Despite diligent efforts by nursing homes during COVID-19 outbreaks, operators need help from lawmakers to ensure better levels of care during future infection control emergencies, the researchers say.
Staffing levels may actually seem higher than normal during COVID outbreaks, but that belies increasingly intense staff time needs, as well as the fact that worker levels typically don’t pick up after COVID outbreaks. an outbreak, a veteran academic team of nursing home researchers discovered.
As a result, policymakers should consider steps like creating centralized “strike” teams to provide temporary staff assistance, as some states have done, and other measures to help get providers up and running when a crisis strikes.
The research is also an indicator of an “altered landscape” for elderly care, said researcher Brian McGarry, PT, PhD, a professor in the Division of Geriatrics and Aging in the Department of Medicine at the University of Rochester Medical Center. The report was published on Friday by the web JAMA Health Forum.
“[The study] it’s a big deal because it really adds some context and tells a different side of the story about the impacts of the COVID pandemic on nursing homes,” he said. by McKnight. “We know a lot about how the pandemic has affected residents. We know much less about how it has affected the staff who have worked there.”
McGarry said the research illustrated that even when nursing homes used an “all hands on deck” approach to cover the absences of sick or resigned staff members during an outbreak, it was often not enough.
Staffing levels remained 5.5% below pre-outbreak levels 16 weeks after an outbreak occurred, revealing chronic leaky bucket syndrome. CNA losses were the highest and the hardest to recover.
the cohort study examined the worst 10% of COVID-19 outbreaks (nearly 3,000) that occurred in US nursing homes during the last half of 2020, before vaccines were available. Data used included weekly federal staff counts, absences/departures, new hires, contracted staff hours, staffing shortages, and resident deaths.
When the outbreaks peaked, around four weeks after they started, staff working hours were 2.6% below average pre-outbreak levels. That number more than doubled four months after the initial outbreak, as overtime returned to normal levels around week nine, contract staffing fell sharply in week 10, and the effect of permanent departures fully took hold. .
“An operator could use some of this data to make the case that they might need help maintaining a safe level of staffing for their residents, especially when we know it may be more difficult to serve residents, given all the infection control. things you should do,” said study leader Karen Shen, of the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health.
The long-term problem must be addressed
He noted that because resident counts typically decreased faster than staff counts during an outbreak, staff hours per resident might actually appear to increase during an outbreak. But the added stress and complexity of care needed, coupled with the shockingly high number of staff permanently leaving the industry, point to a long-term deficit for operators, she explained.
“One of the scary things that we find is that staff leave the industry permanently during these outbreaks,” he said. by McKnight Friday. “They just say, ‘No, thanks. I’ve finished.’ Any support a facility may receive is probably well deserved and much needed.
“We were surprised that it was [permanent] departures and no absences [due to quarantine or sickness] that was the biggest problem. We were surprised that staff didn’t really come back after the outbreak subsided.”
The researchers also expressed surprise that while both RNs and aides can leave during the beginning of an outbreak, it was much easier to rehire RNs to pre-outbreak levels. The data indicates that more resources need to be devoted to hiring CNAs, the researchers said.
The results also show that facilities themselves need to better prepare for outbreaks and their aftermath because apparent early success with an outbreak is not necessarily an indicator of long-term health, Shen added. The researchers found that increased attempts to hire new employees, ask existing staff to work more overtime, and increase agency staff hours were often not enough.
“There is probably a need for short-term emergency staffing solutions that can go beyond individual facilities,” Shen said, pointing to states that sent temporary “strike team” staffing help as a good example. The American Rescue Plan Act of 2021 provided temporary funding for such teams.
“I also think there are long-term lessons, in trying to create a stronger long-term staffing structure that can withstand some of these shocks a little better,” Shen added. “So that might look like investing more in staff, offering better pay and benefits, more PPE, etc. Punctual staff will be important.”
Federal, state required
Federal and state leadership will be important, the study authors concluded.
“Policymakers could also consider extensive investment in nursing home workers through better wages and benefits, such as increasing Medicaid reimbursements along with wage pass-through requirements,” they wrote. Additionally, they feel that policymakers should ask whether traditional staffing measures accurately capture the adequacy of staffing levels during a pandemic.
“The nature of care for nursing home residents has completely changed as a result of the pandemic,” McGarry believes. “Our sense is that the number of staff hours needed per president has increased a lot, relative to what it was before the pandemic. A lot of that has to do with cohort preferences and working with 1-on-1 patients.”
More complex infection control steps, including full donning and doffing of PPE, as well as dining room attendants no longer being able to work with three or four patients at a time, are examples of how workflows have been altered. , I note.
“A key takeaway from this is that staffing ratios themselves are inherently flawed, particularly when there are large changes in the resident population. The ratios are not a good measure of the needs of residents during the pandemic. I think the nature of work has changed, so it’s not an apples to apples comparison,” she added. “But that’s a really nuanced point and it’s hard to make. I’m sure if there are groups that want to use those staffing ratios to make a point, they will continue to do so.”
Staffing rates in question
He said that because residents’ needs and methods of addressing them change over time, staffing ratios don’t work as a benchmark. She asked for case mix adjustments, which CMS currently does to its five-star Care Compare scores.
“This shows that those adjusters, those measures of how long those residents need, can vary over time,” McGarry explained. “Those adjustments are based on some pretty outdated time use surveys where someone went to the nursing home and looked at caring for a group of different residents with different needs and came up with these estimates. That number has probably changed over time and I think it has absolutely changed before and after the pandemic. In the midst of a generational global pandemic, you need a different set of minimum standards than you do before the pandemic or in “normal” times.
He said the latest research also speaks to the challenges of setting a minimum staffing ratio, like CMS is trying to do by spring.
“Before COVID, I think I could have convinced myself that the nature of caring for these residents was pretty stable,” McGarry said. “Things change and the pandemic obviously turned everything upside down and really changed the calculus of how residents are taken care of and how long it takes to do so.”
The pandemic has accelerated broader implications, he believes.
“The nursing home industry appears to be at a crossroads here where COVID has altered the landscape of what it means to care for older adults in nursing homes. It has altered the demand for how willing people are to go to nursing homes and what they look for in nursing homes,” he said. “Combined with PDPM, it is leading to soul searching and questions about how we pay for this care. So much more to come in understanding what the implications are for an overstretched workforce that has just experienced historic losses in terms of the number of people working in that industry.”
Others on the COVID-19 outbreak staffing patterns study team included David Grabowski, PhD, Harvard Medical School; Jonathan Gruber, PhD, of the Department of Economics at the Massachusetts Institute of Technology; and Ashvin Gandhi, PhD, of the UCLA Anderson School of Management.