Researchers found that scheduling CNAs regularly with the same group of teammates reduced turnover by nearly 25%. 

If nursing homes capitalize on the results of the study, it could go a long way toward cheaply and effectively addressing the nursing home staffing crisis, according to lead author Kevin Mayo, PhD, assistant professor of finance and management science at Washington State University. 

“These findings suggest that managers may be able to leverage part-time CNA scheduling to reduce turnover,” the study asserts, “improving both the quality and cost of care.”

The study also found that giving part-time CNAs one additional hour of work per week could reduce turnover by about 2%. Turnover was increased both by too few hours worked and too many, however, so facilities need to be more cautious in this regard. 

Building cohesive, consistent teams is the most important factor to consider, Mayo said, but nursing homes should consider all aspects of the study to achieve the best results. 

“By both balancing working hours and maintaining consistent teams, healthcare facilities can greatly reduce staff turnover,” Mayo told Newswise. 

Between greater scheduling consistency and tweaking hours worked, the authors estimate that facilities can save 7% of their operating costs with greater employee retention. 

Nursing homes have already felt the pressure to employ more flexible, worker-focused scheduling in response to the staffing crisis. The results of this study suggest that there are large benefits to be gained from this approach, and at very low cost.

Greater retention should also lead to higher quality of care for residents. After analysis of their data, the researchers concluded that CNA turnover had measurable negative effects on care quality that could be eliminated by increased retention. 

The study, published in the journal Manufacturing & Services Operations Management, analyzed data for more than 6,000 part-time CNAs from 157 facilities. 

Other authors included University of Cincinnati Assistant Professor Eric Webb, PhD, as well as Indiana University’s George Ball, PhD, and Kurt Bretthauer, PhD.

This is especially true in our post-acute world where only about 7% of RNs work. It can be a challenge to find and keep RNs, and there are also difficulties with LPNs, CNAs and other team members that patients need. 

Post-acute staff have been trading their low-paying yet vital roles for better-paying jobs in other industries that are less burdensome. It’s been projected that by 2026, there will be a shortage of 3.2 million people in the lower-wage ranks of the healthcare labor force. The staffing shortage is a long-term challenge. 

There are root causes of staff shortages that won’t be easily solved by business cycles or public policy. The healthcare staffing challenge can be framed as a fundamental shift that is part of our new reality. This sounds like a doom and gloom view, but I believe this shift is an opportunity to evolve and become stronger. 

Merge staff workflow and tailored software to become your fundamental answer

Collaborative teamwork becomes a resilient foundation that supersedes any individual. Team members use tailored software as the reliable footing that keeps everyone in sync and supported. Teamwork and software create efficiencies that help keep folks from wanting to find new work elsewhere. 

1. Collaborative teamwork: Many buildings are steadily seeing more patients covered by Medicare Advantage (MA) health plans. Traditional fee for service Medicare is not disappearing, but the great shift to managed care is well underway. This means our care teams need to continue implementing MDS protocols for Medicare patients while also being equally well versed in caring for MA patients. Two different workflows. 

As facilities have been slowly but steadily seeing the increase in patients covered by MA plans, a typical team naturally continues its normal MDS-centric protocols. This could pose a problem for the facility because managed care patients do not fit into the same review protocol that traditional Medicare follows. The result often is revenue slipping through the cracks.  

The best way forward is to train staff in a workflow that has managed care protocols top of mind. This workflow is more dynamic and requires daily routines that empowers staff to help the facility maximize its reimbursement for each MA patient. 

This MA-focused workflow has a bonus: It helps staff become a highly functioning interdisciplinary team. This leads to a strong team-based workflow that becomes a resilient foundation that can support the workflow when transitions occur. 

2. Tailored software: Tech that enhances people. It’s all too easy to think of workplace technology as a stand-in or replacement for people. In the context of staff shortages, I see technology as giving power to the people. A well-designed case management application serves as a never-sick, never-quits central hub that anchors the team so they’re on point, on message and always in communication with each other. This software is key when faced with higher Medicare Advantage volume and ongoing staff shortages.

