Research and Studies of PBJ Data

• News: Staffing ‘instability’ might be new mandate metric; providers gear up for battle
• News: Staffing Stability Is Marker of Better Quality of Nursing Homes

• News: Severe Neighborhood Deprivation and Nursing Home Staffing in the United States
• News: Nursing Home Staffing Is Worse in Disadvantaged Communities
• News: Researcher: Target Funding to Address Potentially Harmful Staffing Disparities
• News: Federal Staffing Minimums Won’t Solve Labor Woes for Nursing Homes in Disadvantaged Neighborhoods
• News: Nursing Home Staffing Struggles Add to Health Disparity in Disadvantaged Communities
• News: Study: Nursing Home Staffing in Disadvantaged Neighborhoods

• News: Antipsychotic Use in US LTC Facilities Connected With Staffing Levels
• News: Antipsychotics use falls when LTC nurse staffing hours rise

Shen, Karen, et al. “Staffing Patterns in US Nursing Homes During COVID-19 Outbreaks.” JAMA Health Forum, vol. 3, no. 7, 2022, p. e222151. Crossref, jamanetwork.com/journals/jama-health-forum/fullarticle/2794538.

Findings In this cohort study of 2967 nursing homes in 2020, owing to increased absences and departures, there were statistically significant declines in staffing levels during a severe COVID-19 outbreak that remained statistically significantly reduced 16 weeks after the outbreak’s start. Facilities temporarily increased hiring, contract staff, and overtime to bolster staffing during outbreaks, but these measures did not fully replace lost staff, particularly certified nursing assistants.

Published July 22, 2022

Related News Coverage:

• News: Why Minimum Standards Are Not the Best Way to Monitor Staffing During Covid Outbreaks
• News: More ‘strike’ teams, policy improvements vital for nursing homes
• News: Policy action can stabilize staffing levels
• News: Nursing Home Staffing Challenges Worse During COVID-19 Outbreaks
• News: Nursing Home Vaccine Mandate-Induced Staff Exodus Largely Unfounded
• News: COVID-19 vaccination mandates don’t negatively affect nursing home staffing
• News: Research supports COVID-19 booster shot mandates for SNF workers
• News: Facilities fail to replace workers who quit after COVID outbreaks

Zheng, Qing, et al. “Association between Staff Turnover and Nursing Home Quality – Evidence from Payroll‐based Journal Data.” Journal of the American Geriatrics Society, 2022. Crossref, agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17843.

Staff turnover is considered an important indicator of nursing home quality. We used auditable staffing data from the Centers for Medicare & Medicaid Services (CMS) Payroll-Based Journal (PBJ) system to calculate turnover measures for nurse staff and administrators and examined the relationship between turnover and nursing home quality.

Mean annual turnover rates were about 44% for RNs and 46% for total nurse staff. On average, there was one administrator leaving each nursing home during this period although about half of nursing homes had no administrator turnover.

Turnover rates varied greatly across nursing homes. For-profit and larger nursing homes had higher turnover rates. Higher turnover was consistently associated with lower quality of care.

Conclusions
Our study highlights the importance of staff turnover due to its relationship to nursing home quality. In January 2022, CMS started posting turnover measures on Care Compare to allow consumers to use this information in their assessment of nursing home quality and to motivate nursing homes to implement innovative strategies to retain staff. While these actions are challenging, they are nonetheless warranted for improving the quality of care for nursing home residents.

Published May 7, 2022

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• News: Study confirms lower turnover linked to higher quality of care
• Editorial: Prioritizing nursing home staff and leadership consistency to improve quality

PBJ Central Notes

This study is of particular interest as it was funded by a grant from CMS.  Authors include Evan Shulman, currently Director of the Nursing Homes division at CMS and three employees of ABT Associates, a CMS contractor working on the Five Star Quality Rating System since 2008

John R Bowblis, PhD, The Need for an Economically Feasible Nursing Home Staffing Regulation: Evaluating an Acuity-Based Nursing Staff Benchmark, Innovation in Aging, Volume 6, Issue 4, 2022, igac017, https://doi.org/10.1093/geroni/igac017

Despite concerns about the adequacy of nursing home (NH) staffing, the federal agency responsible for NH certification and regulation has never adopted an explicit quantitative nursing staff standard. A prior study has proposed a benchmark for this purpose based on the 1995/97 Staff Time Measurement (STM) studies. This article aims to assess the extent to which NHs staff to this proposed STM benchmark, the extent to which regulators already implicitly apply the STM benchmark, and compute the additional operating expenses NHs would incur to adhere to the STM benchmark.

