As the Senate Special Committee on Aging continues its exploration of short-staffing in nursing homes, several facts must be addressed:
Public funding for nursing homes under the Medicare and Medicaid programs more than doubled between 1990 and 1998, increasing from $24.8 billion to $51.0 billion.
Resident acuity increased substantially between 1991 and 1998.
The nurse staffing levels reported by Medicare/Medicaid facilities remained largely unchanged between 1991 and 1998, except for some increase in registered nurse coverage, particularly in Medicare-only facilities.
Where did the public money go?
Before Congress increases public reimbursement to nursing homes to increase nurse staffing levels, it must understand how facilities spent the billions of dollars they received. Such a study of reimbursement by the General Accounting Office is presently underway. Congress must also assure that the public regulatory system is adequately funded and supported in order to assure that Medicare and Medicaid reimbursements are actually spent on high quality of care and high quality of life for residents. Finally, legislative proposals to create a new category of Asingle task worker@ are misguided. They would exacerbate, rather than resolve, the staffing crisis and they would not improve care for residents.
Public funding for nursing homes under the Medicare and Medicaid programs more than doubled between 1990 and 1998, increasing from $24.8 billion to $51.0 billion.
Between 1990 and 1998, Medicare and Medicaid funding for nursing home care more than doubled, increasing from $24.8 billion to $51.0 billion.
During this eight-year period, Medicare spending increased more than six-fold, from $1.7 billion to $10.4 billion, and Medicaid spending increased from $23.1 billion to $40.6 billion. Total Government funding (federal, state, and local, including Medicare and Medicaid) increased from $25.9 billion to $53.0 million
Resident acuity increased substantially between 1991 and 1998.
Between 1991 and 1998, the acuity of residents increased in many specific respects.
The percentage of residents who are bedfast more than doubled, increasing from 3.5% in 1991 to 7.8% in 1998.
The percentage of residents who are chairbound increased from 46.5% in 1991 to 48.4% in 1998.
The percentage of residents who have contractures increased from 15.8% in 1991 to 23.2% in 1998.
The percentage of residents with dementia increased from 34.7% in 1991 to 41.6% in 1998.
The percentage of residents with pressure sores increased from 6.8% in 1991 to 7.1% in 1998.
The percentage of residents receiving special skin care nearly doubled, increasing from 27.5% in 1991 to 54.7% in 1998.
The percentage of residents receiving rehabilitation increased from 14.9% in 1991 to 19.0% in 1998.
The percentage of residents receiving ostomy care increased from 2.0% in 1991 to 2.9% in 1998.
The percentage of residents receiving injections increased from 10.2% in 1991 to 12.1% in 1998.
The percentage of residents receiving intravenous therapy increased from 1.1% in 1991 to 2.8% in 1998.
The percentage of residents receiving intravenous tube feeding increased from 5.1% in 1991 to 6.9% in 1998.
The percentage of residents receiving respiratory treatment more than doubled, increasing from 4.1% in1991 to 8.5% in 1998.
The percentage of resident with bladder incontinence increased from 47.0% in 1991 to 50.7% in 1998.
The percentage of residents in a bladder training program increased from 4.8% in 1991 to 5.7% in 1998.
The nurse staffing levels reported by Medicare/Medicaid facilities remained largely unchanged between 1991 and 1998, except for some increase in registered nurse coverage, particularly in Medicare-only facilities.
Harrington cautions that Athe reported staffing ratios [used in the report] reflect payroll hours per resident day and not the actual hours of care delivered directly to residents.@ In other words, the numbers reported below are higher than the hours of care actually provided to residents.
In facilities certified for Medicaid-only and Medicare and/or Medicaid:
The number of nurse assistant hours per resident day remained 2.0 between 1991 and 1998. This coverage means about 114 to 120 minutes per day, or about 38 to 40 minutes per eight-hour shift.
The number of licensed practical nurses/licensed vocational nurse hours per resident day remained 0.6 between 1991 and 1998. This coverage means about 36 minutes per day, or about12 minutes per shift.
The number of registered nurse hours per resident day increased from 0.3 in 1991 to 0.6 in 1998. This coverage includes nurses in administrative positions and means about 36 minutes per resident day, or about 12 minutes per eight hour shift in 1998.
In facilities certified only for Medicare:
The number of nurse assistant hours per resident day increased from 2.4 in 1991 to 2.5 in 1998.
The number of LPN/LVN hours per resident day increased from 1.2 in 1991 to 1.3 in 1998 (declining from a high of 1.6 in 1994). This coverage means about 78 minutes per resident day, or 26 minutes per eight-hour shift, in 1998.
