A national advocacy group for seniors ranked Alabama 50th out of 51 in a report released Thursday ranking the quality of nursing home and home-based care for older people and those with disabilities.

The AARP creates a state scorecard for long term care once every three years, and this is the first released since the start of the pandemic. The report measured performance in five broad areas: access and affordability, consumer choice, safety and quality, support for family caregivers and community integration. Alabama slipped from 48th place in the previous score card.

The pandemic worsened many of the problems that already existed in nursing homes and other long-term care. Staffing became more difficult, and isolation increased during the years nursing homes locked down to prevent the spread of COVID-19, the report found.

Only West Virginia scored worse that Alabama. The rest of the lowest-ranking states are all in the South, including South Carolina, Mississippi and Tennessee. Minnesota scored the highest, followed by Washington state ranked second.

Alabama scored poorly overall, with the lowest scores on access to care at home and community integration. Alabama lags behind the rest of the nation in funding for home-based care, the report found.

Jamie Harding, spokesperson for the AARP of Alabama, said the recent announcement that Help at Home would leave the state and dismiss nearly 800 workers illustrates the problems facing Alabama. It’s difficult to hire and retain workers in the state for jobs that often have low pay and difficult work environments. Alabama is an aging state, and it is becoming increasingly difficult to find workers to care for its growing numbers of seniors, she said.

“We have to start paying attention to this now because it’s already not in a good place,” Harding said. “If we don’t address it now, it’s going to be a crisis.”

Brandon Farmer, president of the Alabama Nursing Home Association, said in a statement the group has worked hard to address workforce issues in Alabama. The association has partnered with the state’s community college system to create apprenticeships that allow nurses in training to work in long-term care facilities. A new certificate program allows specially trained workers to dispense medication, freeing up nurses for other tasks, Farmer said.

“While we appreciate the AARP releasing this scorecard, we don’t think it takes into account all of the initiatives Alabama Nursing Home Association members are undertaking to improve and increase the long-term care workforce in our state,” Farmer said.

The association also played a role in creating a network that allows more people to receive care at home through the Medicaid system, Farmer said.

The AARP of Alabama is pushing legislators to create tax credits for family caretakers. Home-based care can cost more than $40,000 a year, the study said, and many families pay out of pocket. Harding said about 700,000 people care for loved ones at home in Alabama.

The quality of care in Alabama nursing homes had mixed ratings. Alabama has a higher-than-average rate of residents living in nursing homes rated as top quality, but the lowest rate of staff COVID vaccination, the study said.

Alabama also has a high rate of nursing home residents taking anti-psychotic drugs, the study found. Experts have raised concerns about antipsychotic use in nursing homes due to concerns that some patients may receive the drugs unnecessarily.

The study found that Black residents nationwide are less likely than white or Asian people to live in top quality nursing homes. Patients in five-star facilities receive higher quality care and have better outcomes than those in lower-ranked nursing homes, the report said.

“We have continued to see that there are staffing issues and when there is not enough staff, there is not high-quality care,” Harding said.