Longitudinal associations of staff shortages and staff levels with health outcomes in nursing homes

Ming Chen; James S Goodwin; James E Bailey; John R Bowblis; Shuang Li; Huiwen Xu

doi:10.1016/j.jamda.2023.04.017

. Author manuscript; available in PMC: 2024 Nov 1.

Published in final edited form as: J Am Med Dir Assoc. 2023 May 29;24(11):1755–1760.e7. doi: 10.1016/j.jamda.2023.04.017

Longitudinal associations of staff shortages and staff levels with health outcomes in nursing homes

Ming Chen ^1,², James S Goodwin ^3,⁴, James E Bailey ^1,², John R Bowblis ^5,⁶, Shuang Li ³, Huiwen Xu ^3,^7,^*

PMCID: PMC10826288 NIHMSID: NIHMS1958072 PMID: 37263319

Abstract

Objectives

To examine whether facility-reported staff shortages and total staff levels were independently associated with changes in nursing home (NH) outcomes in 2020.

Design

Longitudinal cohort study.

Setting and Participants

8,466 NHs with staffing and outcome data.

Methods

This study used NH COVID-19 Public File (2020), Nursing Home Compare (2019–2020), and Payroll-Based Journal data (2019–2020). Outcome measures included the percentage of long-stay residents in a facility with declines in Activities in Daily Living (ADLs), decreases in mobility, weight loss, and pressure ulcers in 2020 Q2, 2020 Q3, and 2020 Q4. Independent variables were whether NHs reported any shortage of aides or licensed nurses and total staff hours per resident day (HPRD). Separate two-level (NH, state) Hierarchical Generalized Linear Mixed models examined the association of facility-reported shortages and staff hours with key NH resident outcomes, controlling for NH characteristics and COVID-19 infections.

Results

The weekly percentage of NHs reporting any staff shortage averaged 20%. Total staff HPRD increased slightly from 3.7 in 2019 to 3.8 in 2020. Health outcomes were stable during 2019 and 2020 Q1 but worsened substantially starting in 2020 Q2. For example, the percentage of residents with mobility loss increased from 16.2% in 2020 Q1 to 27.9% in 2020 Q4. Facility-reported staff shortages were associated with an increase in the proportion of residents with an ADL decline (0.54 percentage points), mobility loss (0.80 percentage points), weight loss (0.22 percentage points), and pressure ulcers (0.22 percentage points) (all P < 0.01). Total staff HPRD was not associated with changes in any outcomes (all P > 0.05).

Conclusions and Implications

NHs reported worsened health outcomes among long-stay residents in 2020, with worse outcomes found among facilities that reported staff shortages but not among those with lower total staff levels. Facility-reported shortages provide important quality information during the COVID-19 pandemic.

Keywords: Staff shortages, staff hours per resident day, COVID-19 pandemic, health outcomes

Brief summary:

Health outcomes decreased among long-stay nursing home residents in 2020, particularly in facilities with staff shortages. Integration of objective and subjective staffing measures is needed.

INTRODUCTION

Nursing homes (NHs) were the epicenters for the COVID-19 pandemic in the U.S.^1–4 They contributed about one-third of all COVID-19 deaths in 2020.⁵ As of April 2023, the Centers for Medicare and Medicaid Services (CMS) estimated that NH residents represented over 1.5 million COVID-19 cases and over 160,000 deaths.⁶

The pandemic also caused a staffing crisis in NHs, with over 1.5 million employees diagnosed with COVID-19.⁶ Between March 2020 and October 2021, the number of NH employees fell by 221,000.^6–8 Because the number of residents also decreased, total staff levels (the ratio of total nursing staff hours to resident days) remained relatively stable.⁹ In May 2020, CMS introduced a new weekly measure, facility-reported staff shortage, to monitor the perceived adequacy of NH staffing.^{6, 10} The percentage of NHs reporting any perceived nursing shortage increased from 16% in May 2020 to about 20% in December 2020.^{2, 10, 11} Facility-reported staff shortages could capture important aspects of NH staffing not assessed through staffing levels alone. Factors such as reduced care from family members, increased infection control workload, and increased resident acuity may contribute to increased shortages during the COVID-19 pandemic.¹⁰

In March 2020, CMS recommended that all NHs forbid all outside visitors, which eliminated help from informal caregivers.^{4, 12} A Connecticut study found declines in physical function and mental health of NH residents between March and July, 2020.¹³ A recent national study reported adverse changes in health and quality of life in 2020 compared to 2018 and 2019, even among NHs without known COVID-19 cases.⁴

Whether staff levels were associated with changes in resident outcomes during the COVID-19 pandemic is an important yet understudied question. Prior to the pandemic, higher staff levels were found to be associated with better health outcomes.^14–17 If facility-reported staff shortages indeed capture additional information beyond staff levels, an association should exist between facility-reported shortages and health outcomes, even after controlling for objective staffing levels.

