Medicare funds must translate to staff.

There is a way to link staffing levels and quality of care

IN THE WAKE OF A CLINTON ADMINISTRATION REPORT ALLEGING widespread understaffing in the nation's nursing homes, the chairman of a Senate committee says he will oppose reinstating additional Medicare funds cut from nursing homes by the Balanced Budget Act of 1997 unless the increases are tied to specific requirements that the facilities hire more staff. As of press time, the BBA givebacks were slated for possible floor action in September. Sen. Charles Grassley (R-Iowa), chairman of the Senate Special Committee on Aging, also said that he will look into ways to encourage the states to increase Medicaid funding to nursing facilities if they hire more staff. He made the remarks at a hearing July 27 in which officials of the Health Care Financing Administration (HCFA) presented a report to Congress alleging that more than half of the nation's nursing homes are deficient in nurses' aide staffing, almost a quarter fall short in total licensed personnel, and about a third have insufficient RN staffing to meet the ne eds of their patients. The staffing report came as the administration is apparently set to move on the first phase of a five-year $21 billion plan to restore some of the funds cut by the BBA.

"Based on the ... report, I'm not willing to give the nursing home industry a blank check," said Grassley. "The industry has argued repeatedly that it needs more money to hire more staff. If the industry receives more money this year, I'd like to see that increase tied to staffing."

Industry representatives reacted to the report with general agreement over its goals but concerns about financial implications. "Staffing is like apple pie," said Tom Burke, spokesman for the American Health Care Association (AHCA), the organization of 12,000 nursing homes. "Everybody's in favor of more staffing, but how you get there is another issue."

The inherent relationship between staffing and funding was evident to the committee. Sen. Jack Reed (D-R.I.) decried the situation in his own state. He said that, while there are 26,000 licensed nursing assistants in Rhode Island, only 14,000 are actively employed in nursing facilities, presumably because of low wages. He said a hotel maid in Providence earns over $9 an hour, but an aide in a nursing home there averages only $7.69 per hour.

The staffing report had been mandated by Congress in 1990 and was initially slated to take two years. But according to Nancy-Ann DeParle, HCFA administrator, the task turned out to be more complex than anticipated. She said the report is the first phase of research on nursing home staffing and for the first time documents a statistical link between staffing and quality of care. She said the report "establishes for the first time in a statistically valid way that there is, in fact, a strong association between staffing levels and quality of care."

Andrew Kramer, MD, professor of geriatric medicine at the University of Colorado, which conducted some of the research, made the case for minimum staffing levels even more strongly. "We found clear and strong relationships between quality of care and specific staffing levels," he said. "The magnitude of the differences between facilities that met certain staffing levels and did not meet these staffing levels were surprisingly large."

The report is based on data collected from 1,786 nursing facilities in Ohio, New York, and Texas, and sought to identify specific patient outcomes that might be affected by staffing levels. Data were taken from Medicaid cost reports. "Some of the outcomes examined included avoidable hospitalizations, improvement in activities of daily living (ADLs) functioning, incidence of pressure sores, weight loss, and resident cleanliness and grooming," read the report. The report concluded that, "strong associations between low staffing and the likelihood of quality problems across these measures, adjusted for risk, were found for all nurse staffing."

Specifically, the report identified both minimum staffing levels and what it termed "preferred" minimum levels and identified both as thresholds at which improvements in the quality of care were discernable. According to the report, the data suggest "that minimum levels may reduce the likelihood of quality problems in several areas, but higher 'preferred' levels existed above which quality was improved across the board." Minimum staffing levels for nurses' aides were pegged at two hours per resident per day, of total licensed staff at 45 minutes per resident per day, and of RNs at 12 minutes per resident per day. The report says that 54 percent, 23 percent and 31 percent, respectively, of the homes studied failed to meet the minimum levels.

The report set the preferred level of aide staffing at the same two-hour level but suggested total licensed staffing should be one hour per resident per day and RN staffing should be 27 minutes per resident per day. Of the homes studied, 56 percent and 67 percent, respectively, fail to meet the preferred staffing levels.

