What nursing home staffing ratios could mean for hospitals

CMS has proposed establishing staffing requirements in nursing homes, touting the effort as a way to improve quality and safety at these facilities. However, a national group representing hospitals is expressing concerns that this approach could be significant for the broader continuum of care that won't resolve the structural healthcare workforce shortages.

On Sept. 1, CMS issued its proposed rule, which includes, for the first time, national minimum nurse staffing standards for nursing homes. The proposal would require nursing homes that receive Medicare and Medicaid funding to provide residents with a minimum of 0.55 hours of care from a registered nurse per resident per day, and 2.45 hours of care from a nurse aide per resident per day, CMS said. The agency estimates about 75 percent of nursing homes would have to strengthen staffing to comply, and it proposes that implementation of the final requirements will occur in three phases over three years for non-rural facilities.

"Establishing minimum staffing standards for nursing homes will improve resident safety and promote high-quality care so residents and their families can have peace of mind," HHS Secretary Xavier Becerra said in a news release. "When facilities are understaffed, residents suffer. They might be unable to use the bathroom, shower, maintain hygiene, change clothes, get out of bed, or have someone respond to their call for assistance. Comprehensive staffing reforms can improve working conditions, leading to higher wages and better retention for this dedicated workforce."

But representatives from the American Hospital Association told Becker's they are concerned about the effort, especially given the complexity of healthcare staffing.

Akin Demehin, AHA senior director of quality and safety policy, specifically called the proposal a "one-size-fits-all" approach, "which we think takes away the vital role of clinical judgment and the facts on the ground as nursing leaders know them in helping to staff nursing facilities."

Mr. Demehin also cited potential effects a minimum level may have on hospitals if nursing homes are forced to close and it becomes harder to find a nursing home to discharge patients to. An analysis of federal data by The Wall Street Journal found that at least 600 nursing homes have closed in the last six years. At the same time, the AHA found that discharges to post-acute facilities climbed 24 percent between 2019 and 2022. 

"This can have real ripple effects throughout the [continuum of care]," Mr. Demehin said. "The longer that a patient has to wait for a placement in a skilled nursing facility or other post-acute care facility, the longer they'll be in the hospital, and that can create some spillover effects for the rest of the hospital." 

For example, patients may face longer wait times in emergency departments to get onto an inpatient unit, he added.

Caitlin Gillooley, director of quality and behavioral health policy at AHA, told Becker's she is also concerned that the CMS proposal is unsustainable without additionally robust and long-term plans to support the nursing workforce. 

President Joe Biden's administration has announced more than $75 million in financial incentives, such as scholarships and tuition reimbursement, to support staffing in nursing homes. Miranda Lynch-Smith, senior official performing the duties of the assistant secretary for planning and evaluation within HHS, said in a news release that pay is "an important part of job quality and drive challenges in recruitment and retention of direct care workers. Our research shows that in many places these workers can earn higher wages doing other entry-level work." 

Ms. Gillooley commended the investment but said more needs to be done given the magnitude of the workforce that is needed to care for older Americans and those in long-term care facilities.

"We really do have a long-term structural challenge with respect to the healthcare workforce," Mr. Demehin said. "These challenges have been building over decades, and putting a minimum staffing level in place doesn't solve that structural challenge. And it may lead to other challenges that we've described."

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