Improving Conditions in New York Nursing Homes: Adding Much Needed Staff

Improving Conditions in New York Nursing Homes:
Adding much needed staff

Nursing Home Community Coalition
of New York State
Position Statement
March 2, 2001

For more information contact: Cynthia Rudder, Director
11 John Street, Suite 601
New York, NY 10038
Tel. 212-385-0355; Fax. 212-732-6945
www.nhccnys.org

Contents

I.	Executive Summary	3
II.	Nursing Home Staff are Lifelines for Residents	4
III.	New York Nursing Homes are Short on Staff	5
IV.	Low Staffing Equals Poor Care	7
V.	Poor Care is Expensive, Quality Care Costs Less	7
VI.	Mandating Staffing Levels	8
VII.	Challenges of Mandating Staffing Levels	8
VIII.	Paying for Safe Staffing Bills	10
IX.	Improving Recruitment and Retention Problems	10
X	Conclusions	11

This position paper was written by Anat Jacobson under the direction of Cynthia Rudder, Ph.D., Director of the Nursing Home Community Coalition of New York State (NHCC) and of the members of the NHCC Committee on Staffing. The Committee has been working to improve staffing levels in nursing homes for over one year.

Kathy Albowitz, Civil Service Employees Association, AFSCME
Karen Ballard - New York State Nurses Association
Ruth Berger - Suffolk County, Ombudservice, Family Service League
Louis Bonilla - Paraprofessional Healthcare Institute
Gary Cannonier - Civil Service Employees Association, AFSCME
Jacqueline Case - New York City Ombudsman Program
Gail DeMarco - New York State Nurses Association
Les Eason - Civil Service Employees Association, AFSCME
Pearl Granat - 1199/SEIU New York’s Health and Human Services Union
Geoff Lieberman - Coalition of the Institutionalized Aged and Disabled
Cris Parque - Friends and Relatives of Institutionalized Aged
Lee Stokes - 1199/SEIU New York’s Health and Human Services Union
Jay Sackman - 1199/SEIU New York’s Health and Human Services Union
Evelyn Weinstien – Nassua County, Ombudservice, A Program of Family and Children’s Association

Note: Sprinkled throughout this paper are stories from real people: residents, family members, aides, ombudsman.

2

Nursing Home Community Coalition: Position on Gottfried and Hannon bills (A#4171 and S#2185), March, 2001.

Back to Top

Executive Summary

There is a crisis in New York State nursing homes: there is not enough staff to provide good, safe care for the State’s elderly and disabled.

Over the years, nursing home residents have become more frail and dependent on nursing home staff to help them with basic activities of daily living and take care of their progressively complicated medical needs. Unfortunately, in too many cases, New York State nursing homes have not hired the necessary staff to meet their residents’ needs.

Current Federal requirements are very vague. They only stipulate that nursing homes provide “sufficient staff.” Therefore, nursing homes are allowed to decide on the level of staffing for their facilities, without any guidelines or regulations. In too many New York nursing homes levels of ‘sufficient staffing’ have been determined at a point where – according a recent Health Care Financing Administration (HCFA) report, and other studies – the quality of care delivered puts residents at risk.

In fact, according to the HCFA study, 98 percent of New York State nursing homes do not provide enough staff to care for their residents’ basic needs and about half of the homes have such low staffing levels that their residents’ health and well-being are put at risk.

In order to protect nursing home residents and ensure that staffing decisions are made based on residents' needs, minimum staffing levels must be mandated by law. Assemblyman Gottfried’s and Senator Hannon’s bills (A #4171 and S #2185) were developed for this purpose. These bills must be passed to protect the over 100,000 frail elderly who live in New York State nursing homes.

“There were 3 occasions in which my mother was dropped and injured. One fall necessitated having her head stitched. My mother sat or lay in wet soiled clothes or bedding. The problem was never incompetent or uncaring staff. It was always too few people to care for the nursing home residents. Complaints always led to promises by the nursing home director that these things would never happen again, but of course they did, over and over again! This is because sufficient staff are never hired.”

