CMA Alert | March 24, 2022

Instability In Staffing Levels at Nursing Homes Affects Quality of Care for Residents

Nursing home staffing levels often decline on weekends. In November 2018, the Centers for Medicare & Medicaid Services (CMS) identified facilities with low staffing on weekends and directed states to conduct surveys in a portion of these facilities on weekends.[1] Then, in January 2022, CMS began posting weekend nurse staffing levels at nursing homes,[2] in addition to a single staffing measure, citing two reports by the Health and Human Services’ Office of Inspector General about the need for additional staffing information on the federal website Care Compare.[3] 

A new study confirms the importance of providing more detailed staffing information to the public. Analyzing staffing levels at 14,499 nursing facilities in 2017 and 2018, researchers found that daily variation in nurse staffing levels (registered nurses (RNs) and certified nurse assistants (CNAs)), which they describe as “instability of staffing levels,” negatively affects quality of care for residents.[4]  They note that although consumers recognize the importance of staffing hours in general, they may not understand that daily staffing variability is also associated with quality. They explain why:

Everyday tasks, such as medication administration and monitoring, can be adversely affected by both inadequate staffing and a lack of stability in staffing availability. During low staffing days, when residents do not receive needed care, they are more likely to develop various conditions, such as pressure injuries, because staffing was not sufficient to rotate them in bed; exacerbation of wounds when staff is not available to change dressings in a timely fashion; falls with injuries without consistent daily attention to anticipating needs, such as requiring assistance in getting to the bathroom. Most of these consequences of short staffing cannot be fixed by additional staff on other days: more turning or toileting on extra-staffing days cannot eliminate the fall or the wound development that occurred when understaffed.

The researchers find that for-profit nursing facilities, especially those owned by chains, have less stable staffing levels than other facilities.

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[1] CMS, “Payroll Based Journal (PBJ) Policy Manual Updates, Notification to States and New Minimum Data Set (MDS) Census Reports,” QSO-19-02-NH (Nov. 30, 2018), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO19-02-NH.pdf 
[2] CMS, “Nursing Home Staff Turnover and Weekend Staffing Levels,” QSO-22-08-NH (Jan. 7, 2022), https://www.cms.gov/files/document/qso-22-08-nh.pdf  
[3] Office of Inspector General, “Some Nursing Homes’ Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased” (Data Brief), OEI-04-18-00450 (Aug. 20, 2020), https://oig.hhs.gov/oei/reports/OEI-04-18-00450.pdf; Office of Inspector General, “CMS Use of Data on Nursing Home Staffing: Progress and Opportunities To Do More,” OEI-04-18-00451 (Mar. 2021), https://oig.hhs.gov/oei/reports/OEI-04-18-00451.pdf 
[4] Dana B. Mukamel, Debra Saliba, Heather Ladd, R. Tamara Konetzka, “Daily Variation in Nursing Home Staffing and Its Association with Quality Measures,” JAMA Open Network (Mar. 14, 2022), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2790046

Nearly Twice as Many Black COVID-19 Patients Categorized as Lowest Priority Group for Scarce Resources as Enacting Crisis Standards of Care was Considered

At various times during the COVID-19 pandemic, including surges produced by the Delta and Omicron variants, hospitals around the nation experienced tremendous strain, creating a shortage of beds[1] and other resources such as staffing and medical supplies, and producing a situation where the necessary care could not be provided to all patients.[2] In response, Crisis Standards of Care (CSC) were activated in facilities around the country.[3]

CSC provide a guide for medical providers who are forced to ration life-saving treatment. The American Medical Association notes that when CSC is utilized, the commitment to a patient is counterbalanced with the need to protect the welfare of a population of patients.[4] This balancing is carried out by extending available key resources, while minimizing the impact of clinical care shortages.[5] In CSC, specific protocols developed to predict mortality among critically ill patients[6] – such as the Sequential Organ Failure Assessment (SOFA) – are used to determine how care should be rationed.

The Center for Medicare Advocacy has been monitoring the issue of rationing health care since the beginning of the pandemic[7] and has found that CSC plans must be carefully defined in order to avoid discrimination on the basis of age, disability, racial, ethnic or socioeconomic status.[8]

A study recently published in JAMA Open Network, found that nearly twice the proportion of Black patients were scored in the lowest priority group to receive scarce resources compared with all other patients.[9] Researchers analyzed scoring data that were generated when the Boston area experienced a surge in COVID-19 cases. The hospital network in the Greater Boston area preemptively scored patients in order to prepare for a potential shortage of critical care resources, such as ventilators and staffed ICU beds. While CSC ultimately was not implemented, the scoring data shed light on racial inequities in SOFA scores.

Black patients had higher rates of COVID-19 infection and were admitted to ICUs with higher levels of combined acute and chronic severity of illness, which meant that they received lower prioritization for critical care resources. “Had this scoring system been actually used,” the researchers noted, “it could have led to resources being disproportionately allocated away from Black patients due to a higher proportion of Black patients falling into the lowest priority group based on severity of illness scoring.”

