Operators that had more staff coming in and out of a skilled nursing facility, while maintaining comparable direct care hours to those with less staff, had increased susceptibility to COVID outbreaks last year, according to a report released by public policy journal Health Affairs.
Findings are interestingly at odds with industry initiatives to add more part-time staff, and have workers visit multiple facilities across one or more operators to better distribute care and accommodate workers’ schedules.
“Nursing homes were in emergency mode and scrambling to get enough staff in. Part of the way that they met their most basic staffing needs were to use part-time [workers], agencies to fill in,” said David McGarry, assistant professor in the Department of Medicine, University of Rochester in New York and lead author of the July report.
That’s not to say operators with lower staffing levels were running on reduced hours — a comparable amount of hours were provided per patient with less staff coming into the building.
“Our findings suggest a consistent, stable staffing force is important, and full-time is better than part-time. So those two things are definitely at odds with each other in terms of infection control,” added McGarry.
Health Affairs monitored staffing size in 7,000-plus nursing homes with no cases as of the first week of June, observed from June 1 to Sept. 27 last year, then incorporated virus outcomes reported on the Centers for Medicare and Medicaid Services (CMS) COVID-19 Nursing Home Data database, and the New York Times COVID-19 database.
Part-time workers, agency staff, therapy providers and any other workers that set foot in participating facilities were counted as a “unique staff member” in the report.
Data were expressed as rates per 100 beds, researchers said, to account for facility size as it relates to exposure risk.
Nursing homes with the highest number of “unique staff members” had cumulative resident case rates 92% higher than facilities with the lowest number of such workers; Cumulative staff case rates and resident death rates were 69% and 133% respectively, between SNFs with the highest unique staff member count and operators with the lowest count.
McGarry told SNN a fully vaccinated staff should be able to break the link between staff size and COVID risk, but the larger the staff size, the harder it is to get to 100% staff vaccination rates.
One other takeaway from Health Affairs’ study, McGarry said, suggests more of a mindful separation between quality of care and infection control moving forward, since both of these goals have different criteria. Quality of care could mean more specialists on site, meaning increased staff size, which as the report indicated has a negative effect on infection control.
“You shouldn’t conflate quality of care within the nursing home with infection control — those two things can be different. I think sometimes we’ve adopted this lens that views infection control as the same as all other forms of nursing home quality and it’s not, it’s different,” explained McGarry. “Things that matter for keeping COVID out are not necessarily the same things that matter for taking good care of residents within the facility.”
McGarry hopes a better understanding of the relationship between staff size and infection risk can better prepare the industry for the next pandemic or seasonal flu outbreak.
Researchers suggested operators not only reduce their staffing size while maintaining hours per resident, but also make full-time work attractive to nursing home staff by including affordable child care and other social supports.
“We’re looking forward and trying to prepare for the next pandemic or other infectious disease outbreak. What can we do differently? Pay nursing home staff a higher wage and better benefits so that it’s compatible with using consistent full-time staff and reducing turnover,” noted McGarry.
A small-home option called the Green House model was suggested too — eight to 12 residents live together in a home-like setting, the report said, with smaller and more consistent staff.
Remote work for staff that don’t have to come in close contact with residents was suggested as well.
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