3

Nursing Home Community Coalition: Position on Gottfried and Hannon bills (A#4171 and S#2185), March, 2001.

Back to Top

Nursing Home Staff are the Lifeline for Residents

Residents rely on nursing home staff to keep them clean, fed and safe. Care provided by nurse aides and professional nurses in our nursing homes takes time.

For example, a task like showering, that seems simple and quick for someone healthy, can take more than 30 minutes for a frail elderly resident who completely depends on the assistance of an aide. Because many, if not most, of our residents need help with activities of daily living, like showering, eating, and going to the bathroom, aides must spend a significant part of their shift providing individualized care.

Caring for Our Frail Residents Takes Time

Nearly 50 percent of our residents need help bathing [i] – bed baths take 10 to 15 minutes each; showers and baths take 10 to 30 minutes each [ii]
90 percent of our residents need some help going to the bathroom [iii] – taking a resident to the bathroom can take 10 to 15 minutes [ii]
33 percent of our residents require personal hygiene care every time they are incontinent [iii]– it can take at least 10-15 minutes to change a resident [ii]
Almost 80 percent of our residents need some help eating[iii] – it takes between 20 and 60 minutes to completely feed a resident [ii]
45 percent of our residents are wheeled or need help getting out of a bed or a chair; 8 percent need constant supervision walking and 10 percent need intermittent supervision[iii] - it can take 10 to 15 minutes to move a resident from one room to another [ii]

In addition to providing these basic care services, nursing home staff must help dress many residents, monitor and report on each resident’s vital statistics, set up meals, give residents medication, make beds, provide grooming services, empty and measure catheter bags, wash hands between caring for each resident, assess the resident’s health, and perform many other duties with patients of average, and more serious needs.

And, perhaps more importantly, the work of nursing home staff requires more than just completing tasks. Because, nursing homes are ‘homes’ for residents, nursing home staff must have time to just talk with and build relationships with residents in order to help residents develop a good quality of life.

“I am bedbound and have few visitors. I enjoyed speaking to my aides as they took care of me. Now, we are getting less time for care and we are getting no time to talk to the aides.”
—Hannah Sanda, resident.

4

Nursing Home Community Coalition: Position on Gottfried and Hannon bills (A#4171 and S#2185), March, 2001.

Back to Top

New York Nursing Homes are Short on Staff

Nearly all New York State nursing homes lack staff to adequately meet the needs of residents.

According to self-reported nursing home data[iv], the median aide time provided to each resident is about 2 hours a day. But, caring for residents’ basic needs takes more than 2 hours per day. A recent Health Care Financing Administration Report (HCFA)[v] found that, direct aide time of less than two hours a day per resident seriously impairs care. Therefore, half of New York nursing homes provide unsafe staffing levels for their residents.

Furthermore, according to the HCFA study, the amount of aide time needed to provide the level of care at which all residents are helped to reach the highest physical and mental functioning, as required by Federal law, is about three hours a day per resident - ninety-eight (98) percent of New York nursing homes fall below this level. There simply is not enough staff in New York nursing homes to take good, safe care of our elderly and disabled.

Compounding the consequences of low staffing is that while the numbers of residents in New York State nursing homes are growing, and their needs are becoming greater, staffing levels remain about the same.

"Two nurses come to work their floor between 6 and 6:30am. They work until 4:30 to 5pm without taking breaks or lunch to deliver care to 50 elderly residents. Things that need to be done get missed or left behind."

Nursing Home Aide

5

Nursing Home Community Coalition: Position on Gottfried and Hannon bills (A#4171 and S#2185), March, 2001.

Back to Top

Graph 1

But, Staffing has stayed about the same

Graph 2

From Charlene Harrington, et al. (2000) Nursing Facilities, Staffing, Residents and Facility Deficiencies, 1993 – 1999. Department of Social and Behavioral Sciences, University of California San Francisco, CA.

