Staffing Stability

McKnight’s reported on a new research that supports an obvious conclusion. Staffing stability is a critical key component to nursing home quality. Researchers have long understood nurse turnover’s influence and impact on nursing home quality, maybe even for two decades. Still, turnover wasn’t added to Care Compare for over a decade after an overall staffing measure.

A group of long-term care researchers has recommended that federal regulators add this to the metrics they use when rating facilities for consumers. Adding this instability measure to the staffing component of the Centers for Medicaid & Medicare Services Five-Star rating system would affect about 21% of the nation’s nursing homes. This could reward facilities for their consistent staffing levels but warn consumers of facilities with high turnover.

Researcher Dana Mukamel, PhD, of the University of California, Irvine, defined staffing instability as “the percentage of days in a quarter in which hourly per day staffing is 20% or more below the facility average” and “It’s a reflection of absenteeism from work by staff, or staff who just don’t come to work on a particular day. If your staffing levels are tight, having just one person missing from the team means you’re short. That will affect your ability to provide the care your residents need.”

Mukamel has been studying staffing instability for many years and said that consistent staffing is linked to fewer hospitalizations, fewer emergency department visits, and a decrease in residents’ ADL needs. Overall, a better quality of care is related to consistent staffing levels. Additionally, researchers have found a relationship between survey deficiencies and increased staffing instability. Smaller nursing homes and for-profit nursing homes tend to be more volatile with staffing.

This study proposed the addition of the instability metric as the next step in CMS’s efforts to expand staffing at nursing homes. The Five-Star staffing component currently includes six measures: three for turnover, two for nurse staffing hours, and one for weekend staffing. Both the turnover and weekend elements were added in 2022. Researchers have warned that CMS still does not give consumers a full picture of staffing conditions inside individual nursing homes. Including average staffing, turnover, and staffing instability would offer a more extensive perspective on staffing challenges and successes within
a nursing home.

Mukamel, two Irvine colleagues, and coauthor R, Tamara Konetzka of the University of Chicago wrote, “Leaving instability out of the Five-Star composite likely results in an incomplete and potentially biased perception of staffing quality” and “This can potentially mislead consumers and their agents (Medicare, Medicaid, other payers) when choosing nursing homes, ultimately frustrating CMS’ objectives to improve the market through better information about quality, to lead consumers to make more rational choices, and to enhance incentives for providers to improve quality.”

The value of this metric is easily understood by both the consumers and providers, who would need to account for call-outs in order to gain higher scores. Because this measure is based on hours of care per resident day, the metric would automatically adjust for changes in the census.

The researchers of this new measure considered many ways to weigh the instability score and settled on the 5 to 50 points range. This is the same spread that is given to the turnover and weekend elements when added. Using this method, no nursing home gained or lost more than a single star for staffing, and around 80% did not see their rating change. The percentage that would gain and lose a star was about the same, at 11.4% and 10.0%, respectively. Though it is unclear if CMS will consider adding this measure, weighting instability more heavily would impact more providers.