Promoting Nursing Home Success

Since the pandemic, employment stabilization has been an ongoing issue. Post-acute and long-term care communities, including skilled nursing facilities, are lagging behind other fields in returning to pre-COVID staffing levels (I. Telesford et al., “What Are the Recent Trends in Health Sector Employment?” Peterson-KFF Health System Tracker, Dec. 13, 2023, https://bit.ly/42hH708. Staffing challenges have a direct impact on resident care, staff morale, regulatory compliance, and operational success. As is seen in many industries, there is a variance in impact.

Constellation Quality Health, a nonprofit health care quality consultancy, has led a pilot project in the study and implementation of a nursing home business strategy aimed at certified nurse assistant (CNA) retention. In this work, the team has identified techniques that reduce staffing turnover, raise the Centers for Medicare & Medicaid Service’s five-star Care Compare quality ratings, and improve staff morale.

The study, known as the South Carolina Long-Term Care Learning Pilot, has identified measures that strengthen frontline staff retention as the foundation for high performance. The study was funded by the South Carolina Department of Health and Environmental Control (DHEC) through the American Rescue Plan Act of 2021 under the Nursing Home and Long-Term Care Facility Strike Team and Infrastructure Project.

Implementing measures to strengthen retention is seen as critically important. Nationwide there has been a decrease in SNF employment of almost 10% since February 2020; as a result, staff are stretched far too thin. In April 2023 the American Health Care Association (AHCA) reported that 100,000 registered nurses (RNs) left the workforce in the last two years, and more than 600,000 nurses plan to leave by 2027 (AHCA, “State of the Nursing Home Industry,” June 2022, https://bit.ly/3Oqk5i1).

Research studies on nurse staffing and quality provide strong evidence that the quality of care for nursing home residents is improved when nursing staff effort (i.e., hours per resident day) goes up; nursing staff and leadership turnover also are reduced (Nurs Clin N Am 2022; 57:179–189). Frequent staff turnover leads to a lack of familiarity with residents and can lead to quality issues: increased hospitalizations, increased frequency of restraint use, and an increase in infection control violations, potentially resulting in outbreaks.

Unfortunately, the proposed federal staffing regulations may make conditions even more strained. Draft regulations under consideration would require every long-term care facility to ensure a minimum of 0.55 RN hours per resident day and 2.45 CNA hours per resident day. It’s no wonder that 98% of AHCA survey respondents reported they are concerned about being able to meet potential federal staffing mandates.

Phase 1 (2022) of the South Carolina project identified eight high-performing nursing facilities with superior workforce retention rates and strong processes in mitigating COVID-19 impact as measured through the Centers for Disease Control and Prevention’s National Healthcare Safety Network reporting. The researchers studied the CMS Care Compare star ratings for these eight homes and identified outstanding leadership practices and staffing strategies.

These eight homes, they found, stressed caring and compassion, and created conditions where the staff felt safe. Specifically, they found that in each of these homes:

These eight high-performing organizations were then invited to participate in phase 1 of the study. This phase identified their outstanding leadership practices and staffing strategies to build out best practices. The researchers then used the information learned from these eight homes to lay the foundation for phase 2.

Twelve additional nursing homes were invited to participate in phase 2 (2023), in which the project tested rapid-cycle adoption of the best practices identified during phase 1. These homes covered a spectrum of measures and ownership levels: some already had high CMS star ratings and others much lower ratings; some were for-profit, and others were nonprofit.

The project team helped each of these 12 homes develop a unique action plan using low-burden/high-benefit approaches. The sessions focused on testing and implementing low-cost management and leadership best practices, including financial and human resource best practices. The approaches included enhancing communication, reviewing the recruitment and on-boarding process, creating engagement through problem solving during patient rounds, as well as bringing fun to the workplace for improved morale.

In addition, four of the homes participating in phase 2 integrated their CNAs into their care plan meetings, quality improvement initiatives, and community building efforts. Keeping the frontline staff informed of the residents’ status was considered highly important. Physicians also were encouraged to take an active role in the quality improvement meetings, and frontline staff were provided with the opportunity to talk directly with leaders. In these cases, communication between the physicians and nursing staff improved.

Here are a few more examples of what some homes did:

• Developed a program to provide emergency funds for staff.
• Improved the employee break room.
• Developed mentoring programs to help new staff settle in.
• Provided tuition for basic and professional education.

The results were impressive: CMS five-star ratings increased. One nursing home went up from an average of three CMS stars to an average of five. A more complete assessment of the results will be available after phase 3.

The project is currently still in phase 3: the team is recruiting 40 South Carolina nursing homes for a virtual learning collaborative to share best practices and lessons learned from implementation in phase 2. The researchers have predicted these best practices will affirm the long-standing link between staffing stability and resident outcomes. With improved communication and consistent staffing levels, the researchers on this project posit that the staff will become more engaged and empowered, which will enable them to advocate for the residents’ preferences and recognize early changes in their conditions. These outcomes have the potential to be observed in quality-of-care metrics including bladder control, reducing the risk of falling, skin care, or reducing unnecessary hospitalizations.

Once the study is completed, the team will further disseminate their results through publication and other means.