A national nursing home staffing campaign is in development to aid operators in meeting the federal minimum staffing mandate, and the sector will hear more about the campaign this summer.

Dr. Dora Hughes, acting CMS Chief Medical Officer and acting director, Center for Clinical Standards and Quality, mentioned the campaign at the end of a Centers for Medicare & Medicaid Services (CMS) stakeholder call on Tuesday, just one week after the rule was finalized.

Hughes told stakeholders that the finalized rule is “balanced and achievable,” while also acknowledging that some facilities may face unique challenges in rural areas.

Hughes’ views on the finalized mandate are in stark contrast to those shared by the nursing home industry, with LeadingAge and the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) criticizing a lack of financial support for the rule.

CMS officials acknowledged last week that some facilities will end up closing as a result of the mandate, but that the current situation with inadequate staffing has resulted in poor quality of care and necessitated a change.

Hughes said CMS considers the rule a “cornerstone” for President Biden’s action plan regarding skilled nursing facilities.

Hughes was one of many to speak on the latest rules and regulations during Tuesday’s call. Other nursing home topics discussed included changes to the Quality Reporting Program (QRP) and the Transforming Episode Accountability Model (TEAM). 

“We all hope [the rule] will have a meaningful, positive impact on the care of our nation’s elders and people of all ages who reside in nursing homes, as well as the incredible workforce that cares for them,” CMS Administrator Chiquita Brooks-LaSure said during the call.

The finalized staffing rule requires a total nurse staffing standard of 3.48 hours per resident day, with 0.55 hours of direct registered nurse (RN) care and 2.45 hours of direct nurse aide (CNA) care. The 24/7 RN requirement was also kept in the finalized rule.

Quality Reporting Updates and the TEAM Model

Hughes touched on the FY 2025 Skilled Nursing Facility Prospective Payment System (SNF PPS) as well, including the additions to the Quality Reporting Program to add three new social drivers and determinants of health, with living situation, food and utilities among them.

“The addition of these social drivers and determinants of health items across these programs not only allows CMS to elevate the voices of the patient and their caregiver, but also improve data collection on social drivers and determinants of health items, fully aligned with CMS’ national quality strategy goals of equity and engagement,” said Hughes.

In terms of the TEAM model, Dr. Liz Fowler, deputy administrator and director of the Center for Medicare and Medicaid Innovation, said the five-year episode-based payment model for five surgical procedures will test whether hospital financial accountability for these procedures will reduce Medicare spending and preserve or enhance quality of care.

“While the mandatory nature of the model is a shift from our previous bundled payment models, qualitative interviews with past model participants and other key stakeholders suggests that providers are expecting the Innovation Center to move in this direction after more than a decade of work in this area,” said Fowler.

Model participants and other key stakeholders agreed with CMS that episode-based payment models align quality improvement goals across providers and support better care processes and outcomes for beneficiaries, added Fowler.

TEAM would cover all costs associated with an episode of care, including a skilled nursing stay, but it appears that select hospitals would be in the driver’s seat if approved. Operators could be part of the new episode-based proposed mandatory payment model, designed to coordinate care for patients who undergo some surgical procedures under traditional Fee-for-Service Medicare (FFS).

Staggered timeframe, exemptions will help

On the staffing mandate’s staggered timeframe, Hughes said it will help operators experiencing an ongoing staffing crisis to implement the rule more easily. Rural areas have a five-year period while nonrural communities have three years to put the requirements in place. 

“We understand that nursing homes, particularly those in rural areas, may encounter unique challenges in meeting the new minimum nurse staffing standard requirements. These challenges could include workforce shortages in many areas, financial constraints and geographic barriers,” added Hughes.

Time-limited hardship exemptions are meant to provide temporary relief, and CMS expects operators to work toward full compliance as soon as possible, Hughes said.

“CMS issued a final rule to establish the first ever minimum nurse staffing requirements within nursing homes, hoping to drive the delivery of safe quality care for all residents,” said Hughes. “Despite existing requirements that nursing homes provide sufficient levels of staffing, persistent understaffing remains.”

CMS received more than 46,000 comments on the rule, she said, which included many personal stories of residents going hours without toileting assistance, days without showers and having medications delayed or missed entirely, while also experiencing preventable safety events like falls and pressure ulcers.

Family members commented that they helped nursing staff with providing basic care, she said.

“Unfortunately, these dire conditions disproportionately affect residents of color, with existing literature demonstrating that residents of color do not receive nursing home care of comparable quality to white residents,” added Hughes.

The nursing home staffing standard will contribute to reducing health disparities, Hughes said, by ensuring that facilities maintain adequate staffing levels to meet the needs of residents.

Mandating minimum staffing requirements will improve quality of care provided to residents from marginalized communities, she noted, who would otherside be at higher risk for experiencing disparities.