July 22, 2005
Testimony Prepared by Charlene Harrington, Ph.D., RN., Professor, School of Nursing
Associate Director, UCSF John A. Hartford Center for Geriatric Nursing Excellence
Quality of long term care (LTC) continues to be a major problem in the US, especially in nursing homes and in residential care. Literally dozens of studies by researchers, the US General Accounting Office, the US Inspector General and others have documented the persistent quality problems in a sizable subset of the nation’s nursing homes over the past 30 years. Although not studied as much, residential care and assisted living facilities have also had documented quality problems.1 Quality problems in the home are more difficult to observe but reports of poor reliability, lack of timeliness of care, poor attitudes, theft, neglect, and abuse by some providers are not uncommon.3
LTC quality rests entirely in the hands of nurses, nursing assistants, home care workers, personal assistants, and other caregivers who deliver formal care and assistance. LTC is labor intensive and requires education, experience, and compassion. The processes of care include assistance with activities of daily living (such as bathing and dressing) and special nursing services such as wound care, nutrition and incontinence management, medication and behavioral management, chronic disease management, and other complex care processes.
Relationship of Nurse Staffing and Quality
The positive relationship between nurse staffing and quality of care in nursing homes has been shown in a number of studies. Higher staffing hours per resident, particularly Registered Nursing (RN) hours have been consistently and significantly associated with overall quality of care including: improved resident survival rates, functional status, and incontinence care; fewer pressure sores and infections; less physical restraint, catheter and antibiotic use; less weight loss and dehydration; less electrolyte imbalance; improved nutritional status; lower hospitalization rates, improved activity participation rates, and a higher likelihood of discharge to home. 1,2,4 Psychological and physical abuse of residents by nursing assistants is higher where they are working in stressful conditions. Better staffing is associated with lower worker injury rates and less litigation actions. Studies have also found that gerontological nurse specialists and geriatric nurse practitioners contribute to improved quality outcomes in nursing homes and lower risk-adjusted hospitalization rates.
Schenelle and colleagues conducted a study to examine differences in the quality of care processes among randomly selected California nursing homes with high and low staffing levels. Nursing homes with high staffing (4.1 hours per resident day or higher) performed significantly better on 12 of 16 care processes (such as feeding assistance) implemented by nursing assistants compared to lower staffed homes.5 Residents in the highest staffed were significantly more likely to be out of bed and engaged in activities during the day and receive more feeding assistance and incontinence care.5
Comparing the staffing indicator to 8 separate quality clinical measures (weight loss, bedfast, physical restraints, pressure ulcers, incontinence, loss of physical activity, pain, and depression), staffing levels were found to be better predictors of high quality care processes than the eight clinical quality measures.5
A study by Abt Associates for CMS (2001) reported that a minimum of 4.1 hours per resident day were needed to prevent harm to residents with long stays (90 days or more) in nursing homes.4 Of this total, .75 RN hours per resident day, .55 LVN hours per resident day, and 2.8 NA hours per resident day were reported to be needed to protect residents.4 The report was clear that residents in homes without adequate nurse staffing levels faced substantial harm and jeopardy. In order to meet the total 4.1 hours per resident day, 97% of homes would need to add some additional nursing staff. 4
An IOM committee report on Keeping Patients Safe recommended that CMS use the findings and recommendations from the recent Abt study to establish minimum staffing levels (number and skill mix) for all nursing facilities in the US, including 24 hour RN coverage.2 The IOM report identified the strong relationship between higher resident casemix (acuity) and the need for higher nurse staffing levels and greater nursing expertise.
In spite of recent efforts to increase nurse staffing levels in nursing homes, the total average staffing has remained flat, at 3.6 hours per resident day since 1997, and well below the recommended levels.6 Staffing levels vary widely across facilities, and some facilities have dangerously low staffing levels.6
The shocking situation is that the levels of RN staffing in US nursing homes has declined by 25 percent since 2000. 6 The root cause of the decline is directly related to the implementation of the Medicare prospective payment system (PPS) for skilled nursing homes in 1998.7 Under PPS, Medicare rates are based on each facility’s resident needs for nursing and therapy services but skilled nursing homes do not need to provide the level of care that is paid for by the Medicare rates. The declining RN levels in nursing homes and the failure to see improvements in staffing over the last eight years shows the need for regulatory standards and incentives to improve staffing levels.
