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Issue Brief 2: Unreasonable Workloads

The Problem:

With the demographic surge of the aging baby boomers, demand for long-term care will increase dramatically over the next 25 years. Yet, the current staffing levels and potential pool of staffing are inadequate to meet the needs of either nursing home or home care clients. Because of sicker patients and fiscal cutbacks, workers have to do more with less.

Yet, it is almost impossible to give humane, tender, individualized care when caregivers work "short staffed" and do not have sufficient time with each patient in nursing homes and in patients' own homes. Healthcare policymakers must consider how many frontline workers are truly needed to deliver high-quality care to our frail and disabled population.

More Complex Care: In its 1996 study, Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? the Institute of Medicine reported that:

Staffing levels in nursing homes have not kept pace with the increased demand for more and better trained personnel. The case mix of nursing home patients is increasing in complexity as hospitals discharge patients earlier and transfer them to nursing homes.

Hospital emergency room policies also discourage nursing home residents from admission into the hospital and, instead, are returning patients to the nursing home in clinically complex conditions which CNAs are then expected to handle. Additionally, although well over half of all nursing home residents have some form of dementia or mental health diagnosis, frontline staff are rarely trained to serve these patients competently. Caregiving for elders in their homes has also become more complex because of these same hospital "rapid discharge" policies. Home health aides - who deliver 80-85% of the care to patients living at home - are too often unprepared to manage these patients with increasingly complex needs.

Fiscal Cutbacks: The continuing trend of fiscal cutbacks at the state and federal levels has contributed to understaffing. Even budgets that advocate level-funding to nursing homes function as cutbacks to direct-care staff who carry heavier work loads by caring for more acutely ill residents. In home care, cutbacks through Medicare's Interim Payment System and reductions in state Medicaid programs serving the elderly have forced home care workers to deliver more care during shorter visits. Aides spend more time in travel (which is less likely to be reimbursed) and less time with patients.

Increased Demand: The demand for competent paraprofessional caregivers will increase dramatically in the coming decades. While the U.S. population aged 80 and over will increase by 14.3% during the five-year period between 2000 and 2005, the source of paraprofessionals (women aged 25 through 44 in the civilian labor force) is projected to shrink by 2.5 percent.

Temporary Workers: Nursing homes and home health companies with inadequate numbers of frontline workers must rely on temporary agencies to meet client demand. A reliance on temporary workers is a more costly way to staff a nursing home or home care operation and, therefore, further drains personnel budgets. Because temporary workers do not know the clients, they are less able to deliver individualized care.

In the nursing home environment, a reliance on temporary workers frequently places more pressure and responsibility on the experienced workers who - for no extra pay - do double duty by training and overseeing the new workers while trying to attend to their own residents. These increased responsibilities often force these more experienced workers to leave - thus reinforcing the cycle of shortages and reliance on temporary workers.
In home care, rates of turnover among aides average between 40 - 60 percent. Since rates of pay and hours of work are even less for home health aides than for CNAs, paraprofessionals often move from one agency to another for modest increases in hourly wages.

Consequences: Diminished Quality of Care for Beneficiaries

Poor Quality Care: Persons in need of services are underserved with inadequate staff. When healthcare providers are short-staffed and supplement their workforces with temporary help, continuity of care is disrupted and patients are adversely affected. In addition to risk of injury, patients face a new caregiver who is not familiar with their needs, routines or preferences. Patients with higher levels of acuity are more at risk when they are underserved, and often fail to reach their highest level of physical, mental, and psychosocial well-being. This carries a human as well as financial cost. The Career Nursing Assistant Program notes that:

The norm in many nursing homes is "working short." Even with an anticipated workload of 12-15 residents, a single nursing assistant is hard pressed to provide bathing, dressing, toileting, mobility, and feeding to each of these people who need and deserve this care. In fact, if each of these five common tasks takes at least 10 minutes, the nursing assistant who provides these few procedures to 12 residents in a single shift has provided 500 minutes of care or 10 hours of care services in an 8 hour day. This does not include time to coach the slow eater, provide additional fluids, look for washcloths, report, lift and transfer, or the many other tasks that are performed each day.

High Turnover and Poor Quality Job: Understaffing contributes to and is made more difficult by high levels of turnover and absenteeism, and worker shortages. Frontline staff have little incentive to remain in these difficult poverty level jobs for which they are poorly prepared. Nursing homes typically experience nursing assistant turnover rates of 100% or more. When a unit in a nursing home is not fully staffed, the remaining (usually more experienced) aides assume the responsibility of training the temporary replacement staff or newly hired staff. In addition they carry more than a full patient load since the newer aides cannot yet manage that level of work. These more experienced aides take on this additional work without supports or financial incentives and, consequently, are at risk of burning out and resigning.

Potential for Abuse and Neglect: Although allegations of abuse and neglect are typically placed on individual CNAs in nursing homes, the causes of abuse and neglect usually stem from systemic problems of inadequate staffing and supervision. With adequate numbers of well-trained and well-supervised frontline staff, individual CNAs would be better prepared to handle the physically and psychologically demanding nature of their work.

Higher Rates of Injuries to Staff and Clients: The 1996 Institute of Medicine study noted that understaffing and the needs of patients go unmet.

With sicker and more dependent patients than in the past, nursing homes have become more stressful and hazardous in terms of injuries.Understaffing (both quantitative and qualitative) leads to injuries, which leads to further understaffing and the needs of patients go unmet.

Understaffing contributes to injuries to patients as well as to members of the workforce. The system pays at the back-end with hospital admissions and workers' compensation costs. When staff are out on injuries, providers must rely on over-time or temporary workers, increasing the potential for injuries as temporary or new workers have to learn a new environment and new routines. Workers who are injured, sometimes permanently, must live without pay or with decreased pay. If they are too injured to return to work, they are locked into below poverty wages if they retire and/or receive SSI. Their loss also exacerbates the shortage of workers.

In nursing homes, more than 75 percent of all revenues come from public funds through Medicaid and Medicare. In home care, government pays for about 73 percent of services. Yet, staffing levels are woefully inadequate to deliver high-quality or even competent levels of services. HCFA can help assure that sufficient numbers of qualified, caring front-line staff are available to assist clients.