key: cord-1028487-gkppsd8i
authors: Xu, Huiwen; Intrator, Orna; Bowblis, John R.
title: Shortages of Staff in Nursing Homes During COVID-19 Pandemic: What Are the Driving Factors?
date: 2020-08-11
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.08.002
sha: cc0186cc17d32fe503759020287c052f2933cff5
doc_id: 1028487
cord_uid: gkppsd8i

Abstract (300 words) Objectives During the COVID-19 pandemic, U.S. nursing homes (NHs) have been under pressure to maintain staff levels with limited access to personal protection equipment (PPE). This study examines the prevalence and factors associated with shortages of NH staff during COVID-19 pandemic. Design We obtained self-reported information on staff shortages, resident and staff exposure to COVID-19, and PPE availability from a survey conducted by the Centers for Medicare & Medicaid Services in May 2020. Multivariate logistic regressions of staff shortages with state fixed-effects were conducted to examine the effect of COVID-19 factors in NHs. Setting and participants 11,920 free-standing NHs. Measures The dependent variables were self-reported shortages of licensed nurse staff, nurse aides, clinical staff, and other ancillary staff. We controlled for NH characteristics from the most recent Nursing Home Compare and Certification And Survey Provider Enhanced Reporting, market characteristics from Area Health Resources File, and state Medicaid reimbursement calculated from Truven data. Results Of the 11,920 NHs, 15.9%, 18.4%, 2.5%, and 9.8% reported shortages of licensed nurse staff, nurse aides, clinical staff, and other staff, respectively. Georgia and Minnesota reported the highest rates of shortages in licensed nurse and nurse aides (both > 25%). Multivariate regressions suggest that shortages in licensed nurses and nurse aides were more likely in NHs having any resident with COVID-19 (adjusted odds ratio (AOR) = 1.44, 1.60, respectively) and any staff with COVID-19 (AOR = 1.37, 1.34, respectively). Having one-week supply of PPE was associated with lower probability of staff shortages. NHs with a higher proportion of Medicare residents were less likely to experience shortages. Conclusions /Implications: Abundant staff shortages were reported by NHs and were mainly driven by COVID-19 factors. In the absence of appropriate staff, NHs may be unable to fulfill the requirement of infection control even under the risk of increased monetary penalties.

The epicenter of the COVID-19 pandemic in the United States (U.S.) has been in long-term care 45 facilities, particular nursing homes (NHs) . 1 The first COVID-19 case in a NH was confirmed in a 46 Kirkland, Washington facility on February 28, 2020. 2 Since then, the Center for Medicare and Medicaid Services (CMS) reported 107,389 confirmed cases and 71,278 suspected cases of 48 COVID-19 among residents based on self-reported data by NHs released in June 20, 2020. 3 NH 49 residents are extremely vulnerable to COVID-19 because they are older, functionally impaired, 50 and have multiple comorbidities 1, 4 This frail population thus bore over 27.5% of all confirmed 51 cases resulting in death. 3 In fact, a New York Times analysis claims that NH residents and 52 workers accounted for one third of COVID-19 death in the U.S. 5 53 A critical aspect of NH care is staff. [6] [7] [8] [9] [10] Prior to the pandemic, NH staff was the single 54 largest cost to operating a NH. 11 NHs must staff positions to provide direct care to residents 55 but also ancillary services, such as housekeeping and food service. Examples of staffing 56 categories include: licensed nurses [i.e. registered nurses (RNs) and licensed practical nurses 57 (LPNs)], nurse aides that assist licensed nurses and provide direct care to residents [certified 58 nurse aides (CNAs)], clinical staff (i.e. physicians and other advanced practice providers), and 59 other ancillary staff (e.g. recreation and food services). 12 Research suggests that NHs with 60 higher staffing levels tend to provide better quality of care, 4, 6-10, 12-16 but low wages, less-61 desirable work environments compared to alternatives have made it difficult for NHs to hire 62 and retain staff. 10, [17] [18] [19] Reliance on government payment models, such as Medicaid which 63 J o u r n a l P r e -p r o o f reimburses at or below actual costs, 20 further limits NHs' ability to increase wages or offer other 64 benefits to hire and retain staff. 65 These structural challenges have only become worse for NHs during the coronavirus 66 pandemic. 21 Covariates associated with potential shortages included COVID-19 factors, NH and 124 market characteristics, and state policy relating to NHs. 4, 9, 15, 32, 33 COVID-19 factors included 125 the cumulative number of residents and staff diagnosed with COVID-19 per 100 beds. We 126 scaled the number of cases to 100 beds to account for differences in facility size. PPE has been 127 shown to be very critical in preventing the transmission of COVID-19. We included three binary variables indicating whether a NH had one-week supply of N95 masks, eye protection, and 129 gowns. 130 We used CASPER data to extract NH characteristics that might be associated with 131 staffing shortages: staffing levels (RNs, LPNs, and CNAs measured in hours per resident day 132 (HPRD)), NH structure (ownership, chain status, total beds, occupancy rate, and dementia 133 special care unit), resident case-mix and payer-mix (case-mix acuity index, % Medicaid residents, 

