Association of Staffing Instability With Quality of Nursing Home Care

Abstract

ImportanceRecent work suggests that instability in nursing home staffing levels may be an important marker of nursing home quality. Whether that association holds when controlling for average staffing levels is unknown.ObjectiveTo examine whether staffing instability, defined as the percentage of days below average staffing levels, is associated with nursing home quality when controlling for average staffing levels.Design, Setting, and ParticipantsThis quality improvement study of 14 717 nursing homes used the merged Centers for Medicare & Medicaid Services Payroll Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term-Care Focus data for fiscal years 2017 to 2019. Statistical analysis was performed from February 8 to November 14, 2022.Main Outcomes and MeasuresLinear, random-effect models with state fixed effects and robust SEs were estimated for 12 quality indicators as dependent variables, percentage of below-average staffing days as independent variables, controlling for average staffing hours per resident-day for registered nurses, licensed practical nurses, and certified nurse aides. Below-average staffing days were defined as those 20% below the facility average, by staffing type. Quality indicators included deficiency citations; long-stay residents receiving an antipsychotic; percentage of high-risk long-stay residents with pressure ulcers (2 different measures for pressure ulcers were used); and percentage of long-stay residents with activities of daily living decline, mobility decline, emergency department visits, and hospitalizations; and short-stay residents with new antipsychotic medication, mobility decline, emergency department visits, and rehospitalizations.ResultsFor the 14 717 nursing homes in this study, the mean (SD) percentage of days with below-average staffing was 30.2% (12.0%) for registered nurses, 16.4% (11.3%) for licensed practical nurses, and 5.1% (5.3%) for certified nurse aides. Mean (SD) staffing hours per resident-day were 0.44 (0.40) for registered nurses, 0.80 (0.32) for licensed practical nurses, and 2.20 (0.50) for certified nurse aides. In regression models that included average staffing, a higher percentage of below-average staffing days was significantly associated with worse quality for licensed practical nurses in 10 of 12 models, with the largest association for decline of activities of daily living among long-stay residents (regression coefficient, 0.020; P < .001). A higher percentage of below-average staffing days was significantly associated with worse quality for certified nurse aides in 9 of 12 models, with the largest association for short-stay functioning (regression coefficient, 0.030; P = .01).Conclusions and RelevanceThis study suggests that holding average staffing levels constant, day-to-day staffing stability, especially avoiding days with low staffing of licensed practical nurses and certified nurse aides, is a marker of better quality of nursing homes. Future research should investigate the causes and potential solutions for instability in staffing in all facilities, including those that may appear well-staffed on average.

Health Care Staff Turnover and Quality of Care at Nursing Homes

“…Our results are consistent with recent research that has leveraged the same data to demonstrate a link between other staffing dimensions besides the average staffing level (eg, staffing volitivity and turnover) and care quality. [19][20][21][22] Most similar to this article, a previous study leveraged the same data to examine the association between nursing staff turnover in the 2 weeks before a health inspection and an infection control citation. 18 We use a similar turnover measure and empirical strategy but examine a wider range of quality-of-care outcomes from health inspections, resident assessments, and claims data.…”

“…Nursing home staffing has been identified as an area in critical need of investment to improve the care provided to vulnerable older adults, particularly in the aftermath of the COVID-19 pandemic. 21,23,24 In February 2022, the Biden administration proposed policy reforms aimed at increasing staffing levels, most notably a federal minimum staffing requirement. Our results suggest that additional policy reforms that increase staff and administrator retention may provide an additional pathway to improve quality.…”

Long-Term Care Resident Health and Quality of Care During the COVID-19 Pandemic: A Synthesis Analysis of Canadian Institute for Health Information Data Tables

“…It is possible that pandemic period staffing difficulties are also related to Ontario's degraded performance on several quality indicators related to ADLs, particularly since direct care staff instability is associated with quality in this domain in United States nursing homes. 41 The challenge of ecological inferences of this type is reconciling other changes to quality of care that we observed. For example, despite their pandemic preparedness, 42 British Columbia was uniquely challenged in managing pressure ulcers and preventing worsening in mood symptoms of depression.…”

Skilled Nursing Facility Changes in Ownership and Short-Stay Medicare Patient Outcomes

“…Additionally, the risk-adjusted short-stay outcomes used in this study account for a larger variety of patient characteristics than the adjustment methods used by Braun et al Robust risk adjustment would serve to bias differences between treatment and control SNFs toward the null. Finally, we adjusted for clinical and administrative variables, such as staffing, which may have larger impacts on care delivery, and therefore short-stay patient outcomes, than change in ownership on its own …”