Math & Engineering

Staffing and Quality in California s Nursing Homes

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s n a p s h o t in California s s 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
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s n a p s h o t in California s s 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 less turnover, and fewer documented deficiencies in care. Nearly half of resident complaints center on poor food and more than 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. C O N T E N T S Number of Fulltime Nursing Staff in Hospitals and s Nurse Staffing Hours Nurse Staffing Levels Nursing Hours by Ownership Type....6 Facilities that Meet Staffing Goals by Ownership Type by Facility and Ownership Type Total Deficiencies and Citations by Staffing Level Top Ten Deficiencies in Nursing Facilities Complaints Staff Turnover and Satisfaction in Nursing Facilities, National Freestanding (FNH) Turnover Rates Nurse Staff Turnover Rate by Staffing Level Deficiencies Among Freestanding Nursing Facilities, by Turnover Rate 15 Turnover and Deficiencies by Ownership Type Wages in Freestanding Facilities by Nursing Turnover Rates Authors California HealthCare Foundation 2 Number of Fulltime Nursing Staff in Hospitals and s, 2000 vs Of the almost 200,000 Hospital Staff 131, ,990 33,860 30,530 Nursing Assistant Licensed Nurse Registered Nurse nursing staff working in California in 2003, about a third worked in nursing facilities and a majority of those were 10,332 82,128 10,525 86,908 Staff 63,990 59,946 46,024 42,334 nursing assistants. 11,286 12,326 6,326 5, 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 The Registered Nurse Population March 2000: Findings from the National Sample Survey of Registered Nurses. Washington, DC. Office of Statewide Health Planning and Development and Long-Term Care Facility Data. Pivot tables. Sacramento, CA California HealthCare Foundation 3 Nurse Staffing Hours, Average Hours per Resident Day Higher levels of nurse staffing are related to better quality of care. Since legislation was passed for a 3.60 minimum of 3.2 hours per resident day in California in 1999, average nurse staffing hours for residents in nursing homes have 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 California HealthCare Foundation 4 Nurse Staffing Levels, 2001 vs Hours per Resident Day Recommended (4.1+ hours) State Mandated (3.2+ hours) Below State Mandated ( 3.2 hours) Between 2001 and 2003, the number of homes that failed to % 5% meet state-mandated staffing standards fell 58 percent. Still, nearly 41% 56% 24% 71% one in four homes did not meet the standard in 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 s, Report to Congress, California HealthCare Foundation 5 Nursing Hours by Ownership Type, 2003 Total Hours of Care per Resident Day Registered Nurse (RN) Licensed Nurse (LVN) Nursing Assistant In 2003, 11 percent of nursing hours in for profits were provided by RNs while 26 percent of nursing hours were by RNs in nonprofit facilities 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 , 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, California HealthCare Foundation 6 Facilities that Meet Staffing Goals by Ownership Type, Nonprofit Most (93 percent) nonprofit nursing 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 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 , 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, California HealthCare Foundation 7 Facilities that Meet Staffing Goals by Facility and Ownership Type Studies have shown Freestanding 21% Facility Type Hospital-based 79% For Profit 38% Ownership Type Nonprofit 62% that a staffing goal between 4.1 and 4.5 hours per resident day, depending on the needs of the residents in a facility, provides the most appropriate 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 , 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, California HealthCare Foundation 8 Total Deficiencies and Citations by Staffing Level, 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 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 , 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, California HealthCare Foundation 9 Top Ten Deficiencies in Nursing Facilities, 2005 Quality Care Percent Reporting Food 46.2% 38.7% Almost half of surveyed nursing facilities reported food-related deficiencies; more Incomplete Records Dignity Not Respected Unnecessary Drugs 30.2% 28.9% 33.7% than a third reported deficiencies that were quality of care-related. Incomplete Care Plan 28.8% Hazards 28.8% Infection Control 28.2% Pharmacy Procedures 25.4% Housekeeping 24.1% Source: CMS OSCAR Survey Data, updated December Prepared by CAHF IRC January California HealthCare Foundation 10 Complaints Total and Quality of Care, Number of Complaints Total Quality of Care The number of total complaints and quality of care complaints is higher at nursing homes that meet the 2.1 minimum state staffing requirement (3.2 hours 1.6 per resident day) than 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) 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 , 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, California HealthCare Foundation 11 Staff Turnover and Satisfaction in Nursing Facilities, National, 2003 Share of Very Satisfied Staff in a Facility with Very Few Satisfied Staff 8% Staff Satisfaction Turnover Rate Nursing facilities with higher percentages of satisfied staff have lower turnover rates. 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, California HealthCare Foundation 12 Freestanding (FNH) Turnover Rates, Turnover rates for nursing staff in 80% 80% freestanding nursing homes decreased 70% 65% by 19 percent from 2000 to 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 Employee [percent] turnover rates for health care and social services, NOBSCOT California HealthCare Foundation 13 Nurse Staff Turnover Rate by Staffing Level, 2003 The turnover rate for nursing homes that met the recommended nurse staffing goal 66% of 4.1 to 4.5 hours 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 , 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, California HealthCare Foundation 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 16.0 deficiencies than those nursing homes with 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 , 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, California HealthCare Foundation 15 Turnover and Deficiencies by Ownership Type, % For Profit Nonprofit Nonprofit nursing facilities have lower turnover rates and fewer deficiencies than for-profit facilities. 55% Nurse Turnover Rate Average Number of Deficiencies 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 , 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, California HealthCare Foundation 16 Wages in Freestanding Facilities by Nursing Turnover Rates, 2003 Wages for nursing Nursing Assistant Licensed Nurse (LVN) assistants and licensed nurses were $22.52 $23.21 significantly lower in nursing homes with high turnover rates than in nursing homes with low turnover rates. $10.17 High Turnover (72%+) $10.76 Low Turnover ( 47%) Low wages is one of the primary reasons for high turnover rates among nursing staff. 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 , 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, California HealthCare Foundation 17 Authors Charlene Harrington, Ph.D., Janis O Meara, M.P.A., and Taewoon Kang, Ph.D. Department of Social and Behavioral Sciences, School of Nursing, UCSF GIVE US YOUR FEEDBACK Was the information provided in this report of value? Are there additional kinds of information or data you would like to see included in future reports of this type? Is there other research in this subject area you would like to see? We would like to know. Please click here to access our feedback form. Or visit and enter Report Code #1090. Thank you. FOR MORE INFORMATION California HealthCare Foundation 476 9th Street Oakland, CA California HealthCare Foundation 18
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