Introducing the CALTCM White Paper on Nursing Home Staffing

“Now is not the time for additional ‘studies’ to assess the importance of appropriate staffing levels. The combination of inadequate staffing and disparities can only lead to more tragic situations and outcomes, such as those recently seen during the latest hurricane in Louisiana.”  Thus begins CALTCM’s “White Paper on Nursing Home Staffing.”  CALTCM is the medical voice for long term care in California.  Our public policy committee developed this White Paper with the intention of making recommendations based on evidence-based literature.  It was not our intention to debate the financial impact of our recommendations or where nursing staff will come from, given the current huge workforce shortage issues.  We stand for quality care in nursing homes. We absolutely understand many of the issues that have put nursing home care in the precarious state that the COVID-19 pandemic has tragically highlighted. Those issues need to be debated and those problems addressed, but that does not change the existing evidence.  Our White Paper presents the evidence. We’re ready and willing to have a debate over the evidence, though we think it’s more important to have a vigorous discussion on how to finance these recommendations and find the nurses and nursing assistants needed to fulfill these requirements. 

California’s nursing home residents have faced an ongoing humanitarian crisis during the COVID-19 pandemic. Nursing home residents constitute less than one percent of the population but account for a wildly disproportionate percent of California deaths from COVID-19.  They are also human beings who deserve to be treated with respect and dignity.  Surely no reasonable person could seriously dispute that.  

The pandemic has profoundly confirmed and reinforced the previous evidence-based literature on the impacts of inadequate staffing. A University of California, San Francisco (UCSF) study in May 2020 showed nursing homes with Registered Nurse (RN) staffing under 0.75 RN hours per resident day (hprd) were twice as likely to have residents with COVID infections. A subsequent 2020 study by Cal Hospital Compare and UCSF found that higher total nurse staffing hours were associated with a halving of nursing home residents’ COVID infection rates, and that facilities in California with higher RN staffing were associated with COVID death rates half of those in facilities with lower RN staffing. Studies in other states have also confirmed that higher RN staffing levels were associated with fewer COVID-19 outbreaks and deaths.  

These were our recommendations:

  1. All nursing homes provide nurse staffing at a minimum level of a total of 4.1 hprd, with an RN hprd of 0.75, LVN hprd of 0.55 and CNA hprd of 2.8. 
  2. Ensure that wages for licensed nursing personnel are comparable to those of hospital wages in the geographical area. 
  3. Ensure that CNA wages are comparable to the wages for other entry-level positions within the geographical area. 
  4. Before requesting staffing waivers for CNA shortages, ensure that the facility is offering wages at least $3/hour above the minimum wage for competing entry-level positions and that wages offered are comparable to those for nursing assistants in hospitals in the geographical area.
  5. Examine the workload for staff and ensure that the facility is meeting the recommended staffing standards.
  6. Add CNA turnover as a reportable QASP metric in California.
  7. Ensure that nursing homes adjust staffing levels to meet the acuity needs of residents.   

We closed our White Paper with the following conclusion: “The Director of Nursing and Director of Staff Development, in collaboration with an engaged, knowledgeable, and competent medical director, should determine appropriate acuity-based staffing levels in nursing homes. The evidence-based literature supports minimum staffing levels with limited exceptions, even in predominantly custodial nursing homes, due to the medical complexity of today’s residents.  The exceptions should not drive staffing policy, nor should the challenging workforce shortage issues that we are facing.  Policy should be based first and foremost on providing the quality care our residents deserve.  Questions about the financing of appropriate staffing levels must be addressed in the context of full transparency. Workforce shortages cannot be a blanket excuse for allowing poor quality of care.  The COVID-19 pandemic has tragically demonstrated this fact.”  

You may hear critiques of the studies we referenced.  Ask for specifics. We’re more than happy to have an open debate on this important topic. We understand that there’s always value in more studies to further clarify and focus our precise definitions of minimum staffing levels. Unfortunately, nursing home residents, and the quality care they deserve, cannot wait for such studies. Let’s immediately start discussing how we can bring our recommendations to fruition. The time for action is now.

Read CALTCM's White Paper on Nursing Home Staffing
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