Is More Always Better? Financially Motivated Therapy and Patient Outcomes in Skilled Nursing Facilities.

OBJECTIVE: To determine if financially motivated therapy in Skilled Nursing Facilities (SNFs) is associated with patient outcomes. DESIGN: Cohort study using 2018 Medicare administrative data. SETTING AND PARTICIPANTS: 13,949 SNFs in the United States. PARTICIPANTS: 934,677 Medicare Part A patients admitted to SNF for post-acute rehabilitation (N=934,677). INTERVENTIONS: The primary independent variable was an indicator of financially motivated therapy, separate from intensive therapy, known as thresholding, defined as when SNFs provide 10 or fewer minutes of therapy above weekly reimbursement thresholds. MAIN OUTCOME MEASURES: Dichotomous indicators of successful discharge to the community vs institution and functional improvement on measures of transfers, ambulation, or locomotion. Mixed effects models estimated relations between thresholding and community discharge and functional improvement, adjusted for therapy intensity, patient, and facility characteristics. Sensitivity analyses estimated associations between thresholding and outcomes when patients were stratified by therapy volume. RESULTS: Thresholding was associated with a small positive effect on functional improvement (odds ratio 1.07; 95% CI 1.06-1.09) and community discharge (odds ratio 1.03, 95% CI 1.02-1.05). Effect sizes for functional improvement were consistent across patients receiving different volumes of therapy. However, effect sizes for community discharge were largest for patients in low-volume therapy groups (odds ratio 1.27, 95% CI 1.18-1.35). CONCLUSIONS: Patients who experienced thresholding during post-acute SNF stays were slightly more likely to improve in function and successfully discharge to the community, especially for patients receiving lower volumes of therapy. While thresholding is an inefficient and financially motivated practice, results suggest that even small amounts of extra therapy time may have contributed positively to outcomes for patients receiving lower-volume therapy. As therapy volumes decline in SNFs, these results emphasize the importance of Medicare payment policy designed to promote, not disincentivize, potentially beneficial rehabilitation services for patients.

The Workforce Needed to Address Population Health.

Policy Points Although a single definition of the population health workforce does not yet exist, this workforce needs to have the skills and competencies to address the social determinants of health, to understand intersectionality, and to coordinate and work in concert with an array of skilled providers in social and health care to address multiple health drivers. On-the-job training programs and employer support are needed for the current health workforce to gain skills and competencies to address population health. Funding and leadership combined are critical for developing the population health workforce with the goal of supporting a broad set of workers beyond health and social care to include, for example, those in urban planning, law enforcement, or transportation professions to address population health.

Where to start? A two stage residual inclusion approach to estimating influence of the initial provider on health care utilization and costs for low back pain in the US.

BACKGROUND: Diagnostic testing and treatment recommendations can vary when medical care is sought by individuals for low back pain (LBP), leading to variation in quality and costs of care. We examine how the first provider seen by an individual at initial diagnosis of LBP influences downstream utilization and costs. METHODS: Using national private health insurance claims data, individuals age 18 or older were retrospectively assigned to cohorts based on the first provider seen at the index date of LBP diagnosis. Exclusion criteria included individuals with a diagnosis of LBP or any serious medical conditions or an opioid prescription recorded in the 6 months prior to the index date. Outcome measures included use of imaging, back surgery rates, hospitalization rates, emergency department visits, early- and long-term opioid use, and costs (out-of-pocket and total costs of care) twelve months post-index date. We used a two-stage residual inclusion (2SRI) estimation approach comparing copay for the initial provider visit and differential distance as the instrumental variable to reduce selection bias in the choice of first provider, controlling for demographics. RESULTS: Among 3,799,593 individuals, cost and utilization varied considerably based on the first provider seen by the patient. Copay and differential distance provided similar results, with copay preserving a greater sample size. The frequency of early opioid prescription was significantly lower when care began with an acupuncturist or chiropractor, and highest for those who began with an emergency medicine physician or advanced practice registered nurse (APRN). Long-term opioid prescriptions were low across most providers except physical medicine and rehabilitation physicians and APRNs. The frequency and time to serious illness varied little across providers. Total cost of care was lowest when starting with a chiropractor ($5093) or primary care physician ($5660), and highest when starting with an orthopedist ($9434) or acupuncturist ($9205). CONCLUSION: The first provider seen by individuals with LBP was associated with large differences in health care utilization, opioid prescriptions, and cost while there were no differences in delays in diagnosis of serious illness.