In this study, we examine longitudinal trends in both subjective and objective measures of nursing staff and their associations with NH resident health outcomes. We seek to understand whether facility-reported staff shortages and objective total staff levels were independently associated with changes in health outcomes during the early phases of the COVID-19 pandemic.

METHODS

Data Sources

This longitudinal repeated-measures study used public data from the CMS NH COVID-19 Public File (COVID-19 File, 2020),⁶ NH Compare data archive (2019 – 2020),¹⁸ Payroll-Based Journal data (PBJ, 2019 – 2020),¹⁹ Certification and Survey Provider Enhanced Reporting (CASPER, 2019 – 2020),²⁰ LTCFocUS.org data (2019),¹⁴ and USAFacts County COVID-19 Cases (2020).²¹ The COVID-19 File collects facilities’ weekly COVID-19 information from May 2020. NH Compare data have time lags in reporting, so we aligned the data to actual calendar quarters. CASPER surveys in 2020 were suspended for many NHs, for which we used 2019 data. This study was approved by the University of Texas Medical Branch and University of Tennessee Health Science Center Institutional Review Boards.

Study Population

To assemble the longitudinal cohort (Supplemental Figure S1), we selected NHs with complete COVID-19 infection rates for residents and staff from the weeks ending May 31 through December 27, 2020 (N=14,749 facilities). We excluded 5,282 NHs with incomplete outcome data in 2019 or 2020. Finally, we removed 1,001 facilities with missing data on facility-reported staff shortages, total staff levels, or overall 5-star ratings. As a result, our study cohort included 8,466 unique NHs, representing 55% of all U.S. NHs. Compared to the study NHs, the excluded NHs were less likely to be for-profit and chain-affiliated, and had smaller number of beds. Because CMS suspended the recertification surveys and resident assessments during the early pandemic period, missing data were more prevalent in 2020 than that in the pre-pandemic period. Finally, we constructed a longitudinal NH-quarter file (2020 Q2, 2020 Q3, and 2020 Q4), with three observations per facility (25,398 NH-quarter observations). Facility-reported shortage data were unavailable for 2019 and 2020 Q1.

Measures

Outcome measures included the percentage of long-stay residents in a facility with a decline in ADLs, decrease in mobility, weight loss, and pressure ulcers in 2020 Q2, 2020 Q3, and 2020 Q4 from NH Compare.²² These measures assess important aspects of care quality and are possibly associated with staffing variables.^{15, 17, 23} Long-stay residents were chosen because they primarily need care from nursing staff. Decline in ADLs and decrease in mobility measured changes from the previous quarter, using a Minimum Data Set (MDS) assessment in the quarter and one from the previous quarter. Decline in ADL was defined as any decline in the following ADL items: bed mobility (G0110A1), transfer (G0110B1), eating (G0110H1), and toileting (G0110I1). Decrease in mobility was defined as any decrease in locomotion on unit (G0110E1). Weight loss was defined as having a ≥5% weight loss in the last month or ≥10% in the last 6 months, based on the MDS assessment in the quarter (K0300). Pressure ulcers were determined as any stage II-IV or unstageable pressure ulcers for high-risk residents in the quarter (M0300B1 – M0300G1). Outcomes were calculated as the number of residents with the event as a percentage of the total number of eligible long-stay residents in a facility.

Our two main independent variables are facility-reported staff shortages and total staff hours per resident day. Starting in May 2020, CMS required all NHs to report weekly whether they experienced any staff shortage. This is determined by a yes/no response to the question: “Does your organization have a shortage of staff and/or personnel?” and is assessed separately for nursing aides, licensed nurses (registered nurses and licensed practical nurses), clinicians, and other staff.^{6, 10} We constructed a binary facility-reported staff shortage variable to indicate whether a NH experienced a shortage in nursing aides or licensed nurses in a quarter (2020 Q2, Q3, Q4). We used 2019 and 2020 PBJ data to calculate the staffing HPRD as the total number of staff hours divided by the number of resident days in a quarter. This staff hour was calculated separately for aides, licensed practical nurses, registered nurses, and total staff.¹⁹

We included the following NH covariates: ownership, chain status, bed size, occupancy rate, dementia special care unit, overall 5-star rating, resident COVID-19 cases, staff COVID-19 cases, average Resource Utilization Groups-IV case-mix index, average age, % Non-Hispanic White residents, % Medicaid residents, % residents with dementia, and % residents with serious mental illness.^{4, 14, 24–27} We calculated the average weekly number of new resident and staff COVID-19 cases per 100 beds in a quarter.¹⁰ County-level COVID-19 infection rates, measured as the number of COVID-19 cases per 1,000 total population within the county, were categorized into quintiles.

