Is the Quality of Nursing Homes Countercyclical? Evidence From 2001 Through 2015

Business cycles and healthcare employment

Is healthcare employment recession-proof? We examine the long-standing hypothesis that healthcare employment is stable across the business cycle. We explicitly distinguish between negative aggregate demand and supply shocks in studying how healthcare employment responds to recessions, and show that this response depends largely on the type of the exogenous shock triggering the recession. First, aggregate healthcare employment responds procyclically during demand-induced recessions but remains stable during supply-induced recessions. Second, healthcare utilization drops significantly during demand-induced recessions, explaining the decline in healthcare employment during these periods. Finally, there is significant heterogeneity in the employment responses of the healthcare sub-sectors. While healthcare employment in most sub-sectors responds procyclically during recessions caused by both negative demand and supply shocks, it responds countercyclically in nursing-dominant sectors. Importantly, by isolating the recessionary impact of negative aggregate demand shocks from supply shocks on healthcare employment, we provide new empirical evidence that healthcare employment, in general, is not recession-proof.

Nursing Homes Increasingly Rely On Staffing Agencies For Direct Care Nursing

When nursing homes experience a shortage in directly employed nursing staff, they may rely on temporary workers from staffing agencies to fill this gap. This article examines trends in the use of staffing agencies among nursing homes during the prepandemic and COVID-19 pandemic era (2018-22). In 2018, 23 percent of nursing homes used agency nursing staff, accounting for about 3 percent of all direct care nursing hours worked. When used, agency staff were commonly present for ninety or fewer days in a year. By 2022, almost half of all nursing homes used agency staff, accounting for 11 percent of all direct care nursing staff hours. Agency staff were increasingly used to address chronic staffing shortages, with 13.8 percent of nursing homes having agency staff present every day. Agency staff were 50-60 percent more expensive per hour than directly employed nursing staff, and nursing homes that used agency staff often had lower five-star ratings. Policy makers 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.

Beyond Nursing Staff Levels: The Association of Nursing Home Quality and the Five-Star Quality Rating System's New Staffing Measures

Recently, the Centers for Medicare & Medicaid Services (CMS) introduced staffing measures related to staffing variability and turnover in the Nursing Home (NH) Care Compare Five-Star Quality Rating System. While the consensus within the literature is that reduced variability and turnover are associated with higher NH quality of care and life, no existing studies have evaluated the relationship between CMS's newly introduced staffing measures and quality. This study uses regression analysis to estimate the relationship between 13 quality measures (used in Care Compare) and CMS's new staffing measures (i.e., weekend nursing staff levels, total nursing and registered nurse staff turnover, and administrator turnover) as well as a measure of daily staffing variation recently introduced in the literature called the coefficient of variation. Regressions analysis finds strong evidence of an association between quality and these staffing measures, though some measures (e.g., nursing staff turnover) are highly correlated and may be duplicative.

The Impact of Wages on Care Home Quality in England

BACKGROUND AND OBJECTIVES

In many countries, a large proportion of long-term care staff are paid at, or near, minimum wage, leading to concerns of negative effects on care outcomes. This study analyzed the effect of staff wages on care home quality ratings in England.

RESEARCH DESIGN AND METHODS

A national staffing database of long-term care providers was matched with local-area information on needs and supply to construct a 3-year panel (2016-2018) of English care home observations. Using multiple imputation methods to address missing data provided a data set of 12,055 observations of 5,556 care facilities (both residential and nursing homes). We analyzed the effect of the facility-level average hourly wage of care staff on national regulator quality ratings. A measure of the impact of exogenous changes in the national minimum wage on care facilities was used as an instrument for wage.

RESULTS

We find that wages positively affect care home quality ratings. Other things equal, a 10% increase in the average hourly wage of direct care workers would lead to a 7.1% increase in the likelihood that a care home will have a high-quality rating. The wage effect on quality was significant when controlling for staff skill mix, measured as the share of registered nurses in nursing home staff.

