Nurse Staffing and Quality

in Rural Nursing Homes

Peiyin Hung, MSPH, Michelle Casey, MS, Ira Moscovice, PhD

NRHA Annual Meeting | May 2013

Supported by the Office of Rural Health Policy, Health Resources and Services

Administration, PHS Grant No. U1CRH03717

Motivation for Study

• Rural and urban nursing homes are different

• Hospital-based and freestanding nursing

homes are different

• Previous studies have mixed conclusions

• Paucity of research with rural context

Study Objective

• What is the relationship between nurse

staffing levels and care quality in rural

nursing homes?

Methods: Data

• 2011 Nursing Home Compare Data

– Staffing and facility characteristics

– Quality indicators

• Minimum Dataset

– Resource Utilization Group Case Mix index for all residents

admitted to a facility

• 4,825 rural nursing homes in our sample

– 485 hospital-based (10%)

– 4,340 freestanding (90%)

Outcome Measures

• Individual quality indicators

• Composite quality indicators

• Health / Complaint inspections

Outcome Measures I

Individual Quality Indicators

Long-stay Short-stay

Pain Pain

Pressure Sores Pressure sores

Decline of Activities of Daily

Living (ADL)

Physical Restraints

Catheter

Mobility

Urinary Tract Infections

Outcome Measures II and III

Composite Quality

Scores

Average of long-stay measures

(reporting 3 or more measures)

Average of short-stay measures

(reporting any measure)

Health / Complaint

Inspections

Total deficiencies

Total actual harms

Total minimal or potentially-actual harms

Weighted total harms

Statistical Methods

• Multivariate, ordinary least-squares models

– Long-stay and short-stay quality measures

– Weighted total harms

• Negative binomial-regression models

– Health/complaint inspections

Methods: Explanatory Variables

Primary Nurse Staffing Levels

Nursing Home Structure

Secondary / Other Facility Operational Characteristics

Facility Structure Characteristics

State Fixed Effects

Limitations

• Cross-sectional study design limits the ability to

draw causal conclusions on relationships between

staffing and quality.

• Lack of individual resident-level data.

1.260.92

2.74

0.63 0.77

2.43

RN-levels LPN-levels CNA-levels

Hospital-based Freestanding

95% standard error of the mean

Nurse Hours per Resident Day

95% standard error of the mean

% of Long-Stay Residents with Outcome Measures

8.1

14.7

4.2

9.1

1.7

6.1

12.4

9.08.1

15.1

3.5

9.6

2.6

5.4

11.3

9.0

Long-stay

composite

scores

ADL

Decline

Pain Pressure

Sores

Physical

Restraints

Catheter Mobility

Decline

Urinary

Tract

Infection

Hospital-based Freestanding

24.1

2.0

21.5

27.2

2.1

24.5

Total deficiencies Total actual harms Total minimal harms or

potentially actual harms

Hospital-based Freestanding

95% standard error of the mean

Health / Complaint Inspections

Results: Quality Outcome Measures(Higher is better) RN-levels LPN-levels CNA-levels

Hospital-Based

(vs. Freestanding)

Long-stay composite scores − −*** − −***

ADL Decline − −*** − +Pain −** −*** −Pressure Sores −* −** −* −**

Physical Restraints + + +**

Catheter −* −* + −***

Mobility Decline − −* − −Urinary Tract Infection − −*** − −

Short-stay composite scores −*** −*** + −***

Pain −*** −*** + −**

Pressure Sores − −** + −***

*p<0.05 **p<0.01 ***p<0.001

Results: Health/Complaint

Inspections

*p<0.05 **p<0.01 ***p<0.001

(Higher is worse) RN-levels LPN-levelsCNA-

levels

Hospital-Based

(vs. Freestanding)

Total deficiencies −*** −*** − +*

Total actual harms −*** −*** + +*

Total minimal harms or

potentially actual harms−*** + −* +*

Weighted total harms −*** −*** − +*

How Stratified Results Differ

• In hospital-based nursing homes:

– One unit RN-level is correlated with 3% less ADL

decline prevalence rate and 4.7 fewer

deficiencies.

– RN-levels show no associations with other

outcome measures.

How Stratified Results Differ

• In freestanding nursing homes:

– RN-levels and LPN-levels are correlated with

lower quality outcome scores.

– More CNA-levels are correlated with less

pressure sores.

– One unit increase of RN-levels is associated with

4 fewer deficiencies.

Summary

• Relationships between staffing and quality in

rural nursing homes vary by hospital-affiliation

and quality measures.

• Nurse staffing in rural nursing homes correlates

with lower quality in many measures.

Summary (cont.)

• Nurse staffing levels were associated with fewer

deficiencies in both rural hospital-based and

freestanding nursing homes.

• RN-staffing levels in rural hospital-based

facilities had stronger relationships with quality

than in freestanding facilities.

Peiyin Hung

612-623-8317

hungx068@umn.edu

http://www.hsr.umn.edu/rhrc/