Make your team more resilient to turnover AND maximize your managed care revenue

Meeting the moment in our business can feel like a hamster wheel because it seems like there’s always a moment. With staffing, I feel this is a genuine call to action moment.

Focusing on developing a resilient culture based around team workflow and investing in team-strengthening software creates a double win for two of the defining moments of our time. This solution builds resilience against staff turnover while also helping to maximize reimbursements for patients covered by managed care.   

Susie Mix, BS, MBA, NHA, is the founder and CEO of Mix Solutions Inc. She has more than 20 years of experience in the post-acute care industry. Mix has been doing managed-care consulting with facilities since 2009. She can be reached at susie@mixsolutionsinc.net.  

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

Ben Franklin famously assured us life has two guarantees. They are higher taxes and death. If Ben were alive today and owned a nursing home, he’d probably add a third: Unions will ruin everything.

Skilled care operators tend to see unions and their members as sycophants at best, predators at worst. Unions, it seems, are always demanding higher wages and better working conditions. Lofty goals, perhaps. But each can put a real strain on already tight budgets.

Unionized employees also can undermine the ability of managers to, well, manage. But perhaps most unforgivable of all, they often serve as a catalyst for more rules and regulations.

Conversely, unions generally distrust facilities for holding what might be called a cavalier attitude toward working conditions, patient care and service quality.

But could a twist in this fundamentally adversarial relationship be in the offing? As McKnight’s is reporting, new research suggests that unions might be just the medicine nursing homes need if/when staffing mandates take hold. 

A first-of-its-kind research letter published in JAMA Network Open concludes that among unionized facilities, there’s a significant drop in staff turnover. In 2021, about 17.3% of nursing homes had union representation, and the researchers found a 3.2% relative decrease in turnover in these communities. But the real kicker is this: In counties where more than 75% of nursing homes were union shops, the reduction in staff turnover was an impressive 17.1%.

Dr. Adam Dean, an associate professor at George Washington University, who led the research, stated the obvious: “Unions fight to make jobs better for workers, and that could mean higher wages and better benefits, safer working conditions … infection control policies, PPE and protection from COVID-19 during the pandemic. So in all the ways that unions fight to make jobs better, we would expect workers to stay in those jobs because they’re better jobs.”

Imagine that?

What’s interesting here is the timing of this research letter. It’s no secret staffing minimums are a hot and controversial policy matter right now. What Dean is suggesting is that if employers can see unions as partners, the result could be a win for workers, employers, and, most importantly, residents.

Those are certainly desirable outcomes. But nursing homes embracing unions? Any way you slice it, that is a very big ask.

Frankly, it’s a request many operators are unlikely to honor. Unless they have no other choice.

John O’Connor is editorial director for McKnight’s.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

Long-term care providers have a lot to be grateful for and, no, this isn’t an early start on a perfunctory Thanksgiving column.

What I mean is that nursing home operators have a lot of people at the edges of the sector who care a lot about what they are doing, and how they’re doing it. Place academic researchers at, or at least near, the top of that list.

Depending on the results, and one’s point of view, of course, that can have either really good or bad consequences.

Stepping back a bit, sometimes these incredibly intelligent teams might make you wonder what they’re making such a fuss aboutl. That could have happened with study results released just this week. The findings, in a nutshell: Higher nursing home employee turnover is probably a negative influence on patient outcomes.

Who’d have thunk it?

Well before you grab your skewers to chase down these intrepid investigators, you should know that there are also insightful nuances to the overall findings. These researchers are applying some pretty cool math to the jobs that you do. In fact, a relatively small group of degreed scientists, in various permutations, has completed numerous beneficial, scientific studies recently in this field. 

And remember, too, that none of these works have come anything close to the infamous investigations into cow flatulence. And none compare to these head-shaking actual academic investigations in recent years: “The nature of navel fluff,” “Swearing as a response to pain” and “A healthy diet will help you live longer.”

And then there’s this stunner, as reported in the New York Times: “Exercise makes our muscles work better with age.” 

