking about, as humans, what do we value and how do we want to receive care? And we should pay for it.”

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