As the Biden administration looks to establish a minimum staffing requirement for the nursing home industry as part of its reform package, evidence suggests that measuring daily staffing variation may be just as important in understanding how staffing affects care quality.
That’s according to a study published in the JAMA Network Open this week looking at how daily staffing at nursing homes is associated with five-star quality measures.
What the study found was average staffing levels and minimum staffing standards do not fully capture the association of more staffing to better nursing home quality.
“Nursing homes that have more fluctuations in daily measures have lower quality, suggesting that having more daily variations in staffing, or in other words more instability in your labor force, tends to lower your quality at least in terms of some of the five-star measures,” Dana Mukamel, lead researcher in the report, told Skilled Nursing News.
When the Centers for Medicare & Medicaid Services (CMS) conducts research to determine the level and type of staffing needed as part of its proposed minimum standards, the government agency should take into account daily staffing variation, according to Mukamel.
The study included 14,499 Medicare and Medicaid-certified nursing homes nationwide using Payroll Based Journal (PBJ) data in 2017 and 2018.
The data looked at the number of hours worked by each staff member each day, including contracted staff. Resident daily census data was calculated, based on the minimum data set. The researchers used these data sets to create variables measuring the daily number of RN and CNA hours per resident day.
A total of 2,551 facilities (19%) were nonprofit and 9,476 (71%) were for-profit, with 7,727 (58%) chain-affiliated. The majority of residents were also Medicaid beneficiaries.
Following a recommendation from the Department of Health and Human Services Office of Inspector General (OIG), CMS announced earlier this year that it would post numbers on staffing turnover and weekend staffing levels for nursing homes on the Medicare website.
The numbers will be used in its five-star rating system beginning in July as multiple sources, including a New York Times report, have raised concerns over staffing data reporting and discrepancies in weekend staffing numbers.
Mukamel felt her research showed the validity in measuring staffing on a daily basis for nursing homes.
She added that daily staffing is something nursing homes need to be paying attention to on a regular basis if they want to improve quality and run a more efficient, high-quality operation.
“What we are saying is if you use this new measure it actually gives you a different quality ranking for the nursing home,” Mukamel said. “It’s not enough to just look at the average level, you also need to know how stable that average is. You can have two nursing homes with the same average level of staff and if one of them is not very unstable, that’s not a nursing home that provides the same good quality.”
The data also showed that for-profit facilities tended to have less stable staffing. Nonprofit nursing homes had low variability in staffing, for both RNs and CNAs, relative to for-profit nursing homes, according to the report.
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