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 Administration University of Alabama at Birmingham

Disclosure Statement This study was funded in part by Agency for Healthcare Research and Quality (1R01HS023345-01).

Hospital-Based Skilled Nursing Facilities Hospital-based skilled nursing facility (HBSNFs) • • Are financially integrated with the hospital • File their Medicare cost reports together with the hospital • Reimbursed primarily by Medicare HBSNFs provide care to patients who need short-term skilled • nursing or rehabilitation services on inpatient basis after a hospital stay of at least three days .

Background Post-Acute Care • – Minimal involvement of physicians and interdisciplinary input – Choice of Post-acute care sites • Bundled payment programs – Hospitals need to focus on the quality of post-acute care being provided by SNFs Public reporting of quality ratings on Nursing Home Compare • – Hospitals can compare the quality of care between different SNFs Five-star quality ratings (2008) • – Based on three dimensions of facility performance: Health Inspections (survey); Quality Measures; Staffing

Conceptual Framework Resource-based View HBSNFs Staffing Patterns Performance • Staffing Intensity Five-star Quality • Staffing Mix Ratings • Full-time RN Staffing

Resource-based View of the Firm Resource-base View • Explain differences in organizational performance on the basis of differences in resources and capabilities • Three categories:  Physical capital resources  Human capital resources  Organizational capital resources • Since, nurses provide most of the direct patient care, they represent a critical human capital resource for HBSNFs.

Hypotheses • Hypothesis 1: HBSNFs with higher licensed nurse staffing intensity will have higher quality ratings. • Hypothesis 2: HBSNFs with higher RN staffing mix will have higher quality ratings. • Hypothesis 3: HBSNFs with higher full-time RN staffing will have higher quality ratings.

Methods Data Sources: • • Nursing Home Compare • Long Term Care: Facts on Care in the US (LTCFocus) database • Area Health Resource File (AHRF) Sample: • A national sample of all hospital-based skilled nursing facilities (n=4116) Years: • 2008 – 2011 (4 years)

Variables Independent Variables Dependent Variable Staffing Intensity Ratings: • RN hours per resident day  High (1): 4 and 5 star ratings • LPN hours per resident per day  Low (0): 1, 2 and 3 star ratings • CNA hours per resident day  Five-star Health Inspections rating Staffing Mix  Five-star Quality measures rating Ratio of RN FTEs to RN, LPN & CNA FTEs The quality ratings range from one Full-time RN staffing star to five-stars with more stars Ratio of full-time RN FTEs to part-time RN & contract RN FTEs indicating better. Analysis : Ordinary logistic regression, with state and year fixed effects; adjusting for clustering at the facility level

Bivariate Statistics 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

Logistic Regression Results Quality measures ratings Health Inspection ratings Variables Marginal Marginal Odds Ratios Odds Ratios Effects effects Staffing intensity RN hours per 0.71*** -0.06*** 1.04 0.01 resident day LPN hours per 1.25** 0.04** 1.16* 0.03* resident day CNA hours per 1.07 0.01 1.05 0.01 resident day RN Staffing mix 1.01* 0.01* 1.02*** 0.01*** Full-time RN staffing 0.99 -0.01 0.99 -0.01 *** p ≤ 0.01, ** p ≤ 0.05, *p ≤ 0.10

Logistic Regression Results: Control Variables Quality ratings Health Inspection ratings Variables Odds Ratios Marginal Effects Odds Ratios Marginal effects Control Variables Market Factors Market competition (HHI) 1.08 0.01 0.63 -0.09 Medicare managed care penetration 0.99 -0.01 0.99 -0.01 Population 65+ years 0.98 -0.01 1.01 0.01 Poverty 0.99 -0.01 0.95*** -0.01*** Urban location 0.85 -0.02 0.84 -0.01 Organizational Factors For-profit 1.41 0.06 0.61** -0.10** Chain-affiliation 0.83 -0.03 0.89 -0.03 NPs/PAs 1.13 0.02 0.93 -0.05 Agency RN staffing 0.92 -0.01 0.99 -0.01 Size (total beds) 1.01* 0.01* 0.99*** -0.01*** Occupancy rate 1.01** 0.01** 1.01 0.01 Case mix index 0.08*** -0.43*** 2.25 0.16 Minority residents 1.01 0.01 1.01 0.01 Residents with Medicaid 1.01 0.01 0.99 -0.01 Residents with Medicare 0.99** - 0.01** 1.01 0.01 *** p ≤ 0.01, ** p ≤ 0.05, *p ≤ 0.10

Conclusions HBSNFs with greater RN staffing mix had greater odds of having high quality ratings as well as high health inspections ratings. Higher LPN staffing intensity, in terms of more LPN hours per resident day, was associated with high quality ratings. After adjusting for RN skill mix, higher RN staffing intensity lowered the odds of HBSNFs having a high quality rating,

Implications  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 and Future Results Limitations: • Secondary data limited the scope of the study • Dichotomous variable indicating the quality rating of the hospital-based skilled nursing facilities (HBSNFs) • Quality star-rating included both short-stay and long-stay measures of quality. Future Research: • Evaluate the association of staffing patterns with the effectiveness of care processes within HBSNFs and other PAC settings. Evaluate the care processes, specifically those related to the patients’ transition • from acute to various PAC settings and their association with quality of care and patient experience. • Analysis of the effect of star-rating and public reporting on HBSNFs quality of care using detailed data on the short-stay measures included in the current quality ratings and additional measures specifically associated with PAC.

Five-star Rating of HBSNFs for Health Inspections Health Inspections Points assigned to Repeat Revisits according to number, scope & severity of Points assigned only for Five Star Quality Rating deficiencies the second, third, and fourth revisits. proportional Based on relative performance of Additional points to health inspection scores assigned for facilities within a State (up to 85 percent of the substandard quality of Top 10 percent in each State receive health inspection score for care five-star rating. the fourth revisit) Middle 70 percent of facilities receive G-level scores (20 points) two, three, or four stars, with an equal assigned for “past non - number in each rating category. compliance” status & severity is “immediate Bottom 20 percent receive a one-star. jeopardy”

Quality Measures included in Five-star Quality Rating Long-Stay Residents: • Percent of residents whose need for help with activities of daily living has increased • Percent of high risk residents with pressure sores • Percent of residents who have/had a catheter inserted and left in their bladder • • Percent of residents who were physically restrained • Percent of residents with a urinary tract infection • Percent of residents who self-report moderate to severe pain • Percent of residents experiencing one or more falls with major injury Short-stay residents: • Percent of residents with pressure ulcers (sores) that are new or worsened • Percent of residents who self-report moderate to severe pain •