"They say Hawai'i is a healthy state," said David Kowalski, regional vice president of Avalon Healthcare, the biggest long-term care provider in the state.

"But what we have here is an aging population that is growing faster than anywhere in the country."

To remain afloat, many facilities have to carefully watch the mix of Medicaid patients to the profitable private-pay patients. They may also turn to other services such as adult daycare or home care to offset the Medicaid losses. However, private-pay patients who can shell out for pricey long-term care insurance or can afford the more than $70,000 average annual cost for long-term care are only a minority among Hawai'i's long-term care population.

"There are people looking at it, but it still doesn't pencil out economically," said Dennis Daniel of Architects Hawaii.

A review of applications filed with the state Health Planning and Development Agency in the past four years shows most new skilled nursing and intermediate care projects are either expansions of existing facilities or are part of larger retirement developments where land costs aren't as much of a factor.

"It's going to be very difficult," said Kowalski, whose own facilities have more patient requests for beds than they can fill. "Land costs in Hawai'i are very expensive and construction costs are very high so it does pose issues for companies looking to do this."

Maui's Hale Makua, among the biggest long-term care providers in the state, couldn't operate at full capacity earlier this month because it was short 25 nurse's aides. "We have a few empty beds because we can't staff them," said Tony Krieg, Hale Makua president. To cover the nonprofit's 24-hour nurse needs, Krieg had been forced into the costly solution of bringing in 16 Mainland nurses.

SEEKING SOLUTIONS

The state's healthcare community is well aware of the issues and has been searching for solutions.

Work is under way to update the Hawaii Health Performance Plan, a document guiding development of services and facilities here, to more precisely identify what types of long-term care services are needed where.

Coral Andrews, vice president of the Healthcare Association, a group that represents hospitals, long-term care providers and others, said there are other efforts under way to solve the problem.

For example, there's an effort to expose student nurses to long-term care work under a grant from the Robert Wood Johnson Foundation so that more opt for the work instead of hospital jobs, Andrews said.

Kowalski of Avalon Healthcare said he is trying to find ways to develop sub-acute care beds. He said it may be that solutions lie in developers, landowners and acute-care hospitals working together to come up with ways to construct something new.

At Hale Makua, Krieg said he is also looking into other alternatives and is one of 15 organizations to receive funding to develop all-inclusive care for the elderly. Under this concept, programs provide access to all levels of care from preventative to long-term to help people improve their health and keep them in the community longer.

Krieg said other options also need to be explored, including foster-care programs in which senior citizens live with surrogate families.

There is also talk of making long-term care insurance more affordable and more aggressive health education programs to keep people healthier as they age.

"We need to put more dollars into those areas, into more wellness, more prevention," said Sister Agnelle Ching, chief executive officer of St. Francis Healthcare System.

Reach Greg Wiles at gwiles@honoluluadvertiser.com.