Lack of Consistent Investment in Federal Insurance Navigator Program Undermines Navigators' Equity Work in Vulnerable Communities.

CONTEXT: Navigators in the federal Insurance Navigator Program ("Navigator Program"), who are employed by organizations in states with Federally Facilitated Marketplaces, provide enrollment assistance, outreach, and education to individuals who are eligible for health insurance coverage. Such work is central to public health efforts to address inequities but continues to be poorly understood and undervalued. More information is needed to understand the components of navigators' equity work and how decreases in program funding have affected their service provision. OBJECTIVE: To examine navigators' labor at a granular level to better understand and highlight the equity work they do, the training and skills required for this work, and the Navigator Program-based challenges they face. DESIGN: This was a descriptive qualitative study using data collected from interviews conducted in February-May 2021. We used a thematic analysis approach to develop major themes and subthemes. SETTING: This was a national study. PARTICIPANTS: We conducted 18 semistructured interviews with 24 directors, navigators, and other professionals at organizations funded as federally certified Navigator Programs. MAIN OUTCOME MEASURES: Components of navigators' work; required training and skills; and challenges faced in accomplishing the work. RESULTS: We identified 3 major themes: (1) navigators' health equity work goes beyond required responsibilities; (2) equity skills are built on the job; and (3) financial instabilities challenge navigators' health equity work. CONCLUSION: Navigators bring specialized and essential skills and services to underserved communities. They are trusted sources of information, advocates, resource connectors, and, most significantly, health equity workers. However, the Navigator Program fails to support navigators' work and the communities they serve in the long term. To facilitate organizations' capacities to train, keep, and support navigators in this health equity work and to guarantee long-term enrollment assistance for underserved communities, efforts to stabilize funding are needed.

Pathways to Registered Nursing: Influences of Health-Related Work Experience and Education Financing.

A larger and more diverse registered nurse (RN) workforce in the U.S. is needed to meet growing demand and address social determinants of health and improve health equity. To improve understanding of pathways and barriers to becoming an RN, this study examined prior health care employment and financial assistance factors associated with completion of pre-licensure RN education programs, by initial entry degree (associate degree or bachelor of science in nursing) and across racial and ethnic groups, using the 2018 National Sample Survey of Registered Nurses. The study found higher percentages of associate degree-entry RNs held a health-related job prior to completing their initial RN program than did bachelor's degree entrants. Employer support for education financing as well as reliance on loans and scholarships increased among RNs graduating in 2000 and later, and reliance on self-financing was reported less frequently. Hispanic associate degree-entry RNs reported education financing from only federal loans more frequently compared with White RNs, and higher percentages of Black, multiracial, and "some other race" baccalaureate degree entry RNs accessed federal loans compared with White baccalaureate degree-entry RNs. These findings indicate diversifying the RN workforce should remain a priority to increase representation by underrepresented racial and ethnic groups. Equitable pathways into the RN profession will be facilitated and expedited through policies that overcome financial and social barriers that enable individuals from population groups underrepresented in the nursing workforce to identify with the RN role and route to the profession.

Examining Wage Disparities by Race and Ethnicity of Health Care Workers.

BACKGROUND: Prior studies demonstrated that wage disparities exist across race and ethnicity within selected health care occupations. Wage disparities may negatively affect the industry's ability to recruit and retain a diverse workforce throughout the career ladder. OBJECTIVE: To determine whether wage disparities by race and ethnicity persist across health care occupations and whether disparities vary across the skill spectrum. RESEARCH DESIGN: Retrospective analysis of 2011-2018 data from the Current Population Survey using Blinder-Oaxaca decomposition regression methods to identify sources of variation in wage disparities. Separate models were run for 9 health care occupations. SUBJECTS: Employed individuals 18 and older working in health care occupations, categorized by race/ethnicity. MEASURES: Annual wages were predicted as a function of race/ethnicity, age, sex, marital status, having a child under 5 in the household, living in a metro area, highest education attained, and usual hours worked. RESULTS: Non-Hispanics consistently made more than Hispanic licensed practical/vocational nurses (LPNs/LVNs), aides/assistants, technicians, and community-based workers. Asian/Pacific Islanders consistently made more than Black, American Indian/Alaska Native, and Multiracial individuals across occupations except physicians, advanced practitioners, or therapists. Asian/Pacific Islanders only made significantly less when compared with White physicians, but more than White advanced practitioners, registered nurses, LPNs/LVNs, and aides/assistants. Based on observed attributes, Black registered nurses, LPNs/LVNs, and aides/assistants were predicted to make more than their White peers, but unexplained variation negated these gains. CONCLUSIONS: Many wage gaps remained unexplained based on measured factors warranting further study. Addressing wage disparities is critical to advance in careers and reduce job turnover.

