NURSING SHORTAGE COSTS JAIL MILLIONS
Spending on temp firms skyrockets amid shortage of medical staff
The infirmary at the St. Louis County Jail is seen on Friday, Nov. 22, 2019, in Clayton.
Dooley
l Cunningham
CLAYTON — The St. Louis County jail, gutted by the nursing crisis that has hamstrung hospitals since the beginning of the pandemic, has lost dozens of medical workers over the past three years.
To fill the gap, the county has paid out millions of dollars in temporary staffing contracts.
Since 2019, the number of jail nurses and medical assistants has dropped by more than half, from 50 to 23. At the same time, spending on temp firms has skyrocketed by more than $4 million.
And that's meant some jail workers are less familiar with the facility and less invested, staff have said, leading to a drop in morale, and more work for all.
"We've been at the breaking point, and we're beyond it now," David Dooley, a registered nurse at the jail, said last month. "Everybody's stressed. Everybody's burnt out. We can't keep doing this."
The jail is fighting widespread troubles to hire and keep staff. Vacancies in jail guard ranks have jumped to 72 from 53 last
"We've been at the breaking point, and we're beyond it now. Everybody's stressed. Everybody's burnt out. We can't keep doing this." David Dooley, registered nurse at the county jail year. Managers at one point even asked guards to work alone in housing units with dozens of inmates, a violation of jail policy that may have led to an attack on an officer last fall.
"All throughout health care, we're struggling to recruit and maintain staff. We're seeing this mass exodus of people being burned out and leaving health care." Dr. Kanika Cunningham, county health director
The county has also seen at least nine inmate deaths in the past four years, including one who died Monday after reporting chest pains and trouble breathing. An audit of the facility's operations, though it didn't connect the deaths to health care at the jail, found fundamental problems in the medical department. And the use of temporary staff, the audit said, detracts from expertise in the jail and creates low morale among permanent staff.
At the same time, the temporary staffing costs are a burden to an already strained county budget. The county faces a $41 million deficit by the end of the year, according to estimates from the budget office.
"You hear so much about the county having financial difficulties," Dooley said. "This is not a viable strategy long-term and I don't know how much more they can afford to do it."
An analysis of county payroll and spending data shows:
■ In 2019, the county spent about $245,000 on temporary staff for the jail clinic. By the end of 2022, that number hit nearly $4.4 million.
■ In 2019, the jail had 45 nurses and five medical assistants. By the end of last year, it had 19 nurses and four medical assistants.
■ Overall permanent staffing in corrections medicine also fell, to 38 last year from 62 in 2019.
■ About two-thirds of jail nurses, assistants and paramedics were temporary workers at the end of last year.
■ Spending on permanent staff dropped by more than $1 million over the past four years. But the cost of paying contract workers outweighs the savings 4 to 1.
■ County officials acknowledged the issues. Dr. Kanika Cunningham, who started as county health director in January, and Ronald Griffin, who began as director of clinical services in early February, both said they want to phase out temporary staffing and replace it with permanent workers.
"Using staffing agencies is not unique to corrections medicine," Cunningham said. "All throughout health care,we're struggling to recruit and maintain staff. We're seeing this mass exodus of people being burned out and leaving health care."
Jail nurses are swamped
On an average day at the jail, there are about 20 medical staff on hand, including temporary workers.
They work shifts around the clock. They're responsible for the care of roughly 900 inmates, many of whom suffer from ailments with sudden, unpredictable needs — 36% have mental health disorders; 17% suffer from hypertension or a heart condition; and 19% have asthma or a respiratory disease. In December, about 17% of medical visits were to treat a substance use disorder.
They have a packed schedule. They take requests from inmates for medical care, pass out medication and care for patients in the infirmary. They evaluate each incoming inmate, provide urgent care, carry out primary doctor's orders and manage infectious disease prevention.
And they'd ideally have nine more working daily during peak times, according to the health department.
Temp staff contracts last either 13 or 26weeks. The county's primary staffing agency provides paramedics at $132 per hour, emergency medical technicians at $125 per hour and registered nurses at $142 per hour, according to county records. It costs the county about $30 per hour for a registered nurse at the jail.
As of mid-February, the county had filled many vacancies with contract staff, including 14 nurses, two medical assistants and 24 paramedics, according to the health department.
The new health department leaders have taken action on obvious solutions: networking with workforce groups and nursing schools, and trying to permanently hire temp workers as their contracts expire, Griffin said.
