Staffing levels in long-term care facilities

[Two of the authors respond:]

We are in agreement with many, but not all, of Ed Helfrich's points concerning our commentary.¹ First, he acknowledges that there are differences in staffing levels between for-profit and not-for-profit long-term care facilities in British Columbia, something that we and others have found to be true.^2,3 However, in saying that the prime reason for these differences is the variation in the amount of funding given to different types of facilities that care for similar patients, Helfrich describes the current situation, whereas the study we referred to in our commentary was based on data from the mid to late 1990s, before the complex-care patient designation was introduced. Variation in current funding levels cannot be the reason for the differences in quality of care found in that study.

Second, Helfrich argues that the better performance of facilities operated by health authorities must be driven by those facilities' access to additional staff. This is precisely the point of our commentary. Surely it is quite feasible that different forms of ownership imply different types of access to resources; the important question is whether those resources make a difference. Do multisite not-for-profit facilities do better than single-site facilities because they can share the costs of developing policies and care practices? Or is it because they can share the costs of specialized staff, such as nurse geriatricians? Or is there something else at play entirely? In the United States, where Medicare funding levels are the same in for-profit and not-for-profit nursing homes, ownership has been found to be a significant driver of staffing variations.^4,5 The research priorities that follow from our commentary are to provide more flesh to the skeleton of staffing ratios, in order to determine how to maximize the quality of care provided to our communities' most frail members.