Even before COVID-19, the median staff turnover at U.S. nursing homes was nearly 100%, with even less continuity at facilities with lower federal star ratings, a new study has determined.
Workers turned over at a median rate of 94% and a mean rate of 128% in 2017 and 2018, according to an analysis published this week in the journal Health Affairs. The mean rates were greater than 100% across all three primary employee types studied — registered nurses (140.7%), certified nursing assistants (129.1%), and licensed practical nurses (114.1%).
Staffing has long been a challenge for the post-acute and long-term care sector, and the numbers probably won’t come as a shock to those who operate and work at nursing facilities.
But the analysis represents the first comprehensive look at turnover based on payroll-based journal (PBJ) data; while earlier attempts to quantify churn at nursing homes relied on small samples, the study drew from federal data collected from more than 15,000 facilities across the country, totaling 492 million shifts worked by 4.4 million staffers.
The team — Ashvin Gandhi and Hulzi Yu of UCLA, and David Grabowksi of Harvard — developed a weighted metric based on care hours to measure turnover. If two nurses provide 80% and 20% of care at a facility, respectively, and they both leave to find new jobs, the turnover rate would be 100%.
As with other investigations into nursing home quality, familiar patterns emerged within the wider results. Facilities with the lowest one-star rating from the Centers for Medicare & Medicaid Services (CMS) had median turnover of 135.3%, while the best five-star facilities had turnover of 76.7%.
For-profit and chain-owned facilities saw greater turnover, the researchers found.
“This may reflect for-profit nursing homes failing to support the needs of nursing staff and chain-owned facilities imposing stricter standardization and oversight on their employees,” they wrote.
Disparities in pay may also contribute to differences in staffing stability at nursing homes, with facilities in low-income areas — as well as those with greater proportions of residents covered under Medicaid — having greater turnover.
“Because Medicaid reimbursement rates are generally lower than those of Medicare and private payment, it is likely that facilities with a greater
share of Medicaid residents are less financially capable of paying staff higher wages and offering benefits, which could contribute to higher turnover,” the researcher noted.
High turnover and low pay for frontline nursing home workers has emerged as a key issue as regulators and policymakers look to derive lessons from the COVID-19 pandemic; one of the earliest analyses of coronavirus spread identified staffers working at multiple facilities as a major vulnerability for SNFs looking to keep the virus out.
The UCLA-Harvard study stopped short of blaming high turnover for the COVID-19 toll in nursing facilities, but the report concludes with a call to consider making staff turnover a publicly disclosed nursing home quality metric.
“Recent concerns regarding the spread of COVID-19 in care facilities have heightened awareness of the possible implications of nursing
staff stability for infection control, which may prove a particularly important consideration during the current pandemic and in future
public health emergencies,” the team noted. “Facilities with lower turnover rates may be better positioned to withstand challenges, such as absences because of sickness. Staff members at such facilities may also be more familiar with the infection control protocols of their facility.”