U.S. Department of Health and Human Services

State Experiences with Minimum Nursing Staff Ratios for Nursing Facilities: Findings from Case Studies of Eight States

Jane Tilly, Dr.P.H., Kirsten Black, M.P.P., and Barbara Ormond, Ph.D.
The Urban Institute

Jennie Harvell
U.S. Department of Health and Human Services

November 2003

PDF Version

This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Urban Institute. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Jennie.Harvell@osaspe.dhhs.gov.

Inferences and conclusions drawn are solely those of the authors and do not necessarily reflect the views of the Urban Institute, the Technical Advisory Group, or HHS.

The authors would like to thank members of the Technical Advisory Group for their contributions to this project:

Nancy Atkins, West Virginia Department of Health and Human Resources
Carol Benner, Maryland Office of Health Care Quality
Toby Edelman, Center for Medicare Advocacy, Inc.
Steve Edelstein, Paraprofessional Health Care Institute
Marvin Feuerberg, Centers for Medicare and Medicaid Services
Sandra Fitzler, American Health Care Association
Ruta Kadinoff, American Association of Homes and Services for the Aging
Andrew Kramer, M.D., University of Colorado Health Sciences Center
Ed Mortimore, Centers for Medicare and Medicaid Services
Vera Salter, Paraprofessional Health Care Institute
Edwin Walker, Administration on Aging

TABLE OF CONTENTS

ABSTRACT

EXECUTIVE SUMMARY

INTRODUCTION

BACKGROUND AND POLICY CONTEXT

METHODS

FINDINGS

1. Status of State Nursing Staff Ratios in 2003

2. Case Study Findings

DISCUSSION AND SUMMARY

NOTES

APPENDICES

APPENDIX 1. Letter from DHHS

APPENDIX 2. Overview of State's Nursing Home Nurse Staffing Standards

APPENDIX 3. Discussion Guide for State Officials

APPENDIX 4. Summary of Case Study Findings for Eight States

• Arkansas
• California
• Delaware
• Minnesota
• Missouri
• Ohio
• Vermont
• Wisconsin

APPENDIX 5. Comparison of Eight Case Study States

ABSTRACT

This paper reports on (1) what is known about the status of states' minimum nursing staff ratios and (2) findings from case studies that examine states' experiences with implementing or modifying these standards in a selected number of states. A review of the published and unpublished literature on state standards identified 36 states with established minimum ratios in 2003, with the District of Columbia scheduled to implement its ratios in 2005. Since 1997, 23 states have made changes to their minimum nursing staff ratios. We chose 10 states out of the total 23 with a recent change to their minimum nursing staff ratios to find out why the states set, modified, or eliminated their staffing ratios; how the standard in question was implemented; how compliance was monitored; and the perceived effects of the standards. The 10 case study states--Arkansas, Arizona, California, Delaware, Minnesota, Missouri, Nevada, Ohio, Vermont, and Wisconsin--represent a diverse group in terms of population size and geographic area. Of these states, Vermont instituted new staffing ratios; Arkansas, California, Delaware, Minnesota, Ohio, and Wisconsin modified existing ratios; and Arizona, Missouri, and Nevada eliminated their ratios. Guided discussions were held with a set of state officials and key stakeholders in each state. In eight of the 10 states, we were able to have discussions with most state officials and key stakeholders; however, we were not able to hold a sufficient number of discussions in Arizona and Nevada to include these states in the analysis. Findings from our research reveal that staffing ratios can be implemented or removed in different ways, including through passage of new legislation, as part of new regulations, through written administrative policy or procedures, or through the Medicaid reimbursement structure. Among the eight case study states, all but Vermont had some form of a minimum staffing ratio in place prior to the change in their requirement. Recent changes to state ratios typically came about as a reaction to publicity about quality problems in nursing homes and with the goal of improving the quality of resident care in nursing facilities. However, we found considerable variation across the study states in the type of ratio, measurement of the ratio, adjustment for case mix, monitoring and enforcement of the ratio, and payment for ratios, with substantial disagreement about the best approach among various stakeholder groups.

EXECUTIVE SUMMARY

In an effort to improve the quality of care in nursing homes, Congress passed the Nursing Home Reform Act of 1987, requiring, in part, nursing homes that wish to be certified for participation in Medicare or Medicaid to provide a minimum of eight hours per day of registered nursing (RN) service and 24 hours per day of licensed nursing (LN) service. Regulations implementing this legislation also require, "sufficient nursing staff to attain or maintain the highest practicable ... well-being of each resident." However, the Nursing Home Reform Act and resultant regulations do not mandate a specific staff-to-resident ratio or a minimum number of hours per resident day for resident care, and concerns about the quality of care in nursing homes have continued.

The Department of Health and Human Services (DHHS) has sponsored research examining the relationship between the level of nursing staff and the quality of resident care in nursing homes. Recently, the Centers for Medicare and Medicaid Services (CMS) reported the findings of research conducted by Abt Associates in their Phase I and Phase II studies. These reports find a relationship between staffing levels and quality of care and evidence of critical thresholds for nursing staff, below which nursing home residents are at risk for serious quality-of-care problems, and above which no measurable increases in quality of care are observed with additional nursing staff.

Despite improvements in both the data and the analysis from the Phase I to the Phase II studies, DHHS expressed concerns about Phase II's findings. In a letter from DHHS Secretary Tommy Thompson to Congress, Thompson pointed out that the relationship between the number of staff and the quality of care is complex, listing several important staffing issues related to nursing home quality of care that the Phase I and II studies do not adequately address. Subsequently, the DHHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) determined that more information about nursing home staffing requirements was needed.

The purpose of this study is to identify states with established minimum nursing staff ratios for nursing homes and examine those states' experiences with implementing or modifying these standards. A review of the published and unpublished literature on state standards identified 36 states with established minimum ratios in 2003, with the District of Columbia scheduled to implement its ratios in 2005. Twenty-three states have changed their minimum nursing staff ratios since 1997. Three of these states--Arizona, Missouri, and Nevada--previously had staffing ratios but no longer do. The 14 states, and the District of Columbia until 2005, that do not have minimum nursing staff ratios use the federal nursing staff requirements for Medicaid and Medicare participating facilities, or have state professional coverage standards for nursing home licensure that are similar to or exceed the federal requirements. These professional coverage standards are not the focus of this study.

We chose 10 states out of the total 23 with recent changes in their minimum nursing staffing ratios to find out why the states set, modified, or eliminated their staffing ratios; how the standard in question was implemented; how compliance was monitored; and the perceived effects of the standards. The 10 case study states--Arkansas, Arizona, California, Delaware, Minnesota, Missouri, Nevada, Ohio, Vermont, and Wisconsin--represent a diverse group in terms of population size and geographic area. Of these states, Vermont instituted new staffing ratios; Arkansas, California, Delaware, Minnesota, Ohio, and Wisconsin modified existing ratios; and Arizona, Missouri, and Nevada eliminated their ratios.

Research methods involved guided discussions with state officials and key stakeholders. The stakeholders were chosen to represent those affected by the nursing staff standards--consumers, nursing homes, and their employees. Discussants were sent a project description and a copy of the discussion guide we used during the telephone conversations. Discussants were assured that we would not identify or quote anyone by name.

In eight of the 10 states, we were able to have discussions with most state officials and key stakeholders. However, we were not able to hold a sufficient number of discussions in Arizona and Nevada to include these states in the analysis. In Arizona, key state officials had no knowledge of the circumstances surrounding the elimination of the minimum staffing ratios in 1997, and stakeholders told us they had come into their positions after 1997. In Nevada, state officials were not available for interviews. However, we were able to hold a discussion with one key Nevada stakeholder who provided us with some insight into why this state eliminated its staffing ratio.

