Staffing and Quality in California's Nursing Homes

snapshot

Staffing and Quality in California’s Nursing Homes 2006

Introduction Staffing levels in California’s nursing homes are a key indicator of the quality of care. A study from the U.S. Centers for Medicare and Medicaid Services (CMS) found that homes with low staff levels have an increased probability of causing serious harm to residents. In 1999, the state passed a law increasing minimum staffing level from 3.0 to 3.2 hours per resident day. Since that time the percentage of nursing homes not meeting the new standard fell from 41 to 24 percent. Among other findings in this snapshot: •

Seventy-nine percent of hospital-based facilities and 21 percent of free-standing facilities meet the 1999 standards.

•

•

Homes with more staff have higher staff satisfaction rates, significantly

Nursing Home Staffing and Quality >

CONTENTS

Number of Fulltime Nursing Staff in Hospitals and Nursing Homes . . . . . .3 Nurse Staffing Hours . . . . . . . . . . . . . .4 Nurse Staffing Levels . . . . . . . . . . . . . .5 Nursing Hours by Ownership Type . . . .6 Facilities that Meet Staffing Goals by Ownership Type . . . . . . . . . . . . . . .7 by Facility and Ownership Type . . . . .8 Total Deficiencies and Citations by Staffing Level. . . . . . . . . . . . . . . . .9 Top Ten Deficiencies in Nursing Facilities . . . . . . . . . . . . .10 Complaints . . . . . . . . . . . . . . . . . . . . .11

less turnover, and fewer documented deficiencies in care.

Staff Turnover and Satisfaction in Nursing Facilities, National . . . . . . .12

Nearly half of resident complaints center on poor food and more than

Freestanding Nursing Home (FNH) Turnover Rates . . . . . . . . . . . . . . . . .13

38 percent of complaints concern quality of care. Although there have been improvements in increasing staffing levels for California’s nursing homes, this snapshot illustrates that levels are still not at the recommended level for providing high quality care to nursing home residents across the state.

Nurse Staff Turnover Rate by Staffing Level. . . . . . . . . . . . . . . .14 Deficiencies Among Freestanding Nursing Facilities, by Turnover Rate 15 Turnover and Deficiencies by Ownership Type . . . . . . . . . . . . . .16 Wages in Freestanding Facilities by Nursing Turnover Rates . . . . . . . .17 Authors . . . . . . . . . . . . . . . . . . . . . . . .18

©2006 California HealthCare Foundation

2

Number of Fulltime Nursing Staff in

Hospitals and Nursing Homes, 2000 vs. 2003


Of the almost 200,000 Nursing Assistant Licensed Nurse Registered Nurse

Hospital Staff 131,293 122,990

nursing staff working in California in 2003, about a third worked in

33,860

nursing facilities and a

30,530

majority of those were 10,332 82,128

10,525 86,908

Nursing Home Staff 59,946 42,334

2000

2003

nursing assistants.

63,990 46,024

11,286

12,326

6,326

5,640

2000

2003

Source: Division of Nursing, Bureau of the Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services, Spratley, E., Johnson, A., Sochalski, J., Fritz, M. and Spencer, W. 2000. The Registered Nurse Population March 2000: Findings from the National Sample Survey of Registered Nurses. Washington, DC. Office of Statewide Health Planning and Development. 2000 and 2003. Long-Term Care Facility Data. Pivot tables. Sacramento, CA.


3

Nurse Staffing Hours, 2000 – 2003


Higher levels of nurse

Average Hours per Resident Day

staffing are related to better quality of care. Since legislation 3.96

4.06

4.00

3.60

was passed for a minimum of 3.2 hours per resident day in California in 1999, average nurse staffing hours for residents in nursing homes have

2000

2001

2002

2003

increased.

Source: Janis O’Meara and Charlene Harrington, University of California. San Francisco. Calculations provided using Office of Statewide Health Planning and Development’s long term care and hospital annual financial data for 2000 – 2003.


4

Nurse Staffing Levels, 2001 vs. 2003


Between 2001 and

Hours per Resident Day

2003, the number of ■ Recommended

■ State Mandated

(4.1+ hours)

(3.2+ hours)

■ Below State Mandated

homes that failed to

(< 3.2 hours)

2001

meet state-mandated

2003

staffing standards fell 3%

58 percent. Still, nearly

5%

one in four homes did not meet the standard

24% 41%

in 2003.

56% 71%

Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations using the Office of Statewide Health Planning and Development’s long-term care annual financial data for 2001 and 2003; Center for Medicare and Medicaid Services: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Report to Congress, 2001.


5

Nursing Hours by Ownership Type, 2003


In 2003, 11 percent

Total Hours of Care per Resident Day

of nursing hours in Registered Nurse (RN) Licensed Nurse (LVN) Nursing Assistant 6.47

for profits were provided by RNs while 26 percent of nursing

1.68

hours were by RNs in nonprofit facilities.

1.39

3.49 .40

3.40

.70

2.39

Nonprofit

For Profit

Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using California Office of Statewide Health Planning and Development’s long term care and hospital financial data for 2000 – 2003, and California Department of Health, Licensing and Certification Program, Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.


6

Facilities that Meet Staffing Goals by Ownership Type, 2000 – 2003


Most (93 percent) nonprofit nursing Nonprofit

homes meet the minimum state staffing

TOTAL For Profit

standard (3.2 hours per resident day); staffing levels have increased over this four-year period.

