Nursing Staff in Hospitals and Nursing Homes Is It Adequate? (1996) / Chapter Skim
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Nursing Facility Quality, Staffing, and Economic Issues
Nursing Facility Quality, Staffing, and Economic Issues
Pages 453-502
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From page 453... ...
Quality problems are closely associated with historic low registered nurse (RN) staffing levels in nursing facilities.
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Staffing is a structural measure that affects the processes and outcomes of care, but is considered in part to be determined by facility ownership and payment sources. Studies of nursing facilities generally consider the special characteristics of nursing home residents (physical, mental, and social)
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. The MEAP instruments are expensive to administer and are more appropriate for residential living arrangements than for skilled nursing facilities.
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Poor Quality of Care The quality of care provided in nursing facilities has long been a matter of great concern to consumers, health care professionals, and policymakers (NCCNHR, 1983~. The Institute of Medicine (IOM)
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under the Social Security Act. Long-term-care facilities include skilled nursing facilities (SNF)
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Improper restraints (Residents have the right to be free of physical restraints used for discipline or facility convenience; F221) No comprehensive assessment (The facility must make a comprehensive assessment of resident needs; F271)
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forms (Morris et al., 1990~. Nursing facilities must complete the MDS forms for each resident within 14 days of admission and at least annually in order to assess the functional, cognitive, and affective levels of residents and must use the assessment in the care planning process.
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From page 460... ...
Using QI data, state surveyors are expected to determine whether or not the identified QIs are the result of, or are related to, poor care processes. HCFA regulations are being proposed to require nursing facilities to computerize the MDS data, and then the QIs may be a valuable tool for monitoring the quality of nursing home care.
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Nursing Home Staffing Pre-OBRA Staling Levels Staffing is a critical structural factor that affects the processes and outcomes of nursing home care. Staffing levels in nursing facilities have been traditionally
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From page 462... ...
In 1985, the national average was 1 RN per 49 patients in nursing facilities in contrast to a ratio of 1 RN for every 8 patients in hospitals (Jones et al., 1987; Strahan, 1987; Kanda and Mezey, 19911. Another analysis of the National Nursing Home survey data reported an overall average of 6.3 RNs per 100 beds in 1985 (or 0.063 FTEs per bed)
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From page 463... ...
Mohler surveyed states regarding their staffing requirements for nursing facilities. She found that the majority of states had specific minimum staffing standards in addition to the federal standards for nursing facilities.
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It was not known whether this was a result of reporting errors or represented an actual absence of RN staff. State surveyors did give nursing facilities deficiencies for failure to meet the minimum staffing levels.
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Actual staffing levels in nursing facilities may be lower than the levels reported on OSCAR because of overreporting, reporting errors, or both. Staffing data are reported to HCFA by facilities.
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found turnover rates of over 100 percent in California nursing facilities in 1986. Where there is an adequate supply of nursing personnel some nursing facilities may encourage high turnover rates as a means of keeping average wage rates low (Harrington, 1990b)
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Thus, controlling for resident characteristics, nursing facilities have economic incentives to hire fewer nursing personnel in high-cost market areas. Inadequate Educational Training There are many concerns about the adequacy of the education and training of nursing home personnel.
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Thus, heavy-care residents have been shown to require more nursing staff time than other residents. Staffing Levels and Quality of Care Not surprisingly, higher staffing levels in nursing facilities have been associated with higher quality of care.
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Another recent study of nursing facilities using the 1987 data from 449 freestanding nursing facilities in Pennsylvania found, after controlling for case-mix, that nonprofit nursing facilities provided significantly higher quality of care to Medicaid beneficiaries and to self-pay residents than did for-profit nursing facilities (Aaronson et al., 1994~. Nonprofit facilities had higher staffing levels and fewer adverse outcomes from pressure sores controlling for case-mix, but no difference in restraint use was found.
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Additional staff requirements were developed based on patient characteristics and according to a standard methodology that was used for each unit and each shift. This system for determining nursing staff needs was adopted by the Department of Defense as a model for determining minimum standards for nursing facilities.
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Another approach is to change reimbursement policies for nursing facilities or to change the economic incentives to increase staffing levels. Issues of economic and reimbursement policies are discussed in the following section.
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The total number of licensed nursing facilities (including SNFs and NF that are both freestanding and hospital-based)
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Growth trends are useful to examine over time. The number of licensed nursing facilities increased by about 2 percent annually during the 1978 to 1993 period and 1 percent between 1992 and 1993 (DuNah et al., 1995~.