The number of RN hours per day increased from 1.0 in 1991 to 2.2 in 1998.
In all certified facilities (Medicare-only, Medicaid-only, and Medicare/Medicaid):
The number of nurse assistants per resident day increased from 2.0 in 1991 to 2.1 in 1998. This coverage means 126 minutes per resident day, or 42 minutes per eight-hour shift in 1998.
The number of LPN/LVN hours per resident day increased from 0.6 in 1991 to 0.7 in 1998. This coverage means 42 minutes per resident day, or 14 minutes per eight-hour shift in 1998.
The number of RN hours per resident day increased from 0.4 in 1991 to 0.8 in 1998. This coverage means 48 minutes per resident day, or 16 minutes per eight-hour shift in 1998.
Legislative proposals to create single task workers will not solve the staffing crisis in nursing homes.
Creating a new category of staff to perform single tasks seems, at first, to be an appealing temporary solution to a crisis situation. On reflection, however, it becomes apparent that this solution is an overly simplistic response to a complex problem that has many causes and a long history. Such a category of staff will not improve care for residents in the short-run and will only exacerbate care problems in the long-run.
Many practical problems surround such a new category of staff. These problems include:
Training (What training will these staff get? Who will conduct the training? How many hours and with what content?);
Monitoring (Who will monitor that these staff are actually trained and competent before they are assigned to residents?);
Continuity of care for residents;
Orientation to individual residents (How will these staff members be made aware of the specific physical and personal characteristics, medical diagnoses, and other needs of the people they are assigned to provide care for?);
Orientation to the facility=s policies, procedures, staff, and emergency protocols.
The legislation does not assure that single task workers supplement, not replace, existing staff. If there is no budget for single task workers, these staff members replace current staff. They will not, as promised, be supplements to existing staff. If no additional budget is contemplated, there would need to be mechanisms to assure that facilities actually hire additional people within existing reimbursement rates. The legislation would also require mechanisms to assure compliance with (training and other) requirements related to the new category of staff and remedies that could be imposed if facilities failed to comply with (training and other) requirements for these staff.
In addition, the lack of sufficient numbers of staff to provide care to residents affects many areas of care. While a considerable amount of attention has been focused recently on the need for additional staff to feed residents at mealtimes, malnutrition and dehydration are two of many care problems that result from short-staffing. Residents need assistance with many activities of daily living B toileting, transferring, etc. B that are not addressed by staff assigned to the single task of feeding residents. What would be next? Toileting assistants? Transferring assistants? Bathing assistants? Having staff assigned to single functions is not an appropriate way to provide care. Assigning staff to particular care needs also reverses the trend to cross-train and multi-train staff to perform all functions that residents need.
Assigning staff to particular care needs does not promote residents= stated request and need for continuity in caregiving. It also does not respond to what certified nurse assistants say is most rewarding in their jobs B their ongoing relationships with individual residents. Good managers recognize the need to stabilize the workforce, not degrade it with fill-in workers. The workforce is stabilized with practices that improve the quality of workers= jobs.
A new category of staff will not solve problems of short-staffing in either the short-run or the long-run. There is tremendous turnover in CNA staff positions because the jobs are often considered undesirable: workers receive insufficient wages, lack health insurance coverage, lack career ladders and opportunities to advance professionally, have dangerous workloads and poor working conditions, and are inadequately supervised. These negative factors are neither changed nor improved by dividing CNA jobs into an uncoordinated collection of single tasks performed by separate workers.
Residents who need help with eating have physical or cognitive problems that prevent them from being able to feed themselves. Staff who assist such residents need the CNA=s skills and training to provide services to these residents.
Finally, a new category of staff will inevitably be called upon to perform additional tasks in the facility. As a consequence, the already-inadequate 75 hours of training for CNAs required by federal reform law will be watered down, if not virtually eliminated.
Conclusion
Congress needs to mandate staffing ratios for nursing homes, as proposed by the National Citizens Coalition for Nursing Home Reform. The Center for Medicare Advocacy will submit additional comments for the record.
This statement is submitted for the record by the Center for Medicare Advocacy, a private, non-profit organization founded in 1986, that provides education, analytical research, advocacy, and legal assistance to help elders and people with disabilities obtain necessary health care. The Center focuses on the needs of Medicare beneficiaries, people with chronic conditions, and those in need of long-term care. The Center provides training regarding Medicare and health care rights throughout the country and serves as legal counsel in litigation of importance to Medicare beneficiaries nationwide.
