Nursing Home Staffing is Worse in Disadvantaged Communities

Study reveals local disparities in clinical staff hours in nursing homes, particularly among higher-paid workers.

Nursing homes located in disadvantaged neighborhoods are staffed for fewer hours by clinical workers, such as registered nurses and physical therapists, compared with nursing homes in more well-off areas—a disparity that could compromise the safety of residents, according to new research published in the Journal of the American Geriatrics Society.

“Nursing home staffing in the United States is a growing safety concern—one that has been exacerbated by the COVID-19 pandemic,” said Jasmine Travers, assistant professor at NYU Rory Meyers College of Nursing and the study’s senior author. “Most skilled nursing facilities are already concerned about low staff-to-resident ratios, but our analysis reveals that this gap is even worse in disadvantaged communities.”

Residents in nursing homes often have complex medical needs, and research shows that nursing homes with higher levels of staffing have better outcomes. Greater staffing by registered nurses (RNs), in particular, is associated with lower rates of infection and mortality.

While nursing homes in disadvantaged neighborhoods are more likely to serve vulnerable populations of older adults, including racial and ethnic minorities, less is known about how a neighborhood’s socioeconomic factors influence nursing home staffing. Prior research has often relied on poverty as a single socioeconomic indicator and used data by county or zip code, which does not take into account neighborhood-level differences.

To better understand the relationship between communities and nursing home staffing, Travers and her colleagues looked to several more granular sources of data. To examine neighborhoods, they used the area deprivation index, a measure of socioeconomic disadvantage that aggregates income, education, employment, and housing for small geographic units called census blocks, which represent 600 to 3000 residents. The researchers then mapped out the area deprivation index scores of 12,609 U.S. nursing homes and analyzed their quality and payroll-based staffing data.

Using area deprivation index scores, 16% of nursing homes in the study were found to be in severely disadvantaged neighborhoods. These nursing homes were more likely to be for-profit, in rural areas, and serve a higher proportion of Black residents and Medicaid recipients.

The researchers’ analysis also revealed significant staffing differences by neighborhood for most nursing home workers providing direct care to residents. Compared to more well-off neighborhoods, in severely disadvantaged neighborhoods, staffing was 38% lower for physical and occupational therapists, 30% lower for registered nurses (RNs), and 5% lower for certified nursing assistants. Licensed practical nurses (LPNs) were the only exception, with no disparities observed.

“We found that 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 by staff with less training,” said Travers.

A further analysis revealed that in a 100-bed nursing facility in a severely disadvantaged neighborhood, RNs provided five hours and 36 minutes less care per day compared to a similar facility in a less disadvantaged area.

The researchers conclude that targeted interventions are needed to improve staffing levels for nursing homes in disadvantaged neighborhoods in ways that support, not penalize, nursing homes.

“This might include enhancing Medicare and Medicaid reimbursement to these facilities using geographically ‘micro-targeted’ funding sources, workforce recruitment efforts focused on pay, transportation, and working conditions, and efforts to retain staff such as opportunities for CNAs and LPNs to complete training as RNs,” said Jason Falvey, assistant professor of physical therapy and rehabilitation science at the University of Maryland School of Medicine and the study’s first author.

Additional study authors include Erinn Hade and Steven Friedman of NYU Grossman School of Medicine, Rebecca Deng of NYU School of Global Public Health, Joelle Jabbour of NYU Wagner Graduate School of Public Service, and Robyn Stone of LeadingAge, a nonprofit organization that represents aging services providers. The research was supported by the National Institute on Aging (K76AG074922, K76AG074926, P30AG028747) and the Patrick and Catherine Weldon Donaghue Medical Research Foundation.