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474 NURSING STAFF IN HOSPITALS AND NURSING HOMES TABLE 4 Ratio of Licensed Nursing Home Beds per 1,000 Population Aged 85 and Over Percent Growth 1978 1982 1986 1990 1993 1978-1993 Alabama 597.8 538.2 488.0 430.7 398.2 -33.4 Alaska 1,426.6 998.8 833.0 677.8 578.7 -59.4 Arizona 308.9 305.0 460.4 416.6 350.2 13.4 Arkansas 752.7 689.3 689.0 611.3 597.1 -20.7 California 534.6 461.8 419.3 405.8 379.0 -29.1 Colorado 860.6 677.5 600.8 590.5 521.3 -39.4 Connecticut 706.9 652.0 638.3 609.1 595.3 -15.8 District of Columbia 257.2 237.1 303.1 330.7 321.0 24.8 Delaware 556.0 587.6 571.5 606.6 680.2 22.4 Florida 337.7 303.2 305.8 305.1 294.3 -12.9 Georgia 830.1 771.3 666.3 606.7 558.0 -32.8 Hawaii 478.7 403.7 353.7 323.2 288.9 -39.7 Idaho 571.5 505.9 477.2 476.8 438.9 -23.2 Illinois 785.0 699.0 661.8 639.4 622.0 -20.8 Indiana 807.0 853.4 790.2 806.2 758.2 -6.1 Iowa 707.9 655.3 639.7 593.3 612.5 -13.5 Kansas 809.4 720.5 677.7 704.2 636.0 -21.4 Kentucky 483.7 472.6 470.9 472.5 469.5 -2.9 Louisiana 695.9 666.0 741.1 714.0 662.0 -4.9 Maine 635.6 553.4 555.1 520.6 490.4 -22.8 Maryland 635.9 590.3 554.2 554.8 525.0 -17.4 Massachusetts 590.3 507.7 508.3 536.3 520.1 -11.9 Michigan 591.7 505.0 494.3 469.4 421.5 -28.8 Minnesota 794.0 714.6 696.1 640.9 601.7 -24.2 Mississippi 471.1 483.1 475.4 424.2 410.4 -12.9 Missouri 601.8 648.0 646.2 665.6 627.0 4.2 Montana 721.9 643.8 664.7 596.5 532.4 -26.2 Nebraska 809.6 707.6 667.6 663.8 621.6 -23.2 Nevada 621.4 500.4 436.2 397.2 359.6 -42.1 New Hampshire 646.8 603.3 539.2 492.2 461.1 -28.7 New Jersey 419.6 413.3 438.6 473.0 439.1 4.6 New Mexico 339.4 387.4 453.1 424.4 388.7 14.5 New York 457.2 410.4 397.7 390.2 387.3 -15.3 North Carolina 422.7 421.9 383.0 378.4 453.8 7.4 North Dakota 730.7 723.2 671.1 610.8 560.5 -23.3 Ohio 627.6 614.9 647.9 640.2 586.2 -6.6 Oklahoma 822.5 749.3 728.7 707.9 664.9 -19.2 Oregon 542.9 478.1 427.3 383.9 328.1 -39.6 Pennsylvania 530.5 521.7 523.8 495.0 468.6 -11.7 Rhode Island 722.8 653.6 664.0 628.2 603.0 -16.6
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for ICF-MR facilities. Although the occupancy rates were generally high for nursing facilities, states did show a wide range in rates.
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Market Competition Effects Medicaid nursing home days of care account for a major proportion of all patient days (Levis et al., 1994~. Nevertheless, most nursing facilities prefer private clients because facilities can generally charge private-paying residents higher daily rates than Medicaid (Scallion, 1980a,b; Lee et al., 1983; Phillips and Hawes, 1988; Buchanan et al., l991~.
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From page 477... ...
found that nursing facilities had substantially fewer violations for poor quality of care in areas of Wisconsin where there were more available nursing home beds. In areas with an abundant supply of nursing home beds Medicaid recipients should have greater access to care, but this depends in part on the Medicaid reimbursement rates in relationship to the marginal costs of operation (Nyman, 1985, 1989b)
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HCIA and Arthur Andersen (1994) reported a median net patient revenue of $67 per resident day for all free-standing nursing facilities in the United States in 1992 (total revenues divided by total resident days)
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Medicaid Reimbursement The rapidly increasing cost of nursing home care has been a major concern to state policymakers, especially because nursing facilities consumed 32 percent of the Medicaid budget in 1993 (Levis et al., 1994~. Many state Medicaid programs have attempted to control the growth in nursing home reimbursement rates (Holahan and Cohen, 1987; Bishop, 1988; Nyman, 1988a; Holahan et al., 1993; Swan et al., 1993a,c)
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Medicaid nursing home reimbursement rates varied widely across states in response to the varying methodologies used by states. In summary, state Medicaid reimbursement methods for nursing facilities are gradually changing to facility-specific methods and case-mix reimbursement systems.
