“The Happiest Place On Earth” is a title self-awarded and held by Disneyland. With pictures of smiling faces of all ages circulating through ads and social media, it is not hard to see why people view it as a happy place. Venturing to the other side of the spectrum, you would be hard-pressed to find someone who shares a similar reaction when reading, discussing, or thinking about nursing homes or any type of long-term care facility. Thanks in part to heartbreaking news stories and the unfortunate, but necessary, general nature of the work required at such facilities, long-term care establishments have an uphill climb in terms of establishing a solid and promising reputation to potential clients. All nursing homes start behind the eight ball even before potential clients walk through the front doors for a facility tour. With that in mind, do nursing homes deserve the negative notoriety that befalls them?
Over three million Americans rely on services provided by nursing homes at some point during the year. A little less than half of that number reside within the over 15,000 facilities located in the Nation on any given day. The residents, along with their family members and friends, rely on nursing homes to provide high quality care. Because of this, long-term care facilities are constantly looking to improve their services and reduce negative stressors on their reputations.
Just like any other provider of health services, improvements on quality of care is key. Fortunately, in recent years the U.S. government has taken additional steps to further improve these aspects with more involved healthcare regulations and assistance. Approximately 5,000 federal and state surveyors conduct on-site surveys of certified nursing homes every 12 months on average to assure basic levels of quality and safety for beneficiaries. The Centers for Medicare & Medicaid Services, which is a part of the Department of Health and Human Services, identifies staffing as one of the vital components of a nursing home’s ability to provide quality care.
In order to assist patients and their families in determining the best nursing home, CMS created a Five-Star Quality Rating System. This quality rating system gives nursing homes a rating of between 1 and 5 stars. Essentially, the higher the number of stars, the better the overall quality of the facility. In addition to having this overall rating for simple reference, three separate factors are rated on the same five-star scale for each nursing home: Health Inspections, Staffing, and Quality Measures.
While all three factors are incredibly important, “staffing” has grabbed the headlines recently across the nation thanks to the new reporting requirement under the Affordable Care Act (ACA). Section 6106 of the ACA requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data.
The data, when combined with census information, can then be used to not only report on the level of staff in each nursing home, but also to report on employee turnover and tenure, which can impact the quality of care delivered. Prior to this new form of data evaluation, CMS relied on self-reported numbers from the individual facilities.
In November of 2017, CMS released its first sets of data from collecting quarterly payroll-based staffing data nationwide. CMS has developed a system for facilities to submit staffing and census information – the Payroll-Based Journal. This system allows staffing and census information to be collected on a regular and more frequent basis than previously collected. Fortunately, all long-term care facilities have access to this system at no cost to facilities.
Before diving into what the numbers showed, it is important to understand the current standard. A USCMS study in 2001 established that nursing homes should aim to have a minimum 0.75 hours per resident day for Registered Nurse care, 0.55 hours per resident day for a Licensed Vocational Nurse or Licensed Practical Nurse, and 2.8 hours per resident day for Certified Nursing Assistants for a grand total of 4.1 nursing hours per resident day. To be clear, the calculation is performed by taking the number of total logged hours by nurses that day, divided by the number of residents on that same day. This recommended minimum threshold level was also supported in a 2004 observational study of nursing home staffing and a later reanalysis in 2011. Now that we have some standard numbers in mind, let’s take a look at how the Nation appears to be doing.
Results from Data
Based on the released data set, the nursing homes in Missouri average 2.77 staffing hours per resident per day. The average registered nurse hours per resident per day is 0.29. In Illinois, the average staffing hours per resident day is 3.23. The average registered nurse hours per resident per day is 0.59. The National Average is 3.4 hours of direct care staff time per resident per day and 0.4 hours of registered nurse staff time per resident per day. While these numbers are below the numbers shown by the study mentioned previously, we must remember that every nursing home is different and the standard discussed above is a recommendation without considering all relevant factors.
When the information under the ACA was initially released, one of the first groups to evaluate the mind-numbing amount of data was Kaiser Health News. The initial assessment seemed to point toward the possibility that nursing homes were not adequately staffed. Since then, their data and evaluation has been cited and reported on by media ranging from national news to local news. However, KHN disclosed that its methodology of calculations is different from that used by Medicare:
Medicare’s methodology differs from KHN’s calculations of highest- and lowest- staffed days. Medicare included administrators in its tally of staff. Secondly, Medicare averaged staffing on every day of the three- month period, while KHN looked at the 10 best-staffed and 10 worst- staffed days. Finally, Medicare took into account how frail each homes’ residents were to risk-adjust the data to allow fair comparisons among facilities. (Methodology document provided by KHN).
Additionally, KHN’s data set separates those who provide direct care and those who work in administrative roles in nursing homes. This separation, which is a different method than used by Medicare, would explain why many facilities have lower RN statistics. An RN could be in the building for the entire day, but he or she may be doing administrative work rather than caring for patients throughout the day. That would not necessarily mean that the RN does not assist patients in some manner, but that it does not get calculated as such through the payroll. Additionally, it does not account for overtime hours by salaried workers.
To be clear, KHN’s evaluation and resulting data set is not incorrect or misleading, but is simply different than the method used by Medicare. However, it is important to understand this distinction in order to properly understand the state of nursing home staffing in the Nation.
Data results are not conclusive, but may result in a change in Quality Rating
Released data sets are not representative of all nursing homes and all data that may exist. A number of data points were not utilized in calculations as they were deemed “aberrant.” Therefore, positive data points that may have been left off or not counted as a result of mistaken input is not included. Of course, the missing information has an equal chance of dropping the national averages as well. Recently, Medicare reduced ratings of many nursing homes, including many in St. Louis. Medicare said those homes either lacked a registered nurse for “a high number of days” over three months, provided data the government could not verify, or did not supply their payroll data at all.
All in all, while the new method of reporting will eventually generate more accurate data to determine whether or not there is appropriate coverage of patients and staffing, these early data sets should be evaluated with caution. There are plenty of details that need to be worked out and methods that need to be perfected to establish an accurate indication of staffing levels at the facilities nationwide. Keep in mind that Medicare will take into account the frailty of residents in determining how much staffing may be necessary in order to maintain equality among nursing homes. Nursing homes with healthier residents simply may not need as many on staff as nursing homes with residents in poorer health. The former will, therefore, not be penalized for having lower staffing as a result.
Though this stricter manner of monitoring staffing may seem like another stressor on long-term care facilities, just remember that these laws were put in place in order to improve quality of care, which is key to attracting residents. Increasing staffing is, objectively, one of the easier fixes available to facilities if a Quality Rating is downgraded. In order to avoid a reduction in ratings, nursing homes across the nation must keep accurate records and submit them timely as required under the ACA.
Over time, the system’s bugs will be worked out and all nursing homes will see an increase in the quality of care provided. This, in turn, will improve reputation and increase customer satisfaction.
Kevin Peek is a healthcare attorney at Sandberg Phoenix.
