Do Services and Staffing in Residential Care Facilities Vary With Residential Needs? - Executive Summary

Galina Khatutsky, MS, Joshua M. Wiener, PhD, Angela M. Greene, MS, MBA, Ruby Johnson, MA, MS, and Janet O'Keeffe, DrPH

RTI International

July 22, 2013

This report was prepared under contract #HHSP23320095651WC between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Research Triangle Institute. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/office_specific/daltcp.cfm or contact the ASPE Project Officer, Emily Rosenoff, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201.  Her e-mail address is: Emily.Rosenoff@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

For policy makers and consumer advocates seeking to enable individuals with long-term services and supports needs to remain in the community and to reduce the use of nursing homes, residential care facilities (RCFs) may offer an alternative for people who cannot live independently but do not need the level of care provided in nursing homes. For RCFs to meet these objectives, the services offered and staffing provided must correspond with the needs of the residents.

To help determine whether this correspondence is the case, this study uses newly available data from the 2010 National Survey of Residential Care Facilities--the first nationally representative survey of a broad range of RCFs--to profile RCF residents' health and functional status. It then examines the relationship between health and functional status, and: (1) the services available at the facilities and used by residents; and (2) the staffing levels of the facilities. Although not specifically designed to answer this question, the survey is the best available source of nationally representative data on RCFs.

The study results indicate that RCF residents in both the under and over-65 age groups have high rates of chronic conditions, although some of the most prevalent specific conditions vary by age. Most notably, those ages 65 and over are characterized by high rates of Alzheimer's disease and other dementias, hypertension, and depression. Among residents under age 65, serious mental illness, depression, hypertension, and intellectual and developmental disabilities predominate. (Facilities that exclusively serve individuals with severe mental illness and intellectual and developmental disabilities were excluded from the survey and are not part of this study.) Although the estimates use different data sources for comparing health status and disability levels across care settings, this study found that compared with nursing home residents, RCF residents have lower rates of chronic conditions and lower levels of activity of daily living needs.

The results also suggest that RCFs offer a wide range of services that reflect facility case mix. Overall, residents with higher levels of functional and cognitive impairments are more likely to reside in facilities that offer more services and are more likely to use those services than are people with lower levels of functional and cognitive impairment. RCF residents in both age groups also use substantial amounts of hospital, emergency room, rehabilitation facility, and nursing home services.

Staffing adequacy is a key factor that helps to ensure quality of care for RCF residents. Residents with higher levels of functional and cognitive impairment were more likely to live in facilities with higher staffing levels than were people with lower levels of functional and cognitive impairment.

Finally, this study examined the predictors of total direct care staffing in RCFs and found that for-profit status and a large proportion of residents receiving assistance with bathing, eating, or transferring are associated with higher direct care staffing ratios. Larger facilities and chain facilities are likely to have lower total direct care staffing ratios. Although in the regression analysis we controlled for bed size, ownership type, and whether the facility is part of a chain, doing so may not fully control for the large effects on staffing of including direct care administrator hours in small facilities and the correlation among other variables. We also found that, controlling for all other factors, there are no statistically significant differences in direct care staffing ratios between facilities located in a rural or urban areas, and or between facilities with dementia units or those that exclusively serve people with dementia and facilities that do not. Direct care staffing ratios were also not related to the proportion of residents with short-term memory problems. Controlling for a variety of facility characteristics, this analysis found no evidence that facilities serving Medicaid residents have lower staffing levels than facilities not serving Medicaid residents.

In conclusion, there appears to be a relationship between resident disability levels and facility services and staffing levels. Although the mechanism of this relationship is unclear, it is likely to be a combination of several factors: (1) facilities adjusting to the needs of residents; (2) residents' selection of facilities that meet their needs; and (3) relocation or discharge of residents for whom the facility does not provide needed services. States' long-term services and supports rebalancing efforts and individuals' preference to receive long-term care services outside of institutions will likely lead to RCFs playing a larger role in the long-term services and supports' delivery system. Understanding the functional status of RCF residents, the types and amount of services provided and used in RCFs, and the staffing available to serve residents is a first step in determining the appropriate role of RCFs.