Hale Makua, a Maui-based care home, couldn't make use of all its 254 beds in Kahului last week because it couldn't find enough workers in the midst of a nursing and nurse aide shortage gripping the Islands.

"We have beds that we can't staff," said Tony Krieg, chief executive of the facility that provides post-hospital recovery services. "When we stop admitting people, it really puts pressure on the hospital."

Similar stories can be found around the state.

Hawaii Pacific Health Inc., an operator of four hospitals, has an 8 percent nurse vacancy rate and considers itself lucky, given that the national average is in the double digits. At Kokua Nurses, one of the state's oldest nursing and home-care providers, demand for its nurses and certified nurse assistants far outstrips what it can offer.

"More is never enough," said Joanne Parmele, Kokua Nurses director of nursing. "Referrals come in all day, and there's just not enough staff out there."

The shortage is one of a number of disquieting problems for healthcare in Hawai'i, including physicians moving out of state, a shortage of nursing facilities, and rising medical, drug and insurance costs for consumers. The Healthcare Association of Hawaii, in a November report, said expenses at Hawai'i's hospitals have eclipsed patient revenue since 2000.

CARE, ACCESS AT RISK

But the nursing deficit is one of the higher-profile problems and is forecast to get worse.

"We're definitely going to have a nursing shortage that's going to worsen over time," said Barbara Matthews, director of the Hawai'i State Center for Nursing.

A disturbing scenario can be painted if nothing is done, including a decline in access to high-quality healthcare and clinic closings, Matthews said.

"We really need to rapidly increase the number of nurses coming into the workforce," she said.

A January 2007 study by the Center for Nursing estimates that in 2006, the state was short the equivalent of 960 registered- nurse positions. That's more than all of the nurse positions at the state's largest private hospital, the 533-bed Queen's Medical Center, according to Sandra Le-Vasseur, nursing center associate director and author of the study.

In the next several years, the nursing gap will widen. The center's study projects a shortage of 2,669 nurses in 2020.

Viewed another way, more than one in 10 positions that were unfilled in 2006 is estimated to worsen to about one in four in 2020.

The biggest factor contributing to the shortfall locally is a demographic tide in which baby boomers are reaching the age when they need more healthcare. At present, Hawai'i's nursing schools aren't turning out enough graduates to meet demand, something healthcare officials hope to rectify in coming years.

At the same time, more nurses are projected to leave the workforce as they retire. In 2003, the Center for Nursing found the average age of Hawai'i nurses was 49.3 years.

"By 2015, 31 percent of Hawai'i's present registered- nurse workforce will retire," said Richard Meiers, president and chief executive of the Healthcare Association of Hawaii, a group that represents hospitals and long-term care organizations. By 2020, 61 percent of the current registered nurse workforce is scheduled to retire.

A partial solution for addressing past nurse shortfalls, recruiting nurses from elsewhere and using traveling nurses to temporarily fill vacancies, isn't as viable these days. That's because of the increasing magnitude of the shortfall and because the nursing shortage is worldwide. Like Hawai'i, the rest of the U.S. is forecast to have problems meeting demand in coming years.

"We can't do that as easily now," Meiers said. "The nurses aren't even available in the countries we used to get them from."

AGGRESSIVE RECRUITING

At present the hospitals, such as one run by Kaiser Permanente Hawaii, report they either have enough nurses to staff their beds or are able to deal with a moderate shortage. They do that through a combination of on-call staffing, overtime, having a pool of nurses who work where the need is the greatest, traveling nurses, and nurses from temporary agencies.

"We're pretty fortunate," said Carl Hinson, director of workforce development for Hawaii Pacific Health. "We're not having to curtail services or anything like that. I do know there are other organizations in the state that are having to do that."

He's able to keep enough nurses to staff beds through disciplined work in hiring and retaining nurses. Hawaii Pacific Health starts developing relationships with students in the University of Hawai'i-Manoa in the second year of their four-year program and knows when certain nurses who are spouses of military personnel are scheduled to rotate out of Hawai'i.

Hinson and his team also maintain relationships with nursing programs from California to New York, offering students a chance to do clinical work at its hospitals and 18 clinics. It also develops the skills of its own staff for specialized positions.

Hinson offers recent graduates $28.60 an hour to start at Straub Clinic and Hospital. The major hospitals generally attract more applicants than long-term care facilities such as Krieg's Hale Makua, which is short 13 nurses, and home health case managers, or home-care agencies such as Parmele's Kokua Nurses.

ASSISTANTS SCARCE, TOO

Both Hale Makua and Kokua Nurses said besides difficulty getting nurses, there's a big shortage of nurse assistants, people generally paid $10 to $16 an hour whose work can include helping patients dress and shower.

"There's a greater shortage of them right now than there are with nurses," Krieg said. He said Hale Makua is 17 nurse aides short. Concerned about the crisis, recently he helped secure a grant funded by the Robert Wood Johnson Foundation to look at broader community solutions to improving long-term care services, including increasing the workforce.

Said Parmele, "Whether it's because there's no real unemployment, or people just aren't going into the field, we're having problems finding nurses aides."

At Life Care Center of Kona, problems securing enough nurse aides led it to set up its own classes last year.

Now, "we're doing pretty good with nursing assistants," said Ray Marks, executive director of the 94-bed facility. He still has to cope with a nurse shortage and last week asked his sister facility in Hilo to send over registered nurses who were idle.

The worker shortages at the long-term care facilities have indirect effects on hospitals that transfer recuperating patients to them. A survey late last year by the Healthcare Association of Hawaii found 250 hospital patients were waiting for nursing-home beds. The situation is such that Queen's has looked to Mainland long-term care facilities as a practice of last resort. It transferred 11 patients last year to the Mainland facilities.

"You have a population out there who needs facilities, and there are not sufficient facilities," said Aggie Pigao-Cadiz, executive director of the Hawai'i Nurses' Association. She said the shortages, along with other healthcare issues locally, call for all parties to work together to solve the problem, from government agencies that fund Medicare and Medicaid to hospitals to government finding a way to fund more nurse education.

"The system needs to be reformed, any way you look at it."

Reach Greg Wiles at gwiles@honoluluadvertiser.com.