Nursing Home Staffing—Learning to do More With Less


A July 2018 New York Times article reveals that nursing homes have been fudging the numbers on staffing. This article, supported by a Kaiser Health News analysis of data from the new payroll-based journal (PBJ) system, reported that 70 percent of nursing homes had lower staffing than previously thought. Mandated as part of the Affordable Care Act and implemented in 2017, the PBJ system requires nursing homes to report daily payroll data directly to the Centers for Medicare and Medicaid Services (CMS). Previously, nursing homes reported staffing data during the two weeks prior to their annual state survey inspection. Because these surveys occur within a specified time window, nursing homes were often able to staff up before the inspection. While it was long believed that nursing homes inflated their staffing numbers for reporting purposes, the new PBJ data confirms it.

Reaction to the Times article from the two main national nursing home trade associations differed from one another. A representative from LeadingAge, an organization that represents nonprofit nursing homes said, “Our members face a huge challenge in recruiting, training and retaining workers… There is no question that the aging services field is facing a workforce crisis.” And a representative from the American Health Care Association (AHCA), which represents for-profits said, “While staffing is one of many important metrics in quality care, outcomes and satisfaction are what really matters.” Both are technically correct.

Why is staffing a nursing home so challenging?

It is no secret that nursing homes have a huge problem when it comes to recruiting and retaining staff, especially nurses and nursing assistants. Nursing homes are in competition with hospitals and other providers who can pay workers more. Lower pay in nursing homes is in large part because much of a nursing home’s revenue comes from the Medicaid program, which often does not fully cover the costs of providing this care. Turnover is a problem in the industry and is generally worse during periods of low unemployment. Nursing assistants are often able to earn the same, or more, money working less stressful and physically easier jobs in the service industry; for example, fast food workers often earn about the same hourly rate as nursing home nursing assistants.

What are nursing home quality measures and why are they important?

Adequate staffing levels are important for proper patient care. Since 2002, CMS has been measuring patient care in nursing homes and reporting scores on its Nursing Home Compare website. Several of these quality measures were created and are maintained by RTI International. The Compare website includes measures related to structure (e.g., therapist staffing), processes (e.g., the proportion of residents who received a flu shot), and outcomes (e.g., the proportion re-hospitalized, fall rates). According to the AHCA representative quoted above, the outcome measures used by CMS together matter more than staffing levels alone.

And one quality measure will be given even more weight when the new Value-Based Purchasing program begins in a few months. Under this program, 2 percent of a nursing home’s Medicare revenue will be withheld by CMS. Nursing homes that perform well on one measure that focuses on 30-day re-hospitalization after being discharged to a nursing home can earn back incentive payments equaling or exceeding the 2 percent withheld, while poorly performing nursing homes will lose that money. The withheld payments can be significant, amounting to tens or hundreds of thousands of dollars for some nursing homes.

What else can nursing homes do to improve quality of care given staffing challenges?

Given the challenges of retaining and attracting new staff, facilities need to think of ways to improve their quality of care, especially quality as measured by the Value-Based Purchasing program. Nursing homes may consider adding or strengthening programs or processes to reduce re-hospitalizations within staffing constraints. Examples of efforts that may help are those that work to improve staff communication and coordination, identifying and addressing clinical pathways for the most common causes of re-hospitalization, and improving discharge planning. To improve outcomes in the current staffing environment, nursing homes will need to take a hard look at what they currently do well and where they can improve.