Published March 21, 2022

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Mukamel DB, Saliba D, Ladd H, Konetzka RT. Daily Variation in Nursing Home Staffing and Its Association With Quality Measures. JAMA Netw Open. 2022;5(3):e222051. doi:10.1001/jamanetworkopen.2022.2051

Is daily variation in nursing home staffing associated with quality, and does it offer additional information to measures of average staffing levels? This quality improvement study of 13 339 nursing homes found that daily variation of staffing was significantly associated with the 5-Star Survey and Quality Measures rankings. There was little agreement between the variation and the average staffing measures on quality decile rankings of nursing homes, suggesting that staffing variation provides new quality improvement information.

Published March 14, 2022

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• News: Daily Variation in Nursing Home Staffing Led to Poorer Clinical Quality
• News: Instability In Staffing Levels at Nursing Homes Affects Quality of Care for Residents

Medicaid and CHIP Payment and Access Commission. “State Policy Levers to Address Nursing Facility Staffing Issues”. https://www.macpac.gov/wp-content/uploads/2022/03/State-Policy-Levers-to-Address-Nursing-Facility-Staffing-Issues.pdf.  Accessed December 2022.

Many nursing facilities have fewer direct care staff than needed to meet the care needs of their residents, a problem more common in nursing facilities that serve a high share of Medicaid-covered residents. Because such facilities also have a higher share of Black and Hispanic residents, the low staffing rates in these facilities contribute to health disparities. The COVID-19 pandemic exacerbated these disparities further. (Weech-Maldonado 2021).

Although the federal government plays an important role in monitoring compliance with its staffing standards, states can also help address staffing challenges in several ways, including:

• increasing Medicaid payment rates to help facilities hire more direct care staff and pay them higher wages;
• changing Medicaid payment methods to incentivize facilities to spend more of their revenue on staff (e.g., wage pass-through payment policies that require facilities to spend a specified portion of the Medicaid rate on staff wages); and,
• requiring that facilities meet minimum staffing standards that exceed federal requirements.

MACPAC has documented state policies related to nursing facility staffing in State Policies Related to Nursing Facility Staffing (MACPAC 2022). This brief provides background information about staffing challenges before the COVID-19 pandemic, summarizes current state policies related to staffing, and discusses prior research about the effectiveness of these policies.

Published March, 2022

Related MEDPAC Publications

• MEDPAC comments to CMS on Proposed Rule
• MEDPAC transcript of Public Meeting (including Nursing Facility Staffing discussion). Sept. 29, 2022
• MEDPAC Analysis of PBJ Data.  Presented Sept. 29, 2022

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Loomer, Lacey, et al. “Association between Nursing Home Staff Turnover and Infection Control Citations.” Health Services Research, vol. 57, no. 2, 2021, pp. 322–32. Crossref, onlinelibrary.wiley.com/doi/10.1111/1475-6773.13877.

We estimated the association between nurse turnover and the probability of an infection control citation and the scope of the citation while controlling for nursing home fixed effects. Our turnover measure is the percent of the facility’s nursing staff hours that were provided by new staff (less than 60 days of experience in the last 180 days) during the 2 weeks prior to the health inspection. We calculated turnover for all staff together and separately for registered nurses, licensed practical nurses (LPNs), and certified nursing assistants.

Published September 6, 2021

McGarry, Brian E., et al. “Larger Nursing Home Staff Size Linked To Higher Number Of COVID-19 Cases In 2020.” Health Affairs, vol. 40, no. 8, 2021, pp. 1261–69. Crossref, www.healthaffairs.org/doi/abs/10.1377/hlthaff.2021.00323?journalCode=hlthaff.

