In “A Look at Nursing Facility Characteristics Between 2015 and 2023,” KFF reports that between 2015 and 2023, the hours of nursing care provided to residents in nursing facilities declined by 9% (from 4.13 hours per resident day (HPRD) in 2015 to 3.77 HPRD in 2023), “in spite of the generally increasing acuity levels of nursing facility residents.” The largest decline occurred in 2018, when staffing declined to 3.85 HPRD from 4.15 HPRD in 2017.
These staffing numbers may be misleading, however. Data reported on Nursing Home Compare (now Care Compare) before 2018 were often inflated. Until April 2018, nursing facilities self-reported staffing data at the time of their standard survey and the Centers for Medicare & Medicaid Services (CMS) publicly reported that information on Nursing Home Compare,without audit or edit. In April 2018, CMS transitioned to reporting staffing levels based on the Payroll-Based Journal (PBJ) data. PBJ data are electronically submitted, auditable, and more accurate than self-reported data. The sharp drop in staffing levels between 2017 and 2018, reported by KFF, more likely reflects the transition to PBJ, rather than a decrease in actual staffing levels.
However, KFF finds that staffing levels declined by about five minutes per day since 2018 and are now 3.77 HPRD.
KFF suggests that, possibly as the result of insufficient staffing levels, deficiencies have increased. Facilities are cited with more total deficiencies (deficiencies increased by 31%, from 6.8 deficiencies in 2015 to 8.9 deficiencies in 2023) and with more deficiencies classified at the two highest levels of severity (actual harm or immediate jeopardy deficiencies) (17% of facilities in 2015 and 26% of facilities in 2023 were cited with harm or jeopardy deficiencies).
Dispelling an industry myth about massive closures, KFF finds that the total number of nursing homes declined by 4% in the eight-year period (from 15,648 facilities in 2015 to 15,003 facilities in 2023). While more facilities closed in 2020, at the beginning of the pandemic (the 15,397 facilities in 2020 were 126 fewer than the 15,523 facilities in 2019), the rate of closures slowed in 2023 (80 facilities closed between 2022 (15,183 facilities) and 2023 (15,003 facilities)). In earlier Alerts (see here and here), the Center for Medicare Advocacy has described multiple reasons for closures, including deliberate public policies to shift public funding from nursing facilities to home and community-based alternatives.
A steeper decline was experienced in the number of people living in nursing facilities. Between 2015 and 2023, the number of residents declined by 12% (from 1.367,548 residents in 2015 to 1.204,260 residents in 2023). The sharpest decline in the number of residents occurred in 2021, when there were 1,098,305 residents, compared to 1,316,950 residents in 2020. The number of residents has increased since 2021, however; there were 1,204,260 residents in 2023.
KFF finds that key nursing home characteristics have remained relatively stable over time. As of July 2023,
- Medicaid is the primary payer for 62% of residents; Medicare, for 13% of residents; and the remaining 25% of residents rely on out-of-pocket, private insurance, etc.
- 71% of facilities are operated on a for-profit basis; 22% are non-profit; and 6% are operated by government entities.
January 11, 2024 – T. Edelman