Examining the racial and ethnic diversity of associate degree in nursing programs by type of institution in the US, 2012-2018.

BACKGROUND: Increasing nursing workforce diversity is essential to quality health care. Associate Degree in Nursing (ADN) programs are a primary path to becoming a registered nurse and an important source of nursing diversity. PURPOSE: To examine how the number of graduates and racial/ethnic student composition of ADN programs have changed since the Institute of Medicine's recommendation to increase the percentage of bachelor's-prepared nurses to 80%. METHODS: Using data from the Integrated Postsecondary Education System, we analyzed the number of graduates and racial/ethnic composition of ADN programs across public, private not-for-profit, and private for-profit institutions, and financial aid awarded by type of institution from 2012-2018. DISCUSSION: Racial/ethnic diversity among ADN programs grew from 2012-2018. Although private for-profits proportionally demonstrated greater ADN student diversity and provided financial aid institutionally to a higher percentage of students, public schools contributed the most to the number and racial/ethnic diversity of ADN graduates. CONCLUSION: Given concerns regarding private for-profits, promoting public institutions may be the most effective strategy to enhance diversity among ADN nurses.

Does the Patient-centered Medical Home Model Change Staffing and Utilization in the Community Health Centers?

BACKGROUND: Few studies have looked under the hood of practice redesign to understand whether and, if so, how staffing changed with the adoption of patient-centered medical home (PCMH), and whether these staffing changes impacted utilization. OBJECTIVES: To examine the workforce transformation occurring in community health centers that have achieved PCMH status, and to assess the relationship of those changes to utilization, as measured by the number of visits. RESEARCH DESIGN, SUBJECTS, MEASURES: Using a difference-in-differences approach, we compared staffing and utilization outcomes in 450 community health centers that had adopted a PCMH model between 2007 and 2013 to a matched sample of 243 nonadopters located in the 50 states and the District of Columbia. RESULTS: We found that adopting a PCMH model was significantly associated with a growth in use of advanced practice staff (nurse practitioners and physician assistants) [0.53 full-time equivalent (FTE), 8.77%; P<0.001], other medical staff (medical assistants, nurse aides, and quality assurance staff) (1.23 FTE, 7.46%; P=0.001), mental health/substance abuse staff (0.73 FTE, 17.63%; P=0.005), and enabling service staff (case managers and health educators) (0.36 FTE, 6.14%; P=0.079), but not primary care physicians or nurses. We did not observe a significant increase in utilization, as measured in total number of visits per year. However, the visits marginally attributed to advanced practice staff (539 FTE, 0.89%; P=0.037) and mental health/substance abuse staff (353 FTE, 0.59%; P=0.051) significantly increased. CONCLUSIONS: Our findings suggest that the implementation of PCMH actively reengineers staff composition and this, in turn, results in changes in marginal utilization by each staff type.

Occupational mobility among individuals in entry-level healthcare jobs in the USA.

AIMS: The aim of this study was to explore career transitions among individuals in select entry-level healthcare occupations. BACKGROUND: Entry-level healthcare occupations are among the fastest growing occupations in the USA. Public perception is that the healthcare industry provides an opportunity for upward career mobility given the low education requirements to enter many healthcare occupations. The assumption that entry-level healthcare occupations, such as nursing assistant, lead to higher-skilled occupations, such as Registered Nurse, is under-explored. DESIGN: We analysed data from the Panel Study of Income Dynamics, which is a nationally representative and publicly available longitudinal survey of US households. METHODS: Using longitudinal survey data, we examined the job transitions and associated characteristics among individuals in five entry-level occupations at the aide/assistant level over 10 years timeline (2003-2013) to determine whether they stayed in health care and/or moved up in occupational level over time. RESULTS/FINDINGS: This study found limited evidence of career progression in health care in that only a few of the individuals in entry-level healthcare occupations moved into occupations such as nursing that required higher education. While many individuals remained in their occupations throughout the study period, we found that 28% of our sample moved out of these entry-level occupations and into another occupation. The most common "other" occupation categories were "office/administrative" and "personal care/services occupations." Whether these moves helped individuals advance their careers remains unclear. CONCLUSION: Employers and educational institutions should consider efforts to help clarify pathways to advance the careers of individuals in entry-level healthcare occupations.

