Do Services and Staffing in Residential Care Facilities Vary With Residential Needs?. 6. Conclusions


For policy makers and consumer advocates seeking to: (1) enable individuals with long-term services and supports needs to remain in the community; and (2) reduce the use of nursing homes, RCFs may offer an alternative for people who cannot live independently. For RCFs to meet these objectives, the services offered and staffing provided must match the needs of the residents. To help address whether this is the case, this study used newly available data from the NSRCF--the first nationally representative survey of a broad range of RCFs--to profile RCF residents' health and functional status. It then examined 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.

The results indicate that RCF residents in both the under and over-65 age groups have high rates of some chronic conditions, although some 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 (65.7 percent), hypertension (59.1 percent), and depression (39.0 percent). Among those under 65, serious mental illness (39.1 percent), depression (26.2 percent), hypertension (39.8 percent), and intellectual and other developmental disabilities (20.3 percent) predominate. Facilities that serve exclusively individuals with severe mental illness and intellectual and developmental disabilities, which predominantly serve people under 65, were excluded from the survey and are not reflected in these estimates.

RCF residents also have substantial levels of cognitive impairment, IADL impairment, and ADL needs (measured by the amount of services received). RCF residents in both age groups also use substantial amounts of hospital, emergency room, rehabilitation facilities, and nursing home services.

Although this study found that RCF residents have high disability and dementia rates, on average, they have lower rates of chronic conditions and lower levels of ADL needs than do nursing home residents. Because the publicly reported nursing home data do not report the distribution of nursing home resident health, functional, and cognitive status, it is not possible to determine the degree of overlap between RCFs and nursing homes without further analyses.

The results suggest that residents live in facilities offering a wide range of services that reflect facility case mix. Overall, we found that 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 people with lower levels of functional and cognitive impairment. For example, our analyses found that RCF residents needing assistance with three or more ADLs and those with cognitive impairment live in facilities that offer a wider range of services, and they use more services, than residents who receive assistance with fewer ADLs and have no cognitive impairment.

Staffing adequacy is a key factor that helps to ensure quality of care for RCF residents. Our analysis found that residents with higher levels of functional and cognitive impairment were more likely to live in facilities with higher staffing levels than people with lower levels of functional and cognitive impairment. For example, on average, residents needing help with three or more ADLs live in facilities that have 2.90 hours of staffing per resident per day, compared with people with no ADL needs, who live in facilities that provide 1.8 hours of staffing per resident per day.

Consistent with other findings, RN staffing is a very small proportion of total staffing. Indeed, 45.8 percent of all residents live in facilities that do not have any RNs on staff, and about 20 percent live in facilities without any nurses--RNs or LVN/LPNs--on site. Using data collected in 1998, Hawes and colleagues showed that at the time, 71 percent of all facilities had any full or part-time licensed nurse on staff (RN or LPN), with 79.5 percent of facilities providing any care or monitoring by RNs or LVNs (Hawes et al., 2003). The absence or low availability of skilled nursing care on site may be an obstacle to addressing the health needs of RCF residents. It may also explain the emergency room use by residents under age 65.

Finally, this study examined the predictors of total direct care staffing in RCFs in a multivariate analysis 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 chain, doing so may not fully control for the large effects of including administrator direct care hours in small facilities and the correlation among variables. Direct care staffing ratios were also not related to the proportion of residents with short-term memory problems (the only measure of cognitive impairment available in the survey at the facility level). 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 facilities with or without a special dementia unit or which exclusively serve people with dementia. Finally, controlling for other available facility level factors, there is no difference in direct staffing levels between facilities that do and do not serve Medicaid residents. This analysis found no evidence that facilities serving Medicaid residents have lower staffing levels than facilities not serving Medicaid residents.

Although these analyses used the most recent and comprehensive data available on RCFs, this study has several limitations. First, the study was not explicitly designed to address questions of the adequacy of RCF services and staffing. Residents were not directly interviewed for this survey; facility staff reported resident health and functional status on the basis of their knowledge of the residents and facility records. Thus, it is not possible to determine actual level of need and whether those needs are being met; survey data on functional limitations and resident service use do not include resident perspective. In general, because the residents were not interviewed for this survey, the study is able to examine service availability and receipt, but not unmet need for services, adequacy of staffing in responding to resident needs, or resident satisfaction with level and amount of service.

Second, although state licensure requirements vary by state, the NSRCF is not designed to produce state estimates or to assess how RCFs vary by individual state. Third, staffing levels reported by facilities are not verified by any third-party source; studies of nursing find that self-reported staffing ratios are often inaccurate(Abt Associates Inc., 2001; Kash, Hawes, & Phillips, 2007). Finally, consistent with longstanding National Center for Health Statistics policy, the NSRCF is not designed to produce facility-level estimates of resident characteristics. Only a few measures are available, and these are obtained from the administrator rather than by aggregating individual resident data. Thus, the case mix variables available for our multivariate analysis of staffing ratios are limited.

In conclusion, there appears to be a relationship between resident disability levels and facility services and staffing levels. It is likely to be a combination of adjustment by facilities to the needs of residents, selection of facilities that meet their needs by residents, and 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.

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