Statistical Analysis

We describe the NH and county characteristics in 2020 Q2. We present trends in facility-reported staff shortages (05/2020 – 12/2020), staff HPRD (2019 Q1 – 2020 Q4), and four health outcomes (2019 Q1 – 2020 Q4). We also compare outcome measures by whether NHs reported any shortage in 2020 Q2 – 2020 Q4.

To examine the associations of facility-reported staff shortages and total staff hours per resident day with four health outcomes, we conducted two separate regressions for each outcome: a simple model and a full model. Both models included data in 2020 Q2, 2020 Q3, and 2020 Q4 (3 observations for each facility). The simple models included facility-reported staff shortages, total staff HPRD, resident COVID-19 cases, staff COVID-19 cases, quarter, and state random effects. Models on weight loss and pressure ulcers also controlled for baseline outcomes in 2020 Q1. In the full models, we further adjusted for other NH characteristics and the quintile of county COVID-19 infection rates (as outlined in the Measures section). Continuous variables were standardized at means of zero and standard deviations of one to reduce variances.¹⁰ To account for the multilevel data structure, we used two-level (NH, state) Hierarchical Generalized Linear Mixed models with Gaussian distribution and identity link, assuming an unstructured covariance structure.²⁸ Robust standard errors were used to account for potential violations of model assumptions (e.g., the covariance structure).²⁹

Using similar models, we examined the associations of facility-reported shortages of aides and licensed nurses, separately, with health outcomes. We also assessed the associations between total staff HPRD and outcomes after excluding facility-reported staff shortages from the full models.

All analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, NC), and Stata 15 (StataCorp LLC, College Station, TX), with statistical significance defined as two-tailed P < 0.05.

RESULTS

Nursing Home Characteristics in 2020 Q2

Supplemental Table S1 presents the characteristics of the 8,466 NHs in 2020 Q2. Most NHs were for-profit (72.2%), chain-affiliated (60.5%), and with over 100 beds (64.7%). Over 40% of NHs had overall 5-star ratings of 4 or 5 (41.7%). The average weekly new resident and staff COVID-19 cases in 2020 Q2 were 1.3 and 0.8 per 100 beds, respectively.

Trends in Facility-Reported Staff Shortages and Total staff Levels

Figure 1 shows the trends in facility-reported shortages of aides, licensed nurses, or total staff in the last week of each month from May to December 2020. In the week ending 5/31/2020, 20.7% of NHs reported shortages in total staff. The number dropped slightly to 19.8% in the week ending 6/28/2020, then gradually increased to 21.7% in the week ending 12/27/2020. There was a similar pattern for shortages of aides. The increase in facility-reported shortages of licensed nurses was larger, from 15.7% in the week ending 5/31/2020 to 18.6% in the week ending 12/27/2020.

Staff hours per resident day for 2019 Q1 to 2020 Q4 based on PBJ data are described in Supplemental Figure S2. They were stable in 2019 and 2020 Q1, then increased slightly. For example, total staff HPRD increased from 3.68 in 2020 Q1 to 3.85 in 2020 Q2, and to 3.89 in 2020 Q4.

Trends in Health Outcomes

Figure 2 illustrates the changes in four facility-level outcomes for long-stay residents in 2019 Q1 – 2020 Q4. The percentage of residents who experienced declines in ADLs from the previous quarter, decreases in mobility from the previous quarter, new weight loss, or pressure ulcers, were stable during 2019 and 2020 Q1. Starting in 2020 Q2, the percentage of residents with those outcomes increased substantially. For example, the percentage of residents with declines in ADLs grew from 14.8% in 2020 Q1 to 16.7% in 2020 Q2 (P < 0.001), and to 17.5% in 2020 Q4 (P < 0.001). The increase in the percentage of residents with decreased mobility was even larger, from 16.2% in 2020 Q1 to 24.7% in 2020 Q2, and to 27.9% in 2020 Q4 (all P < 0.001).