Examining the Healthcare Administrator's Perspective on "Teamness" in Primary Care.

EXECUTIVE SUMMARY: Team-based care has been identified as an important element of effective primary care practice. While there is a growing body of literature supporting the value of team-based care, research on best practices in team-based care has suffered from the lack of a widely accepted framework with common definitions. We used qualitative interviews to explore healthcare administrators' perspectives regarding team-based care descriptions, their decisions regarding composition of a team, and how they identify characteristics of a well-functioning team. Interviewees discussed six broad themes: (1) definitions of team-based care, (2) team structure and roles, (3) team goals, (4) monitoring team effectiveness, (5) challenges to implementing team-based care, and (6) the influence of healthcare policy on team-based care. The study findings can be used to identify further ways to assess the notion of "teamness."

Comparing efficiency of health systems across industrialized countries: a panel analysis.

BACKGROUND: Rankings from the World Health Organization (WHO) place the US health care system as one of the least efficient among Organization for Economic Cooperation and Development (OECD) countries. Researchers have questioned this, noting simplistic or inappropriate methodologies, poor measurement choice, and poor control variables. Our objective is to re-visit this question by using newer modeling techniques and a large panel of OECD data. METHODS: We primarily use the OECD Health Data for 25 OECD countries. We compare results from stochastic frontier analysis (SFA) and fixed effects models. We estimate total life expectancy as well as life expectancy at age 60. We explore a combination of control variables reflecting health care resources, health behaviors, and economic and environmental factors. RESULTS: The US never ranks higher than fifth out of all 36 models, but is also never the very last ranked country though it was close in several models. The SFA estimation approach produces the most consistent lead country, but the remaining countries did not maintain a steady rank. DISCUSSION: Our study sheds light on the fragility of health system rankings by using a large panel and applying the latest efficiency modeling techniques. The rankings are not robust to different statistical approaches, nor to variable inclusion decisions. CONCLUSIONS: Future international comparisons should employ a range of methodologies to generate a more nuanced portrait of health care system efficiency.

The gender wage gap among health care workers across educational and occupational groups.

Women perform 77% of health care jobs in the United States, but gender inequity within the health care sector harms women's compensation and advancement in health care jobs. Using data from 2003 to 2021 of the Annual Social and Economic Supplement of the Current Population Survey (CPS), we measured women's representation and the gender wage gap in health care jobs by educational level and occupational category. We found, descriptively, that women's representation in health care occupations has increased over time in occupations that require a master's or doctoral/professional degree (eg, physicians, therapists), while men's representation has increased slightly in nursing occupations (eg, registered nurses, LPNs/LVNs, aides, and assistants). The adjusted wage gap between women and men is the largest among workers in high-education health care (eg, physicians, advanced practitioners) but has decreased substantially over the last 20 years, while, descriptively, the gender wage gap has stagnated or grown larger in some lower education occupations. Our policy recommendations include gender equity reviews within health care organizations, prioritizing women managers, and realigning Medicare and Medicaid reimbursement policies to promote greater gender equity within and across health care occupations.

Impact of the COVID-19 Pandemic on the Community Pharmacy Workforce.

This study sought to describe the impact of the COVID-19 pandemic on community pharmacy practice and its workforce. Interviews were conducted with 18 key informants from pharmacy associations and community pharmacists representing chain and independent pharmacy organizations across the United States from January to May 2022. Interview notes were analyzed using a rapid content analysis approach. Four themes resulted: (a) patient care at community pharmacies focused on fulfilling COVID-19 response needs; (b) pharmacists' history as immunizers and scope of practice expansions facilitated COVID-19 response efforts; (c) workforce supply shortages impeded COVID-19 response efforts and contributed to burnout; and (d) maintaining community pharmacy workforce's readiness will be critical to future emergency preparedness and response efforts. Formalizing scope of practice expansion policies and reimbursement pathways deployed during the COVID-19 pandemic could facilitate the community pharmacy workforce's ability to address ongoing public health needs and respond to future public health emergencies.