Staff in skilled nursing facilities (SNFs) are essential health care workers, yet they can also be a source of COVID-19 transmission. We used detailed staffing data to examine the relationship between a novel measure of staff size (that is, the number of unique employees working daily), conventional measures of staffing quality, and COVID-19 outcomes among SNFs in the United States without confirmed COVID-19 cases by June 2020. By the end of September 2020, sample SNFs in the lowest quartile of staff size had 6.2 resident cases and 0.9 deaths per 100 beds, compared with 11.9 resident cases and 2.1 deaths per 100 beds among facilities in the highest quartile. Staff size, including staff members not involved in resident care, was strongly associated with SNFs’ COVID-19 outcomes, even after facility size was accounted for. Conventional staffing quality measures, including direct care staff-to-resident ratios and skill mix, were not significant predictors of COVID-19 cases or deaths. Reducing the number of unique staff members without decreasing direct care hours, such as by relying on full-time rather than part-time staff, could help prevent outbreaks.

Published July 14, 2021

Werner, Rachel M., and Norma B. Coe. “Nursing Home Staffing Levels Did Not Change Significantly During COVID-19.” Health Affairs, vol. 40, no. 5, 2021, pp. 795–801. Crossref, www.healthaffairs.org/doi/10.1377/hlthaff.2020.02351.

Prior research and the popular press have anecdotally reported inadequate nursing home staffing levels during the COVID-19 pandemic. Maintaining adequate staffing levels is critical to ensuring high-quality nursing home care and an effective response to the pandemic. We therefore sought to examine nursing home staffing levels during the first nine months of 2020 (compared with the same period in 2019), using auditable daily payroll-based staffing data from the Centers for Medicare and Medicaid Services. We found that the total number of hours of direct care nursing declined in nursing homes during the COVID-19 pandemic, as did the average nursing home census. When we accounted for changes in census, the number of nurse staff hours per resident day remained steady or, if anything, increased slightly during the pandemic. The observed increases in staff hours per resident day were small but concentrated in nursing homes operating in counties with high COVID-19 prevalence, in nursing homes with low Medicaid census (which typically have more financial resources), and in not-for-profit nursing homes (which typically invest more in staffing). These findings raise concerns that although the number of staff hours in nursing homes did not decline, the perception of shortages has been driven by increased stresses and demands on staff time due to the pandemic, which are harder to quantify.

Published May, 2021

Related News Coverage

• News: Health Affairs Study Clashes with Previous Reports on Nursing Home Shortages
• News: Nursing Home Staffing Hours Held Steady or Rose During Pandemic

McGarry, Brian E., et al. “Medicare’s New Patient Driven Payment Model Resulted In Reductions In Therapy Staffing In Skilled Nursing Facilities.” Health Affairs, vol. 40, no. 3, 2021, pp. 392–99. Crossref, www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00824.

Medicare’s Patient Driven Payment Model (PDPM) significantly altered the way skilled nursing facilities (SNFs) are paid, removing the financial incentive to maximize the volume of therapy services delivered to patients. Using federal payroll-based staffing data, we examined the effect of the PDPM on SNF therapy and nursing staff hours. After PDPM implementation, which took effect October 1, 2019, SNFs significantly reduced their therapy staff hours. Physical therapist and occupational therapist staffing levels were reduced by 5–6 percent during October–December 2019 relative to pre-PDPM levels, and physical therapy assistant and occupational therapist assistant levels were reduced by about 10 percent. These reductions were concentrated among contracted employees and were larger in SNFs with higher shares of Medicare-eligible short-stay residents. No meaningful increases in nursing staff in response to the PDPM were found. Further research is needed to determine the effect of these therapy staff reductions on SNF patient outcomes.

Published March, 2021

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• News: Therapy carnage at start of PDPM not as severe as feared: study
• News: Skilled Nursing Facility Staffing Impacted by New Payment Rules

Gandhi, Ashvin, et al. “High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information.” Health Affairs, vol. 40, no. 3, 2021, pp. 384–91. Crossref, www.healthaffairs.org/doi/abs/10.1377/hlthaff.2020.00957.