Findings from our research reveal that staffing ratios can be implemented or removed in different ways, including through passage of new legislation, as part of new regulations, through written administrative policy or procedures, and/or through the Medicaid reimbursement structure. The state authority establishing the ratios often affects how easy it is to modify or eliminate them.

Among the eight case study states, all but Vermont had some form of a minimum staffing ratio in place prior to the changes in their requirements. Recent changes to state ratios typically came about as a reaction to publicity about quality problems in nursing homes and with the goal of improving the quality of resident care in nursing facilities. However, we found considerable variation across the study states in the type of ratio, measurement of the ratio, adjustment for case mix, monitoring and enforcement of the ratio, and payment for ratios.

Three of the study states--California, Minnesota, and Vermont--use an hours per resident day only (hprd) approach, with the level set at about 3.0 hprd. Another three study states--Delaware, Ohio, and Wisconsin--use a combination hprd and staff-to-resident ratio, which is a compromise that adds to the complexity of the system. Arkansas was the only case study state to use a staff-to-resident ratio only.

The time period to which hprd ratios apply is also a matter of some controversy among stakeholders. Five of the six study states with the hprd have opted to calculate compliance over a 24-hour period. Some observers advocate calculations over a 24-hour period to ensure adequate staffing on all days, particularly weekends, while others generally prefer calculations over a week or more (as in Vermont) to ensure flexibility.

Most observers agreed that adjustment of the ratios to take into account resident case mix would be ideal but recognized that this would add more complexity to the ratios, and few had suggestions about how to form a case-mix adjusted ratio. Only two states--Minnesota and Wisconsin--have adjusted their hprd requirements for resident case mix. Wisconsin's standard has three hprd categories (intensive skilled nursing care, skilled nursing care, and intermediate care) that are based on resident need. Minnesota recently rescinded a case-mix adjusted ratio that relied on data from the state's mandatory resident assessment instrument. Currently, Minnesota is studying how to implement a new case-mix adjusted ratio to accompany its new case-mix reimbursement system. The outcome of this state's study could shed some light on this particular aspect of ratios.

In addition to the variation in ratios, we saw variation in the enforcement of the standards across the states. States generally rely on the state licensing process for monitoring and enforcement of staffing ratios, because meeting the minimum ratios is part of state nursing home licensure and regulatory requirements. In addition to the survey process, Arkansas and Vermont periodically review monthly staffing data submitted by facilities, which helps state officials monitor staffing ratios. Most states also monitor staffing when investigating any complaints about poor quality of care that may be related to insufficient staffing. Nursing facilities that are not in compliance with a staffing ratio receive a deficiency citation and are generally required to submit a plan of correction only when the problem is not severe or has not resulted in serious harm to residents. If the harm is serious or the problem persistent, more severe remedies are available, including directed plans of correction, fines, and restrictions on new admissions. No information was provided regarded states use of these more severe penalties.

Observers had contradictory comments about the use of federal and state staffing standards. For example, most stakeholders agreed that when Missouri eliminated its staffing ratio, staffing and quality did not change as a result. In fact, some discussants suggested that the number of citations for staffing-related quality of care problems had increased, not because there were more quality problems but because it was easier to cite staffing problems under the federal standard of having "sufficient staff" than under the old staff-to-resident ratio. In contrast, stakeholders in other states believed that it is easier to cite a facility for insufficient staff when a ratio exists.

Eight study states have some form of data collection on nursing staff, although the content of the state data sets and the years for which data are available vary widely. The data most often come from Medicaid cost reports, but in Wisconsin and Delaware data are also available from an annual survey of facilities. Arkansas and Vermont collect data from the monthly staffing reports that facilities submit. California has the most extensive and most readily available data, derived from an annual report that merges Medicaid cost reporting with a state public disclosure report.

Most states have not used their data to examine the effects of changes to their staffing ratios, vis-à-vis either the level of staffing or quality. Most respondents were unwilling even to speculate about whether an effect could be found in the data and there are documented limitations associated with current data sources such as OSCAR and MDS. Some state officials said, and the data from California and Wisconsin support the contention, that the implementation or strengthening of a staffing ratio has resulted in increased staffing in nursing facilities overall. Advocates and ombudsmen generally say that it is too early to tell whether ratio changes have had any effect, while providers tend to say that most facilities in the state were already staffing above the new ratios, so there has been no effect. Furthermore, while it might be possible in some states to link the state staffing data to deficiency data, the problem of how to interpret any changes in deficiency citations would remain. Factors such as increased administrative attention to selected care areas and training provided to surveyors on citation practices may increase deficiency citations in those areas.

Although a few advocates complained of lax enforcement and a few providers complained of inadequate reimbursement, for the most part, the implementation of new ratios in three states ran relatively smoothly. These states--California, Ohio, and Wisconsin--had made incremental changes to their existing ratios. Those states where implementation was more controversial include Arkansas, Delaware, and Vermont. These states made more comprehensive changes to staffing requirements, involving phase-in periods, implementing standards by shift, or implementing a new system altogether, as in Vermont. Concern over reporting requirements and delayed increases in Medicaid reimbursement for nursing facilities were some of the implementation issues these states encountered. In most states, observers did not report a statewide shortage of certified nurse assistants (CNAs). However, certain rural and urban areas experience difficulty in recruiting these workers. Most providers asserted that a licensed nurse shortage continues to be somewhat problematic for their facilities but does not appear to have affected their ability to comply with the ratios for these professionals. Observers in some states reported that facilities' use of agency personnel increased as a direct result of changes to minimum staffing requirements, while others said this had not occurred in their states.

Other staffing-related initiatives included increased Medicaid nursing home reimbursement through a variety of mechanisms, such as a bed tax, quality improvement fee, or wage pass-through. Surprisingly, some of the states did not measure whether the funding was spent as intended. Several case study states also have undertaken various special studies or programs to examine issues such as staffing shortages and recruitment and retention in their long-term care labor market, and to provide recommendations to address these problems.

Most observers agreed that minimum ratios can help impose a standard on those facilities where staffing falls below the ratios. Thus, staffing ratios may serve as a minimum bar for facilities, not a standard that most need to strive to reach. Observers also asserted that facility staffing is not the only factor that affects the quality of care that nursing home residents receive. Other factors such as staff training and facility management also affect quality, and when asked for recommendations for the federal level, very few stakeholders called for national standards.

INTRODUCTION

The purpose of this paper is to provide federal and state policymakers with information on the structure, implementation, and enforcement of state-established minimum nursing staff ratios for nursing homes in a selection of the states that have imposed them. The experience of states that have established staffing ratios as a method for addressing quality problems can be instructive for policymakers who are considering implementing, modifying, or eliminating minimum nursing staff ratios.

This paper provides updated background information about federal nursing home nursing staff standards, describes 36 states' and the District of Columbia's minimum ratios as of August 2003, and discusses the experiences of eight states that have made recent changes to their nursing home staffing standards. Researchers reviewed recent literature, obtained state administrative codes, and contacted state officials to refine the description of state standards. From these descriptive data, the researchers chose 10 states with recent changes in their staffing ratios in which to conduct case studies. The case study states were chosen from among those that had made a change in their staffing standard since 1997. Case study methods rather than quantitative analyses were necessary because of the limitations of the data at the national and state levels.

This research reveals great variation among the states in their approach to staffing ratios and little consensus about what constitutes the most appropriate form or level for staffing ratios. Staffing ratios reflect such factors as local conditions in the nursing home market, Medicaid reimbursement policies, and the concerns of key stakeholders. For state policymakers wishing to pursue a new staffing ratio or modify an old one, the variation across the states provides a range of options for consideration.

