For-profit Nursing Homes Research Articles

Loss Of Public Health Emergency Funds Challenges The Financial Viability Of Nursing Homes, Especially Not-For-Profit Facilities.

Before the COVID-19 pandemic, for-profit nursing homes' revenue generally covered their costs, whereas not-for-profit nursing homes often needed donations and other nonpatient revenue to cover expenses. The unprecedented challenges presented by the pandemic caused the industry to report operating losses that were larger among not-for-profits and facilities relying on agency staff. COVID-19 public health emergency funding allowed nursing homes to remain profitable through 2021. By 2022, as these public health emergency funds were cut back, for-profit nursing homes had overall net incomes of $1.68 per resident day, whereas not-for-profit nursing homes lost $31.18 per resident day. Without public health emergency funds, for-profit and not-for-profit nursing homes would have had losses of $7.47 and $42.35 per resident day, respectively, in 2022. These results indicate that as public health emergency funds are entirely withdrawn, the long-term financial viability of nursing homes, especially not-for-profits, will be seriously challenged.

Medical director presence and time in U.S. nursing homes, 2017-2023.

Federal regulations require all nursing homes to have a medical director, where medical directors oversee resident medical care and develop, implement, and evaluate resident care policies and procedures that reflect current standards of practice. This descriptive study examined medical director: (1) presence or absence and the amount of time spent from 2017 to 2023; (2) presence and time by ownership type; (3) variations in presence and time across states; and (4) overall CMS deficiencies for violations of medical director regulations. This study used federal Payroll-Based Journal (PBJ) data on staffing positions for the period of 2017-2023, along with federal nursing home ownership data and deficiencies data for 2023. More than a third of U.S. nursing homes (36.1%) reported zero medical director presence in Quarter 1, 2023. Medical director presence fluctuated between 2017 and 2023 with a decline over the past 4 years. Among nursing homes reporting a medical director, the medical director was on payroll for an average 36 min per day or 4.2 h per week per facility, and less than 1 min per resident day. Medical director presence and time varied significantly by ownership type and state. For-profit nursing homes reported a lower rate of medical director presence (61.4%) compared to non-profit (71.3%) and government (66.5%) nursing homes and reported that medical directors spent less time in the facilities. Facilities seldom (0.2%) receive regulatory deficiencies for medical director requirements. Though medical directors have a critical role in overseeing clinical care, some nursing homes report no medical director time and those that do report about 4 h per week. Together, these findings may indicate the need for improvement. More research is needed to understand these variations and the extent to which medical director regulations are being followed by nursing homes and enforced by regulators.

MEDICAID ADULT DAY SERVICE CENTERS STAFFING AND SERVICE DIFFERENCES BY PROFIT STATUS

Abstract Adult day service centers (ADSC) encompass a broad range of services, yet few studies have examined staffing and service differences in for-profit and non-profit centers. Previous long-term services and supports (LTSS) research has found that for-profit nursing homes have lower levels of staffing, however, this research has not extended to ADSCs. Data from the 2018 wave of the National Post-Acute and Long-Term Care Study were used to examine differences in staff hours per patient day (HPPD) and services offered in ADSCs by profit status. Only ADSCs that accept Medicaid were included because the majority of the responding ADSCs accept Medicaid (76.8%) and Medicaid acceptance and profit status are significantly related (p<.001). Using t-tests, there was a significant difference (p=.002) in total HPPD with higher HPPD in non-profit ADSCs, with a difference of about 13 minutes. Additionally, there were significant differences in the number of transportation (p<.001) and medical (p<.001) services offered by profit status, with for-profit ADSCs offering a higher number of services, although there was no difference in the number of social/behavioral services (p=.122). These findings suggest that ADSCs that accept Medicaid may be subject to similar incentive structures that lead to lower levels of staffing in for-profit LTSS. The higher number of transportation and medical services in for-profit ADSCs that accept Medicaid also suggests different financial models for for-profit and non-profit ADSCs. Future research should more closely examine factors associated with ADSC staffing levels and service provision, and how these measures are associated with quality of care.

Advocating for the Vulnerable: The Clinical Nurse Specialist and Nursing Home Reform.