Who’d have thunk it, indeed.

Luckily, the long-term care studies we’ve come across lately lay out road maps for leaders, frontline workers and government regulators.

That includes the study released this week titled “Health Care Staff Turnover and Quality of Care in Nursing Homes.” Could lots of turnover be good? Of course not.

That’s just what the researchers found. But they also quantified how damaging it could be to lose long-time or even mid-length staff.

Score one for the incumbents.

In an unexpected bonus, also score one for opponents of the controversial proposed nursing home staffing mandate. 

A member of the “turnover” study team noted to McKnight’s Long-Term Care News that findings clearly indicate that staffing mandate advocates should remember that more is not always better. More of the right kind is, however.

“We should be thinking about staffing consistency and retention just as much as overall staffing levels,” study results suggest, said Brian McGarry, PhD, one of investigation team members.

He and his colleagues were so enamored with the value of existing employees, in fact, they made a handful of recommendations that included considering bonus pay for using long-tenured staff and “increasing the prominence” of staff tenure figures and experience in Nursing Home Compare. 

The concept of quality over quantity. A winner yet again. No small thanks to a research team playing in the PhD league.

James M. Berklan is McKnight’s Executive Editor.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

With workforce shortages increasingly threatening the long-term care industry over the past decade, scientists have started looking into potential links between administrative efforts and staff resignations. 

“Often, the aspects of leadership that focus on workers in healthcare are overlooked, and we wanted to see whether worker-focused leadership was associated with turnover rates,” explained researcher Jessica Williams, an associate professor in Pennsylvania State University’s College of Health and Human Development.

Williams and colleagues discovered that leaders who prioritized worker well-being, drove accountability and provided staff with ample resources created positive working conditions and increased staff members’ willingness to stay on the job. Their study was recently published in the Journal of Post-Acute and Long-Term Care Medicine (JAMDA).

“From cleaning to providing patient care, all employees can improve the organization if given the chance to work in a safe and respectful environment,” Williams said. “Communicating the importance of worker safety, health and well-being is a great start, but must be reinforced with resources and demonstrated with actions.” 

Linking turnover

Investigators examined staff information from 495 nursing homes across California, Ohio and Massachusetts to reach their conclusions. Staff rated four statements assessing their organization’s articulation of 1) worker safety, 2) health and 3) well-being as priorities. 

Researchers chose these three factors to be determinants of successful leadership due to their presence in the Workplace Integrated Safety and Health (WISH) Assessment that measures working conditions. Two of the statements that respondents were asked to react to were: “Worker health and safety are part of the organization’s mission, vision or business objectives” and “The organization allocates enough resources, such as enough workers and money to implement policies or programs to protect and promote worker safety and health.” 

After staff members provided their responses, directors of nursing submitted the ratings to researchers. Williams and her team said facilities scoring above the median were determined to have a measure of leadership that supports worker safety, health and well-being.

After determining individual scores for each nursing home, scientists then collected worker retention rates from administrative payrolls. They determined that homes with higher leadership scores had lower unadjusted turnover rates with fewer individuals removed from the payroll.

By collecting data from payrolls and surveys within each facility, researchers were able to identify leadership as an important trait in reducing the number of nursing staff stepping down from their positions. 

It is possible for leaders to revise current leadership strategies to compel positive change, Williams told McKnight’s. She recommends the following tools for nursing leaders: 

In a recent, as-yet unpublished survey of 715 healthcare workers, professional services firm Huron asked nurses, clinicians, other staff and leaders about what they value in their workplaces and their satisfaction with those factors. The variations indicate building leaders and others in middle management roles play an outsize role in keeping nurses satisfied.

Work-life balance, feeling valued, receiving formal recognition and job flexibility were among the areas where leaders and workers showed the biggest disconnect, said Huron Managing Director and healthcare expert Craig Deao. 

“If you look at those, consistent with what Gallup and others have found, probably 70% of what people want out of their workplace are things that are actually influenced by their local leadership,” Deao told McKnight’s Long-Term Care News.

