Covid era changes to census and staffing – as well as closures of nursing homes – should be more closely considered in assessing the right level of staffing being proposed by federal agencies, while a focus on funding can improve the chances of fulfilling the increased requirements.
That’s the analysis of a report released by Altarum on Friday. According to the report, the number of nursing homes in the U.S. steadily declined, with 266 fewer nursing homes in the last quarter of 2022 compared to 2019, a trend intensified by the pandemic.
This closure of nursing homes contributed to delays in patient access to beds, Altarum analysts noted. Similarly, the average resident census in nursing homes decreased until the second quarter of 2021, rebounding thereafter.
The total number of residents and employees in nursing homes also experienced fluctuations, with the workforce recovering to a lesser extent than residents.
“The recent changes in nursing home staffing, census, and the number of nursing homes operating in the U.S. raises the question of how these changes have interacted to affect the extent of understaffing during and after the pandemic and the extent to which the proposed staffing standards are currently being met,” they wrote.
The Altarum report notes that achieving the newly proposed staffing standards would require “a significant increase” in the numbers of registered nurses (RNs) and certified nurse aides (CNAs) employed by nursing homes, accompanied by a rise in labor costs for nursing homes across the country, both through the need to pay additional staff and the higher wages that would likely be needed to attract them.
“[I]ncreasing staffing levels to meet the new requirements would require much faster overall spending growth. To the contrary, where such standards are not enacted with the resources required to meet them, the trends described in this paper suggest that extensive understaffing will likely continue,” Altarum analysts concluded.
Although the Centers for Medicare & Medicaid Services (CMS) estimates that the proposed staffing rule would bear a cost of $4.06 billion per year for the first 10 years of implementation, nursing home advocates estimate the figure to be much larger.
CMS’ proposed minimum staffing standards call for a daily minimum of 2.45 HPRD provided by CNAs and 0.55 HPRD by RNst.
The Altarum paper relied on the Payroll-Based Journal (PBJ), offering detailed information on staffing for every nursing home in the country. Quarterly summaries of these data, prepared by the Long Term Care Community Coalition, form the basis of the analysis. Additional data from Altarum’s Health Sector Economic Indicators (HSEI) Labor Brief complemented the information on nursing home employment.
The analysis of hours worked by RNs and CNAs indicated a temporary improvement in staffing rates during the pandemic, followed by a return to pre-pandemic levels or even lower. The proposed staffing standards were not consistently met, with significant variations among nursing homes, analysts found. Failing to meet these standards was correlated with the size of nursing home census, with larger homes more frequently falling below the proposed levels, they said.
“These results indicate that staffing levels per resident at nursing homes increased slightly during the pandemic, suggesting that, despite absolute declines in the number of staff, there was a temporary improvement in nursing home staffing rates,” analysts noted. “However, this appears to have been primarily the result of declines in staffing levels that lagged declines in the number of residents. As the impacts of the pandemic receded, staffing reverted to levels that were similar to or even below their pre-pandemic values.”
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