Staffing Levels and COVID-19 Infections and Deaths in Korean Nursing Homes.

The novel coronavirus disease 2019 (COVID-19) spread rapidly worldwide. Nursing home (NH) residents are the most vulnerable high-risk population to infection. Professional registered nurses' (RNs') infection control is irreplaceable. We used a secondary data analysis method using the government's senior citizen welfare department large data set about all NHs (N = 3,389) across Korea between January 20 and October 20, 2020. Bed size positively associated with the mortality rate (No. of COVID-19 resident deaths / No. of total residents) (p = .048). When the proportion of RNs to total nursing staff was higher, the infection rate was 0.626% lower (p = .049), the mortality rate was 0.088% lower (p = .076), the proportion of confirmed COVID-19 cases per resident out of the total number of NHs was 44.472% lower (p = .041), and the proportion of confirmed COVID-19 deaths per resident out of the total number of NHs was 6.456% lower (p = .055). This study highlighted nurse staffing criteria and suggests that increasing RNs in NHs will reduce infection and mortality rates during the COVID-19 pandemic. We strongly suggest NHs hire at least one RN per day to properly function, and a minimum of four RNs to provide a fully competent RN workforce in long-term care settings in Korean NHs.

Expert nurse response to workforce recommendations made by The Coronavirus Commission For Safety And Quality In Nursing Homes.

COVID-19 has exposed the longstanding internal problems in nursing homes and the weak structures and policies that are meant to protect residents. The Centers for Medicare and Medicaid Services convened the Coronavirus Commission for Safety and Quality in NHs in April, 2020 to address this situation by recommending steps to improve infection prevention and control, safety procedures, and the quality of life of residents in nursing homes. The authors of this paper respond to the Final Report of the Commission and put forth additional recommendations to federal policymakers for meaningful nursing home reform: 1) ensuring 24/7 registered nurse (RN) coverage and adequate compensation to maintain total staffing levels that are based on residents' care needs; 2) ensuring RNs have geriatric nursing and leadership competencies; 3) increasing efforts to recruit and retain the NH workforce, particularly RNs; and 4) supporting care delivery models that strengthen the role of the RN for quality resident-centered care.

Nurse Staffing and Coronavirus Infections in California Nursing Homes.

In the United States, 1.4 million nursing home residents have been severely impacted by the COVID-19 pandemic with at least 25,923 resident and 449 staff deaths reported from the virus by June 1, 2020. The majority of residents have chronic illnesses and conditions and are vulnerable to infections and many share rooms and have congregate meals. There was evidence of inadequate registered nurse (RN) staffing levels and infection control procedures in many nursing homes prior to the outbreak of the virus. The aim of this study was to examine the relationship of nurse staffing in California nursing homes and compare homes with and without COVID-19 residents. Study data were from both the California and Los Angeles Departments of Public Health and as well as news organizations on nursing homes reporting COVID-19 infections between March and May 4, 2020. Results indicate that nursing homes with total RN staffing levels under the recommended minimum standard (0.75 hours per resident day) had a two times greater probability of having COVID-19 resident infections. Nursing homes with lower Medicare five-star ratings on total nurse and RN staffing levels (adjusted for acuity), higher total health deficiencies, and more beds had a higher probability of having COVID-19 residents. Nursing homes with low RN and total staffing levels appear to leave residents vulnerable to COVID-19 infections. Establishing minimum staffing standards at the federal and state levels could prevent this in the future.

Racial and Ethnic Differences in the Prevalence of Depressive Symptoms Among U.S. Nursing Home Residents.

This study aimed to examine racial and ethnic differences in significant depressive symptoms among long-term nursing home residents. We analyzed the 2014 national Minimum Data Set linked to a nursing home file and estimated multivariable logistic regressions to determine the associations of race and ethnicities with significant depressive symptoms (score ≥ 10 on the 9-item Patient Health Questionnaire [PHQ-9] scale) and whether associations were explained by resident and nursing home covariates. Stratified analyses further determined independent associations in subgroups of residents. We found that the prevalence rate of PHQ-9 scores ≥ 10 was 8.8% among non-Hispanic White residents (n = 653,031) and 7.4%, 6.9%, and 6.6% among Black (n = 97,629), Hispanic (n = 39,752), and Asian (n = 16,636) residents, respectively. The reduced likelihoods of significant depressive symptoms for minority residents compared to non-Hispanic Whites persisted after sequential adjustments for resident and nursing home covariates, as well as in stratified analyses. The persistently lower rate of significant depressive symptoms among racial and ethnic minority residents suggests that training of nursing home caregivers for culturally sensitive depression screening is needed for improved symptom recognition among minority residents.

Failure to Meet Nurse Staffing Standards: A Litigation Case Study of a Large US Nursing Home Chain.