“A lot of middle managers say, ‘If it were up to me, I’d pay them all a million dollars a year, but it’s not up to me: It’s up to the board, the CEO and HR and our budgets.’ But only about 30% of the stuff that really matters to folks requires capital investment, or senior executive or HR policy, things like benefits and pay,” Huron added. “Things like feeling valued and recognized and having good communication and an empathetic leader, those are definitely under the control of management.”

Echoing a presentation he made at AHCA’s Fall Conference for CEOs and senior executive leaders in November, Deao said it’s critical for skilled nursing operators to continue investing in leadership training for mid-level managers even amid staffing and financial challenges.

The national turnover rate for all nursing home employees was an eye-popping 48.5% in 2022, up significantly from 39% in 2021. That’s a jump of more than 25%. At least one other major study put turnover of certified nurse aides at over 100%.

It’s important local managers know how to build a supportive environment and provide the less-tangible, workplace factors that today’s workers essentially demand from their employers. Many middle managers were not trained for the jobs they’ve fallen into, and may need more ongoing training and resources than in years past. But given the right tools, those managers might make a significant difference in workplace satisfaction.

“Our belief is that the heart of culture and performance is all about the skills of middle management,” Deao said. “It’s where the frontline of the leadership teams meets the staff. It’s the key role. Usually, the strategic plans are good. Up at the top, they’re trying to emulate and do those right things. But there’s a huge signal loss as those things get executed out on the frontlines of management.”

Recruitment table stakes 

The survey examined worker and leader views on 24 different job factors considered in previous worker retention studies, including child care; financial incentives; competitive salary; diversity, equity and inclusion efforts; feeling valued; workload and role alignment.

Workers said they were most satisfied with health insurance, transportation and retirement benefits; they were least satisfied with workload, scheduling flexibility, competitive salary and formal recognition, according to a preview supplied by Huron.

Deao said the results reveal opportunities that providers can seize on, particularly around increasing feedback and recognition. He recommended multi-site providers use robust employee engagement surveys so they can begin to understand the influence of softer skills and management decisions on retention.

“If your leader is having formal, touch-base conversations with you on a monthly or so basis, then you’re far more likely to feel engaged than if it’s less than quarterly,” he noted.

Calling it “table stakes” to get potential workers interested in open positions, Deao added that providers must be willing to innovate and respond to worker desires. Turnover rate has been problematic for skilled nursing anyway; new pressures make it harder to refill empty slots.

Creating an experience for workers

“The demographic game just really isn’t in our favor for the workforce. If you believe that, then you start getting much more creative in thinking about how jobs should be designed,” Deao said. “This is the time when we really have to fundamentally experiment with work redesign, changing the job from how it’s always been done, because it wasn’t always good before COVID.”

One of Deao’s health system clients was down 400 nurses and asked its other employees how they could pick up tasks to lessen burden. Housekeeping volunteered to clean rolling medication carts and linens, and transporters turned on location tracking tools that could make moving patients to in-building scheduled activities more efficient. Another client offered four-day on-site schedules for nurses; on the fifth day they now work from home and complete medication reconciliation or quality improvement work.

Surprisingly, endlessly increasing compensation doesn’t necessarily get workers to stay in a job, Deao has observed.

“We’re seeing this with the boomerangs that may have chased a higher bonus or a wage, and then realize that they’re miserable … and are coming back [because] the day-to-day experience is better,” he said.

That’s a way you can really differentiate. Create an experience where people want to spend their days, where they’re making meaningful progress on things they care about, that they’re doing the things they were trained to do, that they’re not just putting out fires all day long doing stuff that’s below their competency.”

That was trailed slightly by administrators at 52%, further proof that the turnover threat at the highest in-building levels is all too real. The 2022 findings come as regulators are putting more emphasis on staffing consistency.

The survey drew nearly 750 responses from directors of nursing, assistant directors of nursing and administrators, who sent mixed signals about job satisfaction and their willingness to remain in leadership positions at the nursing home level.

