Short-staffed nursing homes linked to more readmissions, GAO reports

Skilled-nursing facilities that employ fewer registered nurses send patients back to hospitals or emergency rooms more frequently, a new federal report found.

Short-staffed nursing homes, as measured by RN hours per resident day, sent 24% of their patients back to the hospital within 30 days of being admitted to SNFs in 2018, according to a new Government Accountability Office (GAO) report. The readmission rate was 21% among nursing homes that employed more RNs, even after adjusting for differences in medical conditions. That difference translates to 2,265 more hospital readmissions at facilities with fewer nurses. That trend persisted through 2019. Readmissions declined when staffing levels increased.

“This is important because the Medicare program is spending an estimated $5 billion across all SNFs regardless of staffing levels on these incidents and research has shown that reducing hospital readmissions is important for improving quality of care and patient safety,” said Jessica Farb, managing director of the GAO’s healthcare team and lead author of the report. “The current mechanism intended to reduce hospital readmissions among SNF patients may not include enough of an incentive for SNFs to increase their staffing to avoid such critical incidents.”

CMS reduces up to 2% of certain Medicare payments to SNFs that exceed readmission rate thresholds. Nearly 10,000 of the 15,202 SNFs in the program saw such payment decreases during the 2020 fiscal year, while around 2,900 higher-quality SNFs received payment increases of up to 3%, according to CMS.

Congress should consider directing HHS to implement more aggressive penalties, the GAO recommends. In the meantime, CMS should report weekend decreases in nurse staffing levels rather than just aggregate staffing data via Care Compare and should establish minimum nurse staffing thresholds that ensure quality care, the investigative agency advises. Average RN staffing hours decrease about 40% on weekends, but CMS does not directly report this information, the GAO found.

Policy experts came to similar conclusions. RN weekend staffing per resident day was 42% less than weekday staffing time, according to a Harvard Medical School analysis of data spanning April 2017 to March 2018.

“Adverse events disproportionately happen on weekends when nursing homes are often understaffed. Yet the federal Care Compare website only requires facilities to report their overall staffing averages and does not require nursing homes to report their weekend staffing on the website,” said David Grabowski, a healthcare policy professor at Harvard Medical School who co-authored that study.

“This GAO report makes important recommendations to add weekend staffing to Care Compare and also hold nursing homes accountable when low staffing leads to costly transfers to the hospital and emergency department,” Grabowski said.

The COVID-19 pandemic acutely impacted nursing homes, as evidenced by high case counts and shrinking employment numbers.

Employment in skilled nursing is rebounding more slowly than it has in the healthcare industry overall. Nursing homes shed 1,500 jobs from June to July and employment at SNFs has fallen every month since the outbreak started in the U.S. last year. Up to 94% of nursing homes experienced staff shortages in the past month, according to a June survey.

A few months prior to the pandemic, CMS executed a massive restructuring of the SNF sector. Thousands of physical, occupational and speech therapists had their hours reduced or were laid off around Oct. 1, 2019, when a new payment model took effect.

Policy experts have advocated for an overhaul of nursing home staffing and reimbursement models to limit turnover and minimize pay disparities.

About 20% of nursing home residents are short-stay patients coming from the hospital—largely Medicare beneficiaries recovering from surgeries. Those patients—who are more lucrative than Medicaid enrollees—virtually disappeared during long stretches since the pandemic began. The remainder are long-term residents, largely covered by Medicaid, who are more likely to be cognitively impaired.

Nursing homes are left with residents on whom they mostly lose money, which has pushed some facilities to the brink as staffing and supply costs surge, experts said.


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