Trends in the average nurse staffing levels are reported for certified nursing facilities in the United States from 1991 through 1995. Data from the federal On-Line Survey Certification and Reporting system show a small overall increase in the staffing levels for registered nurses (RNs), licensed vocational and licensed practical nurses (LVNs/LPNs), and nursing assistants over the 5 years, but there are substantial variations across states and regions. A two-stage least squares panel analysis examined predictors of nurse staff levels in states. States with higher resident case mix levels had higher RN and LVN/LPN hours. States with higher percentages of large facilities had lower RN and LVN/LPN levels and states with higher percentages of for-profit facilities had lower RN staff levels. States with a higher percentage of Medicaid residents had higher LVN/LPN staff levels. These findings indicate the need for more studies of staff variations and public policies that affect staffing.
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References
1.
Aaronson, W. E. , J. S. Zinn, and M. D. Rosko. 1994. Do For-Profit and Not-for-Profit Nursing Homes Behave Differently?The Gerontologist34 (6): 775-786.
2.
Aaronson, W. E. , J. S. Zinn, and M. D. Rosko. 1995. Subacute Care, Medicare Benefits, and Nursing Home Behavior. Medical Care Research and Review52 (3): 364-388.
3.
American Health Care Association (AHCA) . 1990. Testimony before the U.S. House Subcommittee on Health. Testimony on H.R. 1649, Minimum Wage Rate for Nursing Homes. Washington, DC.
4.
Arling, G. , R. H. Nordquist, B. A. Brant, and J. A. Capitman. 1987. Nursing Home Case Mix. Medical Care25:9-19.
5.
Arling, G. , R. H. Nordquist, and J. A. Capitman. 1991. Nursing Home Cost and Ownership Type: Evidence of Interaction Effects. Health Services Research22 (2): 255-269.
6.
Bishop, C. E.1988. Competition in the Market for Nursing Home Care. Journal of Health Politics, Policy and Law13 (2): 341-361.
7.
Buchanan, R. J. , R. P. Madel, and D. Persons. 1991. Medicaid Payment Policies for Nursing Home Care: A National Survey. Health Care Financing Review13 (1): 55-72.
8.
Cherry, R. L.1991. Agents of Nursing Home Quality of Care: Ombudsmen and Staff Ratios Revisited. The Gerontologist21 (2): 302-308.
9.
Chiswick, B. R.1976. The Demand for Nursing Home Care: An Analysis of the Substitution between Institutional and Non-Institutional Care. Journal of Human Resources (Summer): 295-316.
10.
Coburn, A. F. , R. Fortinsky, C. McGuire, and T. P. McDonald. 1993. Effect of Prospective Reimbursement on Nursing Home Costs. Health Services Research28 (1): 44-68.
11.
Cohen, J. W. , and L. C. Dubay. 1990. The Effects of Medicaid Reimbursement Method and Ownership on Nursing Home Costs, Case Mix and Staffing. Inquiry27:183-200.
12.
Cohen, J. W. , and W. D. Spector. 1996. The Effect of Medicaid Reimbursement on Quality of Care in Nursing Homes. Journal of Health Economics15:23-28.
13.
Cowles, C. M.1995. 1995 Nursing Home Statistical Yearbook. Tacoma, WA: Cowles Research Group and Johns Hopkins University Press.
14.
Davis, M. A.1991. Nursing Home Quality: A Review and Analysis. Medical Care Review48 (2): 129-166.
15.
Davis, M. A.1993. Nursing Home Ownership Revisited: Market, Cost, and Quality Relationships. Medical Care31 (11): 1062-1068.
16.
Dor, A.1989. The Costs of Medicare Patients in Nursing Homes in the United States. Journal of Health Economics8:253-270.
17.
Elwell, F.1984. The Effects of Ownership on Institutional Services. The Gerontologist24 (1): 77-83.
18.
Evans, L. , and N. Strumpf. 1989. Tying Down the Elderly. Journal of the American Geriatrics Society37:65-74.
19.
Evashwick, C. , G. Rowe, P. Diehr, and L. Branch. 1984. Factors Explaining the Use of Health Care Services by the Elderly. Health Services Research19 (3): 357-382.