Data was collected through email solicitations over a two-week period in July and August.

Among the most positive aspects of the survey remains the meaningful nature of the work. This year, 73% of respondents said they found their work “very meaningful.” It’s still, however, a significant slide from 81% just last year. 

“DONs and administrators really like what they do. They really do love serving the residents, running the building and the mission of what they do. They don’t want to quit,” Cara Silletto, president and chief retention officer at HR consulting firm Magnet Culture, told McKnight’s. “But what I’m picking up on is that organizations continue to push these leaders beyond their limits and beyond what is sustainable long-term. That is a huge wake-up call that these organizations need to realize.”

Those thoughts were echoed by geriatrician and Regenstrief Institute researcher Kathleen Unroe, MD. She recently authored a Journal of the American Geriatrics Society editorial noting the negative effects of turnover at the administrator level. It creates a void that may be disruptive, prompt other staff to leave, and require process reorganization under a new leader, she wrote.

“The administrative team, their leadership sets the tone, creates the culture,” she told McKnight’s in August. “Their level of experience, their investment in the building is so evident when it is present. You can have all kinds of innovative, quality type programs under way, and when you have turnover in the clinical and administrative leadership, they have different priorities.”

Too much sacrifice?

Consistency may be a key goal for nursing homes, but this year’s survey indicates skilled nursing hasn’t staunched the kinds of wounds that lead workers to quit.

Just below 40% of administrators reported being “very” satisfied with their jobs, higher than the 32% among nurses. Overall, 71% of respondents said they were somewhat or very satisfied with their jobs in 2022, down from 74% in 2021.

Experts said that could be because many of them are not working at the full scope of their licenses, and they don’t get to devote much time to things they enjoy most about their work.

“Satisfaction is surveyed as (relatively) high, yet half the people surveyed pondered leaving their jobs in the last three months,” Silletto said. “The people we talk to are hitting their breaking points. There’s too much sacrifice, and their support systems are crumbling underneath them.”

Salary and workload blamed

Other Mood of the Market results indicate the numbers could be skewing lower due to salary and workload concerns.

Only 14% of nurse leaders said they were “very well paid” for the work they do. Among administrators, that share rose to 23%. Across both job categories, the portion claiming to be “very well” or “somewhat well paid” fell nearly 5 percentage points this year to 53.6%, from 58.2% in 2021. 

“That is a little bit lower than I would have thought just because so many people are giving across-the-board increases and market adjustments,” said Matt Leach, a compensation associate at Total Compensation Solutions. “Right now, the environment is, if you’re an administrator or a nurse, especially a nurse, if you feel like you’re underpaid, you can definitely get more money going somewhere else.”

That kind of thinking may drive the number of nurse leaders and administrators seriously considering quitting. But so, too, may the crushing workload of the pandemic; continued regulatory, infection control and PPE-related challenges; and a workforce shortage that has left facilities nationwide looking to fill some 223,700 openings.

Nearly two-thirds of nurse leaders told McKnight’s they were asked to do too much at work “generally” or “very much.” The 64% combined rating beats last year’s 63%. It’s also a full 10% higher than the share of administrators reporting they’re asked to do too much in 2022.

Overall, slightly more than 58% of respondents said they were asked to do too much, with 35% saying generally they were not, and just 7% saying they didn’t think that “at all.” In 2021, just under 56% said they were asked to do much.

Too much hiring

In addition to filling multiple roles within the same building or overseeing more than one building while a new leader is hired, many are often seeing one routine part of their job explode.

“The volume of employee turnover means that all of these administrators and DONs who are considered hiring managers, the recruiting portion of their current job has to take up way more time sourcing, interviewing, selecting, onboarding, training, mentoring all these new people,” Silletto said.  “How do we expect these leaders to sustain that additional workload that is not going away?” 

Leaders clearly want additional help. “More staff” edged out “higher salary” as the No. 1 way to increase job satisfaction, with 52% of survey-takers saying they would choose more staff as one of two biggest satisfaction drivers. That was down significantly from 2021’s 59%. The second-place 2022 choice was higher salary at 51% of respondents — a nearly 10-point jump since the 2021 survey.

