Policy changes have direct effect on nursing home care

Charlene Harrington, PhD, RN

States that set high staffing standards for elder care in nursing homes are the only ones that come close to having enough staff nurses to prevent serious safety violations, according to a new study by a professor in the UCSF School of Nursing.

The majority of the nation’s elderly and disabled in nursing homes remain in situations where staffing is well below national recommendations for safe care, the study found. While no states have ideal nursing levels, those states with higher Medicaid reimbursements or higher mandated nursing levels have come closer to meeting the recommendations, according to the analysis published in the June issue of the journal “Health Services Research.”

The study’s initial objective was to examine the relationship between Medicaid reimbursement rates, which many states have reduced under their cost-containment efforts, and nurse staffing levels in US nursing homes, according to Charlene Harrington, PhD, RN, UCSF professor of sociology and nursing and lead author of the report.

She said previous studies have shown a direct correlation between staffing levels and higher Medicaid reimbursement for nursing homes, but this is the first to show that states with higher mandated staffing standards had substantially higher staffing as well. 
“For years, families have struggled with low staffing levels in the nursing homes that care for their elderly family members, but very few studies have assessed how to change that on a broad level,” Harrington said. “This study shows that the simple step of raising the state minimum staffing ratio has a direct impact on the quality of care our seniors receive.”

Harrington based her analysis on staffing reports submitted by nursing homes to the federal government and data from multiple other sources. She examined the hours that nurses worked in nursing homes in 2002 and analyzed the data against two variables: Medicaid reimbursement rates and the range of acuity in patient care.

Medicaid pays for 67 percent of all nursing home residents in the United States, but only covers 51 percent of the $103 billion in total nursing home costs. Medicare covers 12.5 percent of those costs, private insurance pays 7 percent and consumers pay 29.5 percent.

In 2002, the average US nursing home had 15 percent fewer registered nurses per resident than nationally recommended, Harrington said. That recommendation originated in a 2001 study for the Centers for Medicare and Medicaid Services. A report by the Institute of Medicine two years later, titled “Keeping Patients Safe,” recommended that nursing homes be required to meet the levels from the 2001 study to maintain patient safety.

As expected, this study found that higher percentages of Medicaid residents correlated to lower total staffing levels, Harrington said. While it also showed that nursing homes, on average, do adjust their registered-nursing levels for the acuity of care needed, most do not increase total staffing for more acutely ill residents, which also could result in inadequate care.

Overall, nursing homes with more Medicaid residents, for-profit nursing homes, and those with a larger number of beds had fewer registered nurses and total nursing staff per patient. Nursing homes in counties with more elderly residents, more women in the workforce, and higher incomes had higher registered-nurse staffing levels.

This study found that nursing homes located in states that had increased their minimum standards for registered nursing hours had higher registered-nurse staffing levels.  For example, a 10 percent increase in state minimum staffing standards would result in an increase of 1.66 hours per resident-day (or 16.6 hours for every 100 residents) in actual staffing, if all other factors remain equal, Harrington said.

“There are several possible solutions to this problem, including federal or state minimum nursing level requirements or increases in Medicaid payments,” Harrington said. “We now know that a policy change is an effective way to create an impact, and it might be an easier solution than trying to change Medicaid payments.”

An increase in Medicaid rates of $90 per day would be needed to increase the RN hours to the recommended levels, the study found, and a $50 per day increase would be needed to raise total nursing hours to the recommended levels. 

Co-authors on the study are James H. Swan, PhD, Department of Applied Gerontology, University of North Texas; and Helen Carrillo, MS, UCSF.

UCSF is a leading university that advances health worldwide by conducting advanced biomedical research, educating graduate students in the life sciences and health professions, and providing complex patient care.