Nursing Home Staffing

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Testimony on Nursing Home Staffing by Nancy-Ann DeParle, Administrator
Health Care Financing Administration
U.S. Department of Health and Human Services

Before the Senate Special Committee on Aging
July 27, 2000

Chairman Grassley, Senator Breaux, distinguished Committee members, thank you for inviting me to discuss the need for adequate staffing to ensure quality care in nursing homes. We are completing the first phase of extensive research on this issue, and appreciate this opportunity to share our preliminary findings and describe remaining challenges.

Our findings to date show a strong association between staffing levels and quality care. This is the first time ever that a clear relationship between staffing levels and quality of care has been demonstrated in a statistically valid way, and marks a major step forward in understanding that relationship. The findings demonstrate that there are significantly more problems in facilities with less than 12 minutes of registered nursing care, less than 45 minutes of total licensed staff care, and less than 2 hours of nursing aide care per resident per day. The results are troubling, and suggest that many facilities may need to increase staffing levels.

However, the results at this point are preliminary and represent only the first step in taking action to address staffing issues and improve nursing home quality.

We are now working to:

refine ways to adjust minimum staffing requirements for the case mix, or severity of illness and amount of care required by patients in a given facility;
expand our studies beyond the three States included in research so far;
validate the findings with individual case studies of specific facilities;
determine the costs and feasibility of implementing minimum staffing requirements.

Meanwhile, earlier this year, we began posting data on the number and types of staff at individual nursing homes on our medicare.gov website’s "Nursing Home Compare" page. This is by far the most popular section of our consumer-oriented Internet offerings, and is a key part of our comprehensive efforts to increase nursing home accountability by making information on each facility’s care and safety record available to residents, families, care givers, and advocates.

BACKGROUND

Protecting nursing home residents is a priority for this Administration and our agency. Some 1.6 million elderly and disabled Americans receive care in approximately 16,500 nursing homes across the United States. The Medicaid program, in which States set reimbursement levels, pays for the care of the majority of nursing home patients, while the Medicare program pays for care of about 10 percent of patients. The federal government provides funding to the States to conduct on-site inspections of nursing homes participating in Medicare and Medicaid and to recommend sanctions against those homes that violate health and safety rules.

In July 1995 the Clinton Administration implemented the toughest nursing home regulations ever, and they brought about marked improvements. However, both we and the GAO found that many nursing homes were not meeting the requirements and the State enforcement efforts were uneven and often inadequate. Therefore, in July 1998, President Clinton announced a broad and aggressive initiative to improve State inspections and enforcement, and crack down on problem providers. To strengthen enforcement, we have:

< expanded the definition of facilities subject to immediate enforcement action without an opportunity to correct problems before sanctions are imposed;

< identified facilities with the worst compliance records in each State, and each State has chosen two of these as "special focus facilities" for closer scrutiny;

< provided comprehensive training and guidance to States on enforcement, use of quality indicators in surveys, medication review during surveys, and prevention of pressure sores, dehydration, weight loss, and abuse;

< instructed States to stagger surveys and conduct a set amount on weekends, early mornings and evenings, when quality and safety and staffing problems often occur, so facilities can no longer predict inspections;

< instructed States to look at an entire corporation’s performance when serious problems are identified in any facility in that corporate chain, developed further guidelines for sanctioning facilities in problem chains, and collected State contingency plans for chains with financial problems;

< required State surveyors to revisit facilities to confirm in person that violations have been corrected before lifting sanctions;

< instructed State surveyors to investigate consumer complaints within 10 days;

< developed new regulations to enable States to impose civil money penalties for each serious incident; and

< met with the Department’s Departmental Appeals Board to discuss increased work load due to the nursing home initiative.

We also are now using quality indicators in conjunction with the Minimum Data Set that facilities maintain for each resident. These quality indicators furnish continuous data about the quality of care in each facility and allow State surveyors to focus on possible problems during inspections, and it will help nursing homes identify areas that need improvement.

In addition, we have been working to help facilities improve quality. For example, we have:

< posted best practice guidelines at cms.hhs.gov/medicaid/siq/siqhmpg.htm on how to care for residents at risk of weight loss and dehydration;

< been testing a wide range of initiatives to detect and prevent bed sores, dehydration, and malnutrition in ten states, and worked with outside experts to develop a systematic, data driven process to identify problems and provide focus for in-depth on-site assessments;

< worked with the American Dietetic Association, clinicians, consumers and nursing homes to share best practices for preventing these problems and begun a national campaign to educate consumers and nursing home staff about the risks of malnutrition and dehydration and nursing home residents’ rights to quality care this year.

We also are continuing to develop and expand our consumer information to increase awareness regarding nursing home issues. We are now conducting a national consumer education campaign on preventing and detecting abuse. And we are working to educate residents, families, nursing homes and the public at large about the risks of malnutrition and dehydration, nursing home residents’ rights to quality care, and the prevention of resident abuse and neglect.

