CORSICA, S.D. — Julie Yager's 92-year-old father died in February, but her struggle with the nursing home he lived in didn't end until months later.

Yager, who was not legally responsible for her father, Peter Oberosler, at the time of his death, began receiving bills for his stay at the Good Samaritan Society in Corsica.

“I thought I had made myself pretty straight, that I wasn’t financially responsible for the debt and that my dad didn’t have the money, and they didn’t deserve it," Yager said, referencing a call she made about a bill she was sent in February. "So I thought that would be the end of it, but I continued to get billings."

Yager ignored the bills, which she continued to receive through the spring. She said that while her father had only been at the Corsica facility for four days in January, the bill included the cost of seven days at the full rate of over $200 per day, rather than the prorated rate she said her father was supposed to receive.

She said she was told twice by Good Samaritan executives in Sioux Falls that the bills were mistakes and would go away, but she received additional bills after both of those conversations, and the amount for each bill was for a different amount without explanation. Eventually, Yager said, she was told the bills were going to collections.

“I was so overwhelmed with grief about what had gone on,” said Yager, who was unhappy with the level of care her father received while at the Corsica nursing home. “I advised them I wasn’t financially responsible — there was no estate, they should not continue to send out bills like that.”

Eventually, the bills were waived, and Yager said she was told she never should have been billed in the first place by Good Samaritan for her father's stays at either the Corsica facility or the location in Armour, where she moved him soon before his death. But Yager said the bills were only the culmination of a months-long struggle to navigate the unfamiliar territory that comes with ensuring a parent with dementia receives proper care that can be paid for.

“I was pretty emotional, because I had wasted so much time leaving my dad in the facility in Corsica instead of trying to get him out and moved on somewhere else. Just grasping for answers and trying to figure out what to do, it’s very difficult, very traumatic," Yager said. “There needs to be more resources and people to talk to when you find yourself in this position, and more sharing of information.”

According to the South Dakota State Plan on Aging for 2017 through 2021, it's estimated that the number of elders in the state will be 84% higher in 2035 than it was in 2010, and the number of elders with disabilities will be 71% higher. South Dakota was additionally designated in 2014 as having a significantly higher percentage of adult day services center participants who had been diagnosed with Alzheimer's or another form of dementia — a percentage higher than any surrounding state.

Good Samaritan has facilities in 24 states. Philip Samuelson, Good Samaritan Society's regional vice president for South Dakota, said while challenges and changes in long-term care vary from state to state, one issue in South Dakota is that, especially in rural areas, there is a need for more in-home care options and ways to keep people in their communities as long as possible.

"We’re blessed with a lot of land, and our population is spread out," Samuelson said. "Because of that, some of (the challenge) is reimbursement; some of it’s workforce."

During the middle stages of Alzheimer's, according to information from the Alzheimer's Association, a person will begin needing 24/7 care. For many who are unable to care for family members themselves around the clock or hire in-home services, which are typically less readily available in rural areas, that means putting a loved one into a residential facility.

According to the South Dakota Department of Social Services’ Medicaid report for the 2018 fiscal year, states surrounding South Dakota had higher reimbursement rates than South Dakota, ranging from 7% more in Montana to 46% more in North Dakota.

In March, the South Dakota legislature approved a 10% increase in Medicaid reimbursement to nursing homes, which was made effective for both the 2020 budget and the remainder of the 2019 fiscal year.

“Obviously that was a great investment, in our opinion, from the legislature and from Gov. Noem, and we’re so thankful for that investment," Samuelson said. "With that said, 10% is only a part of the way there. We need another 10%, and another 10%, to really get us above water on our Medicaid losses."

Prior to that increase, Samuelson said, every nursing facility in the state was losing, on average, $35 per resident day. Good Samaritan facilities received $72 per day for each person in assisted living and $155 per day for those in skilled nursing facilities.

Currently, Samuelson said, about 30% of those in the company's long-term care facilities are private pay, meaning they pay out of pocket. The other approximately 70% receive coverage from Medicare, Medicaid, insurance or other services.

Yager said she hadn't felt the staff at the facility in Corsica was adequately trained in how to handle her father's dementia, and that she saw trained staff let go soon after he was moved there. Samuelson said that Good Samaritan will be using the additional reimbursement it now receives from Medicaid to reinvest in its staff.

"Our staff is our greatest asset that we have, and if we have a high-quality staff, we’re going to provide high-quality care," he said.

Yager said she felt that even if nursing homes were receiving reimbursement rates as high as those in other states, facilities need more training on how to handle people with dementia, like her father.

“They’re complaining about the money thing, and I get that," she said. "But I think that there needs to be more assessment on the facility and what kind of patients fit for those facilities, for the sake of the patients."