Nursing homes have been disproportionally affected by the COVID-19 pandemic, particularly because of resident vulnerability, inadequate staffing, and poor quality of care. Despite billions of dollars in funding, nursing homes often do not meet minimum federal staffing requirements and are frequently cited for infection prevention and control deficiencies. These factors significantly contributed to resident and staff deaths. For-profit nursing homes were associated with more COVID-19 infections and deaths. Nearly 70% of US nursing homes are for-profit ownership, where quality measures and staffing levels are often lower than their nonprofit counterparts. Nursing home reform is urgently needed to improve staffing and care quality in these facilities. Some states, such as Massachusetts, New Jersey, and New York, have made legislative progress in establishing standards for nursing home spending. The Biden Administration has also announced initiatives, through the Special Focus Facilities Program, to improve nursing home quality and the safety of residents and staff. Concurrently, the "National Imperative to Improve Nursing Home Quality" report from the National Academies of Science, Engineering, and Medicine made specific staffing recommendations, including an increase in direct care registered nurse coverage. There is an urgent need to advocate for nursing home reform by partnering with congressional representatives or supporting nursing home legislation to improve care for this vulnerable patient population. Adult-gerontology clinical nurse specialists have an opportunity to leverage their advanced knowledge and unique skill set to lead and facilitate change to improve quality of care and patient outcomes.

Evidence on the Effects of the Federal COVID-19 Vaccine Mandate on Nursing Home Staffing Levels.

To assess the federal COVID-19 vaccine mandate's effects on nursing homes' nurse aide and licensed nurse staffing levels in states both with and without state-level vaccine mandates. Cross-sectional study using data from Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, and Economic Innovation Group. Including nursing home facility fixed effects provides evidence on the intertemporal effects of the federal vaccine mandate within nursing homes. The sample contains 15,031 nursing homes, representing all US nursing homes with available data. On January 13, 2022, the US Supreme Court upheld the federal COVID-19 vaccine mandate for health care workers in Medicare- and Medicaid-eligible facilities, with workers generally required to be vaccinated by March 20, 2022 (ie, the compliance date). We examined actual nursing home staffing levels in 3 time periods: (1) pre-Court decision; (2) precompliance date; and (3) postcompliance date. We separately examined staffing levels for nurse aides and licensed nursing staff. Because 28% of nursing homes were in states with state-imposed vaccine mandates that predated the Supreme Court's ruling, we divided the sample into 2 groups (nursing homes in mandate states vs nonmandate states) and performed all analyses separately. Staff vaccination rates and staffing levels were higher in mandate states than nonmandate states in all 3 time periods. After the Court's decision, staff vaccination rates increased 5% in nonmandate states and 1% in mandate states (on average). We find little evidence that the Court's vaccine mandate ruling materially affected nurse aide and licensed nurse staffing levels, or that nursing homes in mandate states and nonmandate states were differentially affected by the Court's ruling. Staffing levels over time were generally flat, with some evidence of a modestly greater increase for nurse aide staffing in mandate states than nonmandate states, and a modestly smaller decrease for licensed nurse staffing in mandate states than nonmandate states. Finally, regression results suggest that for both nurse aides and licensed nurses, staffing levels were lower in rural and for-profit nursing homes, and higher in Medicare-only, higher quality, and hospital-based nursing homes. Results suggest the federal COVID-19 vaccine mandate has not caused clinically material changes in nursing home's nurse aide and licensed nurse staffing levels, which continue to be primarily associated with factors that are well-known to researchers and practitioners.

The Role Of Real Estate Investment Trusts In Staffing US Nursing Homes.

In 2021 real estate investment trusts (REITs) held investments in 1,806 US nursing homes. REITs are for-profit public or private corporations that invest in income-producing properties. We created a novel database of REIT investments in US nursing homes, merged it with Medicare cost report data (2013-19), and used a difference-in-differences approach within an event study framework to compare staffing before and after a nursing home received REIT investment with staffing in for-profit nursing homes that did not receive REIT investment. REIT investment was associated with average relative staffing increases of 2.15percent and 1.55percent for licensed practical nurses (LPNs) and certified nursing assistants (CNAs), respectively. During the postinvestment period, registered nurse (RN) staffing was unchanged, but event study results showed a 6.25percent decrease in years 2 and 3 after REIT investment. After the three largest REIT deals were excluded, REIT investments were associated with an overall 6.25percent relative decrease in RN staffing and no changes in LPN and CNA staffing. Larger deals resulted in increases in LPN and CNA staffing, with no changes in RN staffing; smaller deals appeared to replace more expensive and skilled RN staffing with less expensive and skilled staff.