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[1] Stone, W. “A COVID Surge Is Overwhelming U.S. Hospitals, Raising Fears Of Rationed Care” NPR. (Sept. 5, 2021). Available at: https://www.npr.org/sections/health-shots/2021/09/05/1034210487/covid-surge-overwhelming-hospitals-raising-fears-rationed-care 
[2] Hanfling, D., & Hick, J. Crisis standards of care and COVID-19: What did we learn? How do we ensure equity? What should we do? National Academy of Medicine. (Sept. 10, 2021). Available at: https://nam.edu/crisis-standards-of-care-and-covid-19-what-did-we-learn-how-do-we-ensure-equity-what-should-we-do/ 
[3] Haseltine, W. A. America’s New Triage: Covid Crisis Standards of Care. Forbes. (Oct. 6, 2021).  Available at: https://www.forbes.com/sites/williamhaseltine/2021/10/06/the-crisis-around-crisis-standards-of-care/?sh=40e8ba4f2fda 
[4] American Medical Association. Crisis Standards of Care: Guidance from the AMA Code of Medical Ethics. AMA. (April 5, 2020). Available at: https://www.ama-assn.org/delivering-care/ethics/crisis-standards-care-guidance-ama-code-medical-ethics 
[5] Association of American Medical Colleges. COVID-19 Crisis Standards of Care: Frequently Asked Questions for Counsel. AAMC. (Dec. 18, 2020). Available at: https://www.aamc.org/coronavirus/faq-crisis-standards-care 
[6] Merriam, L. T., Bharadwaj, M., Jezmir, J. L., Leaf, D. E., & Kim, E. Y. Protocol to Assess Performance of Crisis Standards of Care Guidelines for Clinical Triage. STAR Protocols. (Nov. 10, 2021). Available at: https://www.sciencedirect.com/science/article/pii/S2666166721006493 
[7] Kertesz, K. “Advocacy Update: Medical Rationing” Center for Medicare Advocacy. (July 16, 2020). Available at: https://medicareadvocacy.org/advocacy-update-medical-rationing/ 
[8] Center for Medicare Advocacy. Utah Removes Age Discrimination from its “Crisis Standards of Care”. CMA. (Dec. 3, 2020). Available at: https://medicareadvocacy.org/utah-removes-age-discrimination-from-its-crisis-standards-of-care/ 
[9] Riviello, E. D., Dechen, T., O’Donoghue, A. L., Cocchi, M. N., Hayes, M. M., Molina, R. L., Moraco, N. H., Mosenthal, A., Rosenblatt, M., Talmor, N., Walsh, D. P., Sontag, D. N., & Stevens, J. P. (2022). Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in Covid-19. JAMA Network Open, 5(3). https://doi.org/10.1001/jamanetworkopen.2022.1744

Refugees Fleeing Ukraine Have Assistance Available from the Federal Government, Connecticut, and Other States

More than 3.5 million people have fled their homes in Ukraine since Russia’s invasion on February 24, creating a refugee crisis.[1] The scale and speed of this exodus, according to Vox, hasn’t been seen in Europe since World War II.[2] While President Biden pledged to “welcome Ukrainian refugees ‘with open arms if, in fact, they come all the way here,’”[3] the majority of the war’s refugees are being absorbed by neighboring countries. The biggest share – over 2 million people – have fled to Poland.[4]

For the refugees who are able to make it to the U.S., there are levels of support available. The Office of Refugee Resettlement (ORR), within the Department of Health and Human Services, provides assistance and services to refugees, in addition to other eligible groups such as those seeking asylum and victims of trafficking. ORR also provides time-limited cash and medical assistance to new arrivals, along with case management support as part of its resettlement services.  State governments or state-alternative programs administer these medical and cash assistance programs and, therefore, services may vary depending on the state. To learn more about the assistance program in your state, contact your State Refugee Coordinator (here).

In Connecticut, the Office of Community Services of the Department of Social Services (DSS) is responsible for dispensing federal funds to aid with the resettlement of refugees in the state.[5] According to Connecticut’s Official State Website:

“DSS regional offices administer the Refugee Cash Assistance (RCA) and Refugee Medical Assistance (RMA) programs for up to eight months from their date of entry to the U.S. DSS also provides refugees with temporary family assistance/cash assistance, medical coverage and food stamp assistance under those public assistance programs since refugees qualify as legal non-citizens.”

Connecticut contracts with the following agencies to provide these services:

• Catholic Charities Migration, Refugee, and Immigration Services (www.ccaoh.org)
• Connecticut Institute for Refugees and Immigrants (https://cirict.org/)
• Integrated Refugee & Immigrant Services (www.irisct.org)
• Jewish Federation of CT, Inc. (www.jfact.org)
• Connecticut Coalition of Mutual Assistance Associations, Inc. (ct.coalition@yahoo.com)

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[1] Sas, A. Ukrainian Refugees by Country CEE 2022. Statista. (March 22, 2022). Available at: https://www.statista.com/statistics/1293403/cee-ukrainian-refugees-by-country/ 
[2] Zhou, Y., Narea, N., & Animashaun, C. Europe’s embrace of Ukrainian refugees, explained in six charts and one map. Vox. (March 19, 2022). Available at: https://www.vox.com/22983230/europe-ukraine-refugees-charts-map 
[3] Alemany, J., Meyer, T., & Raji, T. Analysis | Biden’s pledge to help Ukrainian refugees could soon be put to the test. The Washington Post. (March 22, 2022). Available at: https://www.washingtonpost.com/politics/2022/03/22/biden-pledge-help-ukrainian-refugees-could-soon-be-put-test/ 
[4] United Nations High Commission for Refugees. Operational Data Portal. Situation Ukraine Refugee Situation. (Updated March 22, 2022). Available at: https://data2.unhcr.org/en/situations/ukraine   
[5] CT.gov. (n.d.). Refugee Assistance Program. (n.a.) Available at: https://portal.ct.gov/DSS/Economic-Security/Refugee-Assistance-Program

REGISTER NOW for the 2022 National Voices of Medicare Summit Senator Jay Rockefeller Lecture

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