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‘‘Hands-on care of elderly is not easy,” Burke said. ‘‘It is very difficult to deal with both emotionally and physically, while the pay scale for many jobs in the facilities is not much above minimum wage.”

Managers of nursing homes and assisted-living communities say increases in Medicaid rates and a $9 million boost in nurse training proposed by Gov. Martin O’Malley (D) may help a little to retain and train workers for their growing senior populations. Because Medicaid is the primary source of nursing home revenues and many facilities offer both assisted living and nursing care, state Medicaid reimbursement policies have a major impact on the long-term care industry.

O’Malley’s budget proposal calls for ‘‘full funding for medical assistance rate increases for nursing homes, assisted living facilities, and other community providers helping seniors in need of long-term care services to stay in their own homes.”

The only pending bills in the General Assembly — HB130 and SB 101 — call for more Medicaid funding, to be matched by federal funds, but does not address salaries and training of the workforce that cares for the elderly.

The Maryland Department of Aging has wanted the legislature to pass such a provision since 2002, said the agency’s spokesman Michael Lachance, but budget restraints from an economic recession have caused the state to postpone even Medicaid increases.

Maryland has 1,337 assisted living facilities and 238 nursing homes, according to Wendy Kronmiller, director of the state Office of Health Care Quality. Kronmiller said the demand for elderly care is growing and the number of openings for seniors is sometimes limited.

Nationally, the median hourly wage was $9.20 for nurse aides, home health aides and personal care workers, in 2003, compared with median wages of $13.53 for all U.S. workers, according to the U.S. Health Resources and Services Administration. Twenty to 30 percent of these direct-care workers are employed on a part-time basis and one-fifth earn incomes below the poverty level.

‘‘There has been a well-established nursing shortage,” said Robert Jepson, associate vice president for government relations and public policy for Adventist Healthcare of Rockville, which owns and operates six nonprofit, long-term care facilities. ‘‘But we now know there is a health care professional shortage. We need to remember this.” Adventist has just over 700 beds and annual revenues of about $70 million for the elderly facilities.

Nursing assistants key

In Annapolis, Mid-Atlantic Lifespan, a senior care service association, has been lobbying legislators since January to create workforce incentives to encourage individuals to work in senior care, in addition to upgrading state Medicaid funding. The effort is part of the organization’s ‘Honor the Promise’ campaign to encourage State officials to adopt four key action items that will ensure Maryland delivers proper care to its rapidly growing senior population.

‘‘The lack of qualified staff will have a profound, negative effect on future senior care,” said Isabella Firth, Lifespan president.

The federal government is partly to blame for the workforce shortage, said Rep. John P. Sarbanes (D-Dist. 3) of Towson.

‘‘It is a shortage that is part and parcel of the overall shortage of the health care in nursing professionals,” Sarbanes said.

Across the country, licenses to operate the care facilities ‘‘are being ratcheted up” while federal regulations are piling up on operators, requiring more training, and Medicaid and Medicare reimbursements are being cut back, he said.

‘‘Everywhere you turn there is a real squeeze,” said Sarbanes, who worked for 16 years in the health care practice at Venable law firm, representing nonprofit hospitals and senior living providers.

The industries’ largest expense is workers’ salaries and benefits, said Tony Mullen, director of research of the National Investment Center for Seniors Housing and Care Industries in Annapolis.

Meg DeSchriver, director of the 30-bed Grace House assisted living in Silver Spring said that there is a ‘‘fair amount of turnover of caregivers in the industry. One of the things we find is that caregivers will go move around to different facilities to get the better wage. Some leave to go to a private duty situation but without benefits that we offer here.”

Maintaining certified nursing assistants is the biggest issue for Marge Burba, executive director of Winter Growth, a small, non-profit adult day care and assisted living center in Olney. Winter Growth has a staff of 80 and Burba said ‘‘we have to maintain a certain staff ratio to keep the residents safe and in activities.”

She said salaries are ‘‘a great concern.” She added, ‘‘It is not good if we cannot compete with McDonald’s ...”

Revenues, reimbursements

Mullen said revenues in the long-term care industry are increasing. For example, annual revenues for the nation’s assisted-living industry is more than $30 billion, according to the Assisted Living Federation of America.

But, Mullen said, ‘‘most communities are raising their rates to match the rate of inflation. And for a number of years, for assisted living, expenses are going up, too, with the rate of inflation.”

Higher state Medicaid reimbursements would help, said Frank McGovern, assistant administrator of the National Lutheran Home, a nursing home in Rockville, because half the residents there are on Medicaid.

‘‘We are not only a business but a ministry” that offers residency to many seniors with limited incomes, he said.

Medicaid funding by the state is directly related to staffing issues, according to Kelley Ray, vice president of government relations for the Health Facilities Association of Maryland, a non-profit trade association.

‘‘You are only reimbursed for so much and so much is put into nursing care, such as staffing, Ray said.

‘‘Yes, obviously, the long term care field is very much in favor of better reimbursements and training programs,” said Burke of the national health care association. ‘‘But legislators feel the support is not out there, taxpayers’ support is not there,” he said of state and federal legislators.

Training is a huge issue, especially for smaller facilities. Fran Blacker, co-owner of the Golden Age Retirement Home, which has eight-bed facilities in Gaithersburg and Bowie, said, ‘‘The cost of training is killing the employees and the employers.”

The perceived inadequacies of nursing homes and assisted-living communities have given rise to a growing industry — visiting home care workers.

Linda Sherman co-owns the Towson franchise of Visiting Angels — Living Assistance Services.

‘‘If you place your loved one in an assisted living facility, you are at the mercy of the caregivers there,” said Sherman, who pays workers $14 an hour to visit seniors in their home.

‘‘These are the people who provide meals and medicine reminders, bathing and errands like taking them to church or the doctor,” she said. ‘‘So you have to find people out there who you can trust, rely on and keep faith in.”

By the numbers

Nearly 2.2 million employees worked in long-term care facilities in 2003, nearly three-fifths of the nation’slong-term care workers. Of these:

545,690 were professionals

1.65 million were nurse aides, home health aides and personal care workers

Source: U.S. Department of Labor