Large for-profit nursing home chains in the United States have generally reported low nurse staffing levels. This historical case study examined a class action litigation case regarding staffing levels, resident rights, and quality outcomes in 12 Arkansas nursing homes owned by a large for-profit chain. The questions were as follows: (1) How did the residents' care needs compare with actual nurse staffing levels? (2) How did the staffing levels compare with federal and state nurse staffing requirements and professional staffing standards? (3) Did the facilities comply with state and federal residents' rights and quality of care requirements? The findings showed staffing levels marginally above state minimum standards, staffing shortages that violated state standards, staffing levels not adjusted for resident acuity, and shortages that resulted in omitted care. Staffing levels were lower than needed according to nursing directors, lower than average facilities in the state, and lower than professional standards. The findings showed many resident grievances regarding basic care and residents' rights, clinical measures of poor quality, and state deficiencies. A large settlement was agreed on to compensate the residents. The case shows that chain's management, as well as the regulatory system, failed to ensure adequate staffing levels that took into account regulatory requirements and professional standards and resulted in violations of residents' rights, health, safety, and well-being.

Assessing the Quality of Nursing Homes in Managed Care Organizations: Integrating LTSS for Dually Eligible Beneficiaries.

Little is known about the quality of nursing homes in managed care organizations (MCOs) networks. This study (1) described decision-making criteria for selecting nursing home networks and (2) compared selected quality indicators of network and nonnetwork nursing homes. The sample was 17 MCOs participating in a California demonstration that provided integrated long-term services and supports to dually eligible enrollees in 2017. The findings showed that the MCOs established a broad network of nursing homes, with only limited attention to using quality criteria. Network nursing homes (602) scored significantly lower on 6 selected quality measures than nonnetwork (117) nursing homes. Low registered nurse and total nurse staffing were strong predictors of network nursing homes controlling for facility characteristics. Managed care organizations should consider greater transparency about the quality of their nursing homes and use specific quality criteria to improve the quality of their networks.

Predictors of Nursing Facility Entry by Medicaid-Only Older Adults and Persons With Disabilities in California.

Nearly one-third of adult Medicaid beneficiaries who receive long-term services and supports (LTSS) consist of older adults and persons with disabilities who are not eligible for Medicare. Beneficiaries, advocates, and policymakers have all sought to shift LTSS to home and community settings as an alternative to institutional care. We conducted a retrospective cohort study of Medicaid-only adults in California with new use of LTSS in 2006-2007 (N = 31 849) to identify unique predictors of entering nursing facilities versus receiving Medicaid home and community-based services (HCBS). Among new users, 18.3% entered into nursing facilities, whereas 81.7% initiated HCBS. In addition to chronic conditions, functional and cognitive limitations, substance abuse disorders (odds ratio [OR] 1.35; 95% confidence interval [CI]: 1.23, 1.48), and homelessness (OR: 4.35, 9% CI: 3.72, 5.08) were associated with higher odds of nursing facility entry. For older adults and persons with disabilities covered by Medicaid only, integration with housing and behavioral health services may be key to enabling beneficiaries to receive LTSS in noninstitutional settings.

Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When Is There Enough Evidence for Policy Change?

Margaret McGregor and colleagues consider Bradford Hill's framework for examining causation in observational research for the association between nursing home care quality and for-profit ownership.

Health Care Expenditures After Initiating Long-term Services and Supports in the Community Versus in a Nursing Facility.

BACKGROUND: Individuals who receive long-term services and supports (LTSS) are among the most costly participants in the Medicare and Medicaid programs. OBJECTIVES: To compare health care expenditures among users of Medicaid home and community-based services (HCBS) versus those using extended nursing facility care. RESEARCH DESIGN: Retrospective cohort analysis of California dually eligible adult Medicaid and Medicare beneficiaries who initiated Medicaid LTSS, identified as HCBS or extended nursing facility care, in 2006 or 2007. SUBJECTS: Propensity score matching for demographic, health, and functional characteristics resulted in a subsample of 34,660 users who initiated Medicaid HCBS versus extended nursing facility use. Those with developmental disabilities or in managed care plans were excluded. MEASURES: Average monthly adjusted acute, postacute, long-term, and total Medicare and Medicaid expenditures for the 12 months following initiation of either HCBS or extended nursing facility care. RESULTS: Those initiating extended nursing facility care had, on average, $2919 higher adjusted total health care expenditures per month compared with those who initiated HCBS. The difference was primarily attributable to spending on LTSS $2855. On average, the monthly LTSS expenditures were higher for Medicare $1501 and for Medicaid $1344 when LTSS was provided in a nursing facility rather than in the community. CONCLUSIONS: The higher cost of delivering LTSS in a nursing facility rather than in the community was not offset by lower acute and postacute spending. Medicare and Medicaid contribute similar amounts to the LTSS cost difference and both could benefit financially by redirecting care from institutions to the community.

Hidden Owners, Hidden Profits, and Poor Nursing Home Care: A Case Study.