Descriptive results by whether NHs had any staff with COVID-19 are presented in Table   166 1. Of the 11,920 NH sample, 15.9%, 18.4%, 2.5%, and 9.8% reported shortages of licensed 167 nursing staff, nurse aides, clinical staff, and other staff, respectively. On average, 5.7 (standard 168 deviation (SD) = 30.2) residents and 3.8 (SD = 18.9) staff per 100 beds were confirmed with 169 COVID-19; 82.2%, 89.8%, and 79.6% NHs had one-week supply of N95 masks, eye protection, 170 and gowns, respectively. The majority of NHs were for-profit (71.8%), chain-affiliated (60.6%), 171 with most residents paid by Medicaid (59.4%), and located in urban areas (66.3%). About one half (46.3%) NHs had overall five-star rating ≥4. The average % Medicare Advantage 173 penetration was 31.6% and state on average reimbursed NHs $179.7 per resident day. Table 1 174 also suggests that almost all predictors were significantly different in NHs having any staff with 175 vs without COVID-19, except for one-week supply of gowns, CNA staffing level, and overall five-176 star rating (all P ≤ 0.01). NHs having any staff with COVID-19 were more likely to experience 177 shortages of licensed nurse, nurse aides, clinical staff, and other staff. week and many respond through phone or video calls. 233 NHs that took care of more post-acute, Medicare paid residents, were less likely to have 234 shortages in clinical staff, as did non-profit NHs. A reason for this may be states putting 235 temporary bans on elective surgeries, which led to reduced Medicare post-acute care stays. 236 While previous work suggests that COVID-19 cases were higher in urban areas, 7 we found no 237 J o u r n a l P r e -p r o o f difference in reported staff shortages in rural versus urban NHs. The lack of available workforce 238 in rural market prior to pandemic makes rural NHs more vulnerable to COVID-19, even they 239 were less likely to have staff with COVID-19 compared to urban NHs (21.8% vs 5.5%). 40 were less likely to suffer staff shortages. Securing the financial health of NHs that allow them to 254 address these staff shortages needs to be a priority which might help NHs assure that fewer 255 residents are exposed to While our study highlights staffing shortages in the NHs, we acknowledge several 257 limitations. Our findings may not be generalizable to all NHs, as 20% NHs did not pass CMS' J o u r n a l P r e -p r o o f 

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Rural 2,300 (19.4%) 368 (8.3%) 1,932 (26.0%) Overall Five-star

Note: RN= Registered Nurse, LPN= Licensed practical nurse, HPRD= hour per resident day, MD=physician, NP= Nurse Practitioner, PA=Physician Assistant, CNA =certified nursing assistant, Micropolitan= Large Rural City/Town, Rural= Small Rural Town/ Isolated Small Rural Town

+ P values measures whether nursing homes of staff with vs without COVID-19 had the same characteristics using t-tests for continuous variables, and Chi-square tests for binary variables

ǂ Nurse aides included the certified nursing assistant, nurse aide, medication aide, and medication technician. Data sources included the COVID-19 Nursing Home Dataset for COVID-19 related information, Nursing Home Compare Data

Consulting, which provides consulting services to long-term care providers. None of the material discussed in this paper are directly related to these services.

J o u r n a l P r e -p r o o f 

Notes: + Licensed nurse staff included the registered nurse, licensed practical nurse, and vocational nurse as reported by the provider; ǂ