Inequities in the incidence and mortality due to COVID-19 in nursing homes in Barcelona by characteristics of the nursing homes.

BackgroundResidents of Nursing Homes (NHs) have suffered greater impacts from the COVID-19 pandemic. However, the rates of COVID-19 in these institutions are heterogeneously distributed. Describing and understanding the structural, functional, and socioeconomic differences between NHs is extremely important to avoid new outbreaks.ObjectivesAnalyze inequalities in the cumulative incidences (CIs) and in the mortality rates (MRs) due to COVID-19 in the NHs of Barcelona based on the characteristics of the NHs.MethodsExploratory ecological study of 232 NHs. The dependent variables were the cumulative incidence and mortality rate due to COVID-19 in NHs between March and June 2020. Structural variables of the NHs were evaluated such as neighborhood socioeconomic position (SEP), isolation and sectorization capacity, occupancy, overcrowding and ownership.ResultsThe cumulative incidence and mortality rate were higher in the low SEP neighborhoods and lower in those of high SEP neighborhoods. Regarding the isolation and sectorization capacity, Type B NHs had a higher risk of becoming infected and dying, while Type C had a lower risk of dying than Type A. Greater overcrowding was associated with greater morbidity and mortality, and higher occupancy was associated with higher incidence. The risk of becoming infected and dying in public NHs was significantly higher than for-profit NH.ConclusionsThe social components together with the functional and infrastructure characteristics of the NHs influence the cumulative incidence and the mortality rate by COVID-19. It is necessary to redefine the care model in the NHs to guarantee the health of the residents.

Mortality in Thai Nursing Homes Based on Antimicrobial-Resistant Enterobacterales Carriage and COVID-19 Lockdown Timing: A Prospective Cohort Study.

Antimicrobial-resistant Enterobacterales carriage and the coronavirus disease 2019 (COVID-19) lockdown measures may impact the incidence all-cause mortality rate among nursing home residents. To determine the all-cause mortality rate in the presence/absence of antimicrobial-resistant Enterobacterales carriage and the incidence all-cause mortality rate before and during COVID-19 pandemic lockdown, this prospective closed-cohort study was conducted at various types of nursing homes in Bangkok, Thailand, from June 2020 to December 2021. The elderly residents included 142 participants (aged ≥60 years) living in nursing homes ≥3 months, who did not have terminal illnesses. Time-to-event analyses with Cox proportional hazards models and stratified log-rank tests were used. The all-cause mortality rate was 18%, and the incidence all-cause mortality rate was 0.59/1000 person-days in residents who had antimicrobial-resistant Enterobacterales carriage at baseline. Meanwhile, the incidence all-cause mortality rate among noncarriage was 0.17/1000 person-days. The mortality incidence rate of carriage was three times higher than residents who were noncarriage without statistical significance (HR 3.2; 95% CI 0.74, 13.83). Residents in nonprofit nursing homes had a higher mortality rate than those in for-profit nursing homes (OR 9.24; 95% CI 2.14, 39.86). The incidence mortality rate during and before lockdown were 0.62 and 0.30, respectively. Effective infection-control policies akin to hospital-based systems should be endorsed in all types of nursing homes. To limit the interruption of long-term chronic care, COVID-19 prevention should be individualized to nursing homes.

Nursing Home Alzheimer's Special Care Units: Geographic Location Matters.

