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One of the goals of health care reform is the reduction of unnecessary hospital readmissions of patients.[1] The Centers for Disease Control and Prevention (CDC) reports in 2010 that, in 2004, 8% of nursing home residents nationwide – 123,600 individuals – had an emergency department (ED) visit in the prior 90 days and that 40% of the ED visits, involving 50,300 residents, were preventable.[2]

According to the CDC, potentially avoidable ED visits resulted from injuries from falls (36%), heart conditions (19%), pneumonia (12%), and other conditions (mental status changes, urinary tract infections, gastrointestinal bleeding symptoms, fever, metabolic disturbances, skin diseases) (33%). Residents with potentially preventable ED visits had shorter lengths of stay in their nursing home prior to their hospitalization and took more medications than other residents. 56% of these residents took nine or more medications, compared to 50% of other residents.[3]

Citing the extensive research literature on the hospitalization of nursing home residents, the CDC reports:

[S]ome of these conditions [leading to ED visits], such as urinary tract infections, could be more appropriately treated in the nursing home. Other conditions prompting ED visits, such as those related to falls or pneumonia, may have been avoided by preventing the adverse health event itself.

CDC's findings suggest that many ED visits by residents could have been prevented with better nurse staffing levels at the nursing facilities. More professional nursing staff in nursing facilities could treat residents' more complex medical needs, and more paraprofessional nursing staff could, for example, answer call bells more quickly and assist residents with transfers, preventing many of the avoidable injuries from falls.[4] Higher nurse staffing levels at all levels can also help achieve health care reform's goal of reducing unnecessary rehospitalizations.

Insufficient Staffing is a Longstanding Problem in Nursing Facilities

The lack of sufficient numbers of professional and paraprofessional nursing staff is a longstanding concern in nursing facilities.[5] Since 1990, federal law has required that facilities have registered nurses (RNs) eight hours per day, licensed nurses around the clock, and otherwise, "sufficient" staff to meet residents' needs.[6] Under the Nursing Home Reform Law, the determination of how many staff members are "sufficient" is left up to individual facilities. Unfortunately, these federal standards have not ensured that facilities have sufficient numbers of well-qualified and well-trained nursing staff to meet residents' increasingly complex needs.

The Centers for Medicare & Medicaid Services' (CMS') nurse staffing study documented in 2001 that more than 97% of facilities failed to have sufficient staff to meet one or more federal staffing requirements and to prevent avoidable harm to residents, and that 91% of facilities did not have sufficient staff to meet five key care processes required by the Reform Law (dressing/grooming, exercise, feeding assistance, changing wet clothes and repositioning, and toileting).[7] CMS reported that more than 40% of facilities nationwide would need to increase their nurse aide staffing by 50%, with more than 10% of facilities needing to increase their nurse aide staffing by more than 100%. The study documented that more than a decade after comprehensive federal legislation directed nursing facilities to determine, and employ, the correct number of staff members they needed to provide care to residents, most facilities failed to employ sufficient direct care staff.

Staffing has not improved since the 2001 study. Between 2003 and 2008, nurse staffing levels in facilities certified for Medicaid only or for both Medicare and Medicaid remained virtually unchanged: RN coverage per resident per day increased from 0.50 hours per resident per day to 0.55 hours; licensed practical nurse/licensed vocational nurse (LPN/LVN), from 0.70 hours to 0.78 hours; and nurse aides, from 2.20 hours to 2.33 hours.[8] In Medicare-only facilities, RN coverage per resident per day actually declined from 2.5 hours in 2003 to 2.25 hours in 2008; LPN coverage similarly declined, from 1.5 hours to 1.31 hours; and nurse aide coverage increased slightly, from 2.7 hours to 2.76 hours.[9]

While nurse staffing did not increase following enactment of the 1987 Nursing Home Reform Law or release of the 2001 staffing study, residents' care needs did. Federal data indicate that residents' acuity levels have increased. CMS reports that:

…the proportion of residents with severe Activities of Daily Living (ADL) impairment has been increasing. Nearly half of all nursing home residents require extensive assistance with at least four of the five Activities of Daily Living (ADL) that were examined (bed mobility, transferring, dressing, eating, or toileting). In 1999, about 35% of residents required assistance with four or more ADLs. In 2004, about 40% of residents required assistance with four or more ADLs. In 2008, about 49% of residents required that level of assistance.[10]

The correlation between the number of nurses (RNs, licensed practical nurses, and certified nursing assistants) who provide direct care to residents on a daily basis and high quality of care and quality of life for residents cannot be disputed. Numerous reports and studies confirm that nursing facilities provide better care to their residents, and residents have better outcomes, when facilities are adequately staffed.[11] No report has ever found better quality with fewer staff.

