United States' Nursing Home Finances: Spending, Profitability, and Capital Structure.

Little is known about nursing home (NH) financial status in the United States even though most NH care is publicly funded. To address this gap, this descriptive study used 2019 Medicare cost reports to examine NH revenues, expenditures, net income, related-party expenses, expense categories, and capital structure. After a cleaning process for all free-standing NHs, a study population of 11,752 NHs was examined. NHs had total net revenues of US$126 billion and a profit of US$730 million (0.58%) in 2019. When US$6.4 billion in disallowed costs and US$3.9 billion in non-cash depreciation expenses were excluded, the profit margin was 8.84 percent. About 77 percent of NHs reported US$11 billion in payments to related-party organizations (9.54% of net revenues). Overall spending for direct care was 66 percent of net revenues, including 27 percent on nursing, in contrast to 34 percent spent on administration, capital, other, and profits. Finally, NHs had long-term debts that outweighed their total available financing. The study shows the value of analyzing cost reports. It indicates the need to ensure greater accuracy and completeness of cost reports, financial transparency, and accountability for government funding, with implications for policy changes to improve rate setting and spending limits.

Examining California nursing home profitability and related factors before and during the COVID-19 pandemic.

BACKGROUND: The financial status of nursing homes (NHs) is a policy concern, especially during a pandemic, because of the higher costs associated with infection prevention and resident care. METHODS: This exploratory study was designed to assess the impact of the federal and state COVID-19 funding support on California NHs profitability during 2020, the first year of the pandemic, compared with 2019, the last pre-pandemic year. The study examined the association of Medicare and Medicaid days, related-party transactions, as well as other facility characteristics on net income profit margins, using cross-sectional regression analysis of data from state NH cost reports and federal NH provider data for 2019 and 2020. RESULTS: California skilled NHs had average reported net income profit margins of 2.26% in 2019 and 7.0% in 2020 with wide variations (from a loss of about 48% to a gain of 74% in 2020). Regression analysis found that the number of beds, occupancy rates, high-quality rating scores, and medium and high proportions of Medicare resident days were positively associated with net income margins in 2019 and 2020. Chains in 2020 (but not 2019), related-party expenditures in 2019 and 2020, median Medicaid days (in 2019), high Medicaid resident days (71%-73% or higher) in 2019 and 2020, and medium and high managed care resident days were negatively associated with net income margins in both years. CONCLUSIONS: Although NH admissions and occupancy rates declined substantially between 2019 and 2020, some (but not all) California NHs had a substantial increase in profit margins in 2020 over 2019. More studies of nursing home financial patterns and profitability are needed to examine trends over time and variations across states.

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

INTRODUCTION: Nursing homes have been disproportionally affected by the COVID-19 pandemic, particularly because of resident vulnerability, inadequate staffing, and poor quality of care. CURRENT STATE: 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. CONCLUSION: 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.

The association of facility ownership with COVID-19 outbreaks in long-term care homes in British Columbia, Canada: a retrospective cohort study.

BACKGROUND: Long-term care (LTC) in Canada is delivered by a mix of government-, for-profit- and nonprofit-owned facilities that receive public funding to provide care, and were sites of major outbreaks during the early stages of the COVID-19 pandemic. We sought to assess whether facility ownership was associated with COVID-19 outbreaks among LTC facilities in British Columbia, Canada. METHODS: We conducted a retrospective observational study in which we linked LTC facility data, collected annually by the Office of the Seniors Advocate BC, with public health data on outbreaks. A facility outbreak was recorded when 1 or more residents tested positive for SARS-CoV-2 between Mar. 1, 2020, and Jan. 31, 2021. We used the Cox proportional hazards method to calculate the adjusted hazard ratio (HR) of the association between risk of COVID-19 outbreak and facility ownership, controlling for community incidence of COVID-19 and other facility characteristics. RESULTS: Overall, 94 outbreaks involved residents in 80 of 293 facilities. Compared with health authority-owned facilities, for-profit and nonprofit facilities had higher risks of COVID-19 outbreaks (adjusted HR 1.99, 95% confidence interval [CI] 1.12-3.52 and adjusted HR 1.84, 95% CI 1.00-3.36, respectively). The model adjusted for community incidence of infection (adjusted HR 1.12, 95% CI 1.07-1.17), total nursing hours per resident-day (adjusted HR 0.84, 95% CI 0.33-2.14), facility age (adjusted HR 1.01, 95% CI 1.00-1.02), number of facility beds (adjusted HR 1.20, 95% CI 1.12-1.30) and facilities with beds in shared rooms (adjusted HR 1.16, 95% CI 0.73-1.85). INTERPRETATION: Findings suggest that ownership of LTC facilities by health authorities in BC offered some protection against COVID-19 outbreaks. Further study is needed to unpack the underlying pathways behind this observed association.

Financial and Quality Metrics of A Large, Publicly Traded U.S. Nursing Home Chain in the Age of Covid-19.

Nursing homes faced serious challenges with large COVID-19 resident infection rates and deaths during the pandemic. This descriptive case study examined the structure, operations, strategies, care outcomes, and owners of The Ensign Group Inc. the second largest U.S. for-profit chain, between 2007 and 2021. Ensign, as a holding company, has a complex organizational structure that uses more than 430 corporate entities to manage its 228 nursing homes and senior living facilities. With mostly Medicare and Medicaid revenues and favorable government COVID-19 relief, Ensign grew rapidly, even during the pandemic, to $2.5 billion (all amounts in U.S. Dollars) in revenues with a market capitalization of $4.5 billion and strong profits and financial metrics in 2020 to 2021. The company used real estate purchasing, debt financing, and spin-off companies, and tax arbitrage to optimize shareholder value. Before and during the pandemic, its 198 nursing homes had low registered nurse and total nurse staffing levels and regulatory violations with below-average ratings, and they had high COVID-19 infection rates during the pandemic. Ensign's small board, executives, and institutional investors protected and enhanced shareholder interests rather than ensuring that its nursing homes met professional standards and regulatory requirements.

