Do Stable Nursing
g Home Staff
Improve Resident Outcomes?
Sally C. Stearns, PhD
Laura P. D’Arcy, MPA
The University of North Carolina at Chapel Hill
AcademyHealth Annual Research Meeting
June 28
28, 2009
Supported by the National Institute on Aging and the Demography and Economics of Aging
Research program at the Carolina Population Center (Grant 5-P30-AG024376)
Facilitated by the National Center for Health Statistics and the Triangle Research Data Center
O
Overview
i

Turnover among NH staff very problematic




High annual rates for nursing assistants (68% to 170%)
High costs to facilities
May compromise quality of care
Evidence on effect of turnover on health outcomes


Mixed or inconclusive results
Most studies:
 Use aggregated facility data
 Do not deal with reverse causality (endogeneity) of
turnover and outcome
R
Research
h Question
Q
ti

What is the effect of facility
facility-level
level turnover among
certified nursing assistant (CNA) staff on resident
outcomes?

Use 2004 National Nursing Home Survey



Merged facility and area data onto resident surveys
Facility fixed effects to control for unobserved facility
characteristics
Instrumental variables approach to control for endogeneity
of turnover
C
Conceptual
t lM
Model
d l (1)
CNA Turnover
or Retention
Resident
R
id t
Characteristics
- Sociodemo
- Medical/clinical
- Functional
Other Facility
Characteristics
Resident
R
id t Outcomes
O t
(Bad)
(B d)
- Hospital Use
- ER Use
- Ulcers
- Pain
- Falls
- Any of the Above
E
Empirical
i i l Model
M d l

Bad Outcomes=f(turnover,
Outcomes=f(turnover resident
characteristics, facility characteristics)



Estimated using resident
resident-level
level observations
Single equation estimation of outcomes could
result in a biased estimate of effect of turnover if
unobserved factors that affect turnover also affect
resident outcomes
Turnover=f(facility characteristics, area IV)

Estimated using facility-level observations
C
Conceptual
t lM
Model
d l (2)
Area Economic
Indicators
- Employment
- Housing Value
- Wages
Resident
R
id t
Characteristics
- Sociodemo
- Medical/clinical
- Functional
CNA Turnover
or Retention
Other Facility
Characteristics
Resident
R
id t Outcomes
O t
(Bad)
(B d)
- Hospital Use
- ER Use
- Ulcers
- Pain
- Falls
- Any of the Above
D t
Data

2004 National Nursing Home Survey

Survey of 1,140 facilities and 13,425 residents

Needed to work at Triangle Census Research
Data Center (RDC) to access file created by
NCHS (t
(two reasons))

Exclusions (age<65 or missing data) resulted in a
analysis file of 9,279 residents at 981 facilities

Range of 1 to 12 residents per facility
T
Turnover
Measures
M

Two measures:

Turnover among certified nursing assistants
((CNAs)) in the past
p
three months ((annualized))
FTEs Left in Last 3 Months


CNA Turnover  
* 4  /100
 FTEs worked in last week  FTE vacancies 


Average turnover: 52%
Proportion of CNAs on staff for less than one year

Average “low retention”: 37%
O t
Outcome
Measures
M







Hospital Admission in past 90 days (7%)
ED visits in past 90 days (8%)
Any pressure ulcer (10%)
Fell in past 30 days (16%)
Fell in past 31-180 days (28%)
Anyy pain
p
in p
past 7 days
y ((25%))
Any negative health outcome above (55%)
A
Area
IInstruments
t
t







County unemployment
Median home value
Median income
Percent housing units vacant
NA hourly mean wage
Food/beverage
g server hourly
y mean wage
g
HHI total certified beds
M th d
Methods

Used linear probability models (OLS)




Three types
yp of outcome models estimated:




Enables facility FE and IV estimation
OK if reasonable variance in dependent variables
Adjusted for survey weights and clustering
Naïve LPM (OLS)
Facility Fixed Effects (w/ variable decomposition)
Facility Fixed Effects – Instrumental Variables
Specification tests to assess model validity
Results: Any Bad Outcome
(
(mean
off 0
0.55)
55)
Models with:
Estimation Method:
Turnover (0.52)
Low Retention (0.37)

Turnover Only
1
2
3
OLS
FE
FE-IV
0.013*
Low Retention Only
4
5
6
OLS
FE
FE-IV
0.030** 0.268**
0.031
0.112** 0.835**
Turnover and Low Ret
7
8
9
OLS
FE
FE-IV
0.012
0.025**
0.043
0.034
0.094** 0.726**
FE are arguably the best estimates:


Increase in CNA turnover of 10 percentage points
associated
i d with
ih0
0.3
3 percentage point
i iincrease iin lik
likelihood
lih d
of bad outcome
Increase in proportion of CNAs at facility less than one year
of 10 percentage points associated with 1 percentage point
increase in likelihood of bad outcome
Li it ti
Limitations

Have not allowed for non-linear effects of turnover or
low retention

Can not distinguish between turnover once in many
positions versus lots of turnover in a few positions

Cross-sectional data

IV correction may not work due to weak instruments

Turnover had unexpected effect on ED use
Summary


FE estimates show modest effect of turnover or low
retention on bad outcomes
Other observed facility characteristics had
comparable effects




High occupancy or seldom having a care plan increased
bad outcomes
For-profit status or offering fully paid health insurance for
the CNA’s family decreased bad outcomes
Effects were strongest for “any
any pain”
pain outcome
IV estimates larger, but weak instruments limit
possible validity of IV results
P li Implications
Policy
I
li ti

Interventions to reduce CNA turnover are
likely beneficial and may reduce cost, but
other observed and unobserved facilityy
characteristics may have as great of an effect
on resident outcomes

Comprehensive programs to ensure quality
administration
d i i t ti and
d oversight
i ht att facilities
f iliti may
be required to jointly reduce CNA turnover
and improve resident outcomes
F t
Future
Work
W k

Longitudinal data rather than cross
cross-sectional
sectional
surveys may yield more accurate results

Turnover among licensed nursing staff may
b more critical
be
iti l ffor resident
id t outcomes
t
th
than
CNA turnover