DISCUSSION AND IMPLICATIONS

This study provides important evidence of the positive impact that staff pay can have on the quality of long-term care. Our finding has important implications for appropriate levels of pay and the funding of long-term care.

Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research

BACKGROUND

The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services.

METHODS

Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes.

RESULTS

The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance.

CONCLUSION

The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture.

Recruitment, retention and employment growth in the long-term care sector in England

This paper studies the relationship between turnover, hiring and employment growth in the long-term care (LTC) sector in England and sheds light on how challenges in both recruitment and retention affect the sector's ability to meet growing demand for care services. Using the Adult Social Care Workforce Data Set (ASC-WDS), a large longitudinal dataset of LTC establishments in England, and fixed effects estimation methods we: (a) quantify the relationship between the in/outflow of care workers and the expansion/contraction of employment within establishments, (b) establish the role of staff retention policy for workforce expansion, and (c) identify the role of recruitment frictions and its impact on hiring and employment contraction. Our analysis indicates that care worker turnover and employment growth are negatively related. A one percentage point increase in employment contraction is associated with a 0.71 percentage point rise in turnover, while a one percentage point increase in employment expansion is associated with a 0.23 percentage point fall in turnover. In contrast, we find that hiring rates and employment growth are positively related. A one percentage point increase in employment expansion is associated with a 0.76 percentage point rise in hiring, while a one percentage point increase in employment contraction is associated with a 0.26 percentage point decrease in hiring. We argue that the negative turnover-employment growth relationship within expanding establishments provides evidence that better staff retention is associated with higher employment growth. Using information on establishments' annual change in vacancies, and controlling for changes in new labor demand, we also find rising year-on-year vacancies amongst establishments with declining employment. This provides evidence that recruitment frictions drive the declining rate of replacement hiring amongst contracting establishments. Across sectors, we find that the employment growth-turnover and the employment decline-hiring relationships are relatively stronger in the private and voluntary sectors compared to the public sector, suggesting that the impact of staff retention and recruitment frictions on employment is more acute in these sectors.

Evidence for Action: Addressing Systemic Racism Across Long-Term Services and Supports

Long-term services and supports (LTSS), including care received at home and in residential settings such as nursing homes, are highly racially segregated; Black, Indigenous, and persons of color (BIPOC) users have less access to quality care and report poorer quality of life compared to their White counterparts. Systemic racism lies at the root of these disparities, manifesting via racially segregated care, low Medicaid reimbursement, and lack of livable wages for staff, along with other policies and processes that exacerbate disparities. We reviewed Medicaid reimbursement, pay-for-performance, public reporting of quality of care, and culture change in nursing homes and integrated home- and community-based service (HCBS) programs as possible mechanisms for addressing racial and ethnic disparities. We developed a set of recommendations for LTSS based on existing evidence, including (1) increase Medicaid and Medicare reimbursement rates, especially for providers serving high proportions of Medicaid-eligible and BIPOC older adults; (2) reconsider the design of pay-for-performance programs as they relate to providers who serve underserved groups; (3) include culturally sensitive measures, such as quality of life, in public reporting of quality of care, and develop and report health equity measures in outcomes of care for BIPOC individuals; (4) implement culture change so services are more person-centered and homelike, alongside improvements in staff wages and benefits in high-proportion BIPOC nursing homes; (5) expand access to Medicaid-waivered HCBS services; (6) adopt culturally appropriate HCBS practices, with special attention to family caregivers; (7) and increase promotion of integrated HCBS programs that can be targeted to BIPOC consumers, and implement models that value community health workers. Multipronged solutions may help diminish the role of systemic racism in existing racial disparities in LTSS, and these recommendations provide steps for action that are needed to reimagine how long-term care is delivered, especially for BIPOC populations.

Comparison of Hydrocolloid Dressings and Silver Nanoparticles in Treatment of Pressure Ulcers in Patients with Spinal Cord Injuries: A Randomized Clinical Trial

Introduction: There are numerous dressings used to treat pressure ulcers (PUs), depending on their advantages to achieve optimum patient outcomes. This study aimed to compare hydrocolloid dressings and silver nanoparticles in treating PUs among patients with spinal cord injury (SCI).