Associations of Facility-reported Staff Shortages and Staffing Levels with Health Outcomes

The unadjusted health outcomes in NHs with versus without facility-reported staff shortages in 2020 Q2, Q3, and Q4 are presented in Table 1. For each quarter, NHs with shortages always reported higher percentages of residents with declines in ADLs, decreases in mobility, new weight loss, or pressure ulcers. For example, in 2020 Q2, 17.8% of residents had decline in ADLs in NHs with staff shortages, compared to 16.1% of residents in facilities without shortages (P <0.001). By 2020 Q4, the percentage of residents with declines in ADLs was 18.8% in NHs with shortages versus 16.5% in those without shortages (P <0.001). Similar patterns were observed for other outcomes.

Table 1.

Unadjusted health outcomes in nursing homes with versus without facility-reported staff shortages (2020 Q2 – Q4).

Variables	Nursing homes with versus without shortages	2020 Q2	2020 Q3	2020 Q4
		Mean (SD)	Mean (SD)	Mean (SD)
Decline in ADLs	Shortages⁺	17.8% (8.6%)	17.1% (8.8%)	18.8% (9.3%)
	No shortages	16.1% (8.5%)	15.1% (8.2%)	16.5% (9.0%)
	P value	<0.001	<0.001	<0.001
Decrease in mobility	Shortages⁺	25.9% (13.6%)	25.0% (12.5%)	29.7% (14.6%)
	No shortages	24.1% (13.3%)	23.1% (12.6%)	26.5% (14.4%)
	P value	<0.001	<0.001	0.002
Weight loss	Shortages⁺	8.2% (5.7%)	8.7% (6.1%)	8.4% (5.9%)
	No shortages	7.8% (5.4%)	8.4% (5.5%)	7.8% (5.6%)
	P value	0.002	0.004	<0.001
Pressure ulcers	Shortages⁺	7.9% (5.0%)	8.1% (5.2%)	8.4% (5.6%)
	No shortages	7.6% (5.0%)	7.8% (5.2%)	8.1% (5.3%)
	P value	0.007	0.005	0.016

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NOTES: Abbreviations: SD=standard deviation; ADL= Activities of Daily Living.

Outcome data in 8,466 nursing homes were obtained from the Nursing Home Compare data archive.

⁺

Shortage of staff was defined as any shortage in aides or licensed nurses (registered nurses and licensed practical nurses).

P values compared differences in health outcomes in nursing homes with versus without facility-reported staff shortages for each quarter, using t-tests.

Two-level (NH, state) hierarchical models examined whether facility-reported staff shortages and total staff levels were independently associated with each health outcome. Table 2 presents the main results of both simple models controlling for resident and staff COVID-19 cases and full models. In the simple models, facility-reported staff shortages were significantly associated with an increase in the proportion of residents with an ADL decline (0.68 percentage points), mobility loss (0.90 percentage points), weight loss (0.22 percentage points), and pressure ulcers (0.22 percentage points) (all P < 0.01). More total staff HPRD were significantly associated only with decline in ADLs (β = −0.41, P = 0.03).

Table 2.

Associations of nursing home staffing with health outcomes (2020 Q2 – Q4).

Variables	Decline in ADLs Coef. (SE)		Decrease in mobility Coef. (SE)		Weight loss Coef. (SE)		Pressure ulcers Coef. (SE)
Variables	Simple Model	Full Model⁺	Simple Model	Full Model⁺	Simple Model^‡	Full Model^+‡	Simple Model^‡	Full Model^+‡
Intercept	18.34^** (0.94)	16.08^** (0.81)	25.34^** (1.65)	23.35^** (1.31)	4.49^** (0.42)	3.99^** (0.44)	4.12^** (0.33)	3.42^** (0.28)
Independent variables
Facility-reported staff shortage^§	0.68^** (0.17)	0.54^** (0.16)	0.90^** (0.29)	0.80^** (0.26)	0.22^** (0.08)	0.22^* (0.08)	0.22^** (0.06)	0.22^** (0.06)
Total staff hours per resident day^\|\|	−0.41^* (0.19)	0.21 (0.15)	−0.03 (0.33)	0.41 (0.24)	0.15 (0.09)	0.18 (0.09)	−0.11 (0.08)	0.07 (0.07)
COVID-19 variables
Weekly resident COVID-19 cases per 100 beds^†	2.48^** (0.14)	2.35^** (0.12)	3.06^** (0.17)	2.94^** (0.17)	0.93^** (0.07)	0.92^** (0.06)	0.44^** (0.06)	0.39^** (0.06)
Weekly staff COVID-19 cases per 100 beds^†	0.21 (0.12)	0.37^** (0.11)	0.40^** (0.15)	0.61^** (0.17)	0.14 (0.08)	0.13 (0.08)	0.01 (0.05)	0.04 (0.05)
Quarter (Ref. = 2020 Q2)
2020 Q3	−0.83^** (0.19)	−0.80^** (0.17)	−0.85^** (0.25)	−0.83^** (0.24)	0.55^** (0.13)	0.54^** (0.13)	0.22^** (0.06)	0.22^** (0.06)
2020 Q4	0.76^** (0.19)	0.81^** (0.19)	3.07^** (0.32)	3.13^** (0.32)	0.10 (0.21)	0.10 (0.21)	0.50^** (0.07)	0.50^** (0.07)