When broken out by category, more nurse leaders chose higher salary (53%) to more staff (52%); the preference was flipped among administrators, who chose more staff most often (52%) and higher salary second most (50%).

“We’re seeing nursing homes give raises, market adjustments pretty much across the board but even with those higher salaries, they still cannot fill all of their positions,” said Leach. “I don’t think there’s an end in sight. Employees see that, and that’s the biggest issue.”

Big ‘Walk-Out’ projected

Most workers told McKnight’s they have “some” or “a lot” of latitude at work (90%), are valued by their colleagues (82%) and have good or excellent opportunities to advance their careers (56%).

But COVID continues to wreak havoc on staying power: More than 43% said the pandemic has made them more likely to leave their profession.

Following the mass exodus of the Great Resignation, Silletto is forecasting the “Great Management Walk-Out” as more leaders tire of “new normal” workloads. Despite mounting evidence of frustration among leaders, Silletto said she still hears about providers delaying advertising — or choosing not to hire at all — when people in positions without regulatory implications quit.

Silletto said many are frustrated by corporate decisions, sometimes made by higher-ups who have been out of the field for years and don’t understand increased patient complexity or ongoing pandemic pressures. Organizational leaders need to take demands for more staff seriously, she added.

“If they are telling you that they need more staff, it’s not just to fill the open positions,” she said. “Are you by chance, or have you in the last five years, not replaced people who left? Have you asked any of your leaders to just absorb more responsibilities when people have walked away?”

She pointed to the disappearing roles of assistant DONs and assistant administrators and recommended restoring them in larger buildings, or adding retention specialists or hiring support.

Seeking satisfying solutions

Signature HealthCare has kept its assistant DONs at all buildings, in addition to trainers and other unit heads who serve nurse leader roles. Chief Nursing Officer Barbara Revelette told McKnight’s earlier in August that the company will be focusing on recruiting and retaining more DON and related staff over the next 12 months.

It includes a DON council that will convene in-person meetings and try to address areas where managers feel squeezed.

“It’s listening. It’s being with them. I need to see how they’re trained, what their competencies are, to be able to truly develop and retain and also provide the best quality of care to our residents,” Revelette said.

Indeed, training factored into job satisfaction for DONs in the McKnight’s survey. After salary and staffing, rounding out the top choices were better health insurance or benefits; more training or learning opportunities; and more paid time off.

Matt Stokes, a compensation analyst with Total Compensation Solutions, said it was important to consider the age and market of employee groups when trying to assess the meaning of falling interest in benefits. Just over 25% of nurses asked for better insurance or other benefits this year; last year that figure was close to 27%. 

“When you’re talking from the nurse’s point of view … it’s just gotten so expensive to live where they really need that cash in hand as soon as they can get it, and they’re willing to forgo anything in benefits, retirement just to get more cash upfront so they can afford their monthly bills,” he said.

Among administrators, the top five wants were rounded out by better health insurance or benefits; more paid time off; and a more flexible schedule.

Nearly 15% of all respondents wrote in other responses, including being able to “use the PTO I have” and “take time away from work” and “not being on call EVER AGAIN.”

Operating pressures, too

In addition to all the other pressures, building leaders are scrambling to cope with inflation and costs that have driven up the price of everything from personal protective equipment to pharmacy services.

With fewer job candidates, high demand and persistent pandemic conditions, it’s no surprise that building leaders put nurse staffing costs first. Nursing home nurses averaged double-digit pay increases this year, with hourly rates for certified nurse aides soaring by 11.2% to $16.87. Registered nurses reported a jump of 11.1%, according to the 45th annual HCS Nursing Home Salary & Benefits Report issued in late July.

But rising construction costs also were a strong contender, with about 36% of all respondents citing it among the costs most affected by inflation. The number rose to over 40% among the administrators-only crowd.