Limited data suggest nursing home (NH) Alzheimer's special care units (ASCUs) may improve care and outcomes among residents with dementia. Unfortunately, information describing NH characteristics related to presence of ASCUs is lacking, especially whether location and neighborhood resources influence their presence. We examined locations of NHs with ASCUs and assessed whether neighborhood socioeconomic deprivation, region, and levels of rurality were associated with NH ASCUs. Cross-sectional. Contiguous United States; we used 2017 LTCfocus and NH Compare data to identify free-standing NHs and obtain addresses (N= 13,207 NHs). NH ZIP+4 codes were linked to the Area Deprivation Index (ADI) (within-state ranking of neighborhood deprivation). The 9 census-defined regions of the United States and Rural Urban Continuum codes categorized location. Descriptive analyses and binary logistic regression models, adjusting for NH characteristics, examined associations between NH ASCUs and location. Nearly 15% of NHs had ASCUs. In adjusted models, odds of NH ASCUs were 58% to 69% lower in Pacific, Middle Atlantic, and Southern regions compared with the East North Central region (P values <.001). Odds of NH ASCUs increased 25% to 47% as rurality increased relative to NHs in the most metropolitan areas (P < .01); however, odds of NH ASCUs decreased 63% in the most rural areas (P < .001). ADI was not significantly associated with NH ASCUs. For-profit NHs had 42% lower and chain-affiliated NHs 34% higher odds of ASCUs (P < .001). NHs with higher total staffing hours had 29% higher odds of ASCUs; odds of ASCUs were 46% lower in NHs with more RN staffing hours (P < .001). Using a robust sample, region, rurality, ownership, and nursing hours significantly predicted NH ASCUs whereas ADI did not. Geographically tailored interventions should be considered to promote use of NH-based ASCUs.

COVID-19 Nursing Home Deaths in Cook County: Predictors and Modifiable Risks

Investigators at the University of Illinois Chicago, the Illinois Department on Aging (IDOA), the Illinois Department of Public Health, and the Health and Medicine Policy Research Group are collaborating to examine comparative rates of Covid-19-related deaths among older adults who reside in nursing homes vs. the community in Illinois. As a first step, we have examined data from the Cook County Medical Examiner’s office to compare nursing home resident fatalities to those who died in the community. Deaths with Covid-19 listed as primary or secondary cause of death that occurred between January 1, 2020 to September 30, 2020 among older adults ages 60 and over were identified from the Cook County Medical Examiner’s Office case archive file. Location at death and race/ethnicity were obtained from the same source. Location at death was matched with data in the Center for Medicare and Medicaid Services (CMS) Covid-19 Nursing Home Data to identify persons who died in skilled nursing facilities (SNFs) as well as facility and staff characteristics. We found that the 3,937 deaths among persons over the age of 60 comprised 75% of total deaths in Cook County. Of the total older adult deaths, 2,090 (53%) died in the community and 1,837 (47%) died in SNFs. Regression analyses that controlled for CMS quality ratings found that larger, for-profit nursing homes, with high levels of staff infected with Covid-19 were associated with higher mortality. The policy implications of these findings will be discussed.

Profit Status and Employee Turnover in Iowa Nursing Homes

Employee turnover is a huge concern for nursing homes that care for millions of older individuals whose physical and cognitive impairments make them vulnerable, especially in the middle of a pandemic like COVID-19. Existing research has shown that high turnover of employees can lead to poorer quality of care. Low pay is often cited as one of the key reasons for high turnover of employees in nursing homes. For-profit nursing homes may try to maximize profits by limiting wages paid to their employees. In this study, we examine whether profit-status of a facility is associated with high turnover of its employees. We obtain data on 415 nursing homes operating in Iowa between 2013-2017. We descriptively examine the turnover trends in nurse employees and all employees over time by profit status. We evaluate whether profit status is associated with high turnover using pooled linear regressions controlling for nursing home and resident characteristics. Descriptive results show that for-profit facilities had higher turnover of nurse employees (61.1% vs. 49.6%) and all employees (56.6% vs. 45.4%). Results from multivariate regressions show that, compared to non-profit facilities, for-profit facilities had 6.93 percentage points higher (p<0.01) turnover of all employees, and 7.76 percentage points higher (p<0.01) turnover of nurse employees after controlling for facility and resident characteristics. Given existing evidence on the adverse impact of high employee turnover on nursing home quality, we need policies aimed at lowering employee turnover, targeting for-profit nursing homes.

