New Research Informs Nursing Home Staffing Minimums in the United States

Quality and safety vary appreciably across U.S. nursing homes. Nurse staffing levels are a critical factor in determining nursing home quality of care.

To support the goal of improving the quality of nursing home care, the Biden Administration announced in 2022 a set of nursing home initiatives that included ensuring that every nursing home provides a sufficient number of staff who are adequately trained to provide high-quality care. In response, CMS contracted with Abt Global to conduct the 2023 Nursing Home Staffing Study. The mixed methods study provides evidence on the costs benefits of potential minimum staffing requirements and also on potential barriers to and unintended consequences of implementation.

SERVICES AND EXPERTISE PROVIDED 

The study used a mixed methods approach to examine expected quality and safety outcomes associated with different minimum staffing requirement options. For each option, the study examined feasibility and costs.

To develop the requested list of options, Abt engaged in the following activities:

• Literature Review. The team summarized for CMS the evidence on the relationship between staffing quality, the role of different nursing types, and the costs associated with implementing minimum staffing requirements.
• Stakeholder Listening Sessions. Abt collected feedback on both the design of the study and the benefits and challenges of implementing minimum staffing requirements. The team gathered feedback from nearly 700 providers, advocates, association, and others.
• Site Visits. Abt researchers visited 31 nursing homes and interviewed more than 360 nursing home staff, residents, and family members about potential barriers to increased staffing levels and possible unintended consequences of those increases, among other topics.
• Safety Data Analysis. Abt used CMS’s Payroll Based Journal staffing reports and the Nursing Home Care Compare quality and safety measures to estimate the relationships between nurse staffing levels and the probability of exceeding different thresholds of acceptable care quality and safety at different staffing levels and types.
• Simulation Studies. The team used more than 8,000 timed observations of common clinical tasks from 20 nursing homes and used that data in computer simulations to study the impact of different staffing levels.
• Existing State Requirements. Abt studied recent changes in nursing home staffing requirements in Massachusetts to estimate how new federal rules would impact quality and safety.
• Cost and Safety Analyses. The team estimated what it costs nursing homes to change staffing levels or the mix of types of staff. We also estimated the savings to Medicare from reduced hospitalizations and emergency department visits. 

REACH & RESULTS 

Collectively, the study provides evidence on both potential minimum staffing requirement benefits and on potential barriers to and unintended consequences of implementation. 

Both qualitative and quantitative findings from the study indicate potential quality and safety benefits associated with increased nurse staffing. The study findings provide CMS options for setting a minimum staffing requirement and illustrate the trade-offs of these policy options, balancing cost and feasibility with implications for quality and safety. 

In April 2024, CMS issuing a set of nursing home minimum staffing standards that corresponds to one of the options analyzed in the study. CMS will require a registered nurse to be on site at all nursing homes 24 hours per day and seven days per week. They will also require that each resident receive 33 minutes of care from an RN and 147 minutes of care from a certified nurse’s aide per day. (This translates to 3.48 nurse staffing hours per resident per day and 0.55 RN hours per resident day.) Nursing homes have four years to comply with the rules and can apply for and receive exemptions to these requirements under certain circumstances. The rules also address the transparency of Medicaid payment reporting, something the Abt study did not cover. 

Ultimately, this comprehensive, mixed-methods study gave policymakers much-needed information on the trade-offs between feasibility and cost. If successfully implemented, the new rules promise to keep nursing home residents safe and ensure they get quality.