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Aiming for the stars? Reflections on staffing to acuity

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Steven Littlehale
Steven Littlehale
An old proverb suggests, “It is better to aim for the stars and hit the fence than aim for the fence and hit the dirt.” Is this good advice for skilled nursing facility operators?

Budgeting the total number of nursing hours for a facility's occupancy and case mix is critical. Understaffing carries risks; overstaffing decreases margins. Fluctuations in occupancy bring additional challenges in managing schedules and overtime. Federal regulations require a facility to ‘assure that sufficient qualified nursing staff are available on a daily basis to meet residents' needs for nursing care in a manner and in an environment which promotes each resident's physical, mental and psychosocial well-being, thus enhancing the resident's quality of life'[1].  

A fine statement of an ideal, with no standard method for translation into hours per resident day (HPRD) by staff type.

Experts have proposed standards for minimum and ideal staffing, and some states have adopted minimums as legal requirements. However, there is no industry-wide agreement on any of the three targets for staffing to acuity, as described in 2002 by the Kaiser Commission on Nursing Home Staffing Standards: the minimum staffing level to avoid harm, the preferred process level and the optimal level.

The Kaiser Commission suggested minimum total nursing staffing of 2.79 HPRD while a Hartford Institute of Geriatric Nursing panel recommended a minimum of 4.44 HPRD. The Centers for Medicare & Medicaid Services publicly rates nursing homes on five-star scales for overall nursing HPRD and for RN HPRD. In their summary staffing score, RN HPRD is effectively counted twice, reflecting CMS's expert consensus that RNs serve a unique role in SNF care.

PointRight, a post-acute care analytics company, has studied the relationship of staffing and care outcomes for more than 15 years. To advise a specific SNF on its staffing, we'd say “start by looking at your data,” but we begin with some general perspectives readers might find helpful.

  1. Staffing ratios are just one of several factors that affect care outcomes. While there truly are minimum ratios below which adverse outcomes become more likely, above those thresholds results depend much more on the quality of the entire staff and overall culture of the facility.
  2. CNA HPRD should be proportional to residents' functional dependency and behavioral management needs; licensed HPRD should be proportional to residents' medical acuity.
  3. When RNs are available for hire, it is better to have an RN than an LPN.  Higher RN staffing is consistently, provably associated with better clinical outcomes and better care processes. Exceptions should be made for LPNs with valuable experience, outstanding personal qualities, or specialized skills.
  4. Facilities should strive for accuracy in tracking and reporting their actual staffing to CMS.
  5. If operators plan to increase their Medicare population, they should plan to increase their licensed (and especially RN) HPRD. If the data show an uptrend in post-acute and rehab services the budget should provide for more licensed staff.
  6. The medical acuity, functional dependency, behavioral status, and adverse event risk for a facility's resident population should be tracked using MDS assessments, and DONs should adjust staff schedules to reflect changes in the facility's resident characteristics.
  7. Overtime should be monitored and excessive use avoided.

The CMS Five-Star System is useful if its limitations are understood. A facility with one-star staffing will have increased risk of adverse events of all kinds: poor clinical outcomes, survey deficiencies and consumer complaints. In general, facilities with three or more staffing stars will perform better than those with two stars. From three stars, up the trade-off of nurse staffing versus other care inputs should be based on the specific needs of the resident population and the facility's resource constraints.

Combining MDS-based outcomes and risk analysis with accurate staffing data can support the operator and the DON in making data driven decisions about staffing and acuity.

Steven Littlehale is a gerontological clinical nurse specialist, and EVP and chief clinical officer at PointRight Inc. 


[1] States Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities; Rev 70, 1-7-11


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