BACKGROUND AND POLICY CONTEXT

The Nursing Home Reform Act of 1987 established new federal requirements for nursing homes participating in Medicare and Medicaid. Federal law requires a minimum of eight hours per day of registered nursing (RN) service and 24 hours per day of licensed nursing (LN) service. In practice, these staffing requirements may be waived if the facility demonstrates that it meets certain conditions, such as the inability to recruit the required personnel despite diligent efforts or location in a rural area with an insufficient labor supply.

Federal regulations also require nursing homes to provide "sufficient nursing staff to attain or maintain the highest practicable ... well-being of each resident." The Nursing Home Reform Act, however, did not mandate a specific staff-to-resident ratio or a minimum number of hours per resident day for resident care.

In response to continuing congressional concerns about the quality of care in nursing homes, the Department of Health and Human Services (DHHS) has sponsored research examining the relationship between the level of nursing staff and the quality of resident care in nursing homes. Two reports detailing the findings of this research have recently been completed. The Phase I report, based on research conducted by Abt Associates and prepared by staff at the Centers for Medicare & Medicaid Services (CMS), found a relationship between staffing levels and quality of care, and identified preliminary evidence of critical thresholds for nursing staff, below which nursing home residents are at risk for serious quality-of-care problems. The analysis, however, had major data and sample limitations.

The Phase II study, conducted by Abt Associates for CMS, attempted to overcome these limitations by replicating the Phase I analyses using a larger, more nationally representative sample of nursing homes along with more recent and improved data. Results of the Phase II analysis support the contention that there is a level of staffing below which residents are at substantially greater risk of suffering from quality-of-care problems. However, each type of nursing staff (i.e., certified nurse assistant (CNA), licensed practical nurse (LPN), RN, and RN/LPN) also has an upper threshold at which quality increases level off. Beyond these upper thresholds, further additions to staff were seen to yield no further measurable increases in the quality of care.

Despite improvements in both the data and the analysis, DHHS continued to raise concerns about the study's findings. In a letter to Congress conveying the Phase II results, DHHS Secretary Tommy Thompson stated that "it would be improper to conclude that the staffing thresholds described in this Phase II study should be used as staffing standards." He pointed out that the relationship between the number of staff and quality of care is complex, listing several important issues related to nursing home quality of care that the Phase I and II studies do not adequately address. Specifically, the quantitative analyses did not take into account factors such as facility management and organizational structure, tenure and training of staff, and the mix of staff by type and level of experience, which are likely to affect quality independently of the numbers of staff. Nor did the study link the effects of the current nursing shortage to the analyses of staffing ratios. Secretary Thompson also expressed DHHS's serious reservations about the reliability of the staffing data used in the study. In addition, he expressed concern that the study did not provide enough information to address the question posed by Congress, the "appropriateness" of establishing minimum ratios. The full text of the letter is provided in appendix 1¹.

The DHHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) determined that more information about nursing home staffing requirements was needed. ASPE sponsored this study to examine the experience of states that have made recent changes to this type of staffing standard.

METHODS

We took a two-pronged approach to determining what is currently known about state minimum nursing home nursing staff ratios and their implementation. We first completed a review of the published and unpublished literature on state standards.² The purpose of the literature review was to identify states with minimum nursing staff ratios and to learn what we could about how this type of standard is being implemented. Second, we attempted to conduct case studies in ten states that had made recent changes to their nursing staff ratios to find out why the states had chosen to set, modify, or eliminate staffing ratios; how the standard in question was implemented; how compliance was monitored; and the perceived effects of the standards. We were successful in completing case studies in eight of the chosen states.

The literature review under the current project examined articles and reports from 1999 to February 2003 to update and verify the earlier information on minimum nursing staff ratios collected under the CMS Phase I staffing study. In this study, Abt researchers completed a review of the relevant literature on nurse staffing and quality of care through 1999. We gathered reports using Internet search engines and searched federal and state web sites, web sites of nursing home advocacy organizations, and online services such as Medline. The literature review also includes conference proceedings from the last three years on state nursing staff standards, CMS Phase I and Phase II staffing studies, and studies completed in the last three years on state-initiated staffing standard activities. To categorize states by type of minimum nursing staff ratio and the date the ratio was established, we reviewed the state code or authorizing language when available and contacted state officials by telephone to update state information. When state code or authorizing language was not available, staff used information from the literature.

From the literature review, we identified 36 states with established minimum ratios in 2003, with the District of Columbia scheduled to implement its ratios in 2005. Another group of 23 states were identified as having made major changes to their staffing ratios since 1997. A change was defined as one of three different actions: instituting a new staffing ratio, or modifying or eliminating an existing ratio. We assumed that if we considered changes that took place before 1997, we risked failing to find state officials or key stakeholders who were familiar with the change and the circumstances under which it was conceived and implemented. A matrix summarizing states' nursing staff ratios appears in appendix 2.

We chose 10 of these 23 states in which to conduct case studies. Since we wanted to examine the full range of state actions regarding staffing ratios, we chose states representing each of the three types of changes in staffing ratios mentioned above. We also focused on states that independently collected some type of data on nursing staff to investigate any quantitative evidence about the efficacy of staffing ratios. To understand how state experiences might vary across the country, we chose states that varied by size and geographic region. Based on these criteria, we chose the following states: Arkansas, Arizona, California, Delaware, Minnesota, Missouri, Nevada, Ohio, Vermont, and Wisconsin. Of these states, Vermont instituted new staffing ratios; Arkansas, California, Delaware, Minnesota, Ohio, and Wisconsin modified existing ratios; and Arizona, Missouri, and Nevada eliminated their ratios.

The primary research method we used in the case studies was guided discussions with a set of state officials and key stakeholders in each state to obtain the perspective of those affected by the nursing staff standards--consumers, nursing homes, and their employees. In each state, we first contacted the nursing home ombudsman, who helped us identify state licensure officials as well as consumer advocates and worker representatives. We identified state nursing home representatives through the American Health Care Association and the American Association of Homes and Services for the Aging, the two largest national associations representing the nursing home industry. As the research progressed, we found that nursing staff ratio changes were frequently linked with changes in Medicaid nursing home reimbursement, so we asked state licensure officials to provide us with contact information for the appropriate state payment officials.

We telephoned each discussant to describe the project and sent each a brief project description and a copy of the discussion guide that we planned to use during the telephone discussion. We also assured discussants that we would not identify or quote anyone by name. We produced detailed summaries of each discussion for later analysis.

In eight of the 10 states, discussions were held with most state officials and key stakeholders for a total of 8 ombudsmen, 8 state licensure officials, 7 state Medicaid reimbursement officials, 5 other state officials³, 8 consumer advocates, 1 worker representative, 1 researcher, and 15 nursing home representatives. We were not able to hold a sufficient number of discussions in Arizona and Nevada, both of which had eliminated their ratios, to include these states in the analysis. In Arizona, key state officials had no knowledge of eliminating their minimum staffing ratios, while stakeholders told us they had come into their positions after the state eliminated its ratio in 1997, and in Nevada state officials were not available for interviews. However, in the latter state we were able to hold a discussion with one key stakeholder who provided us with some insight (see discussion below) into why this state eliminated its staffing ratio. The standard discussion guides that we used for our discussions with state officials and key stakeholders appear in appendix 3.

FINDINGS

This section reports findings in two parts: (1) the status of state staffing ratios as they existed in early 2003 and (2) findings from the eight case study states. Observations obtained from the stakeholder in Nevada are noted when appropriate.