6

Nursing Home Community Coalition: Position on Gottfried and Hannon bills (A#4171 and S#2185), March, 2001

Back to Top

Low Staffing Equals Poor Care

Several studies have shown that low staffing levels lead to poor care. According to the HCFA report, there is a strong association between low staffing and the likelihood of quality problems, including avoidable hospitalizations, deteriorating activities of daily living and increased incidence of pressure sores, weight loss and poor resident hygiene.

A recent report on Long Island nursing homes supports the HCFA report by relating deficiencies found by State surveyors, to low staffing levels. The report found that nearly one-of-five nursing homes that did not meet HCFA suggested staffing levels were cited for violations that caused actual harm to the residents. On the other hand, of the homes that met the staffing levels suggested by HCFA, none were cited for violations that caused harm.[vi]

Poor Care is Expensive, Quality Care Costs Less

Safe staffing levels can reduce Medicaid and Medicare costs. Some of the conditions suffered by nursing home residents are a result of poor care due to low staffing levels. Prevention of some of these conditions could lead to great cost savings.

Incontinence, much of which may be preventable, cost $3.26 billion annually to treat
Bedsores, most of which are preventable, cost up to $12 billion annually to treat
Falls, many of which may be preventable, cost $2.6 billion annually in hospitalization.[vii]

Nursing homes can also save money by providing safe staff to deliver needed care. Cost savings can be realized by reducing expenses related to staff injuries, and frequent recruiting and training.

In addition, reports of negligence and resident harm are now regular features in newspapers and on TV. Many of these stories, albeit reported sensationally, are true, and are often the outcome of too few staff. The result is twofold: litigation and a growing negative image. Litigations

“Adequate staffing levels seem to be the major problem in nursing homes. There have been many times that I have arrived at the home only to find my husband with soiled undergarments and soiled wet shirts from coffee spilled in the morning. My husband would not get enough care if I was not able to be there to assist him with feeding, reaching for a drink or brushing his teeth.”
— Charlotte Lassett

7

Nursing Home Community Coalition: Position on Gottfried and Hannon bills (A#4171 and S#2185), March, 2001

Back to Top

increase legal and insurance fees, require administrative time, and include possible fines and settlements. The resulting negative image leads to more vacant beds and makes recruitment more difficult and expensive.

Mandating Staffing Levels
Federal requirements are very vague. They only require that nursing homes have “sufficient staff.”^v There are no specific numbers of mandated staff, and ‘sufficient staff’ is left up to the nursing home to determine. In New York, too many nursing homes have determined their ‘sufficient staffing’ at a level where – according to a number of studies – the quality of care puts residents at risk. And, ‘sufficient staffing’ numbers have remained virtually the same over the past few years, even though the needs of residents have grown.[viii]

Nursing Home Aide

“It is very sad to see some of our residents who are incontinent have to wait for hours before they can be changed or washed because we just cannot get to them.”
—Maurice Murray, aide

The nursing home industry, for the most part, will not take the initiative to hire additional staff – mandated safe staffing levels become the only option for improving resident care. The Gottfried and Hannon Bills – A #4171 and S #2185, respectively - recommend safe staffing levels that will ensure residents' safety, as well as provide adequately for the residents’ basic needs. These bills include requirements for minimum ratios of staff to residents for the average nursing home resident. The bill also requires higher staffing if a facility cares for residents with higher acuity levels.

Challenges of Mandating Staffing Levels
Mandating staffing levels will ensure that nursing homes adequately staff to provide residents with safe, quality care for all their basic needs. However, to make mandated staffing levels a reality, both the nursing home industry and government need to work together to overcome the challenges of achieving mandated staffing, which include:

Problems hiring nursing home staff because of low wages, benefits, and poor working conditions
An inadequate financing system that does not stress accountability for how state reimbursed money is spent

Problems Recruiting and Retaining Staff
Nursing home owners argue that suggested mandated staffing levels cannot be met because there are not enough available workers. According to the New York Association of Homes & Services for the Aging (NYAHSA), 92 percent of the organization’s nursing home members are experiencing staffing shortages, because there are no workers available to hire as a result of the tight labor market.[ix]

8

Nursing Home Community Coalition: Position on Gottfried and Hannon bills (A#4171 and S#2185), March, 2001

Back to Top

The recent tightening of the labor market has in fact caused increased competition for good employees. But, while many industries have bid for available workers by offering them adequate and competitive wages, work benefits and improved work conditions, nursing homes have not. And, even in times when unemployment was high, many providers did not hire needed staff.

