In the ever-evolving landscape of nursing home care, the use of agency staff has long been a topic of scrutiny, historically linked to concerns about inferior outcomes. However, as we navigate the aftermath of the COVID-19 pandemic, we can benefit from reexamining these somewhat dated perceptions.
A recent study by Zimmet Healthcare Services Group challenged the conventional wisdom, suggesting a departure from the once-assumed negative associations between agency use and care quality. As I delve into this discussion, exploring the shifting paradigms in agency-provider relationships, technological advancements, improvements in staff validation and education, and the emergence of novel staffing/agency business models, it should become increasingly evident that the narrative surrounding agency use demands a nuanced reconsideration.
In our comprehensive study scrutinizing the correlation between agency use and nursing home outcomes, we examined data from more than 14,000 nursing homes. These facilities had submitted their Payroll-Based Journal (PBJ) data, which was subsequently accepted by the Centers for Medicare & Medicaid Services into its staffing database for Q3 of 2023. Our analysis concentrated on 25 outcome measures (dependent variables) encompassing a diverse spectrum of nursing home performance, ranging from survey deficiencies to rehospitalization rates.
Additionally, we included Five-Star Quality Rating System outcomes (Overall, Health Inspection, Staffing, and Quality Measure ratings). Regardless of the specific outcome measures or combinations scrutinized, our investigation yielded a resounding revelation: There was no discernible correlation between agency use and any of these multifaceted outcomes for the time period examined.
We used a measure called the Pearson correlation coefficient to quantify the links between agency use and the various outcomes we examined. In all cases, that coefficient failed to reach the level of statistical significance. So, when we say there’s no correlation between agency use and nursing home outcomes, it means they don’t seem to have a consistent relationship — increases or decreases in agency use don’t reliably predict changes in the outcomes.
To clarify, this study primarily highlights that there isn’t a noteworthy disparity in outcomes between agency staff and permanent staff within nursing homes.
Its aim wasn’t to delve into the financial implications associated with relying on agency staff, nor did it explore the number of staffing hours that might yield the best outcomes. For those seeking insights into the broader relationship between quality and staffing in long-term care, Clemens et al.’s publication “The Relationship Between Quality and Staffing in Long-Term Care: A Systematic Review of the Literature 2008–2020” presents a comprehensive summary that sheds further light on these aspects.
The shift In the relationship between agency use and outcomes from the perspectives presented in earlier seminal articles can be attributed to several notable changes in the healthcare landscape:
- Improved relationship dynamics: Agencies and nursing home operators now prioritize continuity of care by fostering more thoughtful relationships. Encouraging longer-term contracts and consistently assigning the same temporary staff have enhanced rapport and familiarity, potentially improving outcomes.
- Technological advancements: The widespread adoption of electronic health record systems across the nursing home industry has streamlined communication and information sharing. This advancement has likely contributed to smoother transitions between agency and permanent staff, potentially mitigating disruptions in care.
- Enhanced staff validation and education: Certain agencies have excelled in validating staff credentials and competencies and providing ongoing education. This emphasis on maintaining and improving skills among temporary staff members has contributed to better-prepared caregivers, potentially improving outcomes.
- Innovative staffing agency models: The emergence of innovative staffing agency models has injected diversity into the market. These models have introduced novel approaches to staffing, potentially optimizing the match between staff skills and nursing home needs and thereby potentially improving outcomes.
- Staffing dynamics during COVID-19: The pandemic precipitated significant changes in staffing dynamics. Many permanent staff members transitioned to agency roles while remaining in the same nursing home under a different employment arrangement. This shift, while altering the employment structure, might have contributed to a different outlook on outcomes due to the continuity of familiar faces within the care setting.
One agency exec captured many of these points when he said: “Lightweight app-based employment models like ours enable nurses to work part-time in their favorite facilities while eliminating the administrative burden on the facility. We are able to bring nurses back into the workforce part time to support essential care needs.”
These factors collectively reflect a more nuanced and evolved landscape in the relationship between agency use and outcomes, potentially deviating from the associations highlighted in earlier studies.
Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.
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