News | July 28, 2000

HCFA resists pressure to mandate nursing home staffing ratios now

HCFA resists pressure to mandate nursing home staffing ratios now

By Elise Nakhnikian
Managing Editor, Long Term Care

Calls for action
What HCFA knows now…
…And what it hopes to find out
The case for taking it slow

Like prospectors looking for oil, the Health Care Financing Administration is prodding into volatile areas with its investigation of nursing home staffing. But HCFA is doggedly resisting pressure to speed up the process, insisting on gathering more and better data before it drafts recommendations for federal staffing minimums.

Calls for action
Last Sunday, a leak to the New York Times resulted in a widely circulated story that the federal government was about to mandate minimum staffing ratios (click here for details). As those who leaked the information no doubt intended, considerable pressure has since been exerted to urge HCFA to issue the mandates.

In his introduction to a hastily convened Senate Special Committee on Aging hearing on nursing home staffing held yesterday in response to the leak, Senator Charles Grassley (R-IA), chairman of the Special Committee on Aging, noted: "Ten years ago, Congress mandated this study. It was due in 1992. I don't understand what took so long. The well-being of 1.6 million nursing home residents hangs in the balance. Now we have to make up for lost time."

Perhaps Congress should mandate minimum staffing levels for nursing homes, he added, but in order to do so, it needs "two more pieces of the puzzle." First, it needs the second piece of the two-part staffing study, which he said he hopes will "come quickly." Next, it needs "an analysis of how the nursing home industry spends its money. Nursing homes accept $39 billion a year of taxpayer money to care for residents. Where does this money go? Is $39 billion a year enough to get the job done?" The General Accounting Office is looking into that, he noted, and its report is due early next year.

In the meantime, the National Citizens' Coalition for Nursing Home Reform has issued a strongly worded call for early release of federal staffing minimums. "Senator Grassley and HCFA's Administrator Nancy Ann DeParle are to be praised for paying serious attention to consumer concerns," said a release sent out Wednesday by NCCNHR founder Elma Holder. "However, action has been stymied with the admonition that action must be delayed until the long-awaited nurse staffing study was concluded… The needs of vulnerable elders are urgent! Congress should not wait for another report before it takes action to increase staffing requirements."

NCCNHR reiterated its proposed staffing minimum: one direct care worker for every five residents on the day shift, for every 10 residents on the evening shift, and for every 15 residents at night, with "adequate registered nurse (RN) and licensed practical nurse (LPN) supervision." The ratio should be higher, says NCCNHR, at homes whose residents need more than the average amount of care.

The release noted that NCCNHR plans to rally support for its recommendations, issuing "a national effort to alert consumers to the study findings and to gain support for legislative changes that will increase staffing and improve care for nursing home residents."

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What HCFA knows now…
Yesterday's hearing was the second the Special Committee has held on nursing home staffing within the past year (click here for a report on the first.) This time, the stakes were so high that HCFA Administrator Nancy-Ann DeParle herself testified.

DeParle acknowledged that HCFA's report was originally due in 1992. However, she said, gathering the data needed for the study "proved to be much more challenging than expected." The first phase of the two-part report, she said, should be released next week.

That first part, said DeParle, "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 suspected as much, but this had never before been documented."

To establish that link, and to attempt to determine the minimum staffing levels at which care quality was not compromised, HCFA "contracted with several research firms and gathered comprehensive data from 1,786 nursing homes in three states," said DeParle. In addition, the agency consulted with "nationally recognized experts in long-term care, nursing economics, and other disciplines" and with consumer advocates, nursing home representatives, and labor unions.

The researchers looked for connections between nurse staffing ratios and "outcomes such as avoidable hospitalizations, improvement in ability to perform activities of daily living, and incidences of weight loss and pressure sores."

As outlined in the Times story, HCFA's findings indicate that quality of care tends to be "seriously impaired" if staffing ratios are less than two hours per resident day for nursing assistants and 12 minutes per resident day for RNs, said DeParle. Nationwide, she added, 54% of nursing homes came in under that minimum ratio for nursing assistants and 31% fell short for RNs. Nearly one in four (23%) had less than the minimum of 45 minutes per resident day for total licensed staff.

"The research we are unveiling is groundbreaking," she said. "Its results are troubling, and strongly suggest that many facilities will need to increase staffing levels."