Low Wages & Few Benefits
Wages and benefits are an often-mentioned reason for recruitment and retention problems. A 1997 national survey found that nursing home aides earned an average of $6.72 per hour, nearly $1.50 less than aides in hospitals and about $3.00 less an hour than telemarketers and photocopy machine operators. Even fast food cooks have a higher earning potential. [x] And while salaries in some areas of New York State are higher, the cost of living in these areas is very high, often negating the higher salaries.

In addition to the relatively low pay, many nursing facilities do not offer benefits such as retirement and health insurance.[x] However, according to workers, wages and benefits play only a part in the decision to not work in, or to quit a nursing home job.

Poor Work Conditions
Among the most cited reasons for recruitment and retention problems are the working conditions in nursing homes.Many workers complain that they are overworked, never have enough time to talk to residents, are demeaned and not respected by other staff, have a task orientated only job that doesn’t include time “relating” to residents, are scapegoated, are stifled in their sense of personal compassion and humanity, are unfulfilled and dissatisfied, are stuck in a dead-end job and are alienated from the care team. [xi] For aides stress and burnout contributes to the national turnover rate of near 100 percent.[xii]

The high rate of job related injuries also likely causes retention problems. Nursing home work is one of the most dangerous of all industries. Fifty percent of the injuries are severe enough to require days off or light duty work. Injury cases involving lost workdays for nursing home workers are nearly triple the national average for various other industries.^xii

Ironically, many poor work conditions are often the result of low staffing levels. For example, although it sometimes require two or three aides to lift and transport a resident safely, aides sometimes must perform the task alone, increasing their, and the resident’s, risk of injury.

"A stressed out, overworked staff can only do so much, and our residents suffer for this."

Aide

"We are not able to have a decent conversation with residents because of the shortages n staffing. There is no dignity in this."

Aide

"I have 41 residents to care for. I ask why I can’t be there to comfort my residents’ pain. My heart silently cries for them. The rushed care residents receive does not provide them with the comfort they deserve."

Aide

9

Nursing Home Community Coalition: Position on Gottfried and Hannon bills (A#4171 and S#2185), March, 2001

Back to Top

Inadequacies in Financing System
The Federal and State reimbursement rates for nursing homes are calculated based on a prospectively estimated, inflation adjusted, cost of services. Currently, reimbursements can be spent in any way the nursing home sees fit, which means that no one is accountable for ensuring that the money is spent on direct care needs of residents, and nursing homes are able to earn higher profits from the reimbursement at the expense of residents’ care.

However, two studies have indicated that the way nursing homes spend their reimbursements, and not only the amounts of reimbursement, might be leading to the low staffing levels. A 1994 NHCC study of profits and losses in nursing homes in New York State found that those facilities making the most profit on Medicaid were mostly the downstate for-profit facilities and they had the lowest level of aides, even though they were caring for the same type of residents as those not making as much profit.[xiii] Additionally, a NYS Department of Health study found that even though the reimbursement rate to cover the costs of increased resident acuity grew by 17 percent from 1986 to 1992, staffing in nursing homes rose by only 7 percent during those years. [xiv]

Paying for Safe Staffing Bills
In order to be able to fund the ratio initiative, the government and the nursing home industry both need to make concessions and change the payment structure.

Foremost, nursing homes must be required to spend a percentage of the reimbursement rate for direct care, which primarily includes hiring staff. This will cause some redistribution of current funding from profits or indirect care costs to direct care, which will help fund some of the additional staff needed.

Second, Medicaid must add additional funds to pay for required ratios, as the redistribution of current funds will not cover the entire cost for the required ratios. But, any additional money must be tied to direct care staff. If a facility does not use the money for direct care staff, the additional funds must be returned to the State.

