A senior sitting in a wheelchair
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Staffing shortages may be ravaging nursing homes around the country, but the losses may be especially harmful in poorer areas, with fewer qualified clinicians leading to a greater likelihood of poor outcomes, researchers told McKnight’s Wednesday.

In a massive new study of more than 12,000 nursing homes, investigators found startling differences in quality of care, staffing levels and resident outcomes in some of the most disadvantaged areas of the country.

“Most skilled nursing facilities are already concerned about low staff-to-resident ratios, but our analysis reveals that this gap is even worse in disadvantaged communities,” said Jasmine Travers, assistant professor at NYU Rory Meyers College of Nursing and senior author of the Aug. 8 Journal of the American Geriatrics Society study. 

“Socioeconomic deprivation in the local areas surrounding a nursing home may be a barrier to improving staffing rates but has been poorly studied,” Travers said.

Using a novel methodology to map “more granular sources of data,” researchers analyzed quality and payroll-based staffing data for 12,609 U.S. nursing homes. The research team determined 16% of nursing homes in the study were in severely disadvantaged neighborhoods. These facilities were more likely to be for-profit, in rural areas, and serve a higher proportion of Black residents and Medicaid recipients.

Travers and her co-authors determined that a 100-bed nursing facility in a severely disadvantaged neighborhood averaged five hours and 36 minutes less RN care per day compared to a similar facility in more affluent areas, researchers noted.

38% fewer therapists

Structural inequities occur on multiple levels — individual, institutional, community, systemic/policy — and are “deeply embedded in the fabric of our society,” Travers said. Such disparities were found to be partly fueling “fragmented payment system policies that advantages persons with financial resources.” 

The researchers reported facilities in severely deprived neighborhoods had 38% lower for physical and occupational therapy staffing, 30% lower RN staffing, and 5% lower certified nursing aide staffing. No disparities in licensed practical nurse staffing were observed.

“This suggests that nursing homes in more disadvantaged communities may be substituting care by staff with less training,” Travers said.

They also confirmed popular suspicion that nursing homes with higher levels of staffing record better outcomes. Greater RN staffing in this study was associated with lower rates of infection and mortality. The team also found that higher CNA staffing was associated with fewer deficiency citations.

Show them the money

To address significant staffing disparities, study authors recommend “targeted interventions,” including workforce recruitment and retention efforts, to improve staffing levels for facilities in lower socio-economic areas. They also advocate supporting, and not penalizing, nursing homes. 

“This might include enhancing Medicare and Medicaid reimbursement to these facilities using geographically ‘micro-targeted’ funding sources, workforce recruitment efforts focused on pay, transportation, and working conditions, and efforts to retain staff such as opportunities for CNAs and LPNs to complete training as RNs,” said Jason Falvey, assistant professor of physical therapy and rehabilitation science at the University of Maryland School of Medicine and the study’s first author.

Travers said the White House’s current push to create minimum staffing rules would be “a step, but much more is needed then simply setting a minimum standard. You have to have the pool of workers available to hire, which will take concerted efforts around recruitment and retention initiatives and making nursing homes a better place to work.”