Burnout, Exhaustion, Experiences of Discrimination, and Stress among Underrepresented and First-Generation College Students in Graduate Health Profession Education.

OBJECTIVES: Mental health disorders are increasing among health profession students. Compounding this, students from underrepresented backgrounds may face additional stressors and challenges. The aims of this study were to: 1) assess the extent to which burnout, exhaustion, experiences of discrimination, and stress exist among students in dentistry, nursing, occupational therapy, pharmacy, and physical therapist professional education programs; 2) determine if there are significant differences by key demographic characteristics (those who are first-generation college students [FGCS], a member of an underrepresented minority [URM] group), or both); and 3) highlight strategies and solutions to alleviate these challenges identified by students. METHODS: Cross-sectional survey using a mix of question types of a sample of graduate students from dentistry, nursing, occupational therapy, pharmacy, and physical therapy programs from February to June 2020. Utilizing the Maslach Burnout Inventory Student Survey (MBI-SS) and campus climate and stress survey, mean subscale scores were calculated for the following outcomes of interest: MBI-SS burnout, dimensions of stress, and observed racism. Logistic regressions examined student factors that may help explain these outcomes. Content analysis examined participants' responses to open-ended questions. RESULTS: There were 611 individuals who completed all survey questions. FGCS were significantly more likely than non-FGCS to report exhaustion (adjusted odds ratio [AOR]: 1.50; 95% CI: 1.04-2.16), family stress (AOR: 3.11; 95% CI: 2.13-4.55), and financial stress (AOR: 1.74; 95% CI: 1.21-2.50). URM students reported not feeling supported in their program and mentioned needing additional support, particularly for well-being, from staff and faculty. CONCLUSION: Findings from this study are consistent with literature that FGCS students experience additional stressors that may lead to burnout and exhaustion. URM students reported not feeling supported in their programs. This study's findings point to the need for leadership and faculty of health professional schools to implement or strengthen current policies, practices, and strategies that support URM students and FGCS. IMPACT: Research demonstrates that a diverse student body and faculty enhances the educational experience for health professional students, and that diversity strengthens the learning environment and improves learning outcomes, preparing students to care for an increasingly diverse population. However, this study finds that students from underrepresented backgrounds may still experience more burnout, exhaustion, discrimination, and stress than their peers. Programs and policies to support URM students and FGCS throughout their academic careers can help improve graduation and retention rates, leading to improved workforce diversity.

A closer look at disparities in earnings between white and minoritized dentists.

OBJECTIVE: To examine the factors that account for differences in dentist earnings between White and minoritized dentists. DATA SOURCES: We used data from the American Dental Association's Survey of dental practice, which includes information on 2001-2018 dentist net income, practice ZIP code, patient mix between private and public insurance, and dentist gender, age, and year of dental school graduation. We merged the data on dentist race and ethnicity and school of graduation from the American Dental Association masterfile. Based on practice ZIP code, we also merged the data on local area racial and ethnic composition from the American Community Survey. STUDY DESIGN: We used a linear Blinder-Oaxaca decomposition to assess observable characteristics that explain the gap in earnings between White and minoritized dentists. To assess differences in earnings between White and minoritized dentists at different points of the income distribution, we used a re-centered influence function and estimated an unconditional quantile Blinder-Oaxaca decomposition. DATA EXTRACTION METHODS: We extracted data for 22,086 dentists ages 25-85 who worked at least 8 weeks per year and 20 hours per week. PRINCIPAL FINDINGS: Observable characteristics accounted for 58% of the earnings gap between White and Asian dentists, 55% of the gap between White and Hispanic dentists, and 31% of the gap between White and Black dentists. The gap in earnings between White and Asian dentists narrowed at higher quantiles of the income distribution. CONCLUSIONS: Compared to other minoritized dentists, Black dentists have the largest earnings disparities relative to White dentists. While the level of the explained component of the disparity for Black dentists is comparable to the explained part of the disparities for other minoritized dentists, the excess percentage of the unexplained component for Black dentists accounts for the additional amount of disparity that Black dentists experienced. Persistent income disparities could discourage minoritized dentists from entering the profession.

Changes in Performance Measures and Service Volume at US Federally Qualified Health Centers During the COVID-19 Pandemic.