Adapting an Advance Care Planning Website for Persons With Dementia in Nursing Homes During the COVID-19 Pandemic

We partnered with a national for-profit nursing home (NH) organization to test the acceptability and use of an advance care planning (ACP) website for people living with dementia using a randomized controlled trial (RCT) design. Concurrently, the COVID-19 pandemic disproportionately impacted NHs and halted in-person research. We will present challenges, opportunities, and adaptations in site engagement, recruitment, and data collection. Initially, NHs were overwhelmed by pandemic efforts and research staff were unable to enter sites. We capitalized on time and available resources by beta-testing the website in a comparable population and designing surveys to elicit COVID-19’s impact on ACP. Once able, NH staff took on recruitment and data collection efforts intended for research staff. We supported NHs by pivoting to remote data collection, providing technology on site, and offering flexible communication. Flexibility is key in supporting site engagement, recruitment, and data collection and has implications for designing pragmatic RCTs.

Elder abuse and neglect in nursing homes as a reciprocal process: the view from the perspective of care workers

PurposeReciprocal abuse inside care practices remain under-studied due to their invisibility and further research is required. The purpose of this paper is to explore different levels of conflicts inside organisations.Design/methodology/approachThe paper is based on a self-administered questionnaire filled out by care workers (n = 150), in 16 Portuguese care homes.FindingsResults indicated that, overall, 54.7% of care workers had observed abuse, in their daily practice, in the preceding 12 months: 48.7% psychological; 36.0% neglectful care practices; 14.0% physical and 3.3% financial abuse. The figures decreased significantly as regards abuse committed themselves, with 16.7% of those admitting to having committed at least one of these behaviours. The highest figures were also recorded for psychological abuse (13.3%) and neglect (6.7%). However, there is a statistically significant relationship between abuse committed by care workers and abuse committed by residents. Overall, 52.0% of care workers reported having been the target of at least one such behaviour by residents.Research limitations/implicationsThis paper has its limitations as the sample consisted of only 16 nursing homes (12 not-for-profit and 4 for-profit nursing homes). The fact that only 4 of the 16 LTC homes were for-profit is a potential limitation both in general and in particular because research has shown that lower quality of care and elder abuse and neglect are more common in for-profit nursing homes at least in Portugal. The results were also based on self-reported measures.Practical implicationsA reactive behaviour, the risk of retaliation, after a complaint, the difficulty in dealing with dementia and the residents' aggressive behaviour, an absence of a training and support policy in an environment where difficult working conditions prevail, are factors enhancing a reciprocal process of abuse. The analysis followed by a discussion of potential implications to prevent institutional elder abuse and neglect, based on communication and social recognition, including better working conditions and training, and a cooperative work environment.Social implicationsConflict is much more than reducing an interpersonal relationship problem between residents and staff (care workers, professional staff, managers) and extending to the whole organisation. Therefore, there are still uncertainties on how organisations, staff and residents interact between themselves, and affect care practises.Originality/valueReciprocal abuse in nursing homes is an important area of research and this paper enabled a discussion of potential implications concerning the quality of care, which required the identification of levels of conflict, in an organisational system, including interactions, the context where care is provided, difficult working conditions, lack of training and levels of support. All these factors are important when considering elder abuse and neglect and this calls for special attention by policymakers and researchers.

Association of Private Equity Investment in US Nursing Homes With the Quality and Cost of Care for Long-Stay Residents