“We know of projects that were priced six months ago with certain financial models and now the project costs are 50% to 80% higher,” Lisa McCracken, research director for investment firm Ziegler, told McKnight’s. “It has been difficult to estimate costs with the needle constantly moving.” 

Just under 50% of respondents said they’d put off a building or capital improvement project, while that portion climbed to more than 53% among administrators. Nurse leaders chose restricted admissions as a cost-saving measure (second most often at 40%), about 1.5 points higher than administrators. Twenty-nine percent in each job category said they’d discontinued services such as recreation activities, trips or entertainment.

Limiting investment in physical plant while also limiting admissions sets a dangerous precedent for skilled nursing operators, whether or not it’s due to costs of staffing shortages, McCracken said.

“There may have been providers who were going to embark upon reinvestment projects going into the pandemic, put those on hold and are now putting them on hold again because of cost escalation,” she said. “In those instances, you are now years behind a reinvestment that is needed to remain competitive and aligned with what the customer wants.”

6% more say census is back

McCracken said that overdue projects also are affected by lower census, which leads to reduced revenue.

Overall, almost 27% of all Mood of the Market respondents said that their census had already returned to pre-pandemic levels. Last year at this time, only 21% of survey-takers were there.

But for the rest, when more beds will be filled is scattershot. Fifteen percent predicted either the third or fourth quarter of this year, while about 19% chose the first half of 2023. Another 27% predicted full recovery in the second half of 2023, in 2024 or 2025. And just over 12% said they “never” expected a return to pre-pandemic levels, up from 9% last year.

“Reduced occupancy leads to financial challenges, which further pressures the ability to reinvest, and that is where the downward cycle comes into play,” McCracken noted. “We understand that these can be difficult decisions on the cost front, but we would encourage providers to explore all possible scenarios before pulling the plug on a project. Downsizing or a multi-phased approach might be the more balanced alternative, given all of the considerations at hand.”

Nursing home staff turnover rates and weekend staffing levels are now being incorporated into providers’ Five-Star Ratings. 

The Centers for Medicare & Medicaid Services on Thursday announced that Care Compare’s July 2022 refresh includes the revision into the methodology for calculating staffing star ratings. It also is being less generous with star upgrades for some facilities.

CMS first announced in January that it would begin posting facility turnover and weekends staffing data to Care Compare, and that the information would be included into the Five-Star rating system by July.

The new rating is based on six separate staffing measures and assigns points based on how well providers perform on each. The points are then summed up and the total staffing score is compared to the staffing rating point threshold to assign a rating between 1 and 5 stars. 

New staffing measures include: 

• Total nurse staffing hours per resident per day weekends; 
• Total nurse staff turnover within a given year; 
• Registered nurse turnover within a given year; and 
• Number of administrators who have left the nursing home within a given year. 

Those are in addition to the existing measures of registered nurse and total nurse hours per resident day. 

“Additionally, to emphasize the importance of staffing, we will no longer add one star to the overall rating of nursing homes that have a four-star staffing rating,” CMS explained. “Rather, only nursing homes with a five-star staffing rating will be rewarded with an increase in their overall star rating.”

The Centers for Medicare & Medicaid Services, through its consumer‐facing website, has made additional nursing home staffing data available. Doing so during a public health emergency, when the industry is in an unprecedented staffing crisis, seems a bit tone deaf. 

Nevertheless, the addition presents an opportunity to better understand a nursing home’s pathway to improvement.

A stable organization provides a desirable environment within which to give and receive care. We see these new data and resulting metrics as just some of the artifacts of an organization’s stability. Do staff, residents and families have a sense of confidence, security and optimism even in trying times like these? With this confidence, all stakeholders can act rationally and adapt effectively as challenges emerge.

Care Compare now includes the following metrics, all of which are derived from federal PBJ submissions:

1. Total number of nurse staff hours per resident per day on the weekend
2. Registered nurse hours per resident per day on the weekend
3. Total nursing staff turnover
4. Registered nurse turnover
5. Number of administrators who have left the nursing home 

You can read more about these metrics here.

