A higher ratio of staff to residents correlated in the first six months of the pandemic to fewer cases of COVID-19 in nursing homes across Connecticut according to a recent review by Mathematica of the state’s public health policy and practices.
According to Mathematica’s final report published last week, the lower the ratio of staff hours to residents, the more the cases and deaths of COVID-19 in a nursing homes.
“Staffing rating was highly predictive of the ability to limit the spread of COVID-19 in nursing homes,” the report states. “Nursing homes with a high staffing rating (4 or 5 stars) had 0.06 fewer cases and 0.03 fewer deaths per licensed bed than nursing homes with a lower staffing rating.”
According to the report, 45 percent of state nursing homes earn either a 4 or 5 star rating.
The obvious recommendation — to increase staffing at all homes — is complicated, however, by the precarious economics of the industry, a workforce that is at a high risk of contracting the disease and a state economy that may not readily have the resources to cover the additional cost.
“We want to acknowledge that these things would require resources. Increased staffing would require resources,” said Patricia Rowan, project director and health services researcher at Mathematica in a presentation to legislators on Monday afternoon.
Not a new fight
The idea of increasing staff at nursing facilities is nothing new, according to Mairead Painter, the state’s Ombudsman for Long-term Care. According to Painter, a staffing bill has come up every session for at least the last 10 years.
The most recent bill, passed in 2019, required nursing homes to count hands-on staff only when calculating the staff hours to patient ratio.
“That bill said the person couldn’t be out on transport or someone in the office to be counted. It has to be someone providing hands-on care to the residents,” said Painter.
In the shortened 2020 session, another bill to increase staff hours was proposed, but was never called.
“We were asking them to increase the minimum daily staffing ratio to the federal recommendation of 4.1,” said Painter.
In the upcoming session, with the new information provided by Mathematica’s report, Painter said she hopes to see additional momentum behind that bill.
“What we are hoping to see, with COVID and with all the restrictions on visitors in place, is an increase in staffing,” she said.
Painter said she is also hoping to see an increase in reimbursement rates for facilities that do have higher staff ratios.
“If they staff at a higher rate, they should get an extra few cents a person per quarter or something,” she said. “There needs to be some measurable way to show they are providing more than other facilities, some sort of mechanism to promote higher staffing levels.”
But with 72 percent of the care in nursing homes in Connecticut covered by Medicare and Medicaid, that increased pay would also fall directly on taxpayers.
The financial burden
The long-term recommendation made by Mathematica’s report to “increase the minimum required staffing ratios in nursing homes,” would likely require, as the report pointed out, “financing mechanisms to raise the Medicaid reimbursement rate to support greater increases in direct care workers’ pay and benefits.”
As Matt Barrett, president and chief executive officer of the Connecticut Association of Healthcare Facilities, explains it, “when you increase cost for nursing facilities then those directly increase state funded Medicaid costs. It’s not a reason not to do it, but at a time when the state is hemorrhaging financially it’s something to consider.”
And to be sure, it’s not just the state that’s been losing money.
According to Barrett, nursing homes across the state are still at just 72 percent occupancy compared to a typical rate 0f 88 percent prior to the pandemic.
Between COVID-19 related deaths, a sharp decrease in elective surgeries requiring rehabilitation and a lack of consumer confidence in the care, occupancy has been consistently low since the late spring.
“There is a lot of work going on right now to try to come up with some sort of occupancy recovery timetable,” Barrett said. “When can nursing homes go from 72 percent occupied to 88 percent occupied? What kind of financial relief will be available considering that there already has been a lot? There are a lot of variables at play and nursing home recovery is directly related to hospital recovery.”
So far, it is unclear whether these financial pressures — not mention the added costs of any required increase in staffing — will force nursing homes in the state to close. According to Barrett, none have closed yet, but almost all are struggling.
“It’s one thing for Mathematica to report [the need for increased staff], but another thing to do the hard work of sorting that out and aligning your fiscal policies with the policy objectives,” Barrett said. “That’s the whole challenge with OPM, DSS and the industry.”