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found that nursing facilities in Iowa with more private pay residents provided better quality of care (as measured by the number of deficiencies)
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Cost ceilings for direct patient care costs could have negative consequences for the staffing levels in nursing facilities and for quality of care (Swan et al., 1994~. Some state reimbursement methods and rates may be more reflective of state budget resources than tied to the actual costs of providing nursing home care (Swan et al., 1993c)
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argued that case-mix may have distributed payments equitably among nursing facilities such as in New York. On the other hand, administrative costs tended to increase (Ohio costs tripled and Minnesota costs doubled)
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From 1982 to 1985, Congress made some minor changes in the nursing facility reimbursement methods to expand Medicare participation and to control costs (Schieber et al., 1986~. One major advantage of Medicare reimbursement for nursing facilities is that its methodology is uniform across states and regions, unlike Medicaid reimbursement methods.
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If these new systems are adopted, Medicare may have some of the same problems that have resulted from the Medicaid prospective payment systems and case-mix reimbursement for nursing facilities. Other options could be developed for Medicare to address the goals of controlling costs while increasing access, providing care to resource-intensive residents, and improving quality (Holahan and Sulvetta, 1989; Weissert and Musliner,1992a,b)
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From page 486... ...
In 1992, 8 facilities reported between $1 to $2 million in salaries to owners or family members (Rudder, 1994~. The total profit margin for the free-standing nursing home industry (calculated as the difference between total net revenue and total expenses divided by total net revenues reported from facility cost reports)
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In 1985, the Combined Omnibus Budget Reconciliation Act eliminated this provision for hospitals. The 1993 OBRA eliminated this provision for Medicare skilled nursing facilities.
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rily because they had a higher proportion of private pay residents compared with other facilities (HCIA and Arthur Andersen, 1994~. Nonprofit facilities had significantly higher median operating expenses and higher expenditures on direct patient care.
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7.3 3.9 NM D-P 2,937 74 2.5 10.8 10.6 NA 22.4 602 40 6.7 10.4 24.4 38.2a 22.0 2,970 173 5.8 7.1 4.0 NM 31.1 1,470 62 4.2 13.2 14.4 30.0 16.5 1,200 83 6.9 -3.3 -20.5 NM P-D 2,858 -320 Deficit 23.6 13.0 10.8 22.3 1,237 51 4.0 5.5 6.3 -18.8 1 1.8 1,449 60 4.3 Recently, Nyman (1988b) found that nonprofit nursing facilities in Iowa were associated with higher quality of care.
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Alternatively, the Medicaid reimbursement rate could be linked to the proportion of private patients in the home, in order to encourage quality competition for private pay patients. More research is needed on what incentives would be most effective.
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could be beneficial, but such an approach could take a number of years to develop. In spite of the difficulty of instituting reimbursement incentives for quality, reimbursement incentives could be directed toward increasing staffing levels and educating and training staff in nursing facilities.
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Direct patient care and nurse staffing are critical structural factors that impact on both the process and the outcomes of care. Nursing staffing levels in nursing facilities are low compared to hospitals, and this is particularly the case in proprietary nursing facilities.
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Nursing home facilities are primarily private, profit-making organizations that are increasingly part of multiorganizational systems and investor-owned corporations. Consequently, nursing facilities are oriented toward increasing profits.
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Medicaid Payment Policies for Nursing Home Care: A National Survey. Health Care Financing Review 13(1)
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Case-Mix Classification of Medicare Residents in Skilled Nursing Facilities. Medical Care 9:843-858, 1989.
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Nursing Facilities, Staffing, Residents and Facility Deficiencies, 1991-93. Paper prepared for the Health Care Financing Administration.
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HCFA. Medicare and Medicaid Programs; Survey, Certification, and Enforcement of Skilled Nursing Facilities and Nursing Facilities.
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Synthesis of Medicaid Reimbursement Options for Nursing Home Care. Submitted to the Health Care Financing Administration.
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Prospective and "Cost-Plus" Medicaid Reimbursement, Excess Medicaid Demand, and the Quality of Nursing Home Care. Journal of Health Economics 4:237-259, 1985.
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Prospective Payment for Medicare Skilled Nursing Facilities: Background and Issues. Health Care Financing Review 8(1)
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State Medicaid Reimbursement Methods and Rates for Nursing Homes, 1993. Paper prepared for the U.S.
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Zinn, J.S., Aaronson, W.A., and Rosko, D.M. Variations in Outcomes of Care Provided in Pennsylvania Nursing Homes: Facility and Environmental Correlates.
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