New Tool to Determine Safe Staffing

McKnight’s reported on a new tool that will assist nursing homes in determining safe staffing levels based on the needs and condition of the residents. Nursing homes can use this measurement as they complete facility assessments to gain a better understanding of how the facility’s patients’ level of need aligns with staffing plans.

Researchers propose a new tool that utilizes a nursing home’s case-mix index to establish expected daily nurse staffing levels. Charlene Harrington, RN, PhD, and colleagues from across the University of California used the Centers for Medicare & Medicaid Services to evaluate a nursing home’s staffing prowess.

“We don’t know the fate of the staffing regulation and may not know for some time. But this guide does not depend on the regulations. It is designed to help nursing homes staff facilities and units based on their acuity,” Harrington, professor emeritus of social behavioral sciences at the University of California San Francisco, told McKnight’s Long-Term Care News.

This study used past research to determine necessary staffing hours based on a nursing home’s case-mix index. Under the Patient-Driven Payment Model, CMS adjusts providers’ payments using 25 HIPPS codes, ranging from Y (least severe cases) to A (most severe cases), with patients requiring extensive services, such as mechanical ventilation. CMS began publishing each facility’s weighted average quarterly CMI score in provider data files starting in July 2024.

Federal regulators may still be able to improve nursing home staffing by using a new measure of staffing adequacy to increase public pressure, even if a proposed nationwide staffing rule fails. According to new benchmarks developed by researchers, 9 out of 10 nursing homes are failing to meet staffing expectations. On average, nursing homes are falling short of staffing requirements, with an average of 3.84 hours per day per resident, compared to the recommended 4.92 hours. RN staffing was 32% below expectations, CNA was 30%, and overall staffing was 22% below patient needs. At the lowest case mix, X, nursing homes provided 3.7 hours of daily care compared to the expected 4.53 hours. No nursing homes in the US had an average in the Y level, although some individual patients or units could receive that code. Additionally, at the W level, an average of 2.19 hours of daily nursing care was provided, compared to the expected 3.83 hours. “Medicare has always paid based on acuity, but they [CMS] just never had a requirement that the nursing home actually had to deliver that level of nursing services,” Harrington explained.

However, the study authors also noted that CMS should adopt their approach to encourage nursing homes to voluntarily align their staffing decisions with resident conditions, as they have been paid extra to provide additional care. The federal staffing mandate was intended to establish a minimum level of care, with the study using its required 3.48 daily nursing hours as the baseline for residents needing the least assistance.

“It gives residents, families, operators, and policymakers a clear and meaningful way to gauge whether a nursing home is adequately staffed to ensure safe, appropriate care,” Harrington told McKnight’s that CMS could find a better way to use the calculations and combine them with helpful language to better guide consumers looking for quality care.

Richard Mallot, Executive Director of the Long Term Care Community Coalition and the only study co-author not affiliated with the University of California system highlighted new findings on nursing home staffing.

“This new methodology …offers a critical tool for the public to understand what staffing levels a nursing home should be providing — based not on arbitrary benchmarks, but on the facility’s assessment of its residents’ needs,” Mollot said.

This study criticized Care Compare’s current staffing metrics, arguing that its current method, which averages staffing rates and then uses cut points to assign star rankings, is insufficient because it can award high ratings even when actual staffing is insufficient to meet resident needs.

“It’s misleading, maybe to providers as well as to the public, because if you get a 4-star on your staffing, you think you’re doing a good job. But it doesn’t mean you’re staffing your acuity. You’re just doing a good job relative to everyone else,” Harrington said. She added, “CMS could use this to give facilities a better incentive, and it would also be more informative if they would show nursing homes that they’re not meeting their case miss requirements.”

However, the staffing requirements that the team calculated shouldn’t be taken at face value. Harrington noted that factors such as facility layout, staff training, and high patient turnover could all impact even higher staffing levels. “I just don’t think most nursing homes are considering their case mix the way they’re supposed to,” she said. “This [proposed new method] is not a guarantee, but at least it would be closer.”