Resident acuity is a frequently used term, but the meaning is very evasive and rarely defined.

This lack of definition is not by accident, because reimbursement, staffing expenses, and profit drive this issue in many eldercare facilities, not nursing assessment and/or medical judgment.

Of course, few professionals are willing to admit that there is no quantitative process in place to calculate direct care staffing levels other than annual budgets controlled by corporate staff.

Most administrators and Directors of Nursing have the discretion to distribute staff as they please, but they cannot exceed facility labor budgets without jeopardizing their bonus plans and employment. Consequently, trying to squeeze high-acute and high-risk residents into lean staffing patterns forces facility staff to leave the bedside care, supervision, and outcomes of some to chance, even when there are financial resources available to avoid such rationing.

Taking staff time away from one resident and giving it another is not acuity-based staffing. The claim that physicians, DONs, and nurses have more control over facility staffing levels than Administrators and corporate staff is rarely true, but it is a popular defense.

I define acuity as the allocation of clinical expertise and caregiver resources necessary to ensure a resident’s quality of care/life, based on their medical complexity, ADL dependency, and behavior challenges, as determined by a formal assessment process.

Have you ever wondered why some facilities have no policy and procedure on acuity-based staffing in their vast library of operating manuals given the critical importance of this issue? What operational issue is more important than resident acuity?

Most eldercare professionals are reluctant to admit that profit expectations are the driving force behind staffing levels in many eldercare facilities, because they recognize that their admission may be viewed as a betrayal of trust to the vulnerable residents for which they are responsible.

I understand their hesitation and the ethical dilemma this issue raises, but what I find disturbing is individuals who promote the false impression that their staffing levels are acuity-based when the only evidence they can offer are undocumented discussions with facility or corporate staff. When pressed for more convincing evidence, they frequently unleash a flurry of defenses such as : Elevating acuity determinations to the protected realm of nursing and/or medical judgment; insinuating that no individual is more qualified to determine acuity at their facility than they are; using medical records to exaggerate staff contributions; or proclaiming how dedicated their staff is to end the conversation.

However, in the end, they still do not produce any evidence. Like most facility endeavors, acuity-based staffing practices leaves a convincing paper trail.

Many assisted living facilities use level of care rating systems to classify residents according to acuity. However, most are designed to offset the cost of equipment and supplies rather than determine staffing levels. Unfortunately, each LOC is rarely defined by measurable blocks of dedicated caregiver time, so families are expected to trust the judgment of ALF staff, who lack credibility when staffing patterns are derived from annual operating budgets and not LOC assessments.

The problem with these systems is retaining high-risk residents who exceed the capability of an ALF, which cannot be solved by using private sitters or home health agencies. Asking staff for an itemized breakdown of each LOC (i.e., equipment, supplies, and staffing), is a good approach to determine acuity-based staffing practices in ALF’s, especially when you request minutes-per-resident-per-LOC-per-shift.  

Regulatory compliance, governmental rating systems, consumer ratings, and feedback from residents, families, and staff offers valuable insight regarding acuity-based staffing practices. For example, the Centers for Medicare & Medicaid Services’ Five Star Quality Rating System can be an excellent tool for analyzing nursing facilities, although some have gamed the system, and rating domains do not currently isolate aide levels, night shifts, or weekends, which can expose severe understaffing problems. A facility with one star operating below state staffing averages is not in a credible position to claim acuity-based practices. Staffing is the foundation of eldercare regulations, which is very important to remember when analyzing the compliance history of troubled facilities. Unfortunately, surveyor tolerance determines the operating practices of some organizations, and not resident acuity or complying with the standard of care.  

Another obstacle to resident-centered care, which is the essence of acuity-based staffing, is resistance from direct care staff. If you examine the delivery of bedside care at some facilities you will find that they embrace shift routines and focus their energy on efficiency and tasks, rather than defining their roles and success on whether each resident’s daily needs are met. There are contributing factors to this phenomenon including labor agreements, workloads, high turnover, staff burnout, and absentee management, but the real problem is allowing aides and nurses to structure their assignments around their own priorities. Acuity-based staffing can force them to abandon these self-serving mindsets.

Next month I will address the challenge of acuity for memory care residents.

Lance Youles has served as an eldercare executive, consultant, or expert witness in 49 states. He can be reached at