20.
Feder, J. , and W. Scanlon. 1989. Case-Mix Payment for Nursing Home Care: Lessons from Maryland. Journal of Health Politics, Policy and Law14 (3): 523-547.
21.
Fottler, M. D. , H. L. Smith, and W. L. James. 1981. Profits and Patient Care Quality in Nursing Homes: Are They Compatible?The Gerontologist21 (5): 532-538.
22.
Fries, B. E. , and L. Cooney. 1985. Resources Utilization Groups: A Patient Classification System for Long-Term Care. Health Care Financing Review23 (2): 110-122.
23.
Fries, B. E. , D. Schneider, W. Foley, M. Gavazzi, R. Burke, and E. Cornelius. 1994. Refining a Case-Mix Measure for Nursing Homes: Resources Utilization Groups (RUGS-III). Medical Care32 (7): 668-685.
24.
Greene, V. L. , and J. I. Ondrich. 1990. Risk Factors for Nursing Home Admissions and Exits: A Discrete Time Hazard Approach. Journal of Gerontology45 (6): S250-S258.
25.
Greene, W. H.1991. LIMDEP User's Manual and Reference Guide. Version 6. New York: Econometric Software.
26.
Gustafson, D. H. , F. C. Sainfort, R. Van Konigsveld, and D. R. Zimmerman. 1990. The Quality Assessment Index (QAI) for Measuring Nursing Home Quality. Health Services Research25 (1): 97-127.
27.
Hanley, R. J. , L. B. Alecxih, J. M. Weiner, and D. L. Kennell. 1989. Predicting Elderly Nursing Home Admissions: Results from the 1982-84 National Long-Term Care Survey Presented at the 117th annual meeting of the American Public Health Association, October, Chicago.
28.
Harrington, C. , H. Carrillo, S. Thollaug, and P. Summers. 1996. Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 1991-95. Report Prepared for the Health Care Financing Administration. San Francisco: University of California.
29.
Harrington, C. , C. Tompkins, M. Curtis, and L. Grant. 1992. Psychotropic Drug Use in Long Term Care Facilities: A Review of the Literature. The Gerontologist32 (6): 822-833.
30.
HCIA and Arthur Andersen . 1995. The Guide to the Nursing Home Industry 1995. Baltimore: HCIA and Arthur Andersen.
31.
Holahan, J. , and J. Cohen. 1987. Nursing Home Reimbursement: Implications for Cost Containment, Access, and Quality. Milbank Quarterly65 (1): 112-147.
32.
Holahan, J. , D. Rowland, J. Feder, and D. Heslam. 1993. Explaining the Recent Growth in Medicaid Spending. Health Affairs12 (3): 177-193.
33.
Institute of Medicine (IOM). Committee on Nursing Home Regulation . 1986. Introduction and Summary. In Improving the Quality of Care in Nursing Homes, pp. 1-44. Washington, DC: National Academy Press.
34.
Institute of Medicine (IOM). Committee on Nursing Home Regulation . Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?Washington, DC: National Academy Press.
35.
Kanda, K. , and M. Mezey. 1991. Registered Nurse Staffing in Pennsylvania Nursing Homes: Comparison before and after Implementation of Medicare's Prospective Payment System. The Gerontologist31 (3): 318-324.
36.
Kane, R. L. , and R. Matthias. 1984. From Hospital to Nursing Home: The Long Term Care Connection. The Gerontologist24:604-609.
37.
Kemper, P. , and C. M. Murtaugh. 1991. Lifetime Use of Nursing Home Care. New England Journal of Medicine324 (9): 595-600.
38.
Levit, K. R. , H. C. Lazenby, B. R. Braden, C. A. Cowan, P. A. McDonnell, L. Sivarajan, J. M. Stiller, D. K. Won, C. S. Donham, A. M. Long, and M. W. Stewart. 1996. National Health Expenditures, 1995. Health Care Financing Review18 (1): 175-214.
39.
Libow, L. , and P. Starer. 1989. Care of the Nursing Home Patient. New England Journal of Medicine321:93-96.
