Staffing Ratios and Quality: An Analysis of Minimum Direct Care Staffing Requirements in Nursing Homes

Department of Economics, Farmer School of Business, Miami University, 800 E. High Street, Oxford, OH 45056, USA.
Health Services Research (Impact Factor: 2.78). 05/2011; 46(5):1495-516. DOI: 10.1111/j.1475-6773.2011.01274.x
Source: PubMed


To study the impact of minimum direct care staffing (MDCS) requirements on nurse staffing levels, nurse skill mix, and quality.
U.S. nursing home facility data from the Online Survey Certification and Reporting (OSCAR) System merged with MDCS requirements. STUDY DESIGN; Facility-level outcomes of nurse staffing levels, nurse skill mix, and quality measures are regressed on the level of nurse staffing required by MDCS requirements in the prior year and other controls using fixed effect panel regression. Quality measures are care practices, resident outcomes, and regulatory deficiencies. DATA EXTRACTION METHOD: Analysis used all OSCAR surveys from 1999 to 2004, resulting in 17,552 unique facilities with a total of 94,371 survey observations.
The effect of MDCS requirements varied with reliance of the nursing home on Medicaid. Higher MDCS requirements increase nurse staffing levels, while their effect on nurse skill mix depends on the reliance of the nursing home on Medicaid. MDCS have mixed effects on care practices but are generally associated with improved resident outcomes and meeting regulatory standards.
MDCS requirements change staffing levels and skill mix, improve certain aspects of quality, but can also lead to use of care practices associated with lower quality.

30 Reads
  • Source
    • "Further studies may need to focus more on subjective assessment of market demand (e.g., the manager's perceived market demand and perceived scarcity of potential resources in managerial processes). The study findings are consistent with previous studies, in which stronger RN and total staffing standards are related to higher RN and total staffing levels (Bowblis, 2011;Harrington et al., 2007;Mueller et al., 2006). And, the facility-level measurement used in this study could provide additional understanding of the policy impact. "
    [Show abstract] [Hide abstract]
    ABSTRACT: This study investigated the impact of state nursing home staffing standards on nurse staffing levels for the year 2011. Specifically, the study attempted to measure state staffing standards at facility level (i.e., nurse staffing levels that each individual nursing home must retain by its state staffing standards) and analyzed the policy impact. The study findings indicated that state staffing standards for the categories of registered nurse, licensed nurse, or total nurse are positively related to registered nurse, licensed nurse, or total nurse staffing levels, respectively. Nursing homes more actively responded to licensed staffing requirements than total staffing requirements. However, nursing homes did not increase their staffing levels as much as those required by state staffing standards. It is possibly because the quality-oriented inspection allows flexibility in nursing homes' control of nurse staffing levels. © The Author(s) 2015.
    Full-text · Article · Jul 2015 · Medical Care Research and Review
  • Source
    • "These regulations increase costs by forcing many NHs to hire additional nurses, and may lower quality in other dimensions, such as quality of life. For example, NHs substitute higher skilled nurses, such as RNs and LPNs, for lower skilled and less costly CNAs (Park and Stearns 2009; Bowblis 2011a), or NHs reduce staffing in areas not specifically related to nurse staffing, such as support staff (Thomas et al. 2010; Bowblis and Hyer 2013). "
    [Show abstract] [Hide abstract]
    ABSTRACT: The implementation of regulation in the health care sector is often motivated by assuring a minimum level of quality, but there is little understanding of the cost of this regulation. This paper explores the cost of regulation in the nursing home industry. Using panel data on the same nursing homes from 1999 to 2004, this paper examines how financial performance is impacted by regulations that increased the minimum number of nurses that provide direct care to residents. While nursing homes attempt to increase revenues and mitigate the cost of responding to more stringent regulation, various measures of profitability show nursing homes are worse off financially. In fact, more stringent staffing regulations cause some nursing homes to lose money providing services.
    Full-text · Article · Jun 2015 · Journal of Regulatory Economics
  • Source
    • "The severityweighted health deficiency score is directly taken from OSCAR, whereas registered nurses (RNs) to total nurse ratio and direct care hour per patient per day were computed using variables from the same source. These variables are used as indicators of nursing home quality of care in a large number of studies (e.g., Bowblis 2011 and Mor et al. 2004) and are also included on the federal nursing home report card effort and the recent CMS nursing home payfor-performance demonstration. The only outcome variable that is calculated using Medicare claims and enrollment data is the hospitalization rate, which is calculated as the total number of hospitalization events originated from that facility in that year for fee-for-service (non-HMO) Medicare enrollees divided by the total resident days of such patients in that facility in that year divided by 365. "
    [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVE: To estimate the effect of a nursing home's share of residents with a serious mental illness (SMI) on the quality of care. DATA SOURCES: Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims. STUDY DESIGN: We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects. PRINCIPAL FINDINGS: An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non-SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents. CONCLUSIONS: Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight.
    Full-text · Article · Dec 2012 · Health Services Research
Show more