Staffing and Variation in Quality Ratings of Hospital-based Skilled - - PowerPoint PPT Presentation
Staffing and Variation in Quality Ratings of Hospital-based Skilled Nursing Facilities Dr. Shivani Gupta Department of Health Management & Policy Saint Louis University Dr. Robert Weech-Maldonado Department of Health Services
Department of Health Management & Policy Saint Louis University
Department of Health Services Administration University of Alabama at Birmingham
nursing or rehabilitation services on inpatient basis after a hospital stay of at least three days.
– Minimal involvement of physicians and interdisciplinary input – Choice of Post-acute care sites
– Hospitals need to focus on the quality of post-acute care being provided by SNFs
– Hospitals can compare the quality of care between different SNFs
– Based on three dimensions of facility performance: Health Inspections (survey); Quality Measures; Staffing
HBSNFs Staffing Patterns
Performance Five-star Quality Ratings
Physical capital resources Human capital resources Organizational capital resources
A national sample of all hospital-based skilled nursing facilities (n=4116)
2008 – 2011 (4 years)
Dependent Variable Ratings:
High (1): 4 and 5 star ratings Low (0): 1, 2 and 3 star ratings
Five-star Health Inspections rating Five-star Quality measures rating The quality ratings range from one star to five-stars with more stars indicating better.
Independent Variables Staffing Intensity
Staffing Mix Ratio of RN FTEs to RN, LPN & CNA FTEs Full-time RN staffing Ratio of full-time RN FTEs to part-time RN & contract RN FTEs
Variables Quality measures rating Health inspections rating High Low High Low Staffing intensity RN hours per resident day 0.85 1.67*** 1.84 1.25*** LPN hours per resident day 1.00 1.26*** 1.28 1.15*** CNA hours per resident day 2.87 3.16*** 3.34 2.93*** RN staffing mix 19.74 26.14*** 28.29 22.19*** Full-time RN staffing 71.60 74.44*** 73.99 73.66 For-profit 9.33 12.94*** 11.32 12.69 Size (total beds) 73 53*** 45 66*** Occupancy rate 84.83 77.81*** 77.69 80.59*** Case mix index 1.02 1.09*** 1.09 1.07*** Minority residents 11.81 13.58*** 12.49 13.66** Residents with Medicaid 56.48 37.12*** 32.01 48.11*** Residents with Medicare 17.02 39.68*** 44.23 27.82*** Market competition (HHI) 0.40 0.30*** 0.28 0.36*** Medicare managed care penetration 21.15 21.87 21.95 21.54 Poverty 16.11 16.33 15.82 16.60*** Urban location 84.23 90.99*** 90.70 88.89** *** p ≤ 0.01, ** p ≤ 0.05, *p ≤ 0.10
Variables Quality measures ratings Health Inspection ratings Odds Ratios Marginal Effects Odds Ratios Marginal effects Staffing intensity RN hours per resident day 0.71***
1.04 0.01 LPN hours per resident day 1.25** 0.04** 1.16* 0.03* CNA hours per resident day 1.07 0.01 1.05 0.01 RN Staffing mix 1.01* 0.01* 1.02*** 0.01*** Full-time RN staffing 0.99
0.99
*** p ≤ 0.01, ** p ≤ 0.05, *p ≤ 0.10
Variables Quality ratings Health Inspection ratings Odds Ratios Marginal Effects Odds Ratios Marginal effects Control Variables Market Factors Market competition (HHI) 1.08 0.01 0.63
Medicare managed care penetration 0.99
0.99
Population 65+ years 0.98
1.01 0.01 Poverty 0.99
0.95***
Urban location 0.85
0.84
Organizational Factors For-profit 1.41 0.06 0.61**
Chain-affiliation 0.83
0.89
NPs/PAs 1.13 0.02 0.93
Agency RN staffing 0.92
0.99
Size (total beds) 1.01* 0.01* 0.99***
Occupancy rate 1.01** 0.01** 1.01 0.01 Case mix index 0.08***
2.25 0.16 Minority residents 1.01 0.01 1.01 0.01 Residents with Medicaid 1.01 0.01 0.99
Residents with Medicare 0.99**
1.01 0.01 *** p ≤ 0.01, ** p ≤ 0.05, *p ≤ 0.10
Hospital and HBSNF administrators can assess the potential impact of staffing patterns on publically reported star ratings. Inform HBNSFs managers on the formulation of staffing-related strategies to improve the quality of post-acute care. Increase policymakers’ understanding of the role of staffing patterns in creating performance differentials as indicated by quality ratings of PAC sites such as HBSNFs. Assist policymakers in crafting policies incentivizing staffing-related initiatives to minimize disparities in the quality of post-acute care, specifically among HBSNFs with low five-star quality ratings.
Limitations:
nursing facilities (HBSNFs)
Future Research:
processes within HBSNFs and other PAC settings.
from acute to various PAC settings and their association with quality of care and patient experience.
using detailed data on the short-stay measures included in the current quality ratings and additional measures specifically associated with PAC.
Health Inspections Points assigned to according to number, scope & severity of deficiencies Additional points assigned for substandard quality of care Repeat Revisits Points assigned only for the second, third, and fourth revisits. proportional to health inspection scores (up to 85 percent of the health inspection score for the fourth revisit) G-level scores (20 points) assigned for “past non- compliance” status & severity is “immediate jeopardy” Five Star Quality Rating Based on relative performance of facilities within a State Top 10 percent in each State receive five-star rating. Middle 70 percent of facilities receive two, three, or four stars, with an equal number in each rating category. Bottom 20 percent receive a one-star.