New Hampshire's publicly funded nursing homes perform better than their counterparts in other regions of the country, but a review of their inspection reports, architecture and amenities reveals wide disparities in elder care throughout the state.

Coos County's neediest seniors sleep in rooms considered too small by federal standards and endure summers without air conditioning, while their peers at the Rockingham County Nursing Home enjoy an atrium with trees, fountains and a retractable roof. In Grafton County, nursing home staff members use handheld computers to document residents' care. Carroll County, on the other hand, was recently cited by state inspectors for storing records in open cardboard boxes. Merrimack County is replacing its century-old nursing home, while regions with fewer resources struggle to bring outdated buildings in line with modern fire codes.

New Hampshire's public nursing homes, like its public schools, rely on local property taxes to supplement state and federal grants, making it easier for property-wealthy regions to pay for renovations, extra staff, new buildings and other amenities. Meanwhile, some less-fortunate counties fail to meet basic health and safety standards.

Demographics compound the problem: The state's northernmost counties are property poor, but they also have the highest concentration of needy seniors. An analysis by the New Hampshire Center for Public Policy found that, between 2002 and 2004, Coos County spent $360 per capita on nursing home care for its residents. Hillsborough County, meanwhile, spent just less than $49.

"We're struggling," said Jeannette Morneau, administrator at the Coos County Nursing Home in Berlin. "The burden in the county homes is already on the taxpayers. The philosophy of the delegation is that we have to provide quality care. But how far are they willing to go before they say we have to close down beds, we can't afford this anymore?"

For at least a century, New Hampshire's 10 counties have cared for sick, disabled and elderly residents on poor farms and, in more recent decades, at 11 publicly funded nursing homes. Each county maintains a single home, except for Coos, which runs two because of its size. Counties are also responsible for subsidizing other forms of elder care for needy seniors, such as home health aides and stays in private nursing homes with government contracts.

Elected officials have long grappled with who should pay for elder care and will resume the debate during budget negotiations this week. Many lawmakers and county leaders want to end the current practice of dividing costs among the state, county and federal governments, but they can't agree on how.

Some legislators want to remove the state from the equation, leaving the counties and federal government to split the bill. New Hampshire's 10 counties, meanwhile, believe elder care should be a state responsibility. Otherwise, they say it will be hard to offer equitable care to needy seniors in all regions, especially as a large portion of the state's population enters old age.

While lawmakers work out the details, it's up to nursing home administrators to serve their residents with the resources at hand.

Many likenesses

Despite geographic and financial differences, there are many similarities among the county-run homes: Field trips to Wal-Mart are as popular among residents in Berlin as they are in Dover. Local schoolchildren visit often and house pets are a common sight. (Some of the more rural homes have also been known to invite in piglets, calves and other livestock.) Internet access and computer classes are becoming more common, and most residents have the opportunity to garden either at the nursing home or on a nearby county farm.

The challenges are similar, too. All of the homes serve residents who are older and sicker than their counterparts 20 years ago, and are often called upon to house adults with complex illnesses, violent behaviors and limited resources. And each administrator must defend his or her budget to a county delegation weary of increasing property taxes. (next page »)