Importance: Stay-at-home orders, site closures, staffing shortages, and competing COVID-19 testing and treatment needs all potentially decreased primary care access and quality during the COVID-19 pandemic. These challenges may have especially affected federally qualified health centers (FQHCs), which serve patients with low income nationwide. Objective: To examine changes in FQHCs' quality-of-care measures and visit volumes in 2020 to 2021 vs prepandemic. Design, Setting, and Participants: This cohort study used a census of US FQHCs to calculate changes in outcomes between 2016 and 2021 using generalized estimating equations. Main Outcomes and Measures: Twelve quality-of-care measures and 41 visit types based on diagnoses and services rendered, measured at the FQHC-year level. Results: A total of 1037 FQHCs were included, representing 26.6 million patients (63% 18-64 years old; 56% female) in 2021. Despite upward trajectories for most measures prepandemic, the percentage of patients served by FQHCs receiving recommended care or achieving recommended clinical thresholds showed a statistically significant decrease between 2019 and 2020 for 10 of 12 quality measures. For example, declines were observed for cervical cancer screening (-3.8 percentage points [pp]; 95% CI, -4.3 to -3.2 pp), depression screening (-7.0 pp; 95% CI, -8.0 to -5.9 pp), and blood pressure control in patients with hypertension (-6.5 pp; 95% CI, -7.0 to -6.0 pp). By 2021, only 1 of these 10 measures returned to 2019 levels. From 2019 to 2020, 28 of 41 visit types showed a statistically significant decrease, including immunizations (incidence rate ratio [IRR], 0.76; 95% CI, 0.73-0.78), oral examinations (IRR, 0.61; 95% CI, 0.59-0.63), and supervision of infant or child health (IRR, 0.87; 95% CI, 0.85-0.89); 11 of these 28 visits approximated or exceeded prepandemic rates by 2021, while 17 remained below prepandemic rates. Five visit types increased in 2020, including substance use disorder (IRR, 1.07; 95% CI, 1.02-1.11), depression (IRR, 1.06; 95% CI, 1.03-1.09), and anxiety (IRR, 1.16; 95% CI, 1.14-1.19); all 5 continued to increase in 2021. Conclusions and Relevance: In this cohort study of US FQHCs, nearly all quality measures declined during the first year of the COVID-19 pandemic, with most declines persisting through 2021. Similarly, most visit types declined in 2020; 60% of these remained below prepandemic levels in 2021. By contrast, mental health and substance use visits increased in both years. The pandemic led to forgone care and likely exacerbated behavioral health needs. As such, FQHCs need sustained federal funding to expand service capacity, staffing, and patient outreach. Quality reporting and value-based care models must also adapt to the pandemic's influence on quality measures.

Dual impacts of Medicare payment reform and the COVID-19 pandemic on therapy staffing in skilled nursing facilities.

BACKGROUND: Implementation of new skilled nursing facility (SNF) Medicare payment policy, the Patient Driven Payment Model (PDPM), resulted in immediate declines in physical and occupational therapy staffing. This study characterizes continuing impacts of PDPM in conjunction with COVID-19 on SNF therapy staffing and examines variability in staffing changes based on SNF organizational characteristics. METHODS: We analyzed Medicare administrative data from a national cohort of SNFs between January 2019 and March 2022. Interrupted time series mixed effects regression examined changes in level and trend of total therapy staffing minutes/patient-day during PDPM and COVID-19 and by type of staff (therapists, assistants, contractors, and in-house staff). Secondary analyses examined the variability in staffing by organizational characteristics. RESULTS: PDPM resulted in a -6.54% level change in total therapy staffing, with larger declines for assistants and contractors. Per-patient staffing fluctuated during COVID-19 as the census changed. PDPM-related staffing declines were larger in SNFs that were: Rural, for-profit, chain-affiliated, provided more intensive therapy, employed more therapy assistants, and admitted more Medicare patients before PDPM. COVID-19 resulted in larger staffing declines in rural SNFs but smaller early declines in SNFs that were hospital-based, for-profit, or received more relief funding. CONCLUSIONS: SNFs that historically engaged in profit-maximizing behaviors (e.g., providing more therapy via lower-paid assistants) had larger staffing declines during PDPM compared to other SNFs. Therapy staffing fluctuated during COVID-19, but PDPM-related reductions persisted 2 years into the pandemic, especially in rural SNFs. Results suggest specific organizational characteristics that should be targeted for staffing and quality improvement initiatives.