Solving Staffing Problems

Raising reimbursement rates in the hope that facilities will increase their staffing levels has not improved staffing.

In 2000, Congress increased the nursing component of the federal Medicare rate by 16.66%, effective April 1, 2001,[12] giving skilled nursing facilities approximately $1 billion in additional payments per year.[13] The federal Government Accountability Office (GAO) described the rate increase as raising "the overall SNF payment rates by 4% to 12%, depending on the patient's expected care needs."[14] However, as the GAO pointed out, the federal law "did not require facilities to spend this additional money on nursing staff."[15]

Skilled nursing facilities actually used less than 20% of the new staffing dollars for nursing staff. The GAO estimated that nurse staffing would have increased by about 10 minutes per patient day "if SNFs had devoted the entire nursing component increase to more nursing time."[16] But, analyzing available data from slightly more than one-third of all SNFs nationwide,[17] the GAO instead found that:

… in the aggregate, SNFs' nurse staffing ratios changed little after the increase in the nursing component of the Medicare payment rate took effect. Overall, SNFs' average nursing time increased by 1.9 minutes per patient day, relative to their average in 2000 of about 3 and one-half hours of nursing time per patient day.[18]


In contrast to virtually stagnant staffing levels in most states, nursing facilities in four states, which the GAO did not identify, "increased their staffing by 15 or more minutes per patient day."[19] Three of these four states implemented "payment or policy changes . . . aimed at increasing or maintaining SNF nursing staff."[20]

The GAO concluded, "increasing the Medicare payment rate was not effective in raising nurse staffing."[21] The most effective way to increase staffing is to require increased staffing.

Legislation pending in Congress, H.R. 5457,[22] would provide supplemental payments of up to $6 billion to facilities participating in both Medicare and Medicaid, but fails to disqualify facilities from eligibility if they provide poor care and does not prescribe how facilities can spend the additional payments. The result would likely be a windfall to facilities, with little or no improvements in care for residents.


Emergency room visits by nursing home residents and unnecessary rehospitalizations could be reduced with better staffing at nursing homes. Sending more money to nursing homes without also requiring that it be used for patient care has not, and will not, solve staffing problems. The best way to achieve adequate staffing at nursing facilities is to mandate specific staffing levels.

[1] Patient Protection and Affordable Care Act, §3025, 42 U.S.C. §1395ww(q).

[2] Christine Caffrey, CDC, "Potentially Preventable Emergency Department Visits by Nursing Home Residents: Untied States, 2004," NCHS Data Brief, No. 33 (April 2010), CDC found that 104,900 residents (85%) had one ED visit in the prior 90 days and 18,400 residents (15%) and two or more ED visits.

[3] Id. 4.

[4] Analyzing 264,090 death certificates provided by the Minnesota Department of Health for 2002-2008, the Minneapolis Star-Tribune reported in November 2009 that more than 1000 nursing home residents died from falls in Minnesota nursing homes in the seven-year period. Three-quarters of Minnesota nursing facilities are understaffed. Hospital bills in Minnesota for falls of older people (including nursing home residents) totaled more than $1.1 billion between 1998 and 2005. David Joles, "Deadly Falls: More than 100 Minnesotans die each year after suffering falls in nursing homes. Few deaths are fully investigated by the state, and serious penalties for violations are rare," Minneapolis Star-Tribune Nov.19, 2009).

[5] See, e.g., General Accounting Office, Nursing Workforce: Recruitment and Retention of Nurses and Nurse Aides Is a Growing Concern, GAO-01-750T (May 17, 2001),; Robyn I. Stone with Joshua M. Wiener (Urban Institute), Who Will Care for Us? Addressing the Long-Term Care Workforce Crisis (Oct. 2001),

[6] 42 U.S.C. §§1395i-3(b)(4)(C)(i), 1396r(b)(4)(C)(i)(1), (2), Medicare and Medicaid, respectively.