Nursing staff turnover has long been considered an important indicator of nursing home quality. However, turnover has never been reported on the Nursing Home Compare website, likely because of the lack of adequate data. On July 1, 2016, the Centers for Medicare and Medicaid Services began collecting auditable payroll-based daily staffing data for US nursing homes. We used 492 million nurse shifts from these data to calculate a novel turnover metric representing the percentage of hours of nursing staff care that turned over annually at each of 15,645 facilities. Mean and median annual turnover rates for total nursing staff were roughly 128 percent and 94 percent, respectively. Turnover rates were correlated with facility location, for-profit status, chain ownership, Medicaid patient census, and star ratings. Disseminating facilities’ nursing staff turnover rates on Nursing Home Compare could provide important quality information for policy makers, payers, and consumers, and it may incentivize efforts to reduce turnover.

Published March, 2021

Related News Coverage

• News: ‘Alarming’ nurse turnover rates linked to quality, payment woes in major new nursing home study
• News: Nursing Homes Have 94% Staff Turnover Rate — With Even Higher Churn at Low-Rated Facilities.
• News: Is nursing home staff turnover a good quality metric?

Crogan NL and Simha A. Impact of Medication Assistant Use on Nursing Home Staffing Levels and Inspection Results. Gerontol Geriatr Res. 2020; 6(1): 1044

The purpose of this case study is to describe inspection outcomes 1-2 years after the addition of Medication Assistants (MAs) and the reduction of Licensed Practical Nurses (LPNs) to the staffing model in one rural eastern Washington nursing home.

Published September 17, 2020

Harrington, Charlene, et al. “Appropriate Nurse Staffing Levels for U.S. Nursing Homes.” Health Services Insights, vol. 13, 2020, p. 117863292093478. Crossref,www.ncbi.nlm.nih.gov/pmc/articles/PMC7328494.
US nursing homes are required to have sufficient nursing staff with the appropriate competencies to assure resident safety and attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident. Minimum nurse staffing levels have been identified in research studies and recommended by experts. Beyond the minimum levels, nursing homes must take into account the resident acuity to assure they have adequate staffing levels to meet the needs of residents. This paper presents a guide for determining whether a nursing home has adequate and appropriate nurse staffing. We propose five basic steps to: (1) determine the collective resident acuity and care needs, (2) determine the actual nurse staffing levels, (3) identify appropriate nurse staffing levels to meet residents care needs, (4) examine evidence regarding the adequacy of staffing, and (5) identify gaps between the actual staffing and the appropriate nursing staffing levels based on resident acuity. Data sources and specific methodologies are analyzed, compared, and recommended. The goal is to assist nursing home nurses and administrators to ensure adequate nursing home staffing levels that protect resident health, safety, and well-being.
Published June 29, 2020

Williams, Christianna, et al. “Payroll-Based Staffing Measures for Nursing Homes.” Innovation in Aging, vol. 3, no. Supplement_1, 2019, p. S62. Crossref, www.ncbi.nlm.nih.gov/pmc/articles/PMC6846848.

The Centers for Medicare & Medicaid Services (CMS) developed the Payroll-Based Journal (PBJ) system for nursing homes to electronically submit direct care staffing information based on payroll and other auditable data. In spring 2018, CMS started reporting PBJ-based staffing measures on Nursing Home Compare. The objective of this research is to examine nursing home staffing patterns using PBJ data. We created measures of staffing hours per resident day, using PBJ staffing information and resident census calculated from MDS assessments. We examined how PBJ staffing levels varied for different types of nursing homes and the relationship between staffing and performance on other parts of CMS’s Five-Star Quality Rating System. We also examined weekday/weekend variation in staffing levels. We tracked about 15,650 nursing homes from 2017 to 2018. The average staffing level was 3.85 hours per resident day, of which 0.66 hours were for RNs. Average staffing levels were higher for smaller, non-profit, and hospital-based facilities. 

Published November 8, 2019

Ody‐Brasier, Amandine, and Amanda Sharkey. “Under Pressure: Reputation, Ratings, and Inaccurate Self‐reporting in the Nursing Home Industry.” Strategic Management Journal, vol. 40, no. 10, 2019, pp. 1517–44. Crossref, onlinelibrary.wiley.com/doi/abs/10.1002/smj.3063.