1. Status of State Nursing Staff Ratios in 2003

Our review of the recent literature and available state administrative or regulatory code for minimum nursing staff ratios in nursing homes identified 36 states with such ratios. These states' ratios are expressed as either hours per resident day (hprd) or as a ratio of staff to residents or staff to beds; in some cases, both formulations are used. An hprd is defined as the minimum number of hours of direct nursing care for each resident, each day; a staff-to-resident ratio is the minimum number of full-time employees (FTEs) for each resident; and a staff-to-bed ratio is the minimum number of FTEs for each nursing home bed.

The remaining 14 states and the District of Columbia (until 2005) either (1) use the federal nursing staff requirements when surveying nursing homes that wish to be certified for participation in Medicare or Medicaid (i.e., having a minimum of eight hours per day of RN service and 24 hours per day of LN service, and sufficient staff to attain or maintain the highest practicable ... well-being of each resident), or (2) have state professional coverage standards for nursing home licensure that are similar to or exceed the federal requirements. Hawaii is an example of a state that exceeds the federal requirements because it requires one RN on duty at all times. These professional coverage standards (those described in item 2) are not the focus of this study.

Minimum State Nursing Staff Ratios Differ across States

While a majority of states have established minimum nursing staff ratios for nursing homes, these standards are quite complex and differ markedly across the states. Differences include the type of staff to whom the ratios apply, as well as differences in the ratios and the facilities to which they apply. States set their standards in different forms. For example, California requires 3.2 hours of direct care per resident day while Maine maintains a direct care staff-to-resident ratio of 1 to 5 during the day, 1 to 10 in the evening, and 1 to 15 at night. Among the 36 states with minimum nursing staff ratio standards, 21 states express the ratio only as hours per resident day (California, Colorado, Connecticut, Georgia, Idaho, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Minnesota, Mississippi, New Jersey, New Mexico, North Carolina, Tennessee, Utah, Vermont, West Virginia, Wisconsin, and Wyoming). Four express their standard only as a staff-to-resident ratio (Arkansas, Maine, Oregon, and South Carolina). Nine have standards expressed as both hours per resident day and a staff-to-resident ratio (Delaware, Florida, Kansas, Maryland, Michigan, Ohio, Oklahoma, Pennsylvania, and Texas). Alaska expresses the requirement as a staff-to-occupied-bed ratio, while Montana's requirement is based on the number of beds, occupied or not.

In some states with more than one type of ratio, one form may be translated into the other. For example, Texas requires 0.4 hours of licensed care staff per resident per day or a 1 to 20 licensed nurse-to-resident ratio every 24 hours. In other states with more than one ratio standard, one form is in addition to the other. In 2001, Ohio added a standard of 2.75 hours of direct care per resident to complement its 1-to-15 direct care staff-to-resident ratio.

State minimum staffing ratios also differ in other ways. Ratios can vary by facility size or type, such as an intermediate care facility versus a skilled nursing facility. State definitions of these facilities differ, but skilled nursing facilities generally care for residents with more medically related needs. Other variation in standards occurs by personnel group, such as (1) licensed staff (RN, LPN, or licensed vocational nurse [LVN]), (2) nonlicensed staff (CNAs), or (3) other staff who may provide direct care, such as an activities coordinator or therapy aide. The period of time over which the ratio is calculated may also differ. Some states average staff over a week, others over a 24-hour period, and others by shift or time of day (e.g., days versus evenings). Due to the number of dimensions in which ratios can vary, there is little consistency across states in how the ratios are expressed, and direct comparisons across states should be made with caution. Connecticut, for example, has ratios that vary by shift, staff type, and nursing facility licensure category, including Medicare and Medicaid certified nursing facilities, with eight separate nursing staff ratios depending on a facility's licensure category (chronic/convalescent home versus rest home with nursing supervision), whether a staff person is licensed or unlicensed, and the shift. The ratios for chronic/convalescent homes, for example, are 0.47 hprd (days) and 0.17 hprd (nights) for licensed staff, and 1.4 hprd (days) and 0.5 hprd (nights) for direct care staff. The hprd requirements for a rest home with nursing supervision are about half those required for chronic/convalescent homes by shift and staff type.

Most states with minimum nursing staff ratios established their current standards in the past decade. Twelve states (Arkansas, California, Delaware, Florida, Iowa, Maine, Minnesota, Mississippi, New Mexico, Ohio, Oklahoma, and Vermont) established their current standards in the year 2000 or later. Sixteen states (Alaska, Georgia, Indiana, Kansas, Louisiana, Maryland, Massachusetts, New Jersey, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Utah, West Virginia, and Wisconsin) established their standard in the 1990s; seven states (Colorado, Connecticut, Idaho, Illinois, Michigan, Montana, and Tennessee) in the 1980s; and one state (Wyoming) in the 1970s.

Three states (Arizona, Missouri, and Nevada) previously had staffing ratios but no longer do. The District of Columbia will implement its standard in 2005. Eleven other states (Alabama, Hawaii, Kentucky, Nebraska, New Hampshire, New York, North Dakota, Rhode Island, South Dakota, Virginia, and Washington) do not have staffing ratios. At a minimum, these states and the District rely on the federal requirements for "sufficient staff" and eight hours per day of RN service and 24 hours per day of LN service.

2. Case Study Findings

Although we were able to obtain information about the basic structure of state staffing requirements from the literature review, many questions about how states implement, monitor, and enforce these requirements were not addressed in the literature. The case studies shed some light on the following issues:

• History and evolution of staffing ratios in the states
• Structure of the ratios
• Monitoring and enforcement of compliance with staffing ratios
• Cost of monitoring ratios
• State data collection efforts
• Observer opinion on outcomes associated with ratios
• Implementation issues
• Related staffing initiatives
• Cost and financing of staffing ratios.

For states that rescinded their ratios, in addition to the topics listed above we examined the reasons behind the change and the perceived effect on staffing and quality. A detailed summary of the findings from each state's case study appears in appendix 4, and three tables summarizing the information underlying the following cross-state comparison appear in appendix 5.

Evolution of Staffing Ratios

All of the case study states except Vermont had some form of state staffing ratio in place prior to the implementation of their current standard. Vermont had eliminated its earlier ratio in 1997. The older staffing ratios had been in place, in some cases, for several decades, and discussants often viewed them as having been too low to affect staffing or quality in any appreciable way. In all but two of the eight case study states that have modified their ratios, the new ratios represent an increase in the required staffing level. Minnesota eliminated its case-mix adjusted ratio because it was incompatible with the state's move to a new case-mix reimbursement system; however, it maintained an hprd standard that is not adjusted for resident case mix. Missouri eliminated its preexisting ratio.

While the details differ by state, the recent increases in state staffing ratios were typically made in reaction to publicity about quality problems in nursing homes and with the goal of improving the quality of resident care in nursing facilities. Advocacy groups were frequently involved in promoting state action in response to the publicity. Arkansas had experienced high-profile lawsuits concerning nursing home quality, and California has been the subject of some highly negative reviews by the federal General Accounting Office. A state senator in Delaware led that state's effort to change ratios because of the problems his father had experienced in nursing facilities. In Ohio and Wisconsin, state officials responded to a stream of consumer complaints about inadequate staffing, and in Vermont, union-sponsored organizing activity was instrumental in generating support for that state's new ratio.