2000

2001

2002

2003

Nonprofit

81%

90%

90%

93%

TOTAL

43%

60%

71%

76%

For Profit

36%

53%

68%

73%

Sources: Janis O’Meara and Charlene Harrington, University of California. San Francisco. Calculations provided using California Office of Statewide Health Planning and Development’s long term care financial data for 2000 – 2003, and California Department of Health, Licensing and Certification Program, Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.


7

Facilities that Meet Staffing Goals by Facility and Ownership Type


Studies have shown that a staffing goal Facility Type

Ownership Type

between 4.1 and 4.5 hours per resident day, depending on the

Freestanding 21%

Hospital-based 79%

needs of the residents in a facility, provides

For Profit 38%

the most appropriate Nonprofit 62%

level of care. Most nursing homes that meet this staffing goal are hospital-based or nonprofits.

Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using California Office of Statewide Health Planning and Development’s long term care financial data for 2000-2003, and California Department of Health, Licensing and Certification Program, Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.


8

Total Deficiencies and Citations by Staffing Level, 2000 – 2003


Nursing homes that met the recommended Meets… Minimum Standard 3.2 hours per resident day

goal (4.1 to 4.5 hours per resident day) had more than one-third fewer deficiencies than those that met the state minimum staffing standard (3.2 hours per

Recommended Goal 4.1 to 4.5 hours per resident day

2000

2001

2002

2003

13.39

14.83

14.81

14.29

8.57

9.62

9.53

9.13

resident day).

Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using California Office of Statewide Health Planning and Development’s long term care financial data for 2000 – 2003, and California Department of Health, Licensing and Certification Program, Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.


9

Nursing Home Staffing and Quality

Top Ten Deficiencies

>

reported food-related deficiencies; more than a third reported deficiencies that were quality of care-related.

28.2% 25.4% 24.1%

Source: CMS OSCAR Survey Data, updated December 2005. Prepared by CAHF IRC January 2006.


10


Complaints

>

The number of total Number of Complaints Total

Quality of Care

complaints and quality of care complaints is higher at nursing

2.8

homes that meet the minimum state staffing

2.1

requirement (3.2 hours per resident day) than

1.6

those that meet the 1.0

recommended goal (4.1 to 4.5 hours per resident day).

Met Minimum Standard (3.2+ hours)

Met Recommended Goal (4.1+ hours)



11


Staff Turnover and Satisfaction

>

Nursing facilities with

Share of Very Satisfied Staff in a Facility with…

higher percentages Staff Satisfaction Turnover Rate

8%

of satisfied staff have lower turnover rates.

…Very Few Satisfied Staff 79%

18%

…Fair Number of Satisfied Staff 66%

36%

…High Number of Satisfied Staff 58%

Source: Tellis-Nayak, V., Customer Satisfaction in Long Term Care: A Guide to Assessing Quality, AHCA, 2003.


12

Freestanding Nursing Home (FNH) Turnover Rates, 2000 – 2003


Turnover rates for nursing staff in freestanding nursing

80%

80%

homes decreased 70%

by 19 percent from 65%

2000

2001

2002

2000 to 2003.

2003

Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using Office of Statewide Health Planning and Development’s long term care financial data for 2000 – 2003. Employee [percent] turnover rates for health care and social services, NOBSCOT www.nobscot.com/survey/us_voluntary_turnover_0103.cfm.


13

Nurse Staff Turnover Rate by Staffing Level, 2003


The turnover rate for nursing homes that met the recommended nurse staffing goal of 4.1 to 4.5 hours

66%

55%

per resident day was significantly lower than for nursing homes that did not meet the goal.

Below Recommended Goal (< 4.1 hours)

Met Recommended Goal (4.1+ hours)

Source: Janis O’Meara and Charlene Harrington, University of California. San Francisco. Calculations provided using California Office of Statewide Health Planning and Development’s long term care financial data for 2000 – 2003, and California Department of Health, Licensing and Certification Program, Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.


14

Deficiencies Among Freestanding Nursing Facilities, by Turnover Rate, 2003 Average Number of Deficiencies


In 2003, nursing homes with the highest turnover rates received a higher number of deficiencies than those

16.0 14.5

nursing homes with 13.2

average or low turnover rates.

High Turnover (72%+)

Medium Turnover (47% to 71%)

Low Turnover (< 47%)

Source: Janis O’Meara and Charlene Harrington, University of California. San Francisco. Calculations provided using California Office of Statewide Health Planning and Development’s long term care financial data for 2000 – 2003, and California Department of Health, Licensing and Certification Program, Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.


15


Turnover and Deficiencies

>

Nonprofit nursing facilities have lower For Profit

Nonprofit

turnover rates and fewer deficiencies than

66%

for-profit facilities. 55%

15.2 9.7 Nurse Turnover Rate

Average Number of Deficiencies



16

Wages in Freestanding Facilities by Nursing Turnover Rates, 2003


Wages for nursing Nursing Assistant

assistants and

Licensed Nurse (LVN)

licensed nurses were $23.21

$22.52

significantly lower in nursing homes with high turnover rates than in nursing homes with low turnover rates.

$10.76

$10.17

Low wages is one of the primary reasons for high turnover rates among nursing staff.

High Turnover (72%+)

Low Turnover (< 47%)



17