This paper examines firms’ strategic responses to reputational pressures in a critical healthcare domain—the U.S. nursing home industry. We investigate whether organizations improved in terms of care quality following an exogenous change in the required number of nursing hours associated with star-based ratings to which nursing homes are subject. We show that although firms at risk of losing a star tended to self-report higher staffing levels after the policy change, these reported increases were not associated with improvements in an important patient outcome—bedsores. These findings are consistent with false reporting of staffing data, or insufficient or ineffective hiring practices. Although we cannot definitively establish the existence of false reporting, supplementary analyses offer little support for the latter two possibilities.

Published July 18, 2019

Related News Coverage

• News: Under Competitive Pressure, Nursing Homes Appear to Game Rating System
• News: SNFs Appear to Have Gamed the System When Staffing Was Self-Reported

Harrington, Charlene. “A Checklist for Building a Nursing Home Staffing Case” California Advocates for Nursing Home Reform, 21 Dec. 2018, canhr.org/publications/newsletters/NetNews/Feature_Article/NN_2018Q4.htm.

Most nursing home quality problems are caused by inadequate staffing levels or poorly trained and educated nursing staff. Each litigation case should undertake an analysis of whether a skilled nursing facility provides adequate staffing. This entails three basic steps: 1) determining the collective sacuity level of the residents at the facility; 2) determining the staffing levels at the facility; and 3) comparing the collective acuity and staffing levels at the facility in light of recognized staffing requirements and professional standards. Finally, the analysis should look for collaborating evidence of poor quality from deficiencies, complaints and other sources.

Published December 21, 2018

Edelman, Toby. “Special Focus Nursing Facilities That ‘Have Not Improved:’ Poor Care for Residents, Overall Ratings Artificially Boosted by 5-Star Ratings in Self-Reported Quality Measures.” Center for Medicare Advocacy, 15 Aug. 2018, medicareadvocacy.org/special-focus-nursing-facilities-that-have-not-improved.

The Centers for Medicare & Medicaid Services (CMS) identifies some of the worst performing nursing facilities in the country as Special Focus Facilities (SFFs).  This Report looks at one of the four categories of SFFs – those that “have not improved” – and how they game and manipulate CMS’s Five-Star Quality Rating System.

As discussed more fully below, the most striking finding in this analysis is that 13 of 33 SFFs (39%) that CMS identified as not having improved had five stars in their self-reported quality measures domain, leading to an upward adjustment from one star to two stars for their overall ratings.

Published August 15, 2018

“Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016.” KFF, 3 Apr. 2018, www.kff.org/medicaid/report/nursing-facilities-staffing-residents-and-facility-deficiencies-2009-through-2016.

Nursing facilities are one part of the long-term care delivery system that also includes home and community based services, but their relatively high cost has led them to be the focus of much attention from policymakers. Medicaid plays a major role in financing nursing facility care in the United States, and policy proposals to limit federal financing for Medicaid may lead to cuts in eligibility or scope of coverage for long-term care services. In addition, regulations effective November 2016 aimed to address longstanding challenges in quality and safety in nursing facilities. As the demand for long term care continues to increase and policy proposals and regulations unfold, the characteristics, capacity, and care quality of facilities remain subjects of concern among consumers and policy makers.  

Published April 3, 2018

Perraillon, Marcelo Coca, et al. “Nursing Home Response to Nursing Home Compare: The Provider Perspective.” Medical Care Research and Review, vol. 76, no. 4, Aug. 2019, pp. 425–443, doi:10.1177/1077558717725165.

Nursing Home Compare (NHC) publishes composite quality ratings of nursing homes based on a five-star rating system, a system that has been subject to controversy about its validity. Using in-depth interviews, we assess the views of nursing home administrators and staff on NHC and unearth strategies used to improve ratings. Respondents revealed conflicting goals and strategies. Although nursing home managers monitor the ratings and expend effort to improve scores, competing goals of revenue maximization and avoidance of litigation often overshadow desire to score well on NHC…

First Published August 11, 2017