Methods: This randomized clinical trial was conducted on 70 patients with SCI in Iran. Participants were randomly divided into two equal groups (n=35) receiving silver nanoparticle dressing and hydrocolloid dressing, respectively. The groups were evaluated in four assessment periods using the Bates-Jensen Wound Assessment Tool (BWAT). Data analysis was performed using SPSS software version 13, repeated measures ANOVA, non-parametric tests, and chi-square.

Results: Chi-square test was used to investigate the difference between the scores before the intervention, the results of which were not statistically significant. In repetitive measurements, the results of the analysis of variance showed that the average assessment score in both groups decreased and both dressings were effective in the treatment process. Although PU improvement status in the group that received silver nanoparticles was better, between-group analysis of variance did not show any statistically significant difference between the two groups.

Conclusion: Our results indicated that silver nanoparticles and hydrocolloid dressings can be used interchangeably in the treatment of PUs.

Survey Deficiencies as Quality Indicators in Oregon Assisted Living Communities

BACKGROUND AND OBJECTIVES

License inspection data have commonly been used as a quality measure for nursing homes but has not yet been used to assess the quality of assisted living/residential care (AL/RC) communities. Drawing on resource dependency theory, we test the hypothesis that structural and environmental characteristics influence AL/RC quality as measured by deficiency citations ("deficiencies") issued during license inspections.

RESEARCH DESIGN AND METHODS

Using data from 526 licensed AL/RC communities in Oregon that received a license inspection visit between 2008 and 2016, we examined the prevalence of deficiencies by type and year. We estimated regression models to identify structural and environmental characteristics associated with the number of deficiencies.

RESULTS

Most (79%) inspections resulted in at least one deficiency. The most common deficiencies concerned medications and treatments (57%), change of condition and monitoring (48%), and resident health services (45%). Structural characteristics associated with higher odds of receiving one or more deficiencies included: larger size, memory care designation, shorter administrative tenure, and for-profit status. Environmental characteristics associated with higher odds of receiving one or more deficiencies included: rural location, lower unemployment, and market concentration. The number and likelihood of a given community receiving a deficiency decreased over time.

DISCUSSION AND IMPLICATIONS

Resource dependency theory constitutes a useful framework to consider the role of structural and environmental factors that affect AL/RC quality, including resident needs, institutional knowledge, resource availability, and market pressure. License inspection data are a viable option for assessing the quality of AL/RC communities.

The One-Two Punch of High Wages and Empowerment on CNA Retention

OBJECTIVES

The objective of this study was to examine the relationship between high wages and empowerment practices on certified nursing assistant (CNA) retention, necessary for providing high-quality care for nursing home (NH) residents.

METHODS

Measures of provider-level CNA empowerment and wages from the 2015 Ohio Biennial Survey were used to estimate two regression models on retention (n = 719), one without and one with an interaction term of high wages and high empowerment.

RESULTS

Only in the context of the interacted model were NHs that provided both high wages and high empowerment associated with a 7.09 percentage-point improvement in the CNA retention rate (p = .0003). Individually, high wages and a high empowerment score were not statistically significant in either regression model.

DISCUSSION

Retaining CNAs in NH communities requires a combination of empowerment practices (e.g., involving CNAs in decision-making about hiring other staff) and high hourly wages.

Person-Centered Care in Nursing Homes: Potential of Complementary and Alternative Approaches and Their Challenges

A person-centered approach to care shifts the mind-set of care partners from a traditional medical model to a social model in managing chronic conditions. Using a qualitative descriptive approach, this study examines the barriers and facilitators to the implementation of person-centered care (PCC) and how the integration of complementary and alternative approaches (CAA) has the potential to improve residents' quality of life in nursing homes (NHs). Findings indicate that NHs offer a wide range of engagement activities, but these activities are not purposefully integrated into a person-centered plan of care. Factors such as turnover, "working short," supervisor support, and rising resident care needs make it challenging to implement PCC in NHs. This knowledge of the landscape of activities will help us identify and improve strategies for supporting residents at a deeper, more meaningful level. CAA has the potential to be therapeutic for residents if integrated into collaborative approaches to care.