The study states that rescinded their ratios--Arizona, Missouri, and Nevada--each had different reasons for the change. Like Minnesota, Nevada is also changing its reimbursement system and has eliminated staffing ratios that existed for Medicaid-certified facilities. Consumer advocates were influential in eliminating Missouri's ratio because they believed that it was not having the desired effect on staffing or quality. A range of observers there noted that, in their opinion, some facilities provided good care while not meeting the ratio, while poor-quality facilities successfully defended themselves against staffing citations by citing their compliance with the state's then-established staffing ratio. A staffing standard remains part of Missouri's fire and safety code. However, this standard is not specific to nursing staff. Instead, the current ratio applies to all nursing home personnel. We were unable to find any information on Arizona's change because observers in that state were not familiar with the circumstances under which the ratio was rescinded.

Staffing ratios can be implemented in different ways, including through passage of new legislation, as part of new regulations, or as changes to written administrative policy or procedures or the Medicaid reimbursement structure. Often, the history of the ratios and the state authority establishing the ratios affect the evolution of the ratio. In Delaware, the minimum requirement was established through passage of Senate Bill 115, also know as "Eagle's Law." California's 3.2 hprd also resulted from a change in the law. However, this same law authorized the Department of Health to establish staff-to-resident ratios in regulation, and incorporated an accompanying change in Medicaid reimbursement. In contrast, in Ohio the ratio was implemented as part of a routine five-year review of all nursing home licensure requirements. These distinctions are important because the state authority establishing the ratio affects how easy it is to modify or eliminate. Arizona's requirement existed in written state policy.⁴ Therefore elimination did not require passage of legislation or new regulation.

Ratios' Structure

The case study states use an hprd standard, a staff-to-resident ratio, or both mechanisms. Two of the states with staff-to-resident ratios--Arkansas and Delaware--have standards that vary by time of day. This time-specific variation was instituted because of consumer complaints about short staffing during nights or evenings, even while facilities may have met the previously required state-established ratios. In neither of these states do the ratios take into account resident case mix. Delaware attempted to develop an acuity-based staff-to-resident ratio based on the care needs of the residents but found that the resulting scheme would have been too complex to administer.

Consumer advocates and nursing home ombudsmen tend to favor staff-to-resident ratios, saying that this type of standard is easier for consumers to understand and thus easier for them to determine whether a nursing home is in or not in compliance. Advocates and some state officials also say that a staff-to-resident ratio that varies by shift is preferable to the hprd approach because the former is easier to administer and helps ensure adequate coverage for an entire day. Facilities, on the other hand, generally prefer the flexibility that an hprd standard allows. Provider representatives point out that a staff-to-resident ratio with a one-size-fits-all approach fails to address differences in the configuration of a facility's physical structure and local labor market conditions. For example, if a facility has several wings with 20 residents each, a 1-to-15 staff-to-resident ratio may be difficult to meet. And facilities in rural areas, where transportation and day care arrangements may be inadequate, sometimes find it very difficult to find staff for evening, night, or weekend shifts.

Two of the study states--Ohio and Missouri--have or had long-standing staff-to-resident ratios that did not vary by shift. Ohio's standard has existed since 1972, while Missouri first established its ratio in the 1950s but dropped it in 1998. Wisconsin also dropped its staff-to-resident ratio but replaced it with a case-mix adjusted hprd in 1998, in response to consumer complaints about inadequate staffing.

Six of the study states use an hprd approach, with the level set at around 3.0 hprd. These states currently fall into two categories: (1) hprd-only in California, Minnesota, and Vermont; and (2) hprd and a staff-to-resident ratio in Delaware, Ohio, and Wisconsin. Those states using hprd only have chosen this form largely in response to industry concerns about the perceived rigidity of the staff-to-resident approach. The California legislature has directed the Department of Health to devise a staff-to-resident ratio that can be translated into its 3.2 hprd by 2005. This combination presumably would help meet advocates' need for clarity of the standard and providers' need for a more flexible system. Some officials in those states with a combination of standards believe that adds to a system's complexity.

Only two states--Minnesota and Wisconsin--have adjusted their hprd requirements for resident case mix. Minnesota's old system was the most sophisticated of the case study states; it relied on data from the state's mandatory resident assessment instrument to assign residents to one of 11 case-mix groups. Each facility's required hprd depended upon the average case-mix weight calculated for that facility on a daily basis. Wisconsin's standard has three hprd categories (intensive skilled nursing care, skilled nursing care, and intermediate care) that are based on resident need.

Another issue is the time period over which ratios are calculated. Some observers prefer calculations over a week or more, as in Vermont, to ensure flexibility in the application of standards, whereas others prefer calculations over a 24-hour period to ensure adequate staffing on all days, particularly weekends. Yet another set of observers would like calculations by shift to help ensure sufficient staffing at night. Five of the six study states with the hprd have opted to calculate compliance over a 24-hour period.

Most states have separate requirements for licensed nurses and direct care workers. Licensed nurses are generally defined as RNs or LPNs, and direct care workers are defined as staff that provide direct care, generally CNAs, but they can also be licensed nurses. Ohio allows the hours of a wide range of staff to be counted, including activity aides, therapists, and social workers. In all but one of the study states, contract or temporary staff are considered the same as permanent staff. The only state that places a restriction on counting temporary staff's time is California, which requires that these workers have eight hours of orientation to the facility before their hours can be counted toward the hprd.

Most of the study states do not allow waivers of the direct care staffing requirements. However, some states do allow waivers of the licensed nursing staff under limited conditions; facilities generally must demonstrate that they have made serious recruitment efforts. State officials and most stakeholders told us that such waivers are rarely granted in those states that allow them.

In summary, there is considerable variation across the case study states in terms of the type of ratio used, whether the ratio is adjusted for case mix, the time period over which the ratio is measured, and the type of staffing hours that can be counted toward meeting the ratio.

Monitoring and Enforcing Ratios

States generally rely on the state licensing process for the monitoring and enforcement of staffing ratios because meeting the minimum ratios is part of state nursing home licensure and regulatory requirements. During the licensure and certification survey, most states' surveyors take a sample of staff schedules, time sheets, or payroll records to determine facility compliance. States vary in which time period is chosen for the sample. Some states select a random period or the time period immediately preceding the survey. Random selection of a time period and reliance on payroll records is considered more likely to produce data typical of the facility's staffing levels. Two states, Arkansas and Vermont, also periodically review monthly staffing data submitted by facilities in addition to the state survey process. Arkansas requires facilities to submit monthly staffing reports that are desk-reviewed. Site visits are conducted if it appears that a facility has violated the ratios. Vermont requires nursing facilities to submit monthly data on staffing in a uniform format. These reports are audited periodically, with state surveyors comparing payroll records against the facilities' reports to determine their accuracy. Most states also monitor staffing when investigating any complaints about poor quality of care that may be related to insufficient staffing.

Two states have a screening process to determine whether to pull staffing records. Ohio uses a screening tool to see if facilities have had any care problems that may be related to staffing; only then does the surveyor examine staffing records to determine compliance with the state's ratio. California examines nursing staff levels when surveyors' findings indicate that staffing may be inadequate. Missouri followed a similar pattern for monitoring its old ratio.

In most states, the data that surveyors collect typically go into an electronic spreadsheet that calculates whether facilities comply with that state's ratio. If a facility is not in compliance and the problem is not severe or has not resulted in serious harm to residents, the nursing home receives a deficiency citation and is generally required to submit a plan of correction. If harm is serious or the problem persistent, more severe remedies are available in most case study states, including directed plans of correction, fines, and restrictions on new admissions. The study states generally did not provide information on the frequency and severity of sanctions.

Information on the cost of monitoring facility compliance was scanty. When asked about these costs, most states replied that costs are minimal or unknown.

