Irvine, Calif., Jan. 14, 2025 — A study led by the University of California, Irvine has revealed the significant impact of staffing instability on nursing home quality across the country, as reflected in the Five-Star Quality Rating System published by the Centers for Medicare & Medicaid Services. Families and prospective residents often rely on these care assessments when choosing a nursing home.
Research findings , recently published online in the journal Health Affairs Scholar, showed that nursing homes either gained or lost a quality star when the staffing instability measure was included in the Five-Star metric.
"The choice of a nursing home is one of the most emotional and profound decisions a family makes. Adding staffing instability to the Five-Star ratings would empower consumers to make more informed decisions, while encouraging facilities to prioritize consistent staffing," said corresponding author Dana Mukamel, UC Irvine Distinguished Professor of medicine. "After all, consistent, adequate staffing is vital to ensuring the health and well-being of residents."
Currently, the CMS evaluates staffing using two key metrics: the average number of hours per resident per day and turnover rates. Staffing instability refers to daily fluctuations – from fully staffed to struggling to cover shifts – capturing the inconsistency that might not be obvious when only looking at averages. Day-to-day variations can directly impact residents, affecting everything from timely meals to essential care.
Using data from more than 13,600 nursing homes during the third quarter of 2023, researchers tested several scenarios of staffing instability relative to other measures in the ratings. They applied CMS methodologies and discovered that on a conservative 5-to-50-point basis, 21 percent of nursing homes experienced a change in their quality star rating. Under a less conservative 10-to-100-point basis, the number jumped to 40 percent.
"The Five-Star rating system serves as a vital tool for families and caregivers making critical decisions about long-term care options, and adding this measure will ensure that ratings more accurately reflect the quality they can expect," Mukamel said. "This information would also encourage nursing home operators to focus on staffing consistency, leading to better resident outcomes."
The CMS has been updating its nursing home quality measures over the past 20 years to adapt to changing standards and as new data becomes available. The study's authors strongly recommend that staffing instability be incorporated into the Five-Star ratings.
"This change would not upend the entire rating system. Our findings offer the CMS a clear pathway to push the needle on quality care forward, making a real difference in the lives of nursing home residents and their families," Mukamel said.
The team included Heather Ladd, a research associate in UC Irvine's Department of Medicine; Dr. Debra Saliba, UCLA professor of medicine; and R. Tamara Konetzka, Louis Block Professor of Public Health Sciences and professor of medicine at the University of Chicago.
This work was supported by the National Institutes of Health's National Institute on Aging under award number R01AG066742.
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