However, if nursing homes do not meet the mandated ratios, the bills must prohibit them from admitting residents until mandated ratios are met. Just as a hospital emergency room diverts ambulances when it does not have needed staff, so must a nursing home stop admitting new residents when it does not have enough staff to care for residents.

Improving Recruitment and Retention Problems
The first priority in improving recruitment and retaining staff must be to increase wages, benefits and enhance work conditions.

Second, because hiring workers has become an increasingly difficult task for all industries, the state must make recruitment a top priority and work with facilities to find solutions.

10

Nursing Home Community Coalition: Position on Gottfried and Hannon bills (A#4171 and S#2185), March, 2001

Back to Top

Conclusions
New York State nursing homes have been faced with facts – from studies, nursing home surveys and news reports - about dangerous outcomes that result from low staffing. However, historically they have not responded by appropriately increasing staffing levels.

Nursing home direct care staff are a lifeline for residents. As residents' needs and dependence on staff continue to increase, it is imperative that nursing homes provide the care that the State’s elderly and disabled deserve.

Therefore, legislation must be passed to protect nursing home residents from the nursing home practice of understaffing that put residents and staff at high risk of injury, and increases residents' risk of deteriorating health conditions.

The Gottfried and Hannon bills offer a solution by mandating safe staffing levels. These bills (A #4171 and S #2185) must be passed to ensure that residents’ nursing staff lifelines provide safely and effectively for all of their care needs.

Having enough staff to deliver quality care benefits everyone:
Residents receive better, safer care
Workers enjoy improved work conditions
Nursing homes gain a more stable workforce and a better public image
Government saves money on costlier services associated with poor care

[i] OSCAR (1998) Online survey, Certification, and reporting system of state surveys of all certified nursing homes

[ii] The Nursing Service Group Inc. (1999) Daily Duties of the Certified Nursing Assistant. Presentation, June 1999.

[iii] All nursing home residents are assessed twice a year with an instrument called the Patient Review Instrument (PRI). This data is from the PRI data (1997 received from the Department of Health) and 1998 data from the Federal Online Survey, Certification, and Reporting system.

[iv] NYS Medicaid cost reports (1997)

[v] HCFA (2000) Appropriateness of Minimum Nursing Staff Ratios in Nursing Homes. Report to Congress, July 2000.

[vi] Nursing Home Staffing Levels are Inadequate (2000) Report prepared for Rep. Michael P. Forbes, Minority Staff Special Investigations Division, Committee on Government Reform, U.S. House of Representatives.

[vii] National Citizen’s Coalition for Nursing Home Reform (1995). The High Costs of Poor Care. Based on pre-1987 HCFA data and other literature.

[viii] Charlene Harrington, et al. (2000) Nursing Facilities, Staffing, Residents and Facility Deficiencies, 1993 – 1999. Department of Social and Behavioral Sciences, University of California San Francisco, CA.

[ix] New York Association of Homes and Services for the Aging. Public hearing testimony to the New York State Assembly Committees on Health and Aging. December 2000.

[x] National Citizen’s Coalition for Nursing Home Reform (1999) The Staffing Crisis in Nursing Homes Consensus Statement. (November 1999).

[xi] “Preparing for Quality Caregiving in Nursing Homes: Major Change is Needed in the Training and Education of Nurse Aides” - a summary of a nurse aide conference held on Nov 17, 1999 – Nursing Home Community Coalition of New York State.

[xii] Paraprofessional Health Institute (2000) Direct-Care Health Workers: The Unnecessary Crisis in Long-term Care. Case Statement.

[xiii] Rudder, Cynthia (1994). New York State's Nursing Home Industry Profit, Losses, Expenditures and Quality. A report by the Nursing Home Community Coalition, March 1994.

[xiv] NYS Department of Health presentation at the New York State Hospital Review and Planning Council, 9/22/94.

11

Nursing Home Community Coalition: Position on Gottfried and Hannon bills (A#4171 and S#2185), March, 2001

Back to Top