State Data Collection

All of the eight study states have some form of data collection, although the data elements, the years for which data are available, and the availability of the data for outside users vary across the states. California, for example, reports on productive hours by type of staff (nursing category as well as permanent versus contract staff) as well as turnover rates by facility. In contrast, Delaware has only total salary cost for nurses from the Medicaid nursing home cost report; however, the state has data on wages and hours by nursing category (with contract staff reported separately) from the annual Nursing Wage Survey it conducts for reimbursement purposes. The state of Arkansas collects per-shift staffing data broken out by direct care staff and licensed staff, and resident daily census. This requirement has been in place since November 2001and the data are self-reported. Some states audit their data, while others do not, so quality and consistency may vary across states and even across years within states.

The data most often come from Medicaid cost reports but in Wisconsin and Delaware there are also data from an annual survey of facilities, and Arkansas and Vermont collect data from the monthly staffing reports that facilities submit. California has the most extensive and most readily available data, derived from an annual report that merges Medicaid cost reporting with a state public disclosure report. California data are posted on the state's web site and are freely available. However, the state does not regularly analyze the data. Wisconsin, on the other hand, produces annual reports on staff levels, turnover, and retention and provides average data for similarly sized facilities so that consumers can make relevant comparisons. It also reports deficiencies. Vermont makes data from its monthly staffing reports available to the local nursing home association for distribution to its members. The data include total wages and benefits as well as average hourly wages and benefits by category of staff. Missouri has Medicaid cost report data from 1990. The University of Missouri has a longitudinal dataset of Medicaid cost report data dating back to 1990. University staff are able to run analyses and trend data such as nursing staff hours per patient day.

Outcomes Associated with Ratios

Most states have done little analysis to determine the outcome of their ratios, either with regard to the level of staffing or the effect on quality, and state officials and observers differ in their opinions about what the effects have been. State officials tended to say, and the data from California and Wisconsin support the contention, that the implementation or strengthening of a staffing ratio has resulted in increased staffing in nursing facilities overall. Prior to implementation in 2000, California data show that 25 percent of facilities were staffing at or above 3.2 hprd in 1999. By 2001, that number had risen to 67 percent, based on a sample of 111 facilities.⁵ Wisconsin data show that the average hprd increased from 3.2 in 1998/1999 to 3.4 in 2002; during the same time period, citations for staffing ratio violations increased. The reason for the increase in citations is unclear.^{6, 7} An independent consultant's review of the effects of Delaware's Phase I ratios found a statistically significant relationship between the newly required staffing levels and fewer incidents of poor-quality care as measured by quality indicators from CMS OSCAR data.⁸ It is important to note that it can be difficult to relate changes in quality to trends in deficiency citations because many factors can affect citations, including increased administrative focus on certain care areas (e.g., nutrition and hydration), training provided to surveyors on citation practices, and so on.

Advocates and ombudsmen generally say either that it is too early to tell whether ratio changes have had any effect on staffing or quality or that there has been no effect. Most providers said that most facilities in the state were already staffing above the new ratios so there has been no effect. Both the consumer and provider points of view tend to support the contention that these ratios serve as a minimum bar for facilities, not a standard that most need to strive to reach. Interestingly, most stakeholders agreed that when Missouri eliminated its staffing ratio, staffing and quality did not change as a result. In fact, some discussants suggested that the number of citations for staffing-related quality-of-care problems in Missouri had increased, not because there were more quality problems but because it was easier to cite staffing problems under the federal standard of having "sufficient staff" than under the old staff-to-resident ratio.

A state licensure official in one state said that while staffing levels in facilities had not changed appreciably since implementation of the ratios, coverage during nights and weekends had improved because facilities shifted their staff coverage from days to nights and weekends. Such shifts could be one explanation for the contention that overall staffing has changed little in the opinions of most advocates and industry representatives. It is also possible that such shifts in staff coverage could improve the quality of care in the previously understaffed periods. However, it is unknown what, if any, impact on quality might occur during hours for which staffing coverage is reduced as a result of moving staff from one shift to another.

Implementation Issues

Although a few advocates complained of lax enforcement and a few providers complained of inadequate reimbursement, for the most part, the implementation of new ratios in three states ran relatively smoothly. These states--California, Ohio, and Wisconsin--had made incremental changes to their existing ratios.

Those states where implementation was problematic include Arkansas, Delaware, and Vermont. These states made more comprehensive changes to staffing requirements, involving phase-in periods, implementing standards by shift, or implementing a new system altogether, as in Vermont. Implementation of the reporting requirements in Vermont (i.e., nursing homes submitting uniform monthly staffing data and the periodic auditing of it) appears to have been difficult. State officials reacted by simplifying the format and providing assistance to facilities that requested it on how to complete the monthly staffing report.

State budget problems affected the implementation of ratios that were phased in and accompanied by increases in Medicaid reimbursement for nursing facilities. In Arkansas, Phase II of its three-tier, phased-in ratio was delayed and Phase III was postponed due to budgetary problems but implemented on October 1, 2003. Delaware's budget problems also led to an indefinite postponement of Phase III of its implementation, and Phase II ratios were modified because providers complained of a labor shortage.

Surprisingly, labor shortages for CNAs were not seen as critical issues in most states. Some stakeholders speculated that the economic downturn in 2002 and 2003 has led to a larger labor supply for such entry-level positions. However, stakeholders noted shortages of CNAs in certain rural and urban areas where recruitment was difficult. In Vermont, the problem in rural areas relates to a small labor pool. In California, some urban areas reportedly have difficulty recruiting CNAs because of the high cost of living.

Most providers reported that a licensed nurse shortage continues to be somewhat problematic for their facilities but does not appear to have affected their ability to comply with the ratios for this type of profession.

States reported mixed views on whether the use of agency personnel increased as a direct result of increases in minimum staffing ratios, with Delaware and Vermont reporting more agency usage. However, a facility's use of agency staff may be driven by local labor market conditions and competition for labor.

Neither the nursing shortage nor state budget problems were cited as reasons for the actions that Minnesota and Missouri took to rescind their staffing ratios.

Related Staffing Initiatives

Increased Medicaid nursing home reimbursement generally accompanied increased state staffing requirements in the case study states. The states either used some form of bed tax or quality improvement fee to generate increased Medicaid revenue, which they then passed back to facilities to help facilities pay their labor costs, or they implemented wage pass-throughs designed to require facilities to spend the increased funding on staffing. Surprisingly, some of the states did not measure whether the funding was spent as intended. California monitored the use of the pass-through funds and facilities that did not use the funds for staffing were required to return them and pay an additional 10 percent of the amount as a penalty. According to Vermont state officials, the two wage pass-throughs had no observed effect on staffing levels.

Many of the case study states have also undertaken various special studies or programs to examine issues such as staffing shortages and recruitment and retention in their long-term care labor market and provide recommendations to address these problems. Two programs merit particular attention. Minnesota gave facilities funding to start scholarship programs for staff to increase their training; the funding could be used for complementary needs such as child care as well as for tuition payments. Missouri has the Quality Improvement Program of Missouri, which is a technical assistance program run as a partnership between the Missouri Department of Health and Senior Services and the University of Missouri. The goal of the program is to help nursing facilities use data from assessments of residents to improve resident outcomes. The assistance includes confidential on-site consultations on the best use of staff to maximize the quality of care residents receive. More than half of Missouri's nursing facilities have received at least one such consultation.

DISCUSSION AND SUMMARY

Several conclusions can be drawn from our discussions with state officials and key stakeholders. First, most observers agreed that minimum ratios can help impose a standard on those facilities that have inadequate staffing. These observers also emphasized that facility staffing is not the only factor affecting the quality of care that nursing home residents receive. Other factors, such as staff training and facility management, also affect quality.