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NOTES: Abbreviations: ADL= Activities of Daily Living; Coef. = coefficient; SE = standard error.

Estimates were obtained from two-level (nursing home, state) Hierarchical Generalized Linear Mixed models with robust standard errors.

⁺

Full models also adjusted for ownership, chain status, bed size, occupancy rate, dementia special care unit, 5-star overall ratings, resident COVID-19 cases, staff COVID-19 cases, average case-mix index, average age, % Non-Hispanic White residents, % Medicaid residents, % residents with dementia, % residents with serious mental illness, and county COVID-19 infection rates.

The overall five-star rating may overcontrol the staff hours because the rating included staffing information. The sensitivity analyses repeated the multivariable regressions without adjusting for overall five-star rating. The relationship between total staff hours per resident day and all 4 outcomes remained insignificant. The association of facility-reported staff shortages with health outcomes became slightly stronger.

^‡

Baseline outcome values in 2020 Q1 were controlled for weight loss and new pressure ulcers.

^§

Facility-reported staff shortage was defined as any shortage in aides or licensed nurses (registered nurses and licensed practical nurses).

^||

Total staff hours per resident day included aides, licensed practical nurses, and registered nurses.

^†

Continuous variables were standardized at a mean of 0 and a standard deviation of 1 at each quarter. Significance:

P<0.05,

^**

P<0.01.

After adjusting for additional covariates in the full models, the associations of facility-reported staff shortages and health outcomes remained statistically significant for all outcomes (all P < 0.01): decline in ADLs (β = 0.54), decrease in mobility (β = 0.80), weight loss (β = 0.22), and pressure ulcers (β = 0.22). Total staff HPRD was not associated with changes in any of the outcomes (all P > 0.05). The detailed results of the full models are presented in Supplemental Table S2. In separate analyses of facility-reported shortages of aides or of licensed nurses, there were similar associations of health outcomes to any staff shortage (Supplemental Table S3 and Supplemental Table S4). Total staff HPRD was not associated with any of the outcomes even after excluding facility-reported staff shortages (Supplemental Table S5). Finally, except for weight loss, health outcomes became worse in 2020 Q4 relative to 2020 Q2 in all model specifications.

DISCUSSION

This study demonstrates significant facility-reported staff shortages during the first year of the COVID-19 pandemic, with roughly 20% of NHs reporting shortages. Total staff levels remained relatively stable. The high prevalence of facility-reported staff shortages during the COVID-19 pandemic has been well-documented.^{2, 10, 11, 30, 31} In qualitative studies, the difficulty of maintaining staff was also a consistent theme.^{32, 33}

The current study provides the first empirical evidence of the association of facility-reported staff shortages with worse health outcomes among long-stay residents. The percentage of long-stay residents with declines in ADLs and mobility, and with weight loss and pressure ulcers substantially increased during the first 9 months of the pandemic. Staff shortages were significantly associated with these adverse outcomes, even after controlling for NH characteristics and COVID-19 infections. Similar associations were found for shortages of aides and licensed nurses when examined separately. Factors contributing to staff shortages can directly or indirectly influence the quality of care provided to residents. For example, higher turnover rates and increased workload can compromise care quality.¹⁰ Also, NHs increasingly use traveling nurses who may not carry the same load or accountability as employed staff.³⁴ Staff members often experienced stress, burnout, and less engagement with residents, hurting their productivity.³³ Finally, policies like bans on outside visitors may have adversely affected NHs with staff shortages more than those without shortages.³⁵