40.
Linn, M. , L. Gurel, and B. A. Linn. 1977. Patient Outcome as a Measure of Quality of Nursing Home Care. American Journal of Public Health67 (4): 337-344.
41.
McCoy, J. L. , and B. E. Edwards. 1981. Contextual and Sociodemographic Antecedents of Institutionalization among Aged Welfare Recipients. Medical Care19:907-921.
42.
McKay, N.1991. The Effect of Chain Ownership on Nursing Home Costs. Health Services Research26 (1): 109-124.
43.
Mendelson, D. N. , and W. B. Schwartz. 1993. The Effects of Aging and Population Growth on Health Care Costs. Health Affairs12 (1): 119-125.
44.
Munroe, D. J.1990. The Influence of Registered Nursing Staffing on the Quality of Nursing Home Care. Research in Nursing and Health13 (4): 263-270.
45.
Murtaugh, C. M. , P. Kemper, and B. C. Spillman. 1990. The Risk of Nursing Home Use in Later Life. Medical Care28 (10): 952-962.
46.
Nyman, J. A.1988a. The Effect of Competition on Nursing Home Expenditures under Prospective Reimbursement. Health Services Research23 (4): 555-574.
47.
Nyman, J. A.1988b. Improving the Quality of Nursing Home Outcomes: Are Adequacy- or Incentive-Oriented Policies More Effective. Medical Care26 (12): 1158-1171.
48.
Nyman, J. A. , D. L. Breaker, and D. Link. 1990. Technical Efficiency in Nursing Homes. Medical Care28 (6): 541-551.
49.
Omnibus Budget Reconciliation Act of 1987 (OBRA). 1987. U.S. Public Law 100-203. Subtitle C: Nursing Home Reform. Signed by President, Washington, DC, 22 December.
50.
Ouslander, J. , and R. Kane. 1984. The Costs of Urinary Incontinence in Nursing Homes. Medical Care22 (1): 69-79.
51.
Phillips, C. D. , C. Hawes, and B. E. Fries. 1993. Reducing the Use of Physical Restraints in Nursing Homes: Will It Increase Costs?American Journal of Public Health83 (3): 342-348.
52.
Ramsay, J. D. , F. Sainfort, and D. Zimmerman. 1995. An Empirical Test of the Structure, Process, and Outcome Quality Paradigm Using Resident-Based, Nursing Facility Assessment Data. American Journal of Medical Quality10 (2): 63-75.
53.
Ribeiro, B. , and S. Smith. 1985. Evaluation of Urinary Catheterization and Urinary Incontinence in a General Nursing Home Population. Journal of the American Geriatrics Society33:479-481.
54.
Riportella-Muller, R. , and D. P. Slesinger. 1982. The Relationship of Ownership and Size to Quality of Care in Wisconsin Nursing Homes. The Gerontologist22 (4): 50-53.
55.
Scanlon, W. J.1980a. Nursing Home Utilization Patterns: Implications for Policy. Journal of Health Politics, Policy and Law4 (4): 619-641.
56.
Scanlon, W. J.1980b. A Theory of the Nursing Home Market. Inquiry17 (1): 25-41.
57.
Schneider, D. P. , B. E. Fries, W. J. Foley, M. Desmond, and W. J. Gormley1988. Case Mix for Nursing Home Payment: Resource Utilization Groups, Version II. Health Care Financing Review Annual Supplement: 39-52.
58.
Shapiro, E. , and R. B. Tate. 1985. Predictors of Long Term Care Facility Use among the Elderly. Canadian Journal of Aging4:11-19.
59.
Spector, W. D. , and H. A. Takada. 1991. Characteristics of Nursing Homes That Affect Resident Outcomes. Journal of Aging and Health3 (4): 427-454.
60.
Stone, R. , G. L. Cafferata, and J. Sangle. 1987. Caregivers of the Frail Elderly: A National Profile. The Gerontologist27 (5): 616-626.
61.
Strahan, G. W.1997. An Overview of Nursing Homes and Their Current Residents: Data from the 1995 National Nursing Home SurveyAdvance Data280 (23 January).
