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Why is CMS emphasizing staffing more in the Five-Star ratings, and what is the impact?

Dr. Andy Kramer
June 2019

As of April 2019, there were changes to the calculation for the staffing component of the Centers for Medicare & Medicaid Services (CMS) Five-Star Rating System that have a significant effect on the ratings nursing centers receive. Our analysis of national data, comparing current Five-Star ratings with prior ratings, shows that the facility average for the total nursing staff rating dropped 0.3 stars, and the registered nurse (RN) staffing rating dropped 0.5 stars.

The overall Five-Star rating for a facility is further affected by changes to the scoring rules, because the RN rating carries more weight in that calculation. CMS has released “Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide,” that explains these and the other changes to the scoring.

The reason for such emphasis on staffing is the considerable evidence supporting higher staffing levels, particularly RN staffing. While researchers acknowledge that staff competency, low turnover, and strong supervision are all critical staffing issues for maintaining quality of care, staffing levels have repeatedly been related to quality and outcomes.

The CMS Users’ Guide cited a study conducted at the University of Colorado, “The Relationship Between Nurse Staffing Levels and the Quality of Nursing Home Care.” In the 2001 study, a clear relationship was demonstrated between staffing levels and quality measures relating to post-acute care (for example, potentially avoidable hospitalization and community discharge) as well as measures relating to long term care such as pressure ulcers and weight loss.

One problem noted in the full report was the lack of accurate staffing data, as Online Survey, Certification, and Reporting data were not found to be sufficiently accurate. The 2001 study used Medicaid cost report data to obtain staffing levels. A series of studies were conducted over the next decade, aimed at demonstrating how payroll data could be used to determine staffing levels, and re-examining some of these staffing and quality relationships.

‘The reason for such emphasis on staffing is the considerable evidence supporting higher staffing levels.’

In a 2008 report using payroll data, for example, it was shown that for every 15-minute increase in average RN time per resident-day, there was a 19 percent increase in the likelihood of post-acute residents being discharged to the community, and an 8 percent decrease in the likelihood of being readmitted to the hospital. These results were risk-adjusted and were similar whether or not directors of nursing or assistant directors of nursing were included in the RN count.

Once payroll data were required to be submitted for all nursing centers, Kaiser Health News published articles about Kaiser Family Foundation analyses of staffing on weekends and evenings and number of days where there were no RNs available in a building.

The findings of their analyses, in conjunction with prior work in this area, support the changes to the Five-Star Rating System such that nursing centers with no RNs on four or more days in a quarter would receive a One-Star rating, and RN staffing contributes more heavily to the overall rating.

Recognizing that a nursing shortage exists, we must make a concerted effort to hire, train, and retain competent nursing staff, especially RNs. These changes to the Five-Star system make that a clear priority.

Provider Magazine – Quality Forum – June 2019 Issue


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