Staffing for Success

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Studies consistently show a strong correlation between nursing home staffing levels and resident outcomes. Unfortunately, many operators struggle to provide adequate staffing, and their overall quality suffers as a result.

Numerous factors contribute to insufficient staffing. Despite state staffing requirements, some operators continue to let their budgets dictate staffing decisions. Others may misinterpret states' sometimes vague definitions of sufficient staffing, which can lead them to hire too conservatively – or, in some cases, hire liberally, but not necessarily the right type of staff to deliver the best care for the facility's resident population. Regardless, experts agree that insufficient staffing is a recipe for disaster that can spur unsatisfactory clinical outcomes, poor survey performance, increased liability, and more.

“All facilities and all staff are not created equal,” said Steven Littlehale, executive vice president and chief clinical officer for PointRight Inc. A traditional nursing home with mostly frail residents, a fair amount with dementia and perhaps some post-acute residents will have far different staffing requirements than a post-acute care facility that specializes in post-acute care, he explained.

“There is a difference between licensed practical nurses and registered nurses.” While LPNs are well-suited to more traditional resident care, they are not necessarily the best choice for those with more advanced care needs.

Beyond the stars

Many providers rely heavily on the Centers for Medicare and Medicaid Services' Five-Star methodology to help pinpoint potential staffing gaps and guide better staffing decisions.

While Five-Star certainly plays a role in this decision-making process, it alone cannot guarantee positive outcomes. That's because appropriate staffing hinges on resident acuity and unique care needs. Under the Five-Star methodology, CMS gathers staffing data based on the two weeks prior to annual survey, which isn't necessarily indicative of year-round staffing levels. Calculating staffing by Resource Utilization Group scores poses another problem because higher acuity won't necessarily help discern the need for more certified nursing assistants or even LPNs.

“Staffing to acuity and looking beyond what the RUG implies is a more effective approach,” noted Thomas Martin, a research analyst for PointRight. Often, more skilled nursing or rehabilitation staff will be in order, he noted. The Five-Star rating for staffing currently only factors in total nursing hours per resident day (including RN, LPN and CNA hours) and RN hours per resident day. More specialized staff, such as therapists, are not included, even though they can have a more positive impact on resident care and outcomes. The bottom line: facilities that staff to a Five-Star level can't guarantee that their quality will match.

The good news is some key staffing practice changes can go a long way toward driving more appropriate staffing ratios and, above all, better care and outcomes. Hiring an RN when there's a vacant position for a LPN is one of the best steps an operator can take, PointRight's analysis shows.

“A higher RN-to-total-licensed ratio is linked to better outcomes,” confirmed Littlehale. This includes improved clinical outcomes, lower workers' compensation costs, better survey scores and Five-Star ratings, fewer liability claims, and a higher proportion of Medicare and private pay residents. Although hiring more higher-earning RNs may seem like a bad budgetary decision, these numerous associated benefits far outweigh the additional hourly wage expense.

Avoiding or limiting the use of contract staff is another prudent practice, PointRight experts note. Supplemental staff are often associated with process non-compliance, which may lead to practice inconsistencies, negative care outcomes and a greater risk for professional liability loss. The more contract CNAs a facility uses to fill staffing vacancies, the greater the risk – and the same is true of using contractors to fill nursing leadership positions. Although temporarily using contract licensed staff is better than leaving vacancies unfilled, it's far better to limit their use and commit to securing long-term replacements.

Data drives smarter staffing

Proactive data collection and analysis also plays a key role in an operator's ability to establish proper staffing ratios and improve clinical outcomes and survey scores. The more an operator understands the facility's case-mix and what is required to properly care for its residents, the easier it becomes to staff accordingly.

Having a clear picture of expectations and desired outcomes is also critical, according to Martin. Although nearly every operator will strive for improved clinical outcomes and quality of care, reaching those goals requires anything but a one-size-fits-all approach.

“Desired clinical outcomes for a post-acute care facility will be very different from a [memory care] facility, for example,” he reasoned. Although a resident's “optimal level of function is the most important outcome an operator can seek, other factors should be considered when attempting to determine appropriate staffing ratios. This may include an operator's desire to improve survey scores or resident satisfaction, or reduce rehospitalization or professional liability and risk. An operator that lacks a clear desired outcome and a staffing ratio to match may find its efforts falling flat -- or worse, satisfying one objective, while negatively impacting another.

Data-driven analytics and targeted decision-support solutions can help operators take the guesswork out of the staffing process and, at the same time, reduce liability and risk. The PointRight Staffing to Acuity model uses public and private staffing and resident data to document and monitor staffing requirements based upon residents' medical acuity and functional dependency.

“The model is case-mix adjusted and also takes into consideration other staff, including therapists, that play a role in residents' overall wellbeing,” Martin added.

The Staffing to Acuity analysis is part of PointRight's Analytics Insights, a package of data-driven reports that also includes identified areas of professional liability risk, Five-Star rating and Special Focus Facility analysis. The Staffing to Acuity analysis and other Analytics Insights reports are offered individually, so operators can choose the reports that best meet their needs.

Aside from helping a facility pinpoint risk and keep a finger on the pulse of resident acuity and dependency to drive better staffing decisions, the detailed analysis also allows facilities to compare their staffing averages with other facilities across the district, state, region, or nation.

"Data-driven insights give you a clearer picture of what's going on in your own facility, while allowing you to benchmark with other facilities that are truly similar in acuity,” Littlehale explained. “When you can use data to compare apples to apples, you'll have more information to make better decisions that will lead to better outcomes.”
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