Private equity firms have been acquiring US nursing homes; an estimated 5% of US nursing homes are owned by private equity firms. To examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents. In this cohort study of 302 private equity nursing homes with 9632 residents and 9562 other for-profit homes with 249 771 residents, a novel national database of private equity nursing home acquisitions was merged with Medicare claims and Minimum Data Set assessments for the period from 2012 to 2018. Changes in outcomes for residents in private equity-acquired nursing homes were compared with changes for residents in other for-profit nursing homes. Analyses were performed from March 25 to June 23, 2021. Private equity acquisitions of 302 nursing homes between 2013 and 2017. This study used difference-in-differences analysis to examine the association of private equity acquisition of nursing homes with outcomes. Primary outcomes were quarterly measures of emergency department visits and hospitalizations for ambulatory care-sensitive (ACS) conditions and total quarterly Medicare costs. Antipsychotic use, pressure ulcers, and severe pain were examined in secondary analyses. Of the 259 403 residents in the study (170 687 women [65.8%]; 211 154 White residents [81.4%]; 204 928 residents [79.0%] dually eligible for Medicare and Medicaid; mean [SD] age, 79.3 [5.6] years), 9632 residents were in 302 private equity-acquired nursing homes and 249 771 residents were in 9562 other for-profit homes. The mean quarterly rate of ACS emergency department visits was 14.1% (336 072 of 2 383 491), and the mean quarterly rate of ACS hospitalizations was 17.3% (412 344 of 2 383 491); mean (SD) total quarterly costs were $8050.00 ($9.90). Residents of private equity nursing homes experienced relative increases in ACS emergency department visits of 11.1% (1.7 of 15.3; 1.7 percentage points; 95% CI, 0.3-3.0 percentage points; P = .02) and in ACS hospitalizations of 8.7% (1.0 of 11.5; 1.0 percentage point; 95% CI, 0.2-1.1 percentage points; P = .003) compared with residents in other for-profit homes; quarterly costs increased 3.9% (270.37 of 6972.04; $270.37; 95% CI, $41.53-$499.20; P = .02) or $1081 annually per resident. Private equity acquisition was not significantly associated with antipsychotic use (-0.2 percentage points; 95% CI, -1.7 to 1.4 percentage points; P = .83), severe pain (0.2 percentage points; 95% CI, -1.1 to 1.4 percentage points; P = .79), or pressure ulcers (0.5 percentage points; 95% CI, -0.4 to 1.3 percentage points; P = .30). This cohort study with difference-in-differences analysis found that private equity acquisition of nursing homes was associated with increases in ACS emergency department visits and hospitalizations and higher Medicare costs.

Workplace Integrated Safety and Health Program Uptake in Nursing Homes: Associations with Ownership.

Workers in nursing homes are at high risk of occupational injury. Understanding whether—and which—nursing homes implement integrated policies to protect and promote worker health is crucial. We surveyed Directors of Nursing (DON) at nursing homes in three US states with the Workplace Integrated Safety and Health (WISH) assessment, a recently developed and validated instrument that assesses workplace policies, programs, and practices that affect worker safety, health, and wellbeing. We hypothesized that corporate and for-profit nursing homes would be less likely to report policies consistent with Total Worker Health (TWH) approaches. For each of the five validated WISH domains, we assessed the association between being in the lowest quartile of WISH score and ownership status using multivariable logistic regression. Our sample included 543 nursing homes, 83% which were corporate owned and 77% which were for-profit. On average, DONs reported a high implementation of TWH policies, as measured by the WISH. We did not find an association between either corporate ownership or for-profit status and WISH score for any WISH domain. Results were consistent across numerous sensitivity analyses. For-profit status and corporate ownership status do not identify nursing homes that may benefit from additional TWH approaches.

The Stage Was Set for Disaster: For-Profit Nursing Homes, Federal Law, and COVID-19

For-profit nursing homes came to dominate nursing-home care in the United States in the second half of the twentieth century, especially after the passage of Medicare and Medicaid legislation in the 1960s. However, for-profit nursing homes on average provided inferior care when compared to state-run and nonprofit nursing homes. Congress attempted to address the problems in nursing homes in the final decades of the twentieth century, but massive statutes and abundant regulations served mostly to legitimize the problematic for-profit nursing home. COVID-19 then tragically underscored the flaws in the legally sanctioned for-profit nursing home as a major socio-legal institution in American life.

Patterns of productivity changes in nursing homes by using Malmquist DEA index

Motivation to open a for-profit nursing home is the same as motivation to start any other business, and it seems that, due to various demographic and social changes, the interest in this sector, especially in developed countries, will increase in the future. In that context, this research aims to analyze the efficiency of for-profit nursing homes with a focus on Croatian for-profit nursing homes from 2015 to 2019. In order to estimate different kinds of efficiencies, precisely to estimate technological change, which can’t be estimated through windows DEA, and technical efficiency changes, the Malmquist -- DEA performance measure was chosen for this analysis. The results show that for-profit nursing homes in our sample experienced an increase in the total factor productivity by 12.67 % in the analyzed period, where the decline in technical efficiency (-0.21 %) was compensated by an increase in technological change (13.16 %). Although technological innovation shifted the relative efficient frontier to a higher level, for-profit nursing homes in our sample were far from the best production frontier, highlighting managerial inefficiency.

