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States Whose Nursing Facilities Employ Few Registered Nurses Are More Likely To Be Penalized for Readmissions of Their Residents to Hospitals

In 2014, as part of the Protecting Access to Medicare Act, Congress created the Skilled Nursing Facility Value-Based Purchasing Program, whose financial incentives are intended to reduce rehospitaliations of nursing home residents.  In December 2018, for the first time, the Centers for Medicare & Medicaid Services assigned financial bonuses and penalties to specific skilled nursing facilities, judging performance on the rehospitalization rates of their residents within 30 days of discharge.[1] 

Kaiser Health News reports that 85% of nursing facilities in Arkansas, Louisiana, and Mississippi had payment reductions, while more than half the facilities in Alaska, Hawaii, and Washington State received bonuses.

On January 9, 2019, the Center for Medicare Advocacy looked at the nurse staffing levels for the six states, as reported on the federal website Nursing Home Compare.  Federal nurse staffing data, which are now based on data derived from payroll, documented that registered nurses (RNs) are the key to reducing readmissions of nursing facility residents to acute care hospitals.

All three states that had payment reductions have lower RN staffing levels than the national average.  All three states that received bonuses have higher RN staffing levels than the national average. 

Other licensed nurses are not correlated with reduced hospitalizations.  In fact, all three states with payment reductions have higher licensed practical nurse (LPN) rates than the national average and their total licensed nurse staffing levels are either just below or just above national levels.

Moreover, all three states receiving bonuses have lower LPN rates than the national average.  These states have higher total licensed nurse staffing levels, although for two of them (Hawaii and Washington), the licensed nurse staffing rates are between 11 and 15 minutes higher than the national average.

The key staffing factor appears to be having adequate numbers of RNs on staff.


State’s RN staffing

National RN staffing

State’s LPN staffing

National LPN staffing

State’s Total Licensed Nurses

National Total Licensed Nurses

States with Penalties








20 min.

41 min.

1 hr. 3 min.

53 min.

1 hr. 23 min.

1 hr. 34 min.


17 min.

41 min.

1 hr. 9 min.

53 min.

1 hr. 27 min.

1 hr. 34 min.


37 min.

41 min.

1 hr. 5 min.

53 min.

1 hr. 41 min.

1 hr. 34 min.

States with Bonuses








2 hr. 2 min.

41 min.

41 min.

53 min.

2 hr. 43 min.

1 hr. 34 min.


1 hr. 28 min.

41 min.

21 min.

53 min.

1 hr. 49 min.

1 hr. 34 min.

Washington State

1 hr.

41 min.

45 min.

53 min.

1 hr. 45 min.

1 hr. 34 min.

The correlation of higher RN staffing levels with reduced rates of hospitalization is consistent with prior studies that have directly tied appropriate staffing levels with improved resident outcomes.[2] 

CMS has acknowledged the importance of appropriate staffing in meeting residents’ care needs. In an April 2018 memorandum, CMS states, “[r]esearch shows the presence of an RN is strongly related to the quality and outcomes residents experience.”[3]  The memorandum includes a chart showing how nursing homes perform on three claims-based quality measures (30-day readmissions, emergency room transfers, and successful discharge to community) based on the decile of RN hours.[4]  As the chart demonstrates, nursing homes with higher RN hours have better outcomes on all three measures.[5]

January 17, 2019 – T. Edelman

[1] Jordan Rau, “Medicare Cuts Payments To Nursing Homes Whose Patients Keep Ending Up in Hospital,” Kaiser Health News (Dec. 3, 2018),
[2] More Nurses in Nursing Homes Would Mean Fewer Patients Headed to Hospitals, (CMA Alert, Mar. 10, 2011).
[3] CMS, Transition to Payroll-Based Journal (PBJ) Staffing Measures on the Nursing Home Compare tool on and the Five Star Quality Rating System, QSO-18-17-NH (Apr. 6, 2018), Questions & Answers, p. 2,
[4] Id.

[5] Id.


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