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High turnover in nursing homes threatens resident care

The extraordinarily high turnover of nursing home staff, according to the authors of a new study, likely contributed to the shocking number of deaths in facilities during the pandemic.

The study, which was published Monday in Health Affairs, a journal on health policy, represents a comprehensive overview of turnover rates in 15,645 nursing homes across the country, which represents almost all facilities certified by the federal government. The researchers found the average annual rate to be 128%, with some facilities having a turnover rate above 300%.

“It was truly astounding,” said David Grabowski, professor of health care policy at Harvard Medical School and one of the study’s authors. The researchers pointed to the findings to urge Medicare to publish turnover rates on individual nursing home sites, in order to highlight unsanitary conditions and pressure homeowners to make improvements.

Inadequate staffing – and low wages – has long affected nursing homes and the quality of care for the more than one million residents who live there. But the pandemic has exposed these problems even more strongly, with investigations underway into the monitoring of facilities by some states, as Covid cases grow unchecked and deaths skyrocket.

The high turnover has likely made it more difficult for nursing homes to put strong infection controls in place during the pandemic and led to the rampant spread of the coronavirus, said Ashvin Gandhi, senior author and health economist. and assistant professor at the University of California. Los Angeles Anderson School of Management.

Nursing home owners blame the inadequate reimbursement of Medicaid, the state’s federal program for skilled nursing care for the elderly.

“Recruitment and retention of the workforce is among the most pressing challenges facing long-term care providers, and we have been calling for help for years,” said Dr David Gifford, chief medical officer of the American Health Care Association and the National Center for Assisted Living, a trade group, said in an emailed statement.

“It is high time that providers were given the right resources to invest in our frontline caregivers to improve the quality of care,” he said.

According to a database compiled by the New York Times, at least 172,000 deaths from the virus had been reported among residents or employees of nursing homes and other long-term care facilities as of the end of February. The number of nursing home deaths alone has accounted for over a third of all Covid deaths in the United States, although death and case rates have started to drop sharply as more than 70% of residents were vaccinated.

Critics in the industry have also focused on decades of nursing home ownership by private equity firms and other private equity firms, which prioritized investor profits over good. -being residents. These owners have long been accused of not having enough staff in their facilities and of underpaying workers.

Labor is one of the main expenses of operating a nursing home, said Dr Gandhi. “It’s not a very high margin industry, in general,” he said. “Any facility that tries to maximize its profits will think carefully about its personnel costs.”

Nursing home staff have also shown resistance to being vaccinated against the coronavirus, complicating efforts by public health officials and nursing homes to provide comprehensive vaccine protection to an individual facility. If a nurse who has been vaccinated leaves and is replaced, the facility will need to ensure that the new employee is also vaccinated, especially given the reluctance of some workers to be vaccinated against the coronavirus.

“Trying to do a vaccination campaign all at once is not enough,” said Dr Gandhi. “You need a continuous vaccination campaign.”

Registered nurses, who are the most skilled workers, had the highest turnover rates and turnover varied considerably from institution to institution. Oklahoma, Montana, and Kansas are among the states with the highest rates. Facilities that had low ratings on the Medicare Nursing Home Comparison website had the highest median revenue, and nursing homes with high ratings had the lowest revenue. Revenue was also higher at for-profit, chain-owned institutions and those serving Medicaid recipients, according to the study.

Melissa Unger, executive director of SEIU 503, an Oregon division of the International Union of Service Employees, said nurses find it difficult to work in facilities with too few staff to adequately care for residents .

“You don’t feel good about the job you do,” Ms. Unger said, noting that many of the staff are women and people of color. “You are doing all of this for mediocre benefits and low wages.”

Summer Trosko, a union member working at an Oregon nursing home, said she was used to her colleagues leaving exhaustion due to inadequate staff and lack of money. “They are tired and can’t take it anymore and quit,” she said. Many are being replaced by people who have just graduated from high school with little training, she said.

In addition to making turnover rates available to the public, the authors highlight a number of steps lawmakers could take to improve retention. Medicare could incorporate revenue into its star rating system, and Medicare and Medicaid could reward nursing homes with higher rates if they had lower revenue. “If we want to change retirement homes, we have to start with the staff,” Dr Grabowski said.

The researchers used the newly available payroll-based data collected by the Centers for Medicare and Medicaid Services for registered nurses, licensed practical nurses, and certified practical nurses to calculate turnover rates in 2017 and 2018. They looked at the percentage of hours worked by a nursing employee. in a given year and calculated higher rates if the departing person provided more care.

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