‘Counterintuitive to the Goal:’ Impending Five-Star Staffing Measures Don’t Address Ongoing Labor Challenges

Operators and nursing home industry leaders wait with bated breath for the implementation of new staffing measures in its five-star rating system starting in July, a move seen by some as insensitive in light of a historic staffing shortage and soaring agency use.

While facilities have been reporting staffing turnover and weekend staffing data since January, it’s unclear how much weight the Centers for Medicare & Medicaid Services (CMS) will give the new measures compared to other areas like quality and regulatory requirements.

CMS is adding three staffing turnover measures as part of its rating system – the percentage of registered nurses that have left over a year’s time frame; the total number of nurses that have left over the year, including RNs, licensed practical nurses (LPNs) and nursing assistants; and the percentage of administrator turnover.


“I do celebrate the Nursing Home Compare measures in general … I’m not sure I celebrate sometimes how it’s calculated or what goes into it,” said Michael Manuel, vice president of strategic development at AbleHearts. “We’re not addressing the problem, all we’re doing is reporting the problem. In the industry, we’re very familiar with what the problem is.”

Figuring out how to report the good and the bad players is a start, Manuel said, but there should be a component to help the industry figure out how to solve the staffing problem as well.

“When the government asks for more and more information, data collection, we’re taking that clinical leadership off the floor and away from the patient. That’s counterintuitive to the goal,” added Manuel.


AbleHearts operates 16 skilled nursing facilities across Texas, Missouri, Illinois, New York and Florida.

Turnover measures would also include agency staffing, according to Steven Littlehale, chief innovation officer for Zimmet Healthcare Services Group.

“The staffing crisis that we’re in is going to be reflected in how the measures are entered into five-star – it’s not going to be this fabricated ideal that CMS has been judging facilities against,” he told SNN.

Weekend staffing data will also be published on the Care Compare website but will not be part of the five-star system, Littlehale said, at least for now.

If they were to incorporate weekend data into five-star, the metric would be “pretty potent,” spilling over into rehospitalization data and survey performance, according to Littlehale.

He also wonders if the additional measures will have unintended consequences on a system that already acts as a way for CMS to influence market behavior.

If anything, the additional measures would confirm the gap between high performing and poor performing facilities, rather than widen it, he said.

“I’m sure that [CMS is] well aware of how much five-star influences the day to day solvency of a skilled nursing facility,” said Littlehale. “They’re paying the consequences already, they’re already paying the price. This is just going to, I think, underline it a few times and put it in boldface.”

Manuel said the measures could widen that gap, but at the same time force operators to get creative with ways to improve these staffing metrics.

AbleHearts, for one, considers weekend staff members full time employees – many work three 12-hour shifts Friday, Saturday and Sunday, Manuel said.

Implementation remains unclear

With implementation just a month away, facilities still don’t know how much the new measures will influence their overall score or if concessions will be made in light of the ongoing staffing crisis.

Littlehale assumes the measures will be folded into the staffing domain but it’s unclear how the measures will be weighted.

“Is it going to influence your five-star staffing rating a little bit? A lot? We just don’t know at this point. They haven’t specified, even on the most recent open door call … it’s a little late in the game at this point,” said Littlehale.

The five-star “stool” is made up of three legs, Littlehale said, including staffing, quality and regulatory measures. Historically, regulatory measures have been the most weighted, followed by staffing and then quality, he added.

When CMS implemented a star rating overhaul to separate short- and long-term stays, roughly 36% of SNFs saw a drop in their overall star ratings, while 17% saw their rating improve.

“It could be in the final moments that we truly understand how they’re using this data,” Littlehale explained.

CMS may use state averages or national averages as a benchmark for positive staffing data, since they have both, Littlehale said, but he hopes the agency chooses state data.

Staff availability is so regionally influenced by what’s happening in any given community, he said.

Just taking RN turnover, the national average is about 51.2%, according to Care Compare. Florida’s RN turnover is just over 56%, a “pretty decent spread” compared to the national average, Littlehale said.

“This is a proof point that a Florida facility should not be compared to the nation or other states where there’s super low turnover,” he added.

CMS has not indicated if they will acknowledge disparities like this in their methodology.

The federal agency’s timing in collecting this staffing data, and incorporating turnover into five-star “doesn’t land nicely” for leaders in the sector obviously, Littlehale said, with a continuing staffing shortage crippling the industry.

Manuel pointed to the sunsetting of the temporary nurse aide (TNA) program, coupled with “onerous” regulation lacking any financial federal support.

Many facilities across the country are still heavily using agency staff too – further skewing turnover rates.

At the same time, Littlehale doesn’t believe CMS would attach additional penalties to the staffing measures. Repercussions are already built into the survey process for adequate staffing, he said, but there’s really nothing that looks specifically at turnover or agency utilization.

Data opportunities and alternate measures

While Vincent Mor, professor of health services, policy and practice at Brown University, believes the turnover additions to the five-star rating system are a step forward, he also believes retention would be a better quality measure.

But retention, Mor said, can generally be harder to predict than turnover.

“Some of those people aren’t going to make it past the first two weeks … in some sense that’s kind of the cost of doing business in a labor shortage market or environment,” said Mor said. “You can have a very high turnover rate, but still a very high retention rate.”

Littlehale said he’d like to see customer satisfaction better represented in the five-star measures.

CMS has the ability to measure both, Mor added, but it’s increasingly difficult for the agency to squeeze all these variables into one staffing level metric.

Still, the data that exists through the Medicare.gov website can still provide a path for operators to take a hard look at how such staffing data compares to peers, and take steps to improve if needed, explained Littlehale.

“A facility has an opportunity today – and since January – to be looking at their performance compared to the state and compare it to the nation,” said Littlehale. “It’s very easy to say, ‘CMS is doing something to me,’ and dismiss it as more of a regulatory penalty or bureaucracy.”

Manuel said these have always been challenges the nursing home sector, and wider health care industry, has had to face. It will simply be easier to measure who does better at it, he said.

Operators could get “tremendous insight” from the newly reported staffing data, added Littlehale. Facility leaders can see how they fit in with competitors, pinpointing what they’re doing right for turnover or weekend staffing numbers and perpetuate positive data, or shine a light on problematic data before it gets worse.

“Now’s the time to make sure the data you’re submitting is actually accurate, because it is being publicly reported,” said Littlehale. “What more can we squeeze out of this data … what else can it point to? How else can it help me.”

Companies featured in this article:

, ,