Nursing home pay rule reveals CMS strategy on minimum staffing

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If there’s one thing that nursing home providers, consumer advocates, and regulators can all agree on when it comes to crafting a federal minimum staffing rule, it might be. be how difficult the job will be.

The Centers for Medicare & Medicaid Services has given itself until next March to study staffing — the types and levels needed — and come up with a new rule mandating coverage. It’s part of a sweeping initiative by the Biden administration to reform nursing in nursing homes in the wake of the devastating impact of COVID-19.

The federal government has grappled with the relationship between staffing coverage and patient outcomes for more than 20 years, commissioning past studies and failing to update standards in other initiatives. broader health.

The publication of a proposed compensation rule for 2023 on Monday afternoon reiterated earlier comments from agency executives that, this time, CMS intends to abide by. Staffing provisions include a new value-based incentive element for total nursing staffing and an official seeking input on future direct care staffing needs.

CMS, however, has a lot to consider in a year-long study leading up to the minimum staffing proposal expected early next spring. The agency on Monday asked stakeholders to comment on at least 17 related issues. They range from how to calculate which metric to include and how to factor in workforce challenges to the cost of the requirement — and whether better outcomes, such as lower hospitalization rates, might provide compensation.

“It’s obviously very important that we have standards of care and that facilities meet those standards,” said Ashvin Gandhi, Ph.D., a health economist at UCLA who studies staffing and turnover. McKnight Long Term Care News. “CMS needs to think very carefully about whether and to what extent facilities will be able to financially meet staffing needs. You could have unintended consequences.

But rising labor costs and shortages seem unlikely to slow CMS’s effort. On the contrary, the agency’s efforts were bolstered by the release in April of a long-awaited National Academies report on home nursing, which also called for major changes in the workforce.

“It seems like the time is right,” said Steven Littlehale, gerontology nurse specialist and data analyst at Zimmet Health Care Services Group, during a recent McKnight’s Podcast. “It seems like the planets are aligning in that we can actually see real, genuine minimum staffing requirements that go beyond hard-to-define terms like ‘sufficient’ staffing.”

History at work

The basis of current staffing rules dates back to the Nursing Home Reform Act of 1987, which provided 24-hour LPN coverage and eight hours of RN coverage each day. The law also triggered the need for “sufficient” staff to meet residents’ needs, but it did not set any ratios or hourly minimums for other frontline caregivers.

An oft-cited but never mandatory benchmark of 4.1 hours of direct care per day per resident was established in a 2001 study.

“This study showed that for long-term residents, if they did not meet this minimum, there was harm or danger to the residents,” Charlene Harrington, RN, Ph.D., professor emeritus at the University of California San Francisco School of Nursing, says McKnight’s. “For 20 years, we have argued that CMS must establish minimum staffing standards. … Facilities, if they’re trying to make money, just have too much of an incentive not to live up to what we know the norm should be.

She wants CMS to consider adding 24-hour RN coverage and raising the overall minimum above 4.1 – even though at least 60% of nursing homes are currently operating below that threshold, according to one March study. Washington, DC is the only state/region with a requirement of 4.1, and only 20 others require care per day per patient totaling 2.5 hours or more.

CMS repeatedly referenced the 4.1 figure in its proposed compensation rule for 2023, but said further study was needed given changes in patient mix since then. He also added that a stricter RN rule could be “an alternative or complementary approach.

“A greater presence of registered nurses has been associated in the research literature with better quality of care and fewer impairments,” the agency wrote in a request for comment. “Increasing the number of hours per day that a LTC facility must have RNs in the nursing home would alleviate concerns about LPNs engaging in activities outside of their scope of practice in the face of resident needs during times when no AI is on site.”

Who counts ?

Nursing homes today are different places than they were in 1987, with residents who are sicker and often require much more intensive care than once-typical long-term residents. And they are often treated by a wider range of caregivers.