Long-stay residents experienced adverse health outcomes throughout 2020. For example, from 2020 Q1 to Q2, the relative increase was 53% for declines in mobility and 37% for weight loss. Our findings are consistent with recent studies using resident-level data that found substantial increases in ADL limitations and weight loss.^{4, 13} The social distancing measures (e.g., bans on outside visitors) and the cancellation of exercise and other activities may have contributed to these adverse outcomes.^{12, 36} The substantial functional declines and weight loss in 2020 Q2 and Q3 probably increased resident vulnerability to COVID-19 hospitalization and death later in 2020.^{6, 11}

Prior to the COVID-19 pandemic, higher total staff levels were associated with better health outcomes.^{14–17, 23} This association, however, has not persisted during the pandemic, even after excluding facility-reported staff shortages. Those findings suggest that the objective measure – staff hours – may not reflect the actual “adequacy” of staffing during the pandemic. For example, reduced care from family caregivers and increased workload from enforcing infection controls were not captured by staff hours.^{9, 36} Facility-reported shortage may be a proxy for overall perceived stress in maintaining sufficient staff during the COVID-19 pandemic. Shortages may be a result of the complex interplay of different factors, such as COVID-19 infections, fewer available staff, higher turnover rates, use of more agency staff, and increased staff stress and burnout.^{9, 10
10, 32–34}

A question raised by this study is how to integrate objective and subjective measures to better assess NH staffing. Both types of measures have their strengths and limitations. Objective measures such as staff levels in HPRD are easy to calculate and less likely to be manipulated by NHs, making them the basis used by CMS to evaluate NH staffing.²³ Objective measures, however, may be less sensitive to external changes, as demonstrated in this study. Researchers have investigated how other objective staffing measures such as daily variation³⁷ and turnover rate³⁸ are associated with resident outcomes. Subjective measures like facility-reported shortages capture important information not reflected in the “objective” staff hours^{9, 10} and are predictive of important outcomes. Despite that, NHs may hesitate to report these measures that were introduced during the pandemic, are not linked to public reporting or financial incentives, or could be used in future litigation. Approaches beyond a binary question to measure objective staffing are needed after the pandemic. A combined staffing indicator that incorporates both objective and subjective measures can theoretically take advantage of these strengths and minimize limitations.

Limitations

Because the COVID-19 pandemic disrupted routine data collection, we only studied about 50% of U.S. NHs. Our findings may not apply to the excluded facilities. The self-reported staff shortages may mean different things to different persons filling the form. Data quality of the outcomes during the early pandemic might have been impacted. The look-back periods for weight loss measure are 1 and 6 months, the latter of which may not fully align with the quarterly staff measures. Some stage III-IV pressure ulcers may not resolve in a short period despite strong nursing care. Some important factors were unavailable from the datasets we used, for instance, the amount of care from family members, which was also disrupted in the pandemic.¹² Because of the observational study design, causal inference between staffing and health outcomes cannot be ascertained.

CONCLUSIONS AND IMPLICATIONS

NHs had worse health outcomes among long-stay residents in 2020. The deterioration in health outcomes was worse among facilities that reported nursing shortages. Interestingly, total staff levels had no association with these health outcomes. The fact that staff hours were associated with fewer COVID-19 cases and deaths^{23, 39, 40} but not health outcomes may suggest a tradeoff between infection control activities and routine resident care. Facility-reported staff shortages seem to be capturing something independent of the “objective” measure of total staff level in HPRD that has been relied on to evaluate NH staffing levels. More work is needed to combine objective and subjective measures to comprehensively evaluate NH staffing.

Supplementary Material

Supplemental Figure S1. Cohort selection diagram for nursing homes.

Supplemental Figure S2. Time trends in nursing home staffing levels (2019 Q1 – 2020 Q4). Staffing levels in 8,466 nursing homes were calculated using the 2019 and 2020 Payroll-Based Journal data. HPRD=Hours per resident day. Total staff hours per resident day included aides, licensed practical nurses, and registered nurses. The 95% confidence intervals for the points were all less than 0.04 and are not shown in the figure.

Supplemental Table S1. Characteristics of nursing home sample in 2020 Q2.

Supplemental Table S2. Full models on the associations of nursing home staffing with health outcomes (2020 Q2 – Q4).

Supplemental Table S3. Associations of facility-reported shortages of aides with health outcomes (2020 Q2 – Q4).

Supplemental Table S4. Association of facility-reported shortages of licensed nurses (registered nurses and licensed practical nurses) with health outcomes (2020 Q2 – Q4).

Supplemental Table S5. Association of nursing home total staff levels with health outcomes (2020 Q2 – Q4).

