Quality of care in U.S. nursing homes is more likely to improve during periods of high unemployment and worsen when the economy is good, according to a new study by researchers at Georgetown University Medical Center (GUMC) in Washington, D.C.
The reason is likely tied to how the strength of the economy affects the ability of nursing homes to maintain adequate staffing levels and minimize turnover.
For example, most nursing home residents have cognitive dysfunction or physical impairment, requiring round-the-clock care, and providing this care can be physically and mentally draining. As a result, many nursing homes have a hard time hiring and retaining nurses and nurse aides.
“During economic downturns, many people are willing to take positions with work environments they may not prefer because there aren’t many options,” said the study’s principal investigator, Sean Shenghsiu Huang, Ph.D. “But when the economy is good, there are plenty of employment opportunities and taking a nursing home job may not be that attractive.”
Huang is assistant professor in the Department of Health Systems Administration at GUMC’s School of Nursing & Health Studies.
The study, published in The Gerontologist, is among the first to look at whether fluctuations in business cycles (economic expansions and recessions) affect quality of nursing home care, nursing staff levels and turnover/retention of staff.
The researchers analyzed more than a decade of records. Data from 2001 through 2015 were pulled from several sources, such as state annual recertification of all Medicare- and Medicaid-certified nursing homes (about 15,000 nursing homes), and county-level unemployment rates from the Bureau of Labor Statistics.
These records included two economic expansions and contractions. Statistical models were estimated to determine the effect the unemployment rate had on nursing home quality and staffing outcomes.
The findings show that higher unemployment rates were correlated with a statistically significant improvement in quality of care. Nursing homes were found to be more compliant with health regulations during period of higher unemployment. And nursing home residents, on average, were less likely to have pressure ulcers, be physically restrained, or have significant weight loss — all measures of care quality.
“It is clear from our data that as unemployment rates increased, nursing home quality was higher as fewer residents would develop pressure ulcers, be restrained, and experience weight loss,” Huang said.
“This is likely due to nursing home staff. Higher unemployment rates are linked to higher nursing staff levels. In these recessions, nursing homes were better able to retain their staff and reduce turnover.”
The research team also found that when unemployment rates were low, nursing homes have lower nursing staff levels, higher employee turnover, and lower staff retention rates. Because most care is provided by nurses and nurse aides, keeping an adequate and stable workforce is important for delivering high quality of care.
For example, high turnover of staff inhibits the ability of nursing homes to consistently assign staff to the same resident, a practice that is tied to quality care. Given today’s low unemployment rates, it will be challenging to maintain or even attempt to lower the turnover rates, say the researchers.
“The solution lies with changes to federal and state policy, such as measures to increase reimbursement for nursing home care with the goal of paying staff enough to make these positions attractive,” Huang said.
“In general, the work environment offered by nursing homes are not considered desirable, and this situation, especially in today’s economy, needs to be addressed through better compensation and benefits.”
However, any effort to improve the pay and benefits of nursing home workers would require efforts from federal and state policymakers as nearly three-quarters of nursing home residents are funded by Medicare and Medicaid, he says.
“Policymakers and researchers have long been concerned about nursing home quality, and this study suggests strong action is needed now,” Huang said.
Source: Georgetown University