Average day-to-day staffing levels may be a key way to measure impact on nursing home care quality, a new study finds as federal regulators move closer to their goal of a proposed staffing mandate.

Nursing homes that keep day-to-day nursing staff stable, especially by avoiding days with low LPN or CNA presence, perform better on a variety of patient outcomes, researchers from the University of California and the University of Chicago reported in JAMA Network Open Tuesday.

The authors pose their calculations as a method to measure staff adequacy for patient needs, possibly “above and beyond” the traditional hours per resident day metric. A 4.1 hours per-resident-day measure has been widely considered the gold standard since the early 2000s, but it has never been adopted as a formal federal requirement.

A first-ever federal mandate, widely feared by providers who find themselves underpaid and hampered by daunting recruitment challenges, is expected to be issued by early this spring. This week, nursing home advocacy groups ramped up their efforts to insist that any such rule be accompanied by reimbursement and acknowledgement of the ongoing labor crisis.

“Workforce shortages are already limiting new admissions and they’re already forcing organizations to close, so despite the fact that the proposed rule has not been released yet, we’re looking to get ahead of it,” Todd Adams, LeadingAge’s director of health legislative affairs, said on a call with members Monday. He predicted the proposed mandate could drop in March or April “or earlier.”

LeadingAge is encouraging members to write to CMS Administrator Chiquita Brooks-LasSure “opposing the adoption of a minimum staffing ratios mandate without the necessary workforce investments and reimbursement levels to ensure that residents and patients receive the care they deserve.”

“CMS needs to understand that mandating minimum staffing levels won’t lead to meaningful quality improvements and outcomes without enough qualified workers to fill open positions,” Adams added in his comments. “It certainly won’t without adequate reimbursement levels to pay them a living wage. We need real solutions.”

Workforce issues worsening for many

Those statements were echoed Tuesday by the American Health Care Association, which released a new survey showing 45% of nursing home providers said their workforce situation has worsened in the last seven months. Just 30% said workforce situation had gotten somewhat or much better since May.

In addition, 84% said they were facing moderate or high levels of staffing shortages and 96% have difficulty hiring staff. That’s despite the fact that more than 90% had increased wages and offered bonuses to recruit.

“Nursing homes have done everything they can on a fixed government budget — they cannot solve this crisis on their own,” Parkinson said in a statement accompanying the survey results. “We need policymakers to invest in long-term care, so we can compete for health care workers, transform America’s nursing homes, and prepare for a growing elderly population.”

The AHCA survey found that providers’ biggest concern with a potential mandate is finding staff to meet the requirement, followed by having to rely on more costly agency staff to fill shifts Almost all respondents (95%) said they were concerned about being able to meet a 4.1 hours per resident day staffing minimum.

The McKnight’s 2023 Outlook Survey found similar worries, with many providers saying they might stop services or increase reliance on agency nurses if such a high standard were enacted without accommodations in the current labor environment.

LeadingAge, whose new campaign is tied to this week’s start of the 118th Congress, urged letter writers to detail their challenges when possible, including vacancy numbers and length;  

financial impact related to wage changes and state reimbursement; and impact on admissions.

Since the White House announced its plans about a year ago, providers have suggested a variety of alternatives to a straight 4.1 hour standard. Those include counting non-nursing staff such as physical and recreational therapists in calculations and issuing waivers for providers in regions with high employment rates.

CNA, LPN stability promoted

The researchers behind Tuesday’s JAMA Network Open study say their findings should be used to help shape CMS’ draft proposal.

“The information provided here, about both the HPRD and below-average staffing days, is relevant and may inform these efforts,” wrote the team, which included Dana B. Mukamel, PhD, of the Department of Medicine at the University of California-Irvine and R. Tamara Konetzka, PhD, of the Department of Public Health Sciences at the University of Chicago.

Even though stable CNA measures were associated with better performance on nine of the 12 quality measures, stable LPN measures associated with 10 of 12 QMs, no such results were found for stable RN staffing.

“It seems that having enough RN hours is essential to nursing home quality, but stability of those hours does not matter as much, perhaps because nursing home managers find ways to compensate when an RN cannot show up, possibly by delegating some of those tasks to LPNs or to administrative RNs, or postponing those tasks,” they wrote. “On the other hand, instability of LPN and CNA staffing seems to be a red flag for quality, perhaps one that consumers should know about. 

“The ability of a nursing home to avoid days with low LPN and CNA staffing, perhaps by building more flexibility into staffing availability or better planning and anticipation of changes in staff availability or resident census, appears to offer a new pathway to quality improvement.”