Nursing Home Compare Website

Key among our efforts to increase nursing home accountability is making information on each facility’s care and safety record available to residents, their families, care givers, and advocates. One of the most successful ways we are doing this is through our new Nursing Home Compare Internet site at medicare.gov, which allows consumers to search by zip code or by name for information on each of the 16,500 nursing homes participating in Medicare and Medicaid.

As mentioned above, we are now posting data on the number of staff in each of these facilities on the Nursing Home Compare site. These data include the number of registered nurses (RNs), license practical or vocational nurses (LPNs), and nurse aides in each facility. The site also includes information on:

the number and type of residents;
facility ownership;
records of deficiencies or quality problems found during inspections by State survey agencies; and
ratings of each facility in comparison to State and national averages.

Nursing Home Compare is recording 500,000 page views each month and is by far the most popular section of our website. The staffing data are a critical addition, in light of the new research we are unveiling on the strong association between staffing levels and quality care.

MINIMUM STAFFING NEEDS

The ongoing research to quantify the staffing ratios necessary for quality care is another essential step in our efforts to improve the quality of life and care for nursing home residents. Current law and regulations require only that nursing homes provide "sufficient nursing staff to attain or maintain the highest practicable . . . well-being of each resident," with a minimum of 8 hours of RN and 24 hours of LPN coverage per day.

The research was mandated by Congress in 1990, with a report due in 1992, but proved to be much more challenging than anticipated. Our report on the first phase of this research, which we expect to deliver to Congress next week, establishes for the first time in a statistically valid way that there is, in fact, a strong association between staffing levels and quality of care. Many had long suspected as much, but this had never before been documented. This study will provide a basis for further work in this area.

To conduct this research, we contracted with several research firms and gathered comprehensive data from 1,786 nursing homes in three States. We convened a panel of nationally recognized experts in long-term care, nursing economics, and other disciplines. We also consulted extensively with consumer advocates, nursing home industry officials, and labor unions representing nursing home workers.

Multivariate analyses were used to identify potential critical ratios between measures of nurse staffing and outcomes such as avoidable hospitalizations, improvement in ability to perform daily activities, and incidence of weight loss and pressure sores. The data were adjusted for case mix; however, refinement of methods for taking case mix into consideration are necessary to establish national minimum staffing levels.

These multivariate analyses demonstrated that, on average, quality of care is seriously impaired below certain minimum ratios -- 2 hours per resident day for nurses aides, 45 minutes per resident day for total licensed staff (RNs and LPNs), and 12 minutes per resident day for RNs.

They also demonstrated that quality of care is improved across the board at higher "preferred minimum" ratios of 1 hour per resident day for total licensed staff and 27 minutes per resident day for RNs.

	*Suggested Minimum Staffing*	*Preferred Minimum*
RNs	12 minutes	27 minutes
Total Licensed Staff	45 minutes	1 hour
Aides	2 hours	2 hours

Nationwide, more than half (54 percent) were below the suggested minimum staffing level for nurses aides, nearly one in four (23 percent) were below the suggested minimum staffing level for total licensed staff, and nearly a third (31 percent) were below the suggested minimum staffing level for RNs. More than half (56 percent) were below the preferred minimum level for total licensed staff, and two thirds (67 percent) were below the preferred minimum level for RNs. In addition, a time-motion study recommended even higher requirements than this multivariate analysis.

NEXT STEPS

While these findings are very troubling and represent a major step forward in understanding the relationship between staffing levels and quality of care, they are preliminary. We are now working to address remaining issues.

The second phase of this research initiative involves:

evaluating staff levels and quality of care in additional States with more current data;
validating the findings through case studies and examining other issues that may affect quality, such as turnover rates, staff training, and management of staff resources;
refining case mix adjustment methods to ensure that any minimum staffing requirements properly account for the specific care needs of residents in a given facility;
determining the costs and feasibility of implementing minimum staffing requirements and the impact on providers and payers, including Medicare and Medicaid.

In the meantime, we want to work with Congress, States, industry, labor, and consumer advocates to evaluate ways to ensure that all nursing home residents receive the quality care they deserve. These strategies include staffing levels, improved training, increased dissemination of performance data, or enhanced intensity of survey and certification practices.

CONCLUSION

The research we are unveiling is ground breaking. Its results are troubling, and strongly suggest that many facilities will need to increase staffing levels. We are working diligently to take the necessary next steps for determining how to address staffing issues and improve nursing home quality. This Committee has provided invaluable assistance to us in our efforts to improve quality and protect residents in nursing homes. And we look forward to working with you again on this important issue as we move forward. I thank you again for holding this hearing, and I am happy to answer your questions.