NIHMS1958072-supplement-1.pdf^{(274.9KB, pdf)}

Acknowledgements:

We appreciate the editorial assistance of Sarah T. Smith, PhD, from the University of Texas Medical Branch. We also acknowledge Dr. Jim Y. Wan, PhD, at the University of Tennessee Health Science Center for providing statistical consulting.

Funding sources:

This work was supported by the National Institutes of Health (P30 AG024832, UL1-TR001439, R01AG081282).

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Conflict of Interests: JRB provides consulting services to various health care and long-term care stakeholders, including government agencies and providers.

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16.Bowblis JR, Roberts AR. Cost-Effective Adjustments to Nursing Home Staffing to Improve Quality. Medical care research and review : MCRR 2020;77(3):274–284. [DOI] [PubMed] [Google Scholar]
17.Bostick JE, Rantz MJ, Flesner MK, et al. Systematic review of studies of staffing and quality in nursing homes. J Am Med Dir Assoc 2006;7(6):366–376. [DOI] [PubMed] [Google Scholar]
18.The Center for Medicare and Medicaid Services. Nursing Home Compare Datasets; 2022. https://data.medicare.gov/data/nursing-home-compare. Accessed 3/2 2022.
19.The Centers for Medicare and Medicaid Services. Payroll-Based Journal (PBJ) Data; 2022. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ. Accessed 11/6 2022.
20.Cowles Research Group. Certification and Survey Provider Enhanced Reporting (CASPER); 2022. https://www.longtermcareinfo.com/data/casper-and-oscar.php. Accessed 1/26 2022.
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23.Jutkowitz E, Landsteiner A, Ratner E, et al. Effects of Nurse Staffing on Resident Outcomes in Nursing Homes: A Systematic Review. J Am Med Dir Assoc 2023;24(1):75–81 e11. [DOI] [PubMed] [Google Scholar]
24.Xu H, Bowblis JR, Caprio TV, et al. Rural-Urban Differences in Nursing Home Risk-adjusted Rates of Emergency Department Visits: A Decomposition Analysis. Med Care 2021;59(1):38–45. [DOI] [PubMed] [Google Scholar]
25.Xu H, Bowblis JR, Li Y, et al. Medicaid Nursing Home Policies and Risk-Adjusted Rates of Emergency Department Visits: Does Rural Location Matter? J Am Med Dir Assoc 2020;21(10):1497–1503. [DOI] [PubMed] [Google Scholar]
26.Xu H, Bowblis JR, Li Y, et al. Construction and Validation of Risk-adjusted Rates of Emergency Department Visits for Long-stay Nursing Home Residents. Med Care 2020;58(2):174–182. [DOI] [PubMed] [Google Scholar]
27.Cen X, Li Y, Hasselberg M, et al. Aggressive Behaviors Among Nursing Home Residents: Association With Dementia and Behavioral Health Disorders. J Am Med Dir Assoc 2018;19(12):1104–1109 e1104. [DOI] [PubMed] [Google Scholar]
28.StataCorp L Stata multilevel mixed-effects reference manual College Station, TX: StataCorp LP; 2013;9(10). [Google Scholar]
29.Mansournia MA, Nazemipour M, Naimi AI, et al. Reflection on modern methods: demystifying robust standard errors for epidemiologists. Int J Epidemiol 2021;50(1):346–351. [DOI] [PubMed] [Google Scholar]
30.McGarry BE, Grabowski DC, Barnett ML. Severe Staffing And Personal Protective Equipment Shortages Faced By Nursing Homes During The COVID-19 Pandemic. Health Aff (Millwood) 2020;39(10):1812–1821. [DOI] [PMC free article] [PubMed] [Google Scholar]
31.McGarry BE, Gandhi AD, Syme M, et al. Association of State COVID-19 Vaccine Mandates With Staff Vaccination Coverage and Staffing Shortages in US Nursing Homes. JAMA Health Forum 2022;3(7):e222363. [DOI] [PMC free article] [PubMed] [Google Scholar]
32.Titley HK, Young S, Savage A, et al. Cracks in the foundation: The experience of care aides in long-term care homes during the COVID-19 pandemic. Journal of the American Geriatrics Society 2023;71(1):198–205. [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Snyder RL, Anderson LE, White KA, et al. A qualitative assessment of factors affecting nursing home caregiving staff experiences during the COVID-19 pandemic. PLoS One 2021;16(11):e0260055. [DOI] [PMC free article] [PubMed] [Google Scholar]
34.Shallcross L, Burke D, Abbott O, et al. Factors associated with SARS-CoV-2 infection and outbreaks in long-term care facilities in England: a national cross-sectional survey. Lancet Healthy Longev 2021;2(3):e129–e142. [DOI] [PMC free article] [PubMed] [Google Scholar]
35.Hugelius K, Harada N, Marutani M Consequences of visiting restrictions during the COVID-19 pandemic: An integrative review. Int J Nurs Stud 2021;121:104000. [DOI] [PMC free article] [PubMed] [Google Scholar]
36.Coe NB, Werner RM. Informal Caregivers Provide Considerable Front-Line Support In Residential Care Facilities And Nursing Homes. Health Aff (Millwood) 2022;41(1):105–111. [DOI] [PMC free article] [PubMed] [Google Scholar]
37.Mukamel DB, Saliba D, Ladd H, et al. Daily Variation in Nursing Home Staffing and Its Association With Quality Measures. JAMA Netw Open 2022;5(3):e222051. [DOI] [PMC free article] [PubMed] [Google Scholar]
38.Gandhi A, Yu H, Grabowski DC. High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information: Study examines high turnover of nursing staff at US nursing homes. Health Affairs 2021;40(3):384–391. [DOI] [PMC free article] [PubMed] [Google Scholar]
39.Yang H, Rigsby M, Zhu X, et al. COVID-19 in Long-Term Care Facilities: A Rapid Review of Infection Correlates and Impacts on Mental Health and Behaviors. HERD 2022;15(3):277–294. [DOI] [PubMed] [Google Scholar]
40.Konetzka RT, White EM, Pralea A, et al. A systematic review of long-term care facility characteristics associated with COVID-19 outcomes. Journal of the American Geriatrics Society 2021;69(10):2766–2777. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Figure S1. Cohort selection diagram for nursing homes.