[7] CMS, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II Final Report, pages 1-6, 1-7 (Dec. 2001).

[8] Charlene Harrington, Helen Carrillo, Brandee Woleslagle Blank, Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2003 Through 2008, page 60 (Nov. 2009). See also 61-63, Tables 25 and 26. In Medicare-only facilities, RN coverage per resident per day declined from 2.5 in 2003 to 2.25 in 2008; LPN coverage declined from 1.5 to 1.31; and nurse aide coverage increased from 2.7 to 2.76.

[9] Id. 64. See also 65-67, Tables 27 and 28.

[10] CMS, Nursing Home Data Compendium (2009 Edition), page ii. See also 43, Figure 3.1, showing declining number of residents with impairments with one, two, or three ADLs and increasing number of residents with impairments in four ADLs.

[11] One study in California found that facilities whose nurse aide staffing levels were at the highest decile (top 10%) had better results on 13 of 16 care processes, when compared with facilities employing fewer nurse aides. Residents in the highest-staffed facilities "spent more time out of bed during the day; were engaged more frequently; received better feeding and toileting assistance; were repositioned more frequently; and showed more physical movement patterns during the day that could reflect exercise." John E. Schnelle, Sandra F. Simmons, Charlene Harrington, Mary Cadogan, Emily Garcia, and Barbara M. Bates-Jensen, "Relationship of Nursing Home Staffing to Quality of Care," Health Services Research , Vol. 39, No. 2, pages 225-250 (April 2004),

A synthesis of 71 published reports, expert opinion, and peer-reviewed studies of nurse staffing and quality of care, all published between 2002 and 2007, reported:

Higher staffing levels and other staffing characteristics in the nation's nursing facilities, including lower rates of turnover, have been repeatedly associated with better outcomes for residents; . . . .Higher staffing levels and lower rates of staff turnover have also been associated with functional improvement measures, earlier discharges from nursing facilities, and fewer [pressure ulcers]. . . .

Qualitative studies have also established a relationship between staffing characteristics and resident outcomes. For example, inadequate staffing levels, lack of training, and a dearth of supervision of [certified nurse assistants] CNAs have been associated with poor incontinence care, inadequate repositioning, and insufficient mouth care. Inadequate staffing and poor supervision have also been related to insufficient nutritional intake and increased prevalence of malnutrition and dehydration among nursing facility residents . . . . [article citations omitted]

Nicholas G. Castle, "Nursing Home Caregiver Staffing Levels and Quality of Care: A Literature Review," Journal of Applied Gerontology, Vol. 27, pages 375-405 (Aug. 2008).

[12] Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), Pub. L. No. 106-554, App. F, §312(a), 114 Stat. 2763, 2763A-498, Government Accountability Office, Skilled Nursing Facilities: Available Data Show Average Nursing Staff Time Changed Little after Medicare Payment Increase, page 1, GAO-03-176 (Nov. 2002), BIPA also increased daily rates by 6.7% for 14 resident categories, effective April 2001, BIPA §314. In earlier legislation, the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA), Congress raised daily rates by 20% for 15 high-cost resident categories, beginning in April 2000, Pub. L. No. 106-113, App. F, §101, 113 Stat. 1501, 1501A-324; and increased the daily rate for all facilities by 4% for fiscal years 2001and 2002. See GAO, Skilled Nursing Facilities: Available Data Show Average Nursing Staff Time Changed Little after Medicare Payment Increase at 6, notes 17-19.

[12] Government Accountability Office, Skilled Nursing Facilities: Available Data Show Average Nursing Staff Time Changed Little after Medicare Payment Increase, page 6, GAO-03-176 (Nov. 2002),

[13] Government Accountability Office, Skilled Nursing Facilities: Available Data Show Average Nursing Staff Time Changed Little after Medicare Payment Increase, page 6, GAO-03-176 (Nov. 2002),

[14] Id. 1-2.

[15] Id. 2.

[16] Id. 10.

[17] The GAO found that these 6500 facilities and the total of 13,454 facilities were not statistically different "in terms of type of facility, size, ownership, and the share of SNF patients paid for by Medicare." Id. 2.

[18] Id. 3.

[19] Id. 9.

[20] Id. 9.

[21] Id. 4.

[22] The Nursing Home Patient and Medicaid Assistance Act of 2010 is available at

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