Outdated VBP Measures Ignore Realities at Nursing Homes of Staffing Crisis, Leadership Turnover

General staffing metrics used to assess quality of care hold less weight these days and need to be updated, experts say, because the entire skilled nursing industry is struggling to build and retain its workforce.

These quality measures need to be presented through the lens of the pandemic and the staffing crisis, SNF leaders say. For starters, the ongoing labor shortage has meant greater reliance on agency staff, which in turn impacts turnover rates – a metric used to assess value-based purchasing programs and reimbursements. Moreover, figures for turnover among leadership rather than general staffing figures more efficiently capture quality, they said.

And for that reason, the Centers for Medicare & Medicaid Services (CMS) and other government agencies need to be more selective with staffing stats connected to VBP. Such stats would more accurately measure which facilities are delivering better care quality, they argue.

Total staffing turnover isn’t a very good indicator of care quality when high turnover is seen among a large swath of the industry. At the beginning of 2022, the National Consumer Voice found that based on data from Care Compare, the average nursing facility needed to replace half of its direct care staff each year. 

Steve LaForte, director of corporate affairs and general counsel for Cascadia Healthcare, said the staffing-related measures “1,000%” aren’t reflective of the current staffing crisis. A raw staffing turnover number, especially now in the industry, feels like a “punch to the gut,” he said.

“From a quality measure standpoint, staffing should be put on hold, and rather have the conversation, the time and effort focused on how to come up with big picture solutions,” said LaForte. “It’s not just workforce development in a vacuum, it’s not reimbursement in a vacuum to be able to pay staff living wages, it’s not just agency in the vacuum, it’s all those things together … I’d like to see a realistic discussion and a realistic approach.”

The turnover measure in VBP disproportionately impacts rural nursing homes too, according to Aimee Middleton, vice president of operations at the Evangelical Lutheran Good Samaritan Society.

When a registered nurse (RN) leaves a rural facility, Middleton said, it’s even more challenging to recruit and hire a replacement.

“In the rural community of Miller, South Dakota, our position for a night shift nurse has been open for three years. Where we cannot fill open positions, we are forced to make difficult decisions like hiring [agency workers] at triple the cost,” noted Middleton.

Short-term agency contracts negatively impact turnover rates to be included in VBP, she said. And this undermines the efforts of nursing homes.

“In reality, we are doing everything we can to recruit and retain permanent staff for those positions,” Middleton told Skilled Nursing News.

Adjusting benchmarks for current crises

It is important to remember, however, that such measures have benchmarks based on performance, Steven Littlehale, Zimmet Healthcare Services Group’s chief innovation officer, told Skilled Nursing News.

“If everyone is struggling and they go to create a benchmark off of high turnover, those benchmarks are going to be organically altered,” said Littlehale. “That will be built into the methodology.”

Still, low staffing or inconsistent staffing within the industry right now could “absolutely” impact proposed VBP staffing measures like total turnover, partly because they are not more specifically defined nor factor certain on-the-ground realities related to staffing, he added.

“Those measures are very, very broad,” said Littlehale. “They’re looking at the return to hospital, both long-stay and short-stay. They’re looking at successful discharge to the community. All of those things would absolutely be impacted by an increase in staffing and adequacy of staffing. The potential is definitely there.”

Along with total nursing staff turnover starting in 2026, CMS proposed the following measures for VBP:

• Replacing the SNF 30-day all-cause hospital readmission measure (SNFRM) with the SNF within-stay potentially preventable readmission measure (SNF WS PPR) by 2028.
• Monitoring percentage of residents experiencing one or more falls with major injury and resulting in a long stay starting in 2027.
• Monitoring the percentage of SNF residents who meet or exceed an expected discharge score during the reporting period by 2027.
• Monitoring the number of hospitalizations per 1,000 long-stay resident days by 2027.

Measures finalized by CMS in the 2023 SNF PPS Final Rule include:

• Monitoring SNF healthcare-associated infections requiring hospitalization (SNF HAI), to be incorporated in 2026.
• Monitoring total nursing hours per resident day staffing, to be incorporated in 2026.
• Tracking discharge to the community from post-acute care, set to take effect in 2027.

Littlehale hopes CMS continues to hold true to its obligations, and update and adjust these performance metrics so that they don’t ignore the current realities. It seems that the current measures are outmoded, certainly when it comes to accounting for a staffing crisis, he said.

Going forward, CMS’ adjustments to the Five-Star Rating System could be a good indicator for how the agency will adjust the VBP measures, he said.

Honing in on better VBP measures

CMS believes a general staffing turnover figure captures overall care quality well, when actually leadership turnover – including that of administrators – is a much better indicator of care quality, Middleton and LaForte said.

“There needs to be some context. I think focusing on leadership, that speaks to higher quality in an organization,” said LaForte.

Nursing experience and resident acuity matter too, Middleton said, and should be incorporated into VBP measures.

This is especially true when considering the high amount of agency staff that have been in SNFs since the pandemic began, with different short-term workers revolving through facilities and replacing longtime staff, whose presence has proven benefits for resident care.

“In many of our small towns, our nurses have worked there for several years – they are family to the residents,” said Middleton. “We staff to our residents’ needs, drawing from the skills of caregivers within and outside of the nursing department – not just RNs – who know and care for our residents like family.”

Trying to execute on long-term plans tied to quality care delivery – like establishing an institutional special needs plan (I-SNP) – is also near impossible if there’s a revolving door for leadership.

Leadership changes that aren’t tied to mergers and acquisitions in the space should be a big consideration as well for care quality, providers said.

SNF operators in Florida alone have faced a 150% turnover for administrators in a year, with one particularly bad year since the pandemic where the metric reached 250%, according to Longevity Health Plan.

That’s specifically for their clients.

At the beginning of the year, Wisconsin found that out of 345 nursing homes in the state, there were 262 changes in administrator positions and 228 changes in director of nursing positions since 2022.

Littlehale believes CMS and other regulatory agencies can better capture care quality, specifically when it comes to staffing-related measures, through time-appropriate benchmarks. This means, not using a period that predates the pandemic or the current staffing crisis.

Making VBP staffing measures as localized as possible could better measure performance as well, he said, along with tracking resident and staff satisfaction, or career paths of clinical staff.

Going one step further, Middleton said the shortcomings seen in the VBP measure illustrate why a one-size fits-all minimum staffing requirement would be untenable for the industry, and especially for rural facilities.

Federal proposals of any kind that don’t account for today’s historic workforce and pipeline shortages will force seniors to travel further to receive care, she said, as reduced admissions and closures exacerbate access issues.

“The Good Samaritan Society supports more meaningful solutions, like customer satisfaction surveys, as a tool to incentivize better care and educate families on the quality of care being provided in skilled nursing facilities,” she added.