It Is Time to Resolve the Direct Care Workforce Crisis in Long-Term Care

Nearly 4.6 million direct care workers-including personal care aides, home health aides, and nursing assistants-provide daily support to older adults and people with disabilities across a range of settings in the United States, predominantly in long-term care (LTC). Even as the population grows older and drives up demand for LTC, the sector continues its decades-long struggle to fill direct care positions and stabilize this essential workforce. Recent events and emerging trends have converged, however, to produce new opportunities to address this longstanding workforce crisis, including the unprecedented attention generated by the coronavirus disease 2019 (COVID-19) pandemic and the systemic shifts to managed care and value-based payment in LTC. This Forum article outlines the pressing direct care workforce challenges in LTC before describing these potential levers of change, emphasizing the importance of not just expanding the workforce but also maximizing direct care workers' contributions to the delivery of high-quality services for a growing and evolving population of LTC consumers.

The Effect of Business Cycles on Health Expenditure: A Story of Income Inequality in China

Using the panel data of 31 regions in China from 2002 to 2018, this study aims to investigate the effect of business cycles on health expenditure from the role of income inequality. We find that health expenditure experiences a change from pro-cyclical to counter-cyclical with business cycles. Specifically, business cycles have a different influence on health expenditure before and after the financial crisis in 2008. Our findings also show that income inequality can moderate the impact of business cycles on health expenditure in China. More importantly, the role of income inequality in the above issue varies from different regions. We conclude that the government should try to take active steps to control health expenditure by decreasing income inequality.

The Association between Staff Retention and English Care Home Quality

This paper examines the association between workforce retention and related staffing measures and the quality of English care homes using a national database of social care providers' staffing. The analysis finds significant correlations between quality and the levels of staffing vacancies and retention of both residential and nursing homes, but no association was found between quality and the use of temporary contract workers nor the resident to staff ratio. Only for staff vacancy rates was there a significant difference in the size of these relationships between types of home. The findings suggest that quality could change for the average care home with a relatively small alteration in staffing circumstance. Long-term care is a labor-intensive industry and many countries face relatively high levels of staff turnover and job vacancy rates. These findings are therefore of interest for policy internationally and for England in particular, where the development of social care recruitment and retention strategies are ongoing.

Leadership, Staff Empowerment, and the Retention of Nursing Assistants: Findings From a Survey of U.S. Nursing Homes

OBJECTIVES

We examined the relationship between nursing assistant (NA) retention and a measure capturing nursing home leadership and staff empowerment.

DESIGN

Cross-sectional study using nationally representative survey data.

SETTING AND PARTICIPANTS

Data from the Nursing Home Culture Change 2016-2017 Survey with nursing home administrator respondents (N = 1386) were merged with facility-level indicators.

METHODS

The leadership and staff empowerment practice score is an index derived from responses to 23 survey items and categorized as low, medium, and high. Multinomial logistic regression weighted for sample design and to address culture-change selection bias identified factors associated with 4 categories of 1-year NA retention: 0% to 50%, 51% to 75%, 76% to 90%, and 91% to 100%.

RESULTS

In an adjusted model, greater leadership and staff empowerment levels were consistently associated with high (76%-90% and 91%-100%) relative to low (0%-50%) NA retention. Occupancy rate, chain status, licensed practical nurse and certified nursing assistant hours per day per resident, nursing home administrator turnover, and the presence of a union were also significantly associated with higher categories of retention (vs low retention).

CONCLUSIONS AND IMPLICATIONS

Modifiable leadership and staff empowerment practices are associated with NA retention. Associations are most significant when examining the highest practice scores and retention categories. Nursing homes seeking to improve NA retention might look to leadership and staff empowerment practice changes common to culture change.