62.
Swan, J. H. , S. Dewit, and C. Harrington. 1997. State Medicaid Reimbursement Methods and Rates for Nursing Homes, 1995. Paper Prepared for the Department of Housing and Urban Development and the Health Care Financing Administration. Wichita, KS: Wichita State University.
63.
Swan, J. H. , C. Harrington, S. K. de Wit, and M. Zhong. 1997. State-Imposed Limits in Medicaid Reimbursement for Nursing Facility Care. American Journal of Public Health87 (7): 1211-1213.
64.
Swan, J. H. , C. Harrington, and L. A. Grant. 1993. State Medicaid Reimbursement for Nursing Homes, 1978-88. Health Care Financing Review14 (4): 111-131.
65.
Thoms, W.1975. Proposed Criteria for Long Term Care, Quality and Cost Control System. Unpublished manuscript, Nashua, NH.
66.
Ullmann, S. G.1987. Ownership, Regulation, Quality Assessment, and Performance in the Long-Term Health Care Industry. The Gerontologist27 (2): 233-239.
67.
U.S. Bureau of the Census (USBOC), Population Estimates Branch . 1991-95. State Population Estimates. Unpublished Data. Washington, DC: U.S. Bureau of the Census.
68.
U.S. Bureau of Labor Statistics (USBOLS) . 1991-95. Geographic Profile of Employment and Unemployment (Table 12). Annual. Washington, DC: U.S. Department of Labor.
69.
U.S. Department of Commerce, Bureau of Economic Analysis (USDOC) . 1991-1995. State Personal Income and the Survey of Current Businesses. Washington, DC: U.S. Department of Commerce.
70.
U.S. Department of Health and Human Services, Health Care Financing Administration (USDHHS) . 1994. 42 CFR. Parts 401, 431, 435, 440, 441, 442, 447, 483, 488, 489, and 498. Medicare and Medicaid Programs; Survey, Certification and Enforcement of Skilled Nursing Facilities and Nursing Facilities; Final Rule. Federal Register59 (217), 10 November.
71.
U.S. General Accounting Office (GAO) . 1987. Stronger Enforcement of Nursing Home Requirements Needed. Report to the Chairman, Subcommittee of Health and Long-Term Care, Select Committee on Aging, House of Representatives. Medicare and Medicaid. Washington, DC: GAO.
72.
U.S. Senate, Special Committee on Aging . 1986. Nursing Home Care: The Unfinished Agenda 1 (Special Hearing and Report, 21 May 1986). Washington, DC: Government Printing Office.
73.
Weissert, W. G. , and M. C. Musliner. 1992a. Case Mix Adjusted Nursing-Home Reimbursement: A Critical Review of the Evidence. The Milbank Quarterly70 (3): 455-490.
74.
Weissert, W. G. , and M. C. Musliner.1992b. Access, Quality, and Cost Consequences of Case-Mix Adjusted Reimbursement for Nursing Homes. No. 9109. Washington, DC: American Association of Retired Persons.
75.
Zedlewski, S. R. , and T. D. McBride. 1992. The Changing Profile of the Elderly: Effects on Future Long-Term Care Needs and Financing. The Milbank Quarterly70 (2): 247-275.
76.
Zinn, J. S.1993a. The Influence of Nurse Wage Differentials on Nursing Home Staffing and Resident Care Decisions. The Gerontologist33 (6): 721-729.
77.
Zinn, J. S.1993b. Inter-SMSA Variation on Nursing Home Staffing and Management Practices. Journal of Applied Gerontology12 (2): 206-224.
78.
Zinn, J. S. , W. A. Aaronson, and D. M. Rosko. 1993a. The Use of Standardized Indicators as Quality Improvement Tools: An Application in Pennsylvania Nursing Homes. American Journal of Medical Quality8 (2): 72-78.
79.
Zinn, J. S. , W. A. Aaronson, and D. M. Rosko. 1993b. Variations in Outcomes of Care Provided in Pennsylvania Nursing Homes: Facility and Environmental Correlates. Medical Care31 (6): 475-487.
