Vermont, New York and Maryland led the nation in terms of the share of nursing homes utilizing agency nursing staff in 2022.

That’s according to a Health Affairs report published Wednesday. The study authors compared free-standing nursing homes’ usage of agency staff in the years leading up to Covid-19 with usage of agency staff during the pandemic.

In 2018, 23% of nursing homes used agency nursing staff, which accounted for about 3% of all direct care nursing hours worked, the researchers found. But by 2022, nearly half of all nursing homes were using agency staff, and 11% of all direct care nursing staff hours were provided by agency workers.

However, patterns in agency staff usage varied by state. These are the 10 states with the highest share of nursing homes utilizing agency nursing staff in 2022, according to the report:

• Vermont (86.6%)
• New York (73%)
• Maryland (70.9%)
• Pennsylvania (70.5%)
• New Jersey (68.7%)
• Montana (68.1%)
• North Dakota (68%)
• Oregon (67.9%)
• Massachusetts (67%)
• Alaska (66.2%)

On the flip side, Oklahoma (29.9%); Washington, D.C. (26.2%); and Arkansas (16.3%) had the lowest use of direct care agency nursing staff in 2022.

The increasing use of agency staff weighed on nursing homes’ bottom lines, with agency staff being 50% to 60% more expensive per hour than directly employed staff, according to the findings. And more use of agency staff also correlated to lower five-star ratings.

These findings have a bearing on the proposed federal staffing mandate looming over the nursing home sector, the study authors noted.

“Given the recent push to implement more stringent nursing home oversight, including proposed regulations that would increase nurse staffing levels, our findings suggest that policy makers need to consider the recent increased use of agency staff and their higher labor costs,” they wrote.

This research will come as no surprise to nursing home providers. They have been vocal about the severe staffing shortages they faced during Covid-19 and in the pandemic’s aftermath, which led to an increasing reliance on agency workers. Providers also protested what they viewed as price gouging practices on the part of agencies, which has led to reform efforts in various parts of the country.

More recently, many owners and operators have reported the use of agency staff has declined, but concerns still remain about what the future holds, particularly if the federal staffing mandate is implemented as written.