Federal Staffing Minimums Won’t Solve Labor Woes For Nursing Homes in Disadvantaged Neighborhoods

As the Centers for Medicare & Medicaid Services (CMS) seeks to implement health equity across the care continuum, nursing homes in disadvantaged neighborhoods continue to be staffed for fewer hours by clinical workers.

A recent study published in the Journal of the American Geriatrics Society compiled data from more than 12,000 nursing homes, finding the disparity between such nursing homes and those in more economically advantaged areas could compromise the safety of residents.

Physical and occupational therapist staffing levels were 38% lower in severely disadvantaged neighborhoods, registered nurse (RN) levels were 30% lower and certified nursing assistants (CNAs) were 5% lower, according to the study.


Licensed practical nurses (LPNs) were the only exception with no disparities seen.

While it’s been proven that nursing homes in disadvantaged neighborhoods are more likely to serve racial and ethnic minorities, it’s unclear how a neighborhood’s socioeconomic factors influence facility staffing.

County information or a ZIP code used in research doesn’t take into account neighborhood-level differences, Travers said.


Instead, researchers examined neighborhoods using the “area deprivation index” which aggregates income, education, employment and housing for small geographic units representing 600 to 3,000 residents.

The ADI is scored 1-100, Travers said, with higher scores indicating greater socioeconomic disadvantage. Facilities are considered to be located in severely disadvantaged neighborhoods if they fall in a census block with a national ADI ranking greater than or equal to the 85th percentile.

In other words, the index helped researchers determine the range between severely disadvantaged neighborhoods and those with an socioeconomic advantage.

Researchers calculated the area deprivation scores for nursing homes in the study, finding 16% were in the “severely disadvantaged” category. They were more likely to be for-profit, rural facilities serving a higher proportion of Black residents and Medicaid recipients.

Minimum staffing ratios, another CMS initiative, would not fix staffing issues researchers are seeing in these particular nursing homes, according to Jasmine Travers, senior author on the study and assistant professor at NYU Rory Meyers College of Nursing.

It’s a much more wide ranging, multi-faceted problem, she said. Operators and local governments need to think about what would attract people to work in the neighborhood, like educational resources and transportation, to name a few ideas.

“If the nursing home is reflective of the neighborhood, how do we change that to improve the desirability to work in those nursing homes? That’s something that we need to make sure that we’re paying attention to when we’re making these minimum staffing standards,” Travers said.

Targeted interventions are needed to meet the moment, according to the study, including enhancing Medicare and Medicaid reimbursements specifically for nursing homes in disadvantaged neighborhoods.

Micro-targeted funding sources; workforce recruitment efforts focused on pay, transportation, and working conditions; and efforts to retain staff, like bridge programs for CNAs and LPNs to become RNs are sorely needed in these nursing homes, added Jason Falvey, another author on the study and an assistant professor of physical therapy and rehabilitation services at the University of Maryland School of Medicine.

CMS has plans to meet with Travers and other researchers on the study to better inform their federal minimum staffing ratio proposal due next year, she said. The agency is looking at such studies to determine what sorts of unintended consequences might happen from a national minimum staffing standard.

“I would hope, for one, that they recognize that just setting a standard … getting the numbers right is just half the battle,” Travers said. “How do we actually get the numbers to where they need to be, is the other battle. It might just not be CMS alone, increasing Medicaid reimbursement is going to be partially CMS and partially up to the state.”

There was little to no difference in staffing hours for clinical workers with lower salaries and training, like CNAs and LPNs, between disadvantaged and economically advantaged neighborhoods.

This suggests that nursing homes in disadvantaged communities are substituting care with staff who may have less training, Travers noted.

Put another way, RNs provided five hours and 36 minutes less care per day in a 100-bed facility that happened to be located in a disadvantaged neighborhood, compared to similar facilities in more well-off neighborhoods.

This is on top of an industry wide staffing shortage made worse by the pandemic – 223,700 nursing home workers have left the sector since 2020, according to the Bureau of Labor Statistics (BLS).

Nursing home residents are having more complex needs as well; higher levels of staffing, notably more RNs, is associated with lower rates of infection and mortality, according to the study.

Without assistance, workforce recovery in the sector will not happen until at least 2026, the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) has projected.

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