Kramer said the suggested staffing levels were minimums to make a difference in patient outcomes. "When we tested lower thresholds to determine whether quality might be improved by more modest staff increases, we generally found that lower levels of staffing were not associated with improved quality," he told the committee.

John F. Schnelle, PhD, of the Borun Center for Gerontological Research in Los Angeles, conducted research for the report using an alternative approach, examining the amount of nurses' aide time required to complete five basic care processes, including toileting, turning of bed-bound residents, and assistance with eating. He told the committee that his research indicated a need for even more staffing than the report suggests. He said a minimum of 2.9 hours of aide time per resident per day was needed to meet the five basic needs. "Even if we increase nurses' aide staffing to 2 hours per resident per day, that wouldn't be adequate," he said. He said 92 percent of the nation's nursing facilities fall below the 2.9-hour figure.

Whether the report will lead to new nursing home legislation or to revised regulation is unclear. Current law and regulation do not require specific staffing levels at nursing facilities but mandate only that the facilities provide "sufficient nursing staff to attain or maintain the highest practicable ... well-being of each resident."

DeParle said a second phase of the study will involve gathering more data from more states, case studies, refining the data to take case mix into account, and evaluating the "costs and feasibility of implementing minimum staffing requirements and the impact on providers and payers, including Medicare and Medicaid."

The study acknowledged that the second phase would also include a workforce analysis to determine whether the human resources could be assembled to increase nursing home staffing "because, even if cost increases associated with higher staffing levels could be absorbed, it may not be possible to secure the necessary nursing staff at realistic wage levels." Kramer and Schnelle said the case mix adjustments for the second phase might be completed within a year.

PR nightmare

The report and attendant Senate hearing represented both a political and public relations nightmare for the nursing home industry, already besieged by a string of bankruptcies stemming from the 1997 BBA Medicare reductions. Four days before the hearing, The New York Times ran an extensive front-page article headlined "U.S. Recommending Strict New Rules at Nursing Homes" and subtitled "Officials Say Patients May Be Endangered by Shortage of Both Nurses and Aides.' [1]

The Times article quoted sections of the report alleging that, "When employees are in short supply, they often prod patients to eat faster, forcing 'huge spoonfuls of food into their mouths,' so the patients cough and choke." The Times also said, "To prevent severe bedsores, also known as pressure ulcers, patients must be turned or moved every two hours ... but this is unlikely to occur in homes with low numbers of nurses' aides. The sores can become infected and damage underlying muscle and bone."

Industry representatives said they favored increased staffing but generally said the problem lies with Medicare cuts made by the 1997 BBA and with the inherent difficulties in hiring sufficient numbers of qualified staff in a booming economy. "First and foremost, our overall objective as caregivers is providing top-quality care to our nation's frail and elderly," said Dr. Charles H. Roadman II, MD, president and CEO of AHCA. "But any calls for increased staffing levels should be accompanied by a commitment to pay for them, and an appreciation for the labor shortage, pay scales, and challenging working conditions that make it difficult to recruit and retain health care professionals." Roadman said that reimbursement rates from both Medicare and Medicaid are too low. He said his organization favors measures like HR 4547, introduced by Rep. Paul Ryan (R-Wis.), that would allow specially trained nursing assistants to perform some nursing functions that currently require a certified aide.

Despite the publicity surrounding the report, the administration is not now specifically calling for specific staffing standards. In her testimony, DeParle emphasized that it is the second part of the study that will determine the practicality of specific standards.

Furthermore, it's difficult to determine, especially this late in the present Congress and in the administration, how much of the publicity and rhetoric surrounding the staffing report is intended for political grandstanding and how much might actually lead to new legislation or revised regulation. For his part, Grassley appeared to be making the most of the spotlight the report and the hearings afforded him. "The study links staff shortages to poor care. It's a common-sense relationship, but it hasn't been well documented until now. The study is years late. Now we have to make up for lost time," he said.

David Irwin is a New Hampshire nursing home administrator and journalist.

Reference:

(1.) New Yark Times, Sunday, July 23, Vol. CKLIX (51,458); page 1.