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NH nursing homes push back on staffing requirements, citing labor shortage

 Grafton County Nursing Home in North Haverhill.
Dan Tuohy
Grafton County Nursing Home in North Haverhill.

New Hampshire nursing homes are pushing back on a new Biden Administration proposal to establish minimum staffing requirements, saying it’s unworkable at a time when they’re already struggling to hire staff.

The proposal would require nursing homes to maintain certain staff-to-resident ratios for registered nurses and licensed nursing assistants. It would also require facilities to have a registered nurse on site 24/7 — up from the current eight-hour requirement.

Research has linked higher levels of nursing home staffing to improved care for residents, and some experts and advocates have said the proposed rules actually don’t go far enough to ensure adequate staffing.

But groups representing the long-term care industry say they already face challenges hiring enough nurses and nurse aides — and a staffing mandate won’t fix the problem.

“I think we're all in favor of having additional staff,” said Brendan Williams, president and CEO of the New Hampshire Health Care Association. “The problem is we just can't find them right now.”

The proposed rules would require facilities to average staffing levels of at least three hours per resident per day, between registered nurses and nurse aides.

The vast majority of nursing homes in New Hampshire already provide at least three staff hours per resident per day between nurses and nurse aides, according to federal data compiled by KFF Health News.

But Williams says the specific staffing requirements — along with the 24/7 registered nurse requirement — could still represent added burdens for many facilities.

“The idea that you're going to be able to find 24/7 registered nurse coverage in Sullivan County or Coös County or Carroll County — you know, quite apart from even in Hillsborough County — I just don't foresee how that could occur,” he said. “So, you know, basically this is just creating impossible expectations.”

For instance, Catholic Charities New Hampshire, which operates seven skilled nursing facilities, could meet the staffing requirements for licensed nursing assistants, but would have trouble finding more registered nurses, he said. Cheshire County’s nursing home, meanwhile, estimates it would need to add another 20 nursing assistants just to maintain its current capacity, according to Williams.

He said he surveyed the association’s members after the proposed rules came out. Most said they would either have to accept fewer residents or turn to more costly traveling nurse agencies to meet the requirements, and a handful said they may have to shut down altogether.

Williams said a better way to address understaffing in nursing homes would be to ensure they receive adequate funding from state Medicaid programs, so they can pay more competitive wages.

David Grabowski, a professor of health care policy at Harvard Medical School, said the proposed rules could have been stronger. But he said establishing some minimum staffing levels is a step in the right direction.

“There's been a lot of examples of nursing homes putting dollars into other parts of the organization, and not back into direct resident care, because nursing homes haven't been accountable in the past,” he said. “This is a way to make them accountable.”

At the same time, he said that should be part of a larger set of reforms. State Medicaid programs often underfund nursing homes, which leads to lower wages and thus contributes to the current labor shortages.

Grabowski said it would be more effective to pair a staffing mandate with a broader rethinking of how we regulate and pay for long-term care.

“So making sure that they're putting it into direct resident care — but also paying them a higher rate such that they can pay staff the going rate in these markets and attract individuals to work in this sector,” he said.

He said research points to staffing as the biggest factor in the quality of care — and state-level policies have shown that staffing mandates improve outcomes for residents.

“When you don't have enough of those caregivers in the building, bad things happen,” he said. “Falls happen. Pressure ulcers or bed sores happen. Medications are mismanaged. And then ultimately individuals go to the hospital.”

Paul Cuno-Booth covers health and equity for NHPR. He previously worked as a reporter and editor for The Keene Sentinel, where he wrote about police accountability, local government and a range of other topics. He can be reached at pcuno-booth@nhpr.org.
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