8 trends in agency nurse dependency in nursing homes

Nursing homes have increased the number of agency nurses providing direct care nursing hours in the last five years and in one state, 86% of nursing homes were using agency staff in 2022.

The study, published Feb. 14 in Health Affairs, used Payroll-Based Journal data, Nursing Home Compare Archive data and Medicare Cost Reports to find trends in nurse agency use, including the number of hours provided, pay and the number of agency nurses used, in all 50 states. The data sets were from 2018 to 2022, the most recent data available.

The study found that in 2018, 23% of nursing homes used agency nursing staff, which accounted for about 3% of direct care nursing hours. By 2022, almost half of all homes used agency staff, which accounted for 11% of all direct nursing hours.

Homes that used agency staff were more likely to have lower five-star ratings and need more agency staff to address chronic staffing shortages, and 13.8% had agency staff present every day.

Here are seven other trends:

  • In 2018, 22.5% of nursing homes used any direct care agency nursing staff, but in 2022, 49.1% of nursing homes used agency staff, with 17.8% using registered nurses, 31.9% using licensed practical nurses and 40% using nursing aids.

  • In 2022, four states had more than 70% of nursing homes using agency nursing staff: Vermont (86.6%), New York (73%), Maryland (70.9%) and Pennsylvania (70.5%).

  • In 2022, the states with the lowest percentage of nursing homes using agency staff were Oklahoma (29.9%); Alabama (28%), Washington, D.C., (26.2%) and Arkansas (16.3%).

  • In 2022, agency staff accounted for more than 20% of direct nursing staff hours in Vermont (28.1%), Montana (22.3%) and Maine (21.5%).

  • In 2022, the number of nursing homes using agency staff every day increased to 13.8%, with 20.2% of facilities using them for 336 to 364 days. Only 19.4% of facilities used agency staff for less than 90 days, compared to 44.7% of nursing homes in 2018.

  • The median labor cost difference between agency and directly employed nurses increased from $17.20 per hour in 2018 to $23.93 per hour difference in 2022. There was a similar pattern for nurse aids and licensed practical nurses.

  • On average, the hourly labor cost between agency and directly employed staff was 50% higher for registered nurses, 57% higher for licensed practical nurses and 66% higher for nurse aides.

"Policymakers need to consider postpandemic changes to the nursing home workforce as part of nursing home reform, as increased reliance on agency staff may reduce the financial resources available to increase nursing staff levels and improve the quality of care," the study authors wrote.

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