Supplemental Table S1. Characteristics of nursing home sample in 2020 Q2.

Supplemental Table S2. Full models on the associations of nursing home staffing with health outcomes (2020 Q2 – Q4).

Supplemental Table S3. Associations of facility-reported shortages of aides with health outcomes (2020 Q2 – Q4).

Supplemental Table S4. Association of facility-reported shortages of licensed nurses (registered nurses and licensed practical nurses) with health outcomes (2020 Q2 – Q4).

Supplemental Table S5. Association of nursing home total staff levels with health outcomes (2020 Q2 – Q4).

NIHMS1958072-supplement-1.pdf^{(274.9KB, pdf)}

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[R36] 36.Coe NB, Werner RM. Informal Caregivers Provide Considerable Front-Line Support In Residential Care Facilities And Nursing Homes. Health Aff (Millwood) 2022;41(1):105–111. [DOI] [PMC free article] [PubMed] [Google Scholar]

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[R38] 38.Gandhi A, Yu H, Grabowski DC. High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information: Study examines high turnover of nursing staff at US nursing homes. Health Affairs 2021;40(3):384–391. [DOI] [PMC free article] [PubMed] [Google Scholar]

[R39] 39.Yang H, Rigsby M, Zhu X, et al. COVID-19 in Long-Term Care Facilities: A Rapid Review of Infection Correlates and Impacts on Mental Health and Behaviors. HERD 2022;15(3):277–294. [DOI] [PubMed] [Google Scholar]

[R40] 40.Konetzka RT, White EM, Pralea A, et al. A systematic review of long-term care facility characteristics associated with COVID-19 outcomes. Journal of the American Geriatrics Society 2021;69(10):2766–2777. [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Longitudinal associations of staff shortages and staff levels with health outcomes in nursing homes

Ming Chen, MS, MSPharm

James S Goodwin, MD

James E Bailey, MD, MPH

John R Bowblis, PhD

Shuang Li, PhD

Huiwen Xu, PhD

Abstract

Objectives

Design

Setting and Participants

Methods

Results

Conclusions and Implications

Brief summary:

INTRODUCTION

METHODS

Data Sources

Study Population

Measures

Statistical Analysis

RESULTS

Nursing Home Characteristics in 2020 Q2

Trends in Facility-Reported Staff Shortages and Total staff Levels

Figure 1. Time trends in facility-reported staff shortages among nursing homes (May 2020 – December 2020).

Trends in Health Outcomes

Figure 2. Time trends in nursing home health outcomes (2019 Q1 – 2020 Q4).

Associations of Facility-reported Staff Shortages and Staffing Levels with Health Outcomes

Table 1.

Table 2.

DISCUSSION

Limitations

CONCLUSIONS AND IMPLICATIONS

Supplementary Material

Acknowledgements:

Funding sources:

Footnotes

REFERENCES

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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