Turnover Rates. Turnover rates of LTC staff is an important quality indicator. In nursing homes, turnover rates range from 50 to 75 percent of staff leaving employment each year, showing that retention is a bigger problem than recruitment. 1,2,4,,8,9 Turnover rates for home health and home care workers are even higher than for nursing homes. 1 High turnover rates reduce the continuity and stability of care, leads to miscommunications, results in patient safety problems and other quality of care concerns, as well as worker injuries and poor morale. Moreover, turnover of nursing aides is estimated to cost over $4 billion per year in the US.8
Turnover is directly related to heavy workloads, low wages and benefits, poor working conditions, and other factors.1,2,,4,8 Turnover, wages, and benefits are also quality indicators that can be used for public reporting and incentive payment systems. The goal must be to stabilize the LTC workforce by investing in the workers in terms of their training and remuneration. 1,2,,4
Quality Report Cards
One important strategy for improving quality of care is to provide consumers with information about quality of care as a means for making more informed decisions about health care. Public reporting and ratings of LTC providers based on key indicators including nurse staffing levels as well as turnover, wages, and benefits are strongly recommended. An excellent model for such a report card was developed by the University of California with the California Health Care Foundation; see the Foundation’s long term care website (www.calnhs.org).
Payment Incentive Systems
As interest has grown in payment incentive systems, it is important to consider what indicators of quality are the most appropriate to consider. At this point, staffing levels, turnover rates, wages, and benefits are all concrete measures that are directly related to quality. These indicators can be accurately and reliably measured. As noted above, these indicators are more directly related to care than many clinical measures (such as pain) which are sometimes inaccurately measured and reported, are difficult to risk adjust, and can be easily gamed by providers. If we want to give human resources top priority, incentives that encourage more staff, better education and training, and workforce stability should be considered.
Summary
In summary, the most important measure of quality of care is the amount of nursing staff available to provide care. In nursing homes, the decline in registered nurses and the failure to improve staffing shows the need for greater regulatory standards and incentive systems. Provider turnover rates, wages, and benefits are also valuable indicators of quality. These indicators should be reported to the public in an accurate and timely way to guide consumer choices about care. Moreover, they can all be used for payment incentive systems. We must invest in our long term care workforce so that high quality providers will be available to provide care for our family members, friends and ourselves when we need such care.
1. Institute of Medicine (IOM), Wunderlich, G.S. and Kohler, P., Eds. (2001). Improving the Quality of Long-Term Care. Washington, DC: National Academy of Sciences, IOM.
2. Institute of Medicine. 2003. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academy Press.
3. Grossman, B., Kitchener, M., Mullan, J., and Harrington, C. (In Press). Paid Personal Assistance Services: An Exploratory Study of Working Age Consumers’ Perspectives. J. of Aging and Social Policy.
4. US Centers for Medicare and Medicaid Services, Prepared by Abt Associates Inc. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Report to Congress: Phase II Final. Volumes I-III. Baltimore, MD: CMS, 2001.
5. Schnelle, J.F., Simmons S.F., Harrington, C., Cadogan, M., Garcia, E., and Bates-Jensen, B. (2004). Relationship of Nursing Home Staffing to Quality of Care? Health Services Research. 39 (2):225-250.
6. Harrington, C., Carrillo, H., and Crawford, C. Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 1997-03. San Francisco, CA: University of California, 2003. www.nccnhr.org.
7. Konetzka, R.T., Yi, D., Norton, E.C., and Kilpatrick, K.E. Effects of Medicare Payment Changes on Nursing Home Staffing and Deficiencies. Health Services Research. 2004: 39 (3):463-487.
8. National Commission on Nursing Workforce for Long-Term Care (2005). ACT NOW For Your Tomorrow. Washington, DC: National Commission.
9. Harrington, C. and Swan, J.H. Nurse Home Staffing, Turnover, and Casemix. Medical Care Research and Review. 60 (2):366-392.