The crucial role staffing instability plays in nursing home ratings

A recent study led by the University of California, Irvine has shed light on the significant impact of staffing instability on nursing home quality nationwide, as evidenced by the Five-Star Quality Rating System issued by the Centers for Medicare & Medicaid Services. These ratings are often relied upon by families and potential residents when selecting a nursing home.

The research findings, which were recently published online in the journal Health Affairs Scholar, indicate that nursing homes saw a change in their quality star rating when the measure of staffing instability was included in the Five-Star metric.

According to Dana Mukamel, UC Irvine Distinguished Professor of medicine and corresponding author of the study, “The decision to choose a nursing home is one of the most important and emotional choices a family can make. By including staffing instability in the Five-Star ratings, consumers would be empowered to make more informed decisions, while also incentivizing facilities to prioritize consistent staffing, which is crucial for the health and well-being of residents.”

Currently, the CMS evaluates staffing based on average hours per resident per day and turnover rates. However, staffing instability captures daily fluctuations in staffing levels, highlighting inconsistencies that may not be apparent when only considering averages. These day-to-day variations can directly impact residents and their care.

Using data from over 13,600 nursing homes in the third quarter of 2023, researchers tested various scenarios of staffing instability in relation to other rating measures. The results showed that 21% of nursing homes experienced a change in their quality star rating on a conservative 5-to-50-point basis, which increased to 40% on a less conservative 10-to-100-point basis.

Mukamel emphasized that “The Five-Star rating system is a critical tool for families and caregivers making decisions about long-term care options. Incorporating this measure of staffing instability will ensure that the ratings more accurately reflect the quality of care that can be expected, and will encourage nursing home operators to focus on staffing consistency for better resident outcomes.”

Over the past two decades, the CMS has been updating its nursing home quality measures to adapt to evolving standards and new data. The study’s authors strongly recommend the incorporation of staffing instability into the Five-Star ratings, noting that this change would make a real difference in the lives of nursing home residents and their families.

The research team included Heather Ladd from UC Irvine, Dr. Debra Saliba from UCLA, and R. Tamara Konetzka from the University of Chicago.