By Geralyn Magan
Nursing home staffing in severely disadvantaged neighborhoods is significantly lower than staffing in more well-off neighborhoods, according to a new study in which the LTSS Center participated.
Nursing homes located in disadvantaged neighborhoods are staffed for fewer hours by clinical workers like registered nurses (RN) and physical therapists, compared with nursing homes in more well-off areas, according to new research published in the Journal of the American Geriatrics Society (JAGS).
This disparity could compromise the safety of residents, according to the article’s authors, including Robyn Stone, co-director of the LeadingAge LTSS Center @UMass Boston.
The research study was led by Jasmine Travers, assistant professor at New York University’s Rory Meyers College of Nursing, and Jason Falvey, assistant professor of physical therapy and rehabilitation science at the University of Maryland School of Medicine. The National Institute on Aging and the Patrick and Catherine Weldon Donaghue Medical Research Foundation provided funding. The LTSS Center, the study’s primary dissemination partner, published a policy brief based on the research in February 2023.
The original JAGS article, published in August 2022, received an Altmetrics score of 328, which was among the top 10 scores earned for JAGS in 2022. Altmetrics measures and assigns values to article dissemination, taking into consideration the number of news stories that mention the article, Twitter mentions, article citations, and more.
OVERVIEW OF FINDINGS
The JAGS article, begins by reviewing existing research showing that nursing home residents often have complex medical needs, that nursing homes with higher levels of staffing have better outcomes, and that higher levels of staffing by RNs is associated with lower rates of infection and mortality. But researchers point out that less is known about how a neighborhood’s socioeconomic factors influence nursing home staffing.
To better understand these socioeconomic factors, the research team used the Area Deprivation Index (ADI), which measures socioeconomic disadvantage in small census blocks representing 600 to 3,000 residents. After mapping the ADI scores for 12,609 U.S. nursing homes, researchers found that 16% of nursing homes in the study were in severely disadvantaged neighborhoods. These nursing homes were more likely to be in rural areas and to serve a higher proportion of Black residents and Medicaid recipients.
“I really liked this study because it takes you down to the neighborhood level,” commented Stone during a recent interview. “When you’re analyzing data at the larger zip-code level, you may miss the nuances of disadvantaged communities within those zip codes. But when you take the analysis down to the neighborhood level, it is obvious that the negative relationship between a nursing home being in a deprived neighborhood and staffing is pretty substantial.”
The study found that while most U.S. nursing homes are concerned about low staff-to-resident ratios, this gap is even worse in disadvantaged communities. By analyzing the quality and payroll-based staffing data of nursing homes in severely disadvantaged neighborhoods, researchers found that:
- Staffing in these nursing homes was 38% lower for physical and occupational therapists, 30% lower for RNs, and 5% lower for certified nursing assistants (CNA), compared to nursing homes in more well-off neighborhoods. Licensed practical nurses (LPN) were the only exception, with no disparities observed.
- Nursing staff with generally lower salaries and training—CNAs and LPNs—had smaller or no disparities in staffing, compared with RNs. This suggests that nursing homes in more disadvantaged communities may be substituting care traditionally provided by RNs with care provided by staff with less training.
NEXT STEPS
The JAGS article calls for increased government intervention, including “micro-targeting” of policy interventions to skilled nursing settings with the worst staffing disparities. Expanding on this recommendation, Stone suggested that policymakers should think about designating certain neighborhoods as “disadvantaged and worker-shortage zones” so nursing homes located in those zones could receive targeted attention from national and state agencies.
“Maybe we establish a corps of professional caregivers who could help these nursing homes address the staffing challenges they face,” she said. “Maybe we develop incentives for individuals, particularly nurses, to work in vulnerable and disadvantaged neighborhoods. Is there a way to build a workforce that’s indigenous to these communities, a workforce that could work and stay and contribute to local economies? Are there nursing schools that could partner with nursing homes to recruit and train these individuals?”
Stone said she was struck by study findings indicating that nursing homes in more disadvantaged communities were relying on CNAs and LPNs to carry out care tasks usually assigned to RNs.
“The most obvious solution to these RN staffing shortages is to attract more RNs to these care settings,” said Stone. “But if we can’t do that, we need to either skill-up LPNs and CNAs to their highest level of practice, so they are prepared to carry out more of these nursing tasks, or we need to help those LPNs and CNAs become RNs. Clearly, we need to think more creatively about positive actions we can take to address this serious staffing situation.”