Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016

The federal OSCAR/CASPER system provides comprehensive information about nursing facility characteristics, resident characteristics and services provided, staffing, and deficiencies, which enables policymakers and the public to monitor and understand changes in nursing facility care in the United States.  These survey findings are particularly important as policies are implemented to encourage improvements in the quality of nursing facility care.

Over the eight years included in this analysis, 2009 through 2016, nursing facility capacity has remained fairly flat, but occupancy rates have declined. This trend may reflect a shift from institutional to community-based long-term care. Home and community-based services have increased over the past decade due to the desire of long-term care users to stay in the community as well as the availability of new and expanded options for states to deliver these services through Medicaid, and this trend may continue in the future. However, overall demand for long-term care services may increase in coming years as the “baby boom” generation ages. The next few decades will require states and policy makers to determine sufficient capacity to accommodate long-term care user choice in both institutional and community-based settings.

As in the past, Medicaid remains the primary payer for most nursing facility residents. Medicare, the primary source of health coverage for the elderly, only covers short-stay nursing facility care following hospitalization, and few people have the personal resources to afford extended nursing facility care (which typically costs over $82,000 per year¹) on their own. As the only major payer that covers this care, Medicaid is the long-term care safety net for millions of people who need such assistance. Medicaid’s large role in financing nursing facility care has made this service a priority policy area for state and federal governments that finance it. It is also one of the mechanisms that enables the federal government to enforce quality standards and accountability in nursing homes. Proposals to limit federal financing for Medicaid could have repercussions for states’ ability to maintain Medicaid spending for long-term services and supports. Given that nursing facility care is one of the costliest services in Medicaid, it is likely that spending in this sector would be subject to cuts if states faced more limited federal financing. For example, proposals that limit federal per enrollee spending growth for seniors to inflation (or an amount indexed to inflation) could lead states to limit eligibility for nursing facility care in an effort to keep Medicaid costs within federal limits.²

Continuing a trend that started before 2009, the share of nursing facilities that are for-profit or chain-owned continued to grow slightly from 2009 to 2016. These facility characteristics are important to policy makers and consumers because of their link to poorer quality of care. States vary in the distribution of facilities by ownership, so continued monitoring of facility ownership by states can help to ensure that a high quality of care is provided at these facilities.

As expected, many nursing facility residents need assistance with basic activities of daily living; however, notable shares have more extensive behavioral or physical health needs. In particular, nearly half of residents have dementia, and nearly a third have a psychological diagnosis. This pattern likely reflects the high need for care among people with these illnesses. However, nursing assistants who provide most of the care to these individuals often have limited training in working with this population. Some may interpret residents’ behavior as aggressive or have difficulty managing these residents’ needs.  Despite regulations to limit the use of psychoactive medication unless such drugs are shown to be necessary for particular resident problems, a higher share of residents receives these medications than has a psychological illness, confirming several studies finding that some use is among residents with other cognitive problems such as dementia. This pattern may be indicative of nursing facilities lacking systematic plans to address the needs of residents with dementia or other cognitive impairments. The November 2016 regulations implement an ACA requirement that dementia management and resident abuse prevention training be a part of 12 hours per year in-service training for nurse aides. In addition, the regulations expand requirements limiting the use of anti-psychotic drugs to also include other psychotropic agents (such as antidepressants or antianxiety medication).

Despite a large body of research demonstrating a link between staffing levels and quality and outcomes of care, overall staffing levels are below some recommendations³ and are primarily filled by non-licensed nurses. The data in this report also show substantial state variation in staffing levels. Several factors could explain this state variation. Variation could reflect different Medicaid reimbursement rates across states, since some research has shown that low Medicaid rates are related to low staffing levels.^4,5,6 However, other research points to state variation in staffing regulations as a key factor. For example, Harrington and colleagues⁷ found that although higher Medicaid reimbursement rates were related to higher staffing levels, minimum state staffing standards were a stronger predictor of higher staffing levels than reimbursement rates.

Last, the data show that nursing facility deficiencies have declined between 2009 and 2016, though there is still much state variation in rates of deficiencies. While voluntary guidelines for compliance programs have been in place for many years, the ACA authorized new, mandatory compliance programs to improve quality of care. Under the Quality Assurance and Performance Improvement (QAPI) program, the federal government will establish standards for such programs and provide technical assistance to meet these standards. All facilities (including chains) must submit a plan for how they will meet these standards. The regulations outlined standards for QAPI programs, building on existing requirements for quality assessment and assurance programs to address quality deficiencies. They also establish new requirements for food services and residents’ rights in nursing facilities, in part to address common deficiencies in these areas.

Moving forward, it will be important to continue to monitor nursing facility characteristics, residents’ needs, and staffing and deficiency reports to understand whether and how new requirements are affecting care and outcomes and to identify additional areas of concern for future policy changes.