​Wagner, S.D., is a town of 1,500 residents in the southeastern part of the state, where most of the locals farm to make a living. The Evangelical Lutheran Good Samaritan Society, a nonprofit provider with corporate headquarters in Sioux Falls, S.D., operates a 55-bed skilled nursing facility (SNF) there.

The SNF, which also has eight assisted living units, is situated in an open Yankton Sioux Indian reservation, says Administrator Michele Juffer. Some of the Native Americans are residents, and some are staff members. Of all the 119 people who called Good Sam home at one point or another in 2010, a total of 76 percent received Medicaid assistance.

Good Sam lost $12,000 last year, Juffer says, and that is including a good amount of donations from various fund raisers put on by a sturdy group of volunteers that nicknamed themselves the Fun Bucks Committee.
“There are two ways we have survived. One is that we have some of the best staff anywhere, and two is the volunteers,” she says.

The staff numbers 82, with about one-third full time. They care for the residents in a building put up in 1963, making it less modern-looking on the outside than the well-funded basic care hospital not too far from the nursing care center. 

Volunteers Save The Day

The volunteers have done much in recent times to help make ends meet, or almost meet at Good Sam, through a number of creative ventures, like selling a recipe book, running rummage sales and food booths for a slice of the profits, and staging an annual carnival-walk that makes around $7,000 to $11,000 for the SNF, Juffer notes. All of that good work allows for some vital upgrades for residents, like when Good Sam recently bought a new van to keep being able to transport residents, a much-needed investment given that the more advanced hospital care for rural Wagner lies some 120 miles away. Juffer says since buying it six months ago, she has logged 24,000 miles.
Good Sam is run on a shoestring, with every efficiency pondered and weighed for effect. This frugality is a way of life for Juffer and her staff, who work to make their facility operate at peak efficiency so residents don’t see any slackening off in care. It just wouldn’t be right, Juffer says, noting the Evangelical Lutheran credo of the Good Samaritan nonprofit is, “In Christ’s Love, Everyone is Someone.”

Medicaid Cuts Tough To Take

This frugality is being put to the test like never before. When new South Dakota Gov. Dennis Daugaard (R) came into office, he proposed a 10 percent cut in Medicaid. The proposal pushed Juffer to write her representatives and the governor himself protesting in the strongest terms by calling the idea “pathetic.”
She stressed to the lawmakers and governor that her facility was barely getting by on Medicaid reimbursement of $124 per patient, per day, and with a 10 percent chop, the dollar amount would drop to $112. Those round trips to the hospital 120 miles away alone would eat away at the reimbursement, which is supposed to pay for wages and all aspects of care for residents.
Over time, the Medicaid cut proposal changed and was softened somewhat. Now, the reductions are being implemented on a tiered basis, with some facilities taking more of a hit and others less. Good Sam–Wagner is taking a 1.8 percent cut starting July 1, but there is talk of more serious cuts coming in January.
This comes as no relief to Juffer, who has held numerous discussions with staff on what to do to save money. These ideas have resulted in some of the full timers going part time, and an end to many employee perks.
“We let staff have meals at reduced costs,” she says, and she continues to do so because many of her workers are barely able to make ends meet themselves. To cut a little of the cost of doing so, all staff meals are now put on paper plates, cutting the amount of time a dishwasher has to operate to clean the regular china.
Health monitoring of workers has also been changed to save money. Many staff have serious health concerns, and the program once allowed weigh-ins and checking of blood pressure with a nurse able to monitor any pressing issues. Now, the vital signs can be checked, but there is no nurse oversight, Juffer says.

Caring For Those Who Cannot

Sacrifices are part of the job at Good Sam. And, amidst all of the efficiencies, Juffer has been working to upgrade the building to include federally mandated sprinklers, a cost she has had to go to her corporate headquarters to pay. “We just could not afford it otherwise,” she says.
The talk of money and reimbursement is not Juffer’s core problem with the way nursing facility residents are treated; instead it is her feeling they are being taken advantage of because of a generational mind set that does not exist much today. “My issue is that the people that grew our country to what it is today, they are not going to complain, they know how to live without. Because they can do without, they get neglected,” Juffer says. The fear is that without Good Sam in operation, who would care for the mostly poor residents of Wagner and surrounding areas. “I had a staffer, tears running down her face, ask who is going to take care of the people. If not us, who?” Juffer says. “The issue is the reality out here in these small towns. A lot of these folks are living at the poverty level,” she says.
Since her letters to the governor Juffer says she has met Daugaard at a function and had a few moments to speak to him, with the governor actually seeking her out. Her advocacy for her facility and its residents and staff got the attention of elected officials after all.
All of it, the cost-cutting, the letter-writing campaigns, the appeals for donations, all of it continues, day in and day out, as does the nursing care for residents who cannot care for themselves. As these residents reach their twilight, they can only hope Good Sam continues on, though in this fight for survival, Juffer knows why she marches on.
“If not us, who?” she repeats.