Despite diligent efforts by nursing homes during COVID-19 outbreaks, operators need help from policy makers to ensure better levels of care during future infection control emergencies, researchers say.
Staffing levels may actually appear higher than normal during COVID outbreaks, but that belies increasingly intense staff-time needs, as well as the fact that worker levels generally do not recover after an outbreak, a veteran academic team of nursing home researchers found.
As a result, policy makers should consider steps such as creating centralized ‘strike’ teams to supply temporary staffing assistance, as some states did, and other measures to help lift providers when a crisis hits.
The research also is an indicator of an “altered landscape” for senior care, said researcher Brian McGarry, PT, PhD, a professor in the Division of Geriatrics & Aging in the Department of Medicine at the University of Rochester Medical Center. The report was released Friday by the online JAMA Health Forum.
“[The study] is a big deal because it really adds some context and tells a different side of the story about the impacts of the COVID pandemic on nursing homes,” told McKnight’s. “We know a lot about how the pandemic has impacted residents. We know a lot less about how it’s impacted the staff who have worked there.”
McGarry said the research illustrated that even when nursing homes used an “all-hands-on-deck” approach to filling absences for sick or resigned staff members during an outbreak, it often still wasn’t enough.
Staffing levels remained 5.5% below pre-outbreak levels 16 weeks after an outbreak hit, revealing a chronic leaky bucket syndrome. CNA losses were the highest, and the hardest to recover from.
The cohort study examined the 10% worst COVID-19 outbreaks (nearly 3,000) that took place in U.S. nursing homes during the last half of 2020, before vaccinations were available. Data used included federal weekly staffing counts, absences/departures, new hires, contract staff hours, staff shortages and resident deaths.
When outbreaks peaked, around four weeks after their start, staffing hours were 2.6% below mean pre-outbreak levels. That number more than doubled four months after the initial outbreak, as overtime returned to normal levels around week nine, contract staffing was severely cut back by week 10, and the effect of permanent departures took full hold.
“An operator could use some of this data to argue that they might need some assistance in order to maintain a safe level of staffing for their residents, especially when we know that it can be more difficult to care for residents, given all the infection control things you need to be doing,” said study leader Karen Shen, of the Department of Health Policy and Management of the Bloomberg School of Public Health at Johns Hopkins University.
‘Scary’ thing: Permanent departures
She noted that because the resident count typically fell faster than the staff count during an outbreak, staff hours per resident could actually appear to rise during an outbreak. But the added stress and complexity of care needed, along with the surprisingly high number of staff permanently leaving the industry, point to a long-term deficit for operators, she explained.
“One of the scary things we find is staff are leaving the industry permanently during these outbreaks,” she told McKnight’s Friday. “They’re just saying, ‘No thank you. I’m done.’ Any support a facility can get is probably well deserved and well needed.
“We were surprised that it was [permanent] departures and not absences [due to quarantine or sickness] that were the biggest deal. We were surprised that staff didn’t really come back after the outbreak dissipated.”
Investigators also expressed surprise that while RNs and aides both may leave during the start of an outbreak, RNs were much easier to hire back to pre-outbreak levels. The data indicate that more resources need to be dedicated to recruiting CNAs, researchers indicated.
The results also show that facilities themselves need to better prepare for outbreaks and their aftermath because apparent early success with an outbreak is not necessarily an indicator of long-term health, Shen added. Investigators found that increased attempts to hire new employees, asking existing staff to work more overtime and a rise in agency staff hours often weren’t enough.
“There’s probably a need for short-term emergency staffing solutions that might go beyond individual facilities,” Shen said, pointing out states that sent out temporary “strike team” staffing help as a good example. The American Rescue Plan Act of 2021 provided temporary funding for such teams.
“I also think there are lessons for the long term, in trying to create a more robust staffing structure in the long-term that can withstand some of these shocks a little better,” Shen added. “So that might look like investing more in staff, offering better wages and benefits, more PPE, and so forth. Spot-staffing is going to be important.”
Federal and state leadership will be important, study authors concluded.
“Policy makers might also consider broad investment in nursing home workers through better pay and benefits, such as increasing Medicaid reimbursements alongside wage pass-through requirements,” they wrote. In addition, they feel that policy makers should question whether traditional staffing measures accurately capture the adequacy of staffing levels during a pandemic.
“The nature of caring for nursing home residents has totally changed as a result of the pandemic,” McGarry believes. “Our sense is that the number of staff hours needed per president is way up, relative to what it was pre-pandemic. A lot of that has to do with cohorting preferences and working with patients 1-on-1.”
More complex infection control steps, including full donning and doffing of PPE, as well as dining aides no longer being able to work with three or four patients at a time are examples of how workflows have been upended, he noted.
“A key takeaway from this is staffing ratios in and of themselves are inherently flawed, particularly when you have large changes in the resident population. Ratios are not a good measure of resident need during the pandemic. I think the nature of work has changed so it’s not an apples-to-apples comparison,” he added. “But that’s a really nuanced point and it’s hard to make. I’m sure if there are groups who want to use those staffing ratios to make a point, then they will continue to do that.”
Staffing ratios doubted
He said that because resident needs, and the methods of addressing them, change over time, staffing ratios don’t work as a benchmark. He called for case-mix adjustments, which CMS currently does in its Five-Star scores on Care Compare.
“This shows those adjusters, those measures of how much time those residents need, may vary over time,” McGarry explained. “Those adjustments are based on some pretty outdated time-use surveys where somebody went into the nursing home and observed care of a bunch of different residents with different needs and kind of came up with these estimates. That number has probably changed over time and I think it’s absolutely changed pre/post pandemic. In the midst of a generational global pandemic, you need a different set of minimum standards than you do pre-pandemic or “normal” times.”
He said the most recent research also speaks to the challenges of setting a minimum staffing ratio, as CMS is attempting to do by spring.
“Before COVID, I think you could have convinced me that the nature of caring for these residents was pretty stable,” McGarry said. “Things change and the pandemic obviously turned everything upside down and really changed the calculus of how residents are cared for and how much time it takes to do that.”
The pandemic has accelerated broader implications, he believes.
“The nursing home industry appears to be at a crossroads here where COVID has kind of altered the landscape of what it means to care for older adults in nursing homes. It’s altered the demand of how willing people are to go to nursing homes, and what they look for in nursing homes,” he said. “In combination with PDPM, it’s sort of leading to some soul-searching and question asking as to how do we pay for this care? So, lots more to come as to understanding what the implications are for an overtaxed workforce that just saw historic losses in terms of the number working in that industry.”
Others on the COVID-19 outbreak staffing patterns study team included Harvard Medical School’s David Grabowski, PhD; Jonathan Gruber, PhD, of the Massachusetts Institute of Technology Department of Economics; and Ashvin Gandhi, PhD, of UCLA’s Anderson School of Management.