"If you look at the financial aspect of it, we can parlay those savings and then be able to allow competitive salaries across the board," said Griffin, the clinical services director. "It's going to take a little time to undo some of the harm that was done, and we have to build trust. But we hear what the employees are saying."
Paying more for less
Jails across the country face crisis levels of clinical staff shortages because of a cutthroat market. Even private health care companies are struggling. But unlike local governments, private industries and temporary staffing agencies can charge high rates and then pay their workers generous salaries and sign-on bonuses.
"Jails and prisons, which often have lower compensation levels and less efficient hiring systems, have extreme difficulty in attracting clinical staff in this environment," the authors of the jail audit wrote.
And there's no indication hiring conditions are improving.
Americans are opting out of local government jobs altogether, from police to bus drivers, a review of federal employment data by The Marshall Project found. While jobs in the private sector rebounded by 2% after the pandemic, jobs in the government sector declined by about 1%, according to the nonprofit news organization.
St. Louis County last spring sought bidders to privatize the jail's clinical services in an effort to address staffing shortages. But by August, no adequate bidders came forth, and the county has now shifted to chasing permanent staff.
"We need to do our best to actively recruit and create that environment that makes you passionate about the care and the work you do," Cunningham said. "And we want to make sure we have salaries and pay, huge issues in health care."
It's more expensive to employ nurses now. From December 2019 to the end of last year, the cost of paying health care workers in local government increased by about 11%, according to the Federal Reserve Bank of St. Louis.
But if the county trimmed temp contracts, it could afford far more than 11%: Spending on permanent nurses and medical assistants decreased last year to $1.3 million, but the county spent $5.7 million on all those jobs plus staffing contracts. Even if the county doubled current full-time numbers, it could double the pay of staff and still come in under current totals.
St. Louis County Council Chair Shalonda Webb said temporary agencies are a "bandaid, not a permanent solution." Webb, a Democrat from north St. Louis County, is leading a private committee of county officials, including council members, the county executive and county staff, studying the budget deficit.
"You can't fix the past, but going forward I would like to find some long-term solutions," Webb said.
A spokesman for County Executive Sam Page said reviewing spending on temporary agencies will be part of budget talks.
"Health care salaries have gone up across the country and we need to stay competitive," spokesman Doug Moore said in a prepared statement. "When we are successful in recruiting and retaining staff in a very competitive market, we will spend less money contracting for the same service. Certainly, this will be part of the ongoing budget discussions."
Disorganization and delayed care
The mixture of temporary and permanent staff is a symptom of a poorly organized facility that needs policy revisions to keep inmates safe, the audit by jail consulting services firm CGL Companies found.
Auditors found two separate occasions where medical staff said inmates were faking illness and declined to follow up. In another case, a clinic manager said staff wouldn't respond if a corrections officer alone said an inmate was sick.
"This is contrary to standard practice in most jails," the audit said.
The audit also found if less than four nurses are available when they distribute medicine in the morning, the nurses don't collect slips from inmates requesting medical attention. Instead, they're told to report their illness at the next opportunity, delaying care.
Auditors recommended the jail implement a policy where all sick call requests are responded to within a day, regardless of staffing.
Confusion surrounding these policies leads to high turnover, the audit said, and more reliance on temporary staff.
They also might contribute to another source of increased costs: Lawsuits stemming from inmate deaths,which largely allege medical neglect, have cost the county at least $2.7 million since the beginning of 2021, according to Post-Dispatch coverage of settlements.
Lisa Maxwell, a former nurse manager at the jail, confirmed the audit's findings. After 11 years working there, the 43-year-old Ballwin resident quit in November and took a nursing job at a nonprofit organization.
"We couldn't pay what people were paying the temp agency workers, so our staff morale went down because they made significantly less,"Maxwell said.
The new public health director has visited the jail to observe operations in corrections medicine, and the new clinical director holds office hours at the jail every Tuesday and Thursday. Maxwell said that's already an improvement.
"They need to listen from the ground up instead of making the decisions at the administrative level,"Maxwell said. "They need to talk to the people that are actually on the floor. Because you can't make decisions at the top level and not know how things work."
Kelsey Landis• 314-340-8304 @kelseylandis on Twitter klandis@post-dispatch.com
'They need to listen from the ground up instead of making the decisions at the administrative level. They need to talk to the people that are actually on the floor. Because you can't make decisions at the top level and not knowhow things work.'
Lisa Maxwell,a former nurse manager at the jail