When asked for recommendations and lessons learned, very few stakeholders called for national standards. States can develop their own ratios through negotiations among the key stakeholders and state officials. When these negotiations occur, there is substantial disagreement between advocates and the industry over the form these ratios should take--staff-to-resident ratios or hprds--with advocates generally arguing for the former on the grounds of clarity of standard and the industry arguing for the flexibility inherent in the latter. Delaware has settled the issue by adopting both approaches, which is a compromise that adds to the complexity of the system.

Most observers agreed that adjusting the ratios to take into account facility case mix would be important but recognized that this would add more complexity to the ratios. Furthermore, few had any suggestions about the form a case-mix adjustment should take. Minnesota had a case-mix adjusted ratio and is studying how to implement a new one to accompany its new case-mix reimbursement system. The outcome of this state's study could shed some light on this particular aspect of ratios.

In addition to the variation in ratios, we saw variation across the states in how the standards were enforced, and observers had contradictory comments about the interplay of federal and state staffing standards. In some states, observers asserted that poor-quality facilities could use compliance with a state staffing ratio as a defense when they were cited under the federal staffing requirements for failing to provide "sufficient staff." In other states, observers said that it is easier to cite facilities for inadequate staff when there is a numerical standard against which to judge them.

We did not find any quantitative evidence that definitively linked improvements in quality to changes in a state's staffing ratio. Most respondents were unwilling even to speculate on whether an effect could be found in the data. There are documented limitations associated with survey deficiency data (OSCAR data) and the nursing home minimum data set (MDS) data from which quality indicators and measures are calculated. Most of the study states collect staffing data but these data are not generally designed nor have they been used for the purpose of assessing changes in quality at the facility level.

It might be possible in some states to link the state staffing data to deficiency data but the problem of how to interpret any changes in deficiency citations would remain. Specifically, in most states, change in the staffing standard came about as a result of negative publicity about the quality of care in nursing facilities. The increased attention to the issue of quality could have spurred surveyors to document deficiencies that might otherwise have been overlooked or addressed without official sanction. In addition, as mentioned, increased administrative attention to selected care areas may increase deficiency citations in those areas.

In the states we have studied, increasing staffing requirements generally involves increasing Medicaid payment to nursing homes, through a variety of mechanisms. While state budget shortfalls have delayed implementation of phased-in ratios, it is not clear how much additional reimbursement facilities need to meet the new standards. If most facilities are already staffing at or above the required level, additional funds would not necessarily be needed to meet new state minimum staffing requirements. For example, Ohio set aside $13 million in state fiscal year 2002 to help pay for facilities' compliance with the new hprd. Only 19 facilities applied for funds through the state's cost-based reimbursement system and just $1 million in total was distributed.

An issue that often arises in public policy discussions concerning nursing home staffing ratios is how to equitably pay nursing homes for the staffing costs associated with such ratios. Equity is an important consideration because nursing homes have a range of approaches to staffing their facilities. As stated, observers reported that most nursing homes in our study states have a history of staffing at or above the state-established standard. Interestingly, in our discussions with stakeholders the issue of payment equity across facilities did not arise. However, as was seen in how states define and enforce staffing ratios, states varied in how they paid for staffing costs related to the state-established ratios. Minnesota intends to adjust its case-mix payment method for staffing costs using results from a study that measures staff time devoted to residents with varying levels of care needs. Ohio has limited staffing payment increases to those facilities that incurred additional costs when they increased staffing levels up to the state-established ratio. Arkansas and Delaware increased payments, which were linked to changes in staffing ratios, to all facilities.

Currently no clear path toward a staffing ratio acceptable to all parties exists. Considerable work will be needed to balance the interests of all stakeholders while keeping the cost of reform within the constraints of increasingly strapped state and federal budgets.

In summary, some of the critical details that would have to be worked out and for which we found considerable variation across the study states include the following:

• Type of ratio
• Type of staff counted toward meeting the ratio
• Adjustment for case mix
• Measurement of the ratio
• Monitoring and enforcement of the ratio
• Payment for ratios

Even if all these details could be worked out, it is hard to say what effect a ratio will have once it is in place. It is plausible that ratios serve effectively as a minimum boundary for those facilities that previously have not provided staffing at the level the new ratio requires. Further, depending on the type of ratio, ratios could result in a redistribution of existing staff across shifts, potentially improving care on some shifts while negatively affecting care on others. It is also likely that the desirable minimum boundary moves over time as the type of residents changes over time.

Staffing standards are generally not enacted or increased in a policy vacuum but, rather, may be just one tool policymakers use to try to improve nursing home quality in the state. Many of the study states put in place other quality initiatives at the same time they changed their ratio. Observers generally agree that teasing out the effects of staffing ratios, when implementation was accompanied by other quality improvements or increased reimbursement, would be very difficult, if not impossible.

Finally, it is important that attention to the number of staff not divert attention from other important staffing and quality initiatives. Reports of facilities that were staffing above the state-mandated minimums but still providing substandard care and, conversely, facilities with clearly superior care but only average levels of staffing provide evidence, albeit anecdotal, that our understanding of the relationship between staffing and quality of care is still incomplete. While there was near-universal agreement among discussants that quality and staffing were related, there was similar agreement that the number of staff alone does not determine quality.

NOTES

1. The full text of the letter can be accessed at www.cms.hhs.gov/medicaid/reports/rp1201ltr.asp.

2. An annotated literature review appears in "State Experiences with Minimum Nursing Staff Ratios for Nursing Facilities: Findings from the Research to Date and a Case Study Proposal" (February 2003). The full report can be accessed at http://aspe.hhs.gov/daltcp/whatsnew.shtml#sep2003. [Full Report]

3. Other state officials include Department of Health staff involved in compiling and reporting data and policy analysis.

4. Charlene Harrington. Nursing Home Staffing Standards in State Statutes and Regulations. Kaiser Commission on Medicaid and the Uninsured. San Francisco, CA: University of California, May 2001.

5. Department of Health Services' Licensing and Certification Program. Nursing Staff Requirements and the Quality of Nursing Home Care: A Report to the California Legislature. Sacramento, CA: California Department of Health Services' Licensing and Certification Program, June 2001.

6. Wisconsin Department of Health and Family Services, Division of Health Care Financing, Bureau of Health Information, Trends in Wisconsin Nursing Homes 1990-1999 (PHC 5308). October 2001.

7. Wisconsin Department of Health and Family Services, Division of Health Care Financing, Bureau of Health Information, Wisconsin Nursing Homes and Residents, 2001 (PHC 5347). December 2002.

8. Delaware Nursing Home Residents Quality Assurance Commission. Efficacy of Minimum Nursing Staffing Levels Required under Eagle's Law: Quality of Care, Labor Trends, and Nursing Home Cost and Availability. December 2001.

APPENDIX 1. LETTER FROM DHHS

March 19, 2002

The Honorable J. Dennis Hastert
Speaker of the House of Representatives
Washington, D.C. 20510

Dear Mr. Speaker:

As required by the Omnibus Budget Reconciliation Act of 1990, a study was performed on the appropriateness of establishing minimum staffing ratios in nursing homes. The enclosed study reflects the conclusions of Abt Associates, Inc., which prepared the work under a contractual relationship begun by the previous administration in 1998.

This Phase II study was designed to respond to the current public concern about inadequate nursing home staffing and a long-standing requirement for a study and report to Congress on the "appropriateness" of establishing minimum nurse staffing ratios in nursing homes. As you know, the Phase I report was delivered to Congress in July 2000.

The question of the relationship between the number of staff and quality of care is complex and the Phase I and Phase II studies made good faith efforts at addressing the question. However, the Department has concluded that these studies are insufficient for determining the appropriateness of staffing ratios in a number of respects. Specifically, we have serious reservations about the reliability of staffing data at the nursing home level and with the feasibility of establishing staff ratios to improve quality given the variety of quality measures used and the perpetual shifting of such measures.

