Implications of Socioeconomic Status (SES) on Nursing Home Staffing in the U.S.

The COVID-19 pandemic further exposed the fragility and inadequacies of our current healthcare infrastructure. As health equity becomes a focal point of the public health enterprise, the perils of health disparities as a byproduct of social determinants of health, such as SES, have become a critical issue.

In a recent study, researchers Drs. Jason Falvey and Jasmine Travers aimed to evaluate the extent of nursing home staffing variation across distinct levels of neighborhood deprivation. The overarching objective of this research was to assess the extent of nursing home staffing disparities across different levels of neighborhood deprivation. One of the study’s primary outcomes was to 1) identify the number of clinical staffing hours per resident day stratified by licensed nursing home staff category. Using a retrospective cross-sectional study design, they leveraged data from sources such as the Area Deprivation Index (ADI), 2018 Minimum Data Set (MDS), and 2018 Long-Term Care Focus (LTCFocus) file to compile data on socioeconomic neighborhood deprivation percentile rankings, and facility characteristics on over 12,000 nursing homes across the US.

For this study, nursing home staffing was measured by staffing hours. The ADI indicates the percentile of socioeconomic deprivation distributed across geographic neighborhoods. Based on prior research, the researchers established a threshold of an ADI score ≥ 85 to identify facilities located in severely deprived areas. In addition, facility-level acuity levels were considered to assess the complexity of care needed within a facility against existing staffing capacities. These descriptive statistics were then analyzed and compared between severely deprived and less deprived neighborhoods.

The results of this study indicated that nearly 20% of facilities within the study sample were in severely deprived neighborhoods. Facilities located within severely disadvantaged communities had a higher prevalence of Black and Medicaid-insured residents and were more likely to be for-profit. In addition, these facilities were also associated with lower staffing rates and lower staff utilization. It was observed that disparities in staffing rates were seen primarily amongst registered nurses (RNs) and certified nursing assistants (CNAs); however, LPN staffing rates remained consistent with the national average among nursing homes located in severely deprived neighborhoods. Most notably, facilities in economically disadvantaged areas had RN staffing rates of 30% less than more affluent neighborhoods, which on average meant facilities had 5.6 hours less daily RN coverage per 100 resident days. CNA staffing rates were 5% less in economically disadvantaged areas than in more affluent areas, meaning facilities had 3.2 hours fewer CNA coverage per 100 resident days.

While these results are consistent with prior studies, the use of measures such as nursing home staffing and neighborhood assessments at the census block group level provides data that provides valuable insight into targeted interventions and policies that can be used to improve neighborhood staffing in these areas.

Major Findings

• Higher neighborhood deprivation is associated with lower staffing within nursing homes. While not as definitive as a clinical trial, these findings suggest that increasing staffing support to these facilities could benefit resident care and safety.
• Findings of stable staffing for LPNs in low-income areas compared to sharply lower RN staffing suggest nursing homes in deprived areas routinely interchange LPN and RN in nursing home settings despite educational requirements and scope of practice varying between the two. Facilities insufficiently staffed with RNs are often associated with poor quality of care due to the inability to cater to residents’ acuity levels. As a result, these substitutions may be related to resident harm.

Considerations and Future Implications for Policy and Practice:

1. Procurement of resources, research, and guideline on establishing adequate professional staff mixes to ensure staffing, quality, and capacity-driven factors and considerations are conducive to residents’ acuity levels and optimal health outcomes (e.g., best practices on meaningfully differentiating RNs, LPNs, CNAs, evaluation of multi-variate staffing characteristics in nursing homes, staffing needs assessment, etc.).
2. There are concerns regarding how low-value care in nursing home facilities can contribute to health disparities and poor health outcomes—especially in socioeconomically disadvantaged areas. How should executives and key personnel adequately evaluate the quality and value of care in nursing homes to improve patient outcomes in severely deprived neighborhoods?
3. While the clinical roles and responsibilities of LPNs are still necessary, much of the healthcare infrastructure is pushing LPNs into more ancillary care delivery services. Should more training and education be available to LPNs to correspond with their work without sufficient RN presence effectively?

To access the published literature on Drs. Falvey and Travers’ research entitled “Severe neighborhood deprivation and nursing home staffing in the United States,” click here.