From these new data points, we created measures that point to organizational stability. These measures are defined as:

• Staffing consistency (in staffing ratios between weekday and weekend). The idea here is that nursing staff ratios should be relatively the same across all days of the week (two variables).
• Staff turnover. The lower the turnover, the more stable the nursing home (three variables).

With these measures defined, we next excluded any nursing home that had missing data or was an extreme outlier (like the nursing home that reported 52 administrators had turned over within 12 months). These exclusions do make you wonder about the integrity of the data. But I digress.

Of the 15,238 nursing homes, 10,462 (69%) were included in the analysis. We used a statistical procedure called cluster analysis to group nursing homes into cohorts based on their stability profile. Next, we profiled the nursing homes in each cohort to determine if nursing home stability was associated with different (independent) performance outcomes, which are discussed below.

Through cluster analysis, we placed each nursing home into one of three cohorts:

1. Unstable (38% of nursing homes): These nursing homes had the most variation in staffing patterns and the highest staff turnover.
2. Somewhat stable (21% of nursing homes): These nursing homes had unremarkable staffing patterns and staff turnover.
3. Stable (41% of nursing homes): These nursing homes had the most consistency in staffing patterns and low staff turnover.

There is a positive association between nursing home stability and overall Five‐Star rating

The more stable a nursing home, the better its overall Five‐Star rating tends to be:

(Remember that the new data metrics are not currently part of Five‐Star, but they will be by July 2022.)

There is an inverse relationship between nursing home stability and key CMS measures such as SFF and the Abuse Icon

The more stable a nursing home, the less likely it is to land on the SFF or SFF candidate list:

The more stable a nursing home, the less likely it is to be assigned an Abuse Icon:

Doesn’t this make sense? If a nursing home has low turnover and staffing consistency, one could speculate it is providing consistent quality care.

Staffing is key to success, and unfortunately the most difficult to ascertain. Availability of staffing varies dramatically by state and county, but currently, all staffing metrics use national averages as reference points, rendering them insensitive to local influences and state‐level staffing requirements.

Hopefully, when the new data metrics are added to Five‐Star, CMS will place them in the context of each nursing home’s local operating environment. However, don’t wait. Look at your data now. Do they make sense to you? Are they accurate? Do they offer any insights into your nursing home’s operational stability?

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Paying certified nursing assistants higher hourly wages should mean less turnover, but it shouldn’t be the only solution skilled nursing operators rely on, researchers say. 

Non-wage factors are important in keeping turnover lower, the researchers found.

While new study results show a “significant relationship” between CNA retention and wage growth, they don’t show the same effects with licensed practical nurses and registered nurses. And might not have commensurate influence anyway.

“[A] dollar increase in CNA wages (a 7% increase from current mean wages of $14.09) is associated with only 1.8 percentage points reduction in CNA turnover in our facility fixed effects regressions, suggesting that it is difficult to achieve substantial reduction in turnover by small increases in wages,” authors Hari Sharma, Ph.D. and Lili Xu wrote. 

The findings have implications for the policies operators may implement to address high turnover among nursing home nurses. But increasing wages to that select group shouldn’t be the sole strategy, they wrote. 

“While offering competitive wages paid to direct care workers is a necessary step to strengthen the workforce in crisis, especially for low wage earners like CNAs, our results, together with previous literature on the relationship between wages and turnover, suggest that increasing wages alone will not be sufficient to reduce turnover among all types of nursing home staff,” they concluded. 

“Non-wage factors including improving work environment, a culture that empowers staff, as well as fringe benefits such as health insurance should be considered along with higher wages,” they added. 

The findings were published Saturday in Innovation in Aging. University of Iowa researchers used hourly wage and turnover data among CNAs, licensed practical and registered nurses between 2013 and 2017 from nearly 400 nursing homes in the state.

Data revealed that the average hourly wage was $27 for RNs, $21.60 for LPNs and $14.10 for CNAs from 2013 and 2017. Average turnover rates were 46% for RNs, 44.4% for LPNs and 64.7% for CNAs during the same time period.