Happy Hump Day! Another Wednesday with news too heavy to ignore. I’ll try to return to some levity and light in future Wednesday features.
For a number of years, CMS has been playing with developing a staffing level mandate. The first CMS study from 20 years ago recommended a 4.1 hours per day benchmark. Recently, numbers have flowed around 3.5 hours per day.
The Biden administration, earlier this year, commissioned Abt and Associates to conduct another study on “Nursing Home Staffing”. The study was actually complete in June of this year and via a quick breaking story yesterday from Kaiser (KFF), the study became available. Recall, the Biden administration promised last year that it would have a staffing mandate published by February of this year – six months ago. CMS has since pulled the study, but I have a copy that readers can access within this post.
I have written a number of articles/posts on the concept of a staffing a mandate for SNFs. The general consensus is that more staff, properly qualified, especially RNs, creates a significant benefit in terms of resident care. The question, however, is what the right number in terms of a per patient day level is, AND if that kind of metric even makes sense. I have long abandoned the hard matrix of per resident/patient day staffing as SNFs today and their census is heavily influenced by acuity levels (care needs). In this vein, I favor acuity-based staffing models as more reflective of resident/patient needs and the type and numbers of staff that should be on any given shift. Nonetheless, a recent staffing mandate post that I wrote is available here: https://wp.me/ptUlY-FD
Yesterday’s story from KFF highlights the complexity of the staffing mandate quest coming from the Biden administration. KFF noticed, as did I when I read the report, that Abt worked off a 3.88 hour per day benchmark, down from the 4.1 Biden and CMS have mused about for years. The report actually noted that there was no staffing level, mandated by hours per resident/patient day, that would guarantee quality care. I would argue as I read the findings that the report also said that the one-size fits all model is problematic (see my comments above regarding an acuity model vs. hours per day). The report did note that more staffing likely would reduce hospitalizations (ED and inpatient) and wait times for care (and thus, likely reduce falls, medication errors, etc.).
The Abt study looked at four minimum staffing levels, all of which were below the 4.1 hours per day benchmark. The highest model used was 3.88 daily staff hours. At 3.88 hours, the study estimated 0.6% of residents would get delayed care and 0.002% would not get required care. It also indicated that the 3.88 staffing level would result in 12,100 fewer hospitalizations and 14,800 fewer emergency room visits. Abt found that three-quarters (75%) of nursing homes would need to add staff to achieve 3.88 hours and that it would cost SNFs $5.3 billion more each year.
The lowest staffing level analyzed was 3.3 daily hours. At this level, the report said, 3.3% of residents would get delayed care and 0.04% would not get required care. This level would reduce hospitalizations of residents by 5,800 and result in 4,500 fewer emergency room visits. More than half of nursing homes would have to increase staff levels to meet this ratio, the report said. It would cost SNFs $1.5 billion more each year. The full Abt report is available for download here: Abt-Associates-CMS-NH-Staffing-Study_Final-Report_-Apndx_June_2023
A core argument against mandated staffing levels via the SNF industry is that insufficient numbers of staff exist to meet the mandate. Further, the costs associated with compliance would be so exorbitant that facilities could not afford the mandate and thus, likely close or reduce beds to adjust the ratio for compliance (hours per day increases with fewer occupied beds). In rural areas with existing staff supply issues, facilities are already closing leaving patients stranded in hospitals. Similarly, staff shortages have hindered the ability of Home Health Agencies to accept referrals thereby, changing referrals patterns away from home discharges to SNFs. The reality of labor shortages is that the problem is not solvable via a staffing mandate and now, Abt has basically said the same thing.
A good analysis of the staffing mandate issue came a day before via Clifton Larsen Allen (CLA). The analysis indicated that $11.7 billion more dollars would need to be spent by SNFs to achieve a 4.1 hours per day standard. The American Health Care Association had indicated that a 4.1 hours standard would displace 446,000 residents. An article regarding the CLA findings is available here: https://www.mcknights.com/news/as-forecast-price-of-federal-staffing-mandate-climbs-to-11-7b-analysts-offer-alternatives/