John F. Schnelle, Ph.D., of the UCLA School of Medicine's Borun Center for Gerontological Research in Los Angeles, testified about his part of the research, which looked at how many nursing assistants were needed to ensure that residents get the following care:

  • Changed or toileted, if incontinent
  • Repositioned, if immobile, to prevent pressure ulcers
  • Given feeding assistance, if oral food intake is low
  • Provided exercise to prevent decline
  • Helped to independently dress themselves
  • "The most time efficient staffing model for delivering the selected care processes varied staffing throughout the day and involved a minimum of one aide working with approximately five to six residents on the 7 a.m. to 3 p.m. shift, seven to eight residents on the 3 p.m. to 11 p.m. shift, and 26 residents on the 11 p.m. to 7 a.m. shift," he reported. "This ‘time efficient' staffing model did not consider resident preferences (individualized care) and required that some staff be scheduled to work four-hour shifts during peak work load times (e.g., 6:00 a.m. to 10:00 a.m.)."

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    …And what it hopes to find out
    However, DeParle stressed that these results are preliminary, and more work needs to be done before HCFA can determine "how to address staffing issues and improve nursing home care." Her caveat was echoed by researchers involved in HCFA's study.

    Schnelle called for field tests to validate "the conservative assumptions that we were forced to make concerning some labor requirement issues" and to determine how much additional staff would be required to schedule care processes according to resident preferences. In addition, he said, field tests are needed to determine what resources are needed to implement the five care processes, and to document the effect of that implementation on "enhancing resident quality of life and clinical outcomes."

    Andrew Kramer, M.D., professor of geriatric medicine and research director at the University of Colorado Health Sciences Center's Center on Aging testified that researchers don't yet know how to determine how staffing levels should be changed to allow for changes in resident acuity levels. "Nevertheless," he warned, "we would be doing a disservice if we were to implement a staffing minimum regulation that disregards differences in the types of residents that facilities treat. In short, a single minimum standard would be too low for some facilities and too high for other facilities."

    Kramer noted that "the specific staffing levels identified in this report are not ready for national implementation." Not only is more study needed about adjusting staffing to case mix, but "A sample of facilities from three states is not sufficient to set national staffing levels." What's more, he said, "Other important attributes of staffing such as staff turnover, staff training, and staff allocation among units or shifts in nursing homes must be taken into consideration before national policy can be drafted."

    In conclusion, he noted that "we definitely need a method for assuring that higher levels of staffing are provided in nursing homes in order to improve quality of care" and acknowledged "a need to proceed expeditiously." However, he warned, "we must take care at this stage to design an approach that is fair to both residents and facilities, and is feasible for successful implementation."

    For the second part of HCFA's report, DeParle said, researchers will do the following:

    • Refine ways to adjust minimum staffing requirements to reflect the case mix, or severity of illness and amount of care required by patients, in a given facility

    • Expand the study beyond the three states included thus far

    • Validate findings with individual case studies of specific facilities

    • Determine the costs and feasibility of implementing minimum staffing requirements.

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    The case for taking it slow
    Beth Klitch, president of Survey Solutions Inc. (Columbus, Ohio) and another of the researchers who is gathering data for HCFA's study, thinks HCFA should be commended for taking its time. The agency had initially intended to recommend staffing ratios this summer, she told Long Term Care, but it is now targeting the end of this year or the beginning of the next.

    "They were pretty upset about that leak," she says of HCFA officials' reactions to the Times story, "because none of the major decisions have been made and they were trying to delay them until they had good enough data."

    In structuring the study, Klitch says, HCFA had to answer two basic questions. First, should staffing be measured in staff-to-resident ratios, as in NCCNHR's formulation, or in terms of hours per resident per day? Klitch applauds HCFA for adopting the latter, which she says is a more accurate measure of amount of care provided. It also dovetails more neatly, she says, with the way homes determine and track their staffing levels.

    Next, HCFA's researchers looked at the staffing information currently collected through HCFA's 671 form and reported as part of its OSCAR data to see how accurate it was. To check that, she says, they compared payroll journal data and resident census data to the data on the 671 forms for a number of nursing homes. They found the HCFA forms were inaccurate. Surprisingly, homes tended to report less staff than were on duty, not more.

    As a result, HCFA determined that its 671 data wasn't accurate enough to be the basis of staffing recommendations. Partly for that reason, she says, HCFA "decided to defer permanent policy decision until they had better data."

    "I think they made they made the right decision in delaying the recommendation," she adds, "and they should get credit where credit is due."

    For the full text of the Senate Aging Committee testimony on nursing home staffing, go to

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