The study examined the ownership transparency, financial accountability, and quality indicators of a regional for-profit nursing home chain in California, using a case study methodology to analyze data on the chain's ownership and management structure, financial data, staffing levels, deficiencies and complaints, and litigation. Secondary data were obtained from regulatory and cost reports and litigation cases. Qualitative descriptions of ownership and management were presented and quantitative analyses were conducted by comparing financial and quality indicators with other California for-profit chains, for-profit non-chains, and nonprofit nursing home groups in 2011. The chain's complex, interlocking individual and corporate owners and property companies obscured its ownership structure and financial arrangements. Nursing and support services expenditures were lower than nonprofits and administrative costs were higher than for-profit non-chains. The chain's nurse staffing was lower than expected staffing levels; its deficiencies and citations were higher than in nonprofits; and a number of lawsuits resulted in bankruptcy. Profits were hidden in the chain's management fees, lease agreements, interest payments to owners, and purchases from related-party companies. Greater ownership transparency and financial accountability requirements are needed to ensure regulatory oversight and quality of care.

Comparing the nurse staffing in Korean and U.S. nursing homes.

INTRODUCTION: The quality of nursing home care has been problematic in both the United States and South Korea; quality is limited to inadequate nurse staffing levels. This article addresses how South Korean nursing home education and training requirements, nurse staffing standards, and actual nurse staffing levels compare with those in the United States. METHODS: The study used secondary documents and data to compare the two countries. RESULTS: Korea has lower registered nurse and certified nursing assistant standards and actual staffing levels than the United States. In contrast, staffing standards and actual staffing levels for care workers who provide direct care to residents are higher in Korea than in the United States. CONCLUSIONS: Research is needed in Korea to establish an empirical basis for educational requirements, staffing standards, and staffing levels in nursing homes.

Medicaid home and community-based services: how consumer access is restricted by state policies.

State Medicaid programs have expanded home and community-based services (HCBS). This article compares trends and variations in state policies for Medicaid HCBS programs in 2005 and 2010. State limitations on financial eligibility criteria and service benefits have remained stable. Although the use of consumer direction, independent providers, and family care providers has increased, some states do not have these options. The increased adoption of state cost control policies have led to large increases in persons on waiver wait lists. Access could be improved by standardizing and liberalizing state HCBS policies, but state fiscal concerns are barriers to rebalancing between HCBS and institutional services.

The effects of regulation and litigation on a large for-profit nursing home chain.

This article examines the effects of state regulation and civil class action litigation on corporate compliance with nurse staffing and quality standards, corporate strategies to manage staffing and quality, and corporate financial status of a large for-profit nursing home chain. A historical case study was used to examine multiple public data sources, focusing on facilities in California from 2003 to 2011 during and after regulatory actions and litigation. The results showed that the state issued numerous deficiencies for violations of the nurse staffing and quality standards with minimal impact on quality compliance with state law. A class action jury trial found that the chain violated the state's minimum staffing standard on one-third of the total days during a six-year period and awarded a $677 million verdict. A court settlement and supervised injunction resulted in compliance with minimum staffing and some improvement in quality measures, but quality levels remained below the average California facilities. The litigation also had some negative financial impact on Skilled Healthcare Group's California facilities and parent company. Civil litigation had more impact on the chain than the regulatory oversight.

The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations.

BACKGROUND: Little is known about the relationship of cognitive impairment (CI) in nursing home (NH) residents and their use of emergency department (ED) and subsequent hospital services. METHODS: We analyzed 2006 Medicare claims and resident assessment data for 112,412 Medicare beneficiaries aged >65 years residing in US nursing facilities. We estimated the effect of resident characteristics and severity of CI on rates of total ED visits per year, then estimated the odds of hospitalization after ED evaluation. RESULTS: Mild CI predicted higher rates of ED visits relative to no CI, and ED visit rates decreased as severity of CI increased. In unadjusted models, mild CI and very severe CI predicted higher odds of hospitalization after ED evaluation; however, after adjusting for other factors, severity of CI was not significant. CONCLUSIONS: Higher rates of ED visits among those with mild CI may represent a unique marker in the presentation of acute illness and warrant further investigation.

United States' Nursing Home Finances: Spending, Profitability, and Capital Structure.

Little is known about nursing home (NH) financial status in the United States even though most NH care is publicly funded. To address this gap, this descriptive study used 2019 Medicare cost reports to examine NH revenues, expenditures, net income, related-party expenses, expense categories, and capital structure. After a cleaning process for all free-standing NHs, a study population of 11,752 NHs was examined. NHs had total net revenues of US$126 billion and a profit of US$730 million (0.58%) in 2019. When US$6.4 billion in disallowed costs and US$3.9 billion in non-cash depreciation expenses were excluded, the profit margin was 8.84 percent. About 77 percent of NHs reported US$11 billion in payments to related-party organizations (9.54% of net revenues). Overall spending for direct care was 66 percent of net revenues, including 27 percent on nursing, in contrast to 34 percent spent on administration, capital, other, and profits. Finally, NHs had long-term debts that outweighed their total available financing. The study shows the value of analyzing cost reports. It indicates the need to ensure greater accuracy and completeness of cost reports, financial transparency, and accountability for government funding, with implications for policy changes to improve rate setting and spending limits.