Nursing Home Vulnerabilities amid COVID-19 Pandemic: A Study of Midwestern States

Background: The COVID-19 pandemic disproportionately affected the older adult population, especially those in nursing homes (NHs). However, there is also evidence that some NHs fared better than others. Objectives: This study examines a set of nursing home related factors to understand whether these factors are associated with the number of COVID-19 cases. Design: We combined three datasets from the Centers for Medicare &amp; Medicaid Services (CMS) – the Star Rating Dataset, the Provider Information Dataset, and the COVID-19 Nursing Home Dataset. Setting and Participants: 4390 NHs that responded to the CMS survey. Methods: Data used is from the period of Jan 1–Dec 27, 2020 for all 12 Midwestern states. The measures used were self-reported information on ratings, staff shortages, PPE shortage, number of beds, Registered Nurse (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA) hours per resident, star rating and ownership. Results: Of the 4390 NHs in 12 Midwestern states, high performing NHs were less likely to have more than 30 COVID-19 cases versus low-performing facilities for two of the CMS domains (health inspections, 520 NHs [27.6%] vs 1363 NHs [72.4%]; and staffing 773 NHs [41.1%] vs 1110 NHs [58.9%]). There was also a statistically significant association COVID-19 cases and star rating, NH ownership, NH size, RN, LPN, and CNA staffing in NHs (all p ≤ 0.01). NH ownership status persisted as a predictor of COVID 19 cases when controlled for NH size. Conclusions: Our study highlights two interesting findings. A) a statistically significant association between NH ownership structure and COVID-19 cases among residents - for-profit NHs had higher number of COVID-19 cases B) a statistically significant negative association between RN and CNA staffing and COVID-19 cases (i.e., more staffing hours of RNs and CNA correlated with a smaller number of COVID-19 cases) and a statistically significant positive association between LPN staffing and COVID-19 cases. We discuss ensuing policy implications for NHs.

Compress the curve: a cross-sectional study of variations in COVID-19 infections across California nursing homes

ObjectiveNursing homes’ residents and staff constitute the largest proportion of the fatalities associated with COVID-19 epidemic. Although there is a significant variation in COVID-19 outbreaks among the US nursing homes,...

Nonprofit vs. For-Profit: Allocation of Beds and Access to Care in U.S. Nursing Homes

Motivated by empirical observations of U.S. nursing homes, we formulate a queueing network model to study nursing homes' bed allocation decisions and the resulting access to care for economically disadvantaged populations. To distinguish nonprofit from for-profit nursing homes, we incorporate altruism into a nonprofit nursing home's objective function to capture resident welfare including the blocking cost of high-margin Medicare residents and the waiting cost of low-margin Medicaid residents. Nursing homes can allocate a fixed number of beds among Medicare-dedicated, Medicaid-dedicated, and flexible beds. This model makes three predictions. First, it is generally suboptimal to allocate Medicaid-dedicated beds. Second, when the Medicaid arrival rate is sufficiently high, nonprofit nursing homes would allocate more Medicare-dedicated beds than their for-profit counterparts, thereby providing lower access to care for the Medicaid population. Third, when the Medicare arrival rate is sufficiently low, nonprofit nursing homes would allocate fewer Medicare-dedicated beds than their for-profit counterparts, thereby providing higher access to care for the Medicaid population. These theoretical predictions are validated by empirical observations of U.S. nursing homes and by a difference-in-differences (DID) analysis exploring nursing home ownership conversions from nonprofit to for-profit. Taken together, our theoretical and empirical findings inform the public that the growth of the for-profit nursing home segment does not necessarily hurt the access to care for the Medicaid population, and surprisingly, under high Medicaid demand, for-profit nursing homes might provide higher access to care than their nonprofit counterparts.