In addition, the studies do not fully address important related issues such as:

• the relative importance of other factors, such as management, tenure, and training of staff, in determining nursing home quality;
• the reality of current nursing shortages; and
• other operational details such as the difference between new nurses and experienced nurses, staff mix, retention and turnover rates, staff organization, etc.

For these reasons and others, it would be improper to conclude that the staffing thresholds described in this Phase II study should be used as staffing standards. Most important, the Phase I and Phase II studies do not provide enough information to address the question posed by Congress regarding the appropriateness of establishing minimum ratios. We will continue to work to address critical knowledge gaps. For example, one project that we are currently funding will develop a method to more accurately collect nurse-staffing information. Apart from this report, the Department has taken and continues to take several important actions toward fulfilling this Administration's commitment to achieving high-quality nursing home care and providing reliable, understandable information to the public. Last November, we announced an initiative that will help Medicare and Medicaid beneficiaries find those nursing homes that consistently provide high-quality care using risk-adjusted, valid quality measures. Under the initiative, CMS is developing reliable, straightforward information on the quality of nursing homes, to help beneficiaries find the best facility for their needs. In order to accomplish this, CMS is conducting a pilot program in six states using Quality Improvement Organizations (QIOs), formerly known as Peer Review Organizations, to help disseminate and publish this information. The six states in the pilot program are Colorado, Florida, Maryland, Ohio, Rhode Island, and Washington. Following successful implementation of the pilot project, CMS will refine and expand the initiative to provide risk-adjusted quality information for nursing homes in every state. Importantly, the QIOs will work with the nursing home industry on quality improvement efforts based on the publicly reported measures and will actively help people to better use quality information.

While we implement this nursing home quality initiative, CMS will continue to move forward with our Nursing Home Oversight Improvement Program. This program is a multi-pronged approach designed to improve our oversight of nursing homes and to build consistency and accountability into the survey and certification process. The Nursing Home Data Compendium for 2000 that we recently forwarded to Congress is a direct result of this initiative: This report, the first comprehensive aggregation of individual-level data will serve as a valuable resource for policy makers concerned with nursing home care.

I look forward to working closely with you as we strive to improve nursing home quality in America. I am also sending a copy of this report to other Congressional leaders.

Sincerely,

Tommy G. Thompson

Enclosures

APPENDIX 2. OVERVIEW OF STATE'S NURSING HOME NURSE STAFFING STANDARDS

APPENDIX 3. DISCUSSION GUIDE FOR STATE OFFICIALS

Discussion Guide for State Officials

Description of Ratios

1. Our research revealed the following information about your state's nursing staff ratios; is this information correct? By nursing staff ratio we mean any nursing staff standard that is expressed in the form of an hour to resident day (hprd), staff-to-resident, or staff-to-bed.

Implementation of Ratios

1. What were the state's goals when it set its ratios and what factors influenced the state's decision? Factors might include:
   • Quality issues
   • Cost issues

   • Consumer and provider advocacy

2. What factors influenced the state's choice of ratio type (i.e., hprd, staff-to-resident, or staff-to-bed) and level?

3. How does the state measure whether its goals were achieved?

4. In your opinion, what factors have affected implementation of staffing ratios? Factors might include:
   • Nursing home quality
   • Nursing home payments
   • State budgetary situations

   • Labor shortages

5. Has your state taken into account the following factors when implementing ratios?
   • Resident case-mix?
   • Experience and training of staff?
   • Turnover of staff ?

   • Innovative models (e.g., Wellspring, the Eden Alternative)?

6. When were the ratios actually implemented?

Monitoring and Enforcing Ratios

1. How does your state monitor and enforce the staffing ratios? Please address the following:
   • Measurement of staffing level. What types of personnel are counted? Are staff counted by category or aggregated, or counted by shift? How frequently are staff counted and for what period of time?
   • Use of waivers. Are waivers permitted? If so, what criteria are used to grant them and how long can waivers remain in effect? Does the state collect data on the waivers?
   • Involvement of survey process
     • How do states determine whether a facility has complied with ratios?
     • Can providers use contract staff to comply?
     • What are the sanctions for non-compliance?

   • Monitoring staffing through cost reports.

2. What issues have arisen during monitoring and enforcing staffing requirements?

Other State Staffing Initiatives

1. Has your state implemented any other initiatives designed to increase staffing in nursing facilities? If so, how do these initiatives fit in with the staffing ratios? State initiatives might include:
   • Recruitment of workers
   • Increasing payment to nursing homes
   • Linking payment incentives with staffing levels
   • Wage-pass-throughs

   • Training and career ladders for workers

2. If your state uses payment incentives to increase staffing, how are these payments structured and what are their costs to the state Medicaid program?

Lesson Learned from Staffing Ratios

1. What are your opinions about the outcomes of the staffing ratios? How has a change in staffing ratios affected the following:
   • Staffing in nursing homes
   • Provider use of agency personnel
   • Quality of care

   • Costs to providers and the state

2. Does your state have reports or data related to any of these outcomes? How does the state use reports on staffing levels?

3. Does your state collect data on nursing facility staffing either through Medicaid Cost Reports or some other state data collection effort? If so,
   • What source(s) and types of data are collected?
   • Are data available electronically and/or stored in a database?
   • Is there an independent review of this data?

   • Who is the state contact person for these data?

4. What lessons has your state learned as a result of implementing ratios?

5. Any recommendations for federal policy on staffing levels in nursing homes?

Discussion Guide for State Officials
(states that have rescinded/reduced standards)

Description of Ratios

Our research revealed the following information about your state's former nursing home nursing staff ratios established ______, rescinded ______.

Is this information correct? When were these ratios first established? [By nursing staff ratio we mean any nursing staff standard that is expressed in the form of an hour per resident day (hprd), staff-to-resident, or staff-to-bed.]

Implementation of Ratios

1. What were the state's goals when it set its ratio(s), and what factors influenced the state's decision to establish this standard? Factors might include:
   • Quality concerns
   • Cost issues

   • Consumer and/or provider advocacy

2. Which constituencies supported the implementation of the standards? Which opposed it and why?

Monitoring and Enforcing Ratios

1. How did your state monitor and enforce the staffing ratios while they were in place? Please address the following:
   • What types of personnel were counted? Were staff counted by category or aggregated; were they counted by shift? Were contract staff counted in the totals? Were any type of nursing staff or nursing activity explicitly excluded from the calculation?
   • What method was used to count staff (e.g., self-reported, in the survey process, on-site time card reviews, cost reports, other)? How frequently were staff counted and over what time period?
   • Were waivers permitted? If so, what criteria were used to grant them? How many waivers were granted?
   • What role did survey and certification or licensure personnel play in compliance?

   • What were the penalties for non-compliance?

2. What issues arose during monitoring and enforcing staffing requirements? How were these resolved?

3. Do you have an estimate of the cost to the state for administration, monitoring, and enforcement of the staffing standards?

4. While the staffing ratios were in place, how did they affect the following:
   • Staffing in nursing homes
   • Quality of care
   • Provider use of agency personnel

   • Costs to providers and the state

5. Has the state produced any reports on outcomes in these areas?

6. Does or did your state collect data on nursing facility staffing or quality either through Medicaid Cost Reports or some other state data collection effort? If so,
   • What source(s) and types of data are/were collected?
   • Are data available electronically and/or stored in a database?
   • Is/was there an independent review of this data?

   • Who is the state contact person for these data?

Change in the State Staffing Standard

1. What factors influenced the state's decision to rescind/reduce/replace this