Observers believe that CMS will take this into account when formulating its minimum. CMS acknowledged this on Monday, noting an increase in residents with dementia, psychiatric diagnoses and hospital admissions. He also cited Arkansas regulations, including a wide range of therapists and other non-nursing positions as staff.

In Florida in April, Governor Ron Desantis (R) signed a provider-backed bill that changed who counts for global staffing hour rankings to include those who provide dietary, therapeutic and mental health services. . The state still requires a minimum weekly average of 3.6 hours of care per resident per day provided by CNAs and licensed nurses and at least one CNA on duty for every 20 residents.

Lori Porter, CEO of the National Association of Healthcare Assistants, said her members support a federal minimum and she would like to see CNA coverage expressed as a staff-to-patient ratio, ideally at 1:10. . Regardless of how CMS approaches the metric, it wants to keep the focus on CNAs.

“People who really know nursing homes realize that 90% of the care a resident needs comes from a CNA,” she said. “In this context, there are very few skilled needs of a resident that require a nurse.”

But Littlehale said accounting for care provided by non-nursing staff should come under serious scrutiny, given the increasing complexity of nursing home patients and the specialties that providers implement for nursing homes. to tend to.

“We really need to encourage flexibility and creativity,” Littlehale said. “What about the establishment that sees the value and has access to, for example, therapeutic aids or more social workers or recreational therapy? They are really important players in the interdisciplinary team. Perhaps depending on your particular unique case mix, you really want to have more at the bedside for very valid reasons.

How do you make sharpness count?

Harrington noted that the current rule requires more nursing when patient needs increase, a provision she says has been largely ignored by regulators.

She said CMS would be wise to go beyond weather study methods and build on existing research using simulation models. This would allow the agency to better understand how long certain care, such as assistance with activities of daily living, takes per patient, and how those numbers might change depending on a building’s patient population.

“There is every reason to think that the cluster of cases has increased over time since 2001, so as acuity increases the minimum standard must probably be higher than 4.1,” she said. . “You can’t just look at what care homes are doing. You have to look at what nursing homes should do.

One way to do this would be to base the acuity on MDS submissions from previous months to get a reading on the typical acuity level of a facility’s patients. In 2020, Harrington and Mary Ellen Dellefield of San Diego VA outlined acuity categories based on the patient-based payment model, creating a guide to determining if nursing home staffing is adequate.

How to measure success?

Providers will likely have time to work on new standards, and some observers suspect the CMS may create tiered goals rather than a single measure of hours per patient day.

The VBP element of the proposed total staffing hours would not be added until 2026. It would rely on verifiable payroll-based log data, and CMS expects this to be a key way to do this. advance staffing.

“Given the strong evidence regarding the relationship between sufficient staffing levels

and improving patient care, the inclusion of this measure in the SNF VBP program adds an important new dimension to provide more comprehensive assessment and accountability of the quality of care provided to residents and serves to drive improvements in the staffing that are likely to result in better resident care,” the agency said in proposing the addition of VBP.

There is no doubt that the CMS will make the ability of providers to meet the new staffing standards they set easily visible to the public. Against this backdrop, provider associations remain concerned about worker unavailability and how this could harm both compliance and reputation.

“Anyone who wants to can recommend that there be more staff, better staffing, more RN coverage, and we’re all for it — except there’s nobody,” said Ruth Katz, vice- Senior Chair of Public Policy and Advocacy for LeadingAge. At the beginning of April. ‘There is a kind of fear that new requirements could be imposed…and that care homes would then be punished for not meeting requirements when there is no one to apply for jobs.’

A walk One study found that the cost of meeting Harrington’s acuity-based benchmarks in 2020 would average over $500,000 per US institution. CMS said it would consider adequate funding as part of its rulemaking process, though it cannot increase overall spending without congressional approval.

Gandhi said CMS should make a serious effort to consider suppliers’ financial concerns, and whether this is hyperbole or reality. If CMS sets its parameters too high, he warns, CMS could unwittingly lead some providers to reject more Medicaid patients or cut costs in ways that “negatively affect” resident care.