Staffing Levels and COVID-19 Infections and Deaths in Korean Nursing Homes.

The novel coronavirus disease 2019 (COVID-19) spread rapidly worldwide. Nursing home (NH) residents are the most vulnerable high-risk population to infection. Professional registered nurses' (RNs') infection control is irreplaceable. We used a secondary data analysis method using the government's senior citizen welfare department large data set about all NHs (N = 3,389) across Korea between January 20 and October 20, 2020. Bed size positively associated with the mortality rate (No. of COVID-19 resident deaths / No. of total residents) (p = .048). When the proportion of RNs to total nursing staff was higher, the infection rate was 0.626% lower (p = .049), the mortality rate was 0.088% lower (p = .076), the proportion of confirmed COVID-19 cases per resident out of the total number of NHs was 44.472% lower (p = .041), and the proportion of confirmed COVID-19 deaths per resident out of the total number of NHs was 6.456% lower (p = .055). This study highlighted nurse staffing criteria and suggests that increasing RNs in NHs will reduce infection and mortality rates during the COVID-19 pandemic. We strongly suggest NHs hire at least one RN per day to properly function, and a minimum of four RNs to provide a fully competent RN workforce in long-term care settings in Korean NHs.

Expert nurse response to workforce recommendations made by The Coronavirus Commission For Safety And Quality In Nursing Homes.

COVID-19 has exposed the longstanding internal problems in nursing homes and the weak structures and policies that are meant to protect residents. The Centers for Medicare and Medicaid Services convened the Coronavirus Commission for Safety and Quality in NHs in April, 2020 to address this situation by recommending steps to improve infection prevention and control, safety procedures, and the quality of life of residents in nursing homes. The authors of this paper respond to the Final Report of the Commission and put forth additional recommendations to federal policymakers for meaningful nursing home reform: 1) ensuring 24/7 registered nurse (RN) coverage and adequate compensation to maintain total staffing levels that are based on residents' care needs; 2) ensuring RNs have geriatric nursing and leadership competencies; 3) increasing efforts to recruit and retain the NH workforce, particularly RNs; and 4) supporting care delivery models that strengthen the role of the RN for quality resident-centered care.

A Call to the CMS: Mandate Adequate Professional Nurse Staffing in Nursing Homes.

Editor's note: This article is by 22 nursing gerontology experts who are all advocates of nursing home reform. They are listed at the end of this article.

Racial Disparities in Financial Security, Work and Leisure Activities, and Quality of Life Among the Direct Care Workforce.

BACKGROUND AND OBJECTIVES: Personal care, home health, and nursing aides provide the majority of care to chronically ill and disabled older adults. This workforce faces challenging working conditions, resulting in high turnover and workforce instability that affect the quality of care for older adults. We examine financial security, work-life balance, and quality of life of Black, Hispanic, and workers of other race/ethnicity compared to White workers. RESEARCH DESIGN AND METHODS: We hypothesize that Black and Hispanic workers experience greater financial insecurity, spend more time on work-related activities and have less time available for leisure activities, and have a lower quality of life compared to White workers. To test these hypotheses, we analyze the American Time Use Survey using descriptive analyses and multivariable and compositional regression. RESULTS: Black and Hispanic individuals were 2-3 times more likely to live in poverty than White individuals. The time use analysis indicated that Black and Hispanic workers spent more time on work-related activities and less time on nonwork-related activities, including longer work commutes and less time exercising. In analyses of aggregated paid/unpaid work and leisure, Black workers were the only group that spent significantly more time working and less time on leisure activities compared to White workers. This may explain the lower quality of life that we only observed in Black workers. DISCUSSION AND IMPLICATIONS: Racial/ethnic disparities in well-being among direct care workers may affect the care older adults receive and contribute to widening inequities in this workforce and society. Policymakers should direct efforts toward securing funding for workers, incentivizing employer provisions, and implementing racial equity approaches.

Appropriate Nurse Staffing Levels for U.S. Nursing Homes.

US nursing homes are required to have sufficient nursing staff with the appropriate competencies to assure resident safety and attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident. Minimum nurse staffing levels have been identified in research studies and recommended by experts. Beyond the minimum levels, nursing homes must take into account the resident acuity to assure they have adequate staffing levels to meet the needs of residents. This paper presents a guide for determining whether a nursing home has adequate and appropriate nurse staffing. We propose five basic steps to: (1) determine the collective resident acuity and care needs, (2) determine the actual nurse staffing levels, (3) identify appropriate nurse staffing levels to meet residents care needs, (4) examine evidence regarding the adequacy of staffing, and (5) identify gaps between the actual staffing and the appropriate nursing staffing levels based on resident acuity. Data sources and specific methodologies are analyzed, compared, and recommended. The goal is to assist nursing home nurses and administrators to ensure adequate nursing home staffing levels that protect resident health, safety, and well-being.

Nurse Staffing and Coronavirus Infections in California Nursing Homes.

In the United States, 1.4 million nursing home residents have been severely impacted by the COVID-19 pandemic with at least 25,923 resident and 449 staff deaths reported from the virus by June 1, 2020. The majority of residents have chronic illnesses and conditions and are vulnerable to infections and many share rooms and have congregate meals. There was evidence of inadequate registered nurse (RN) staffing levels and infection control procedures in many nursing homes prior to the outbreak of the virus. The aim of this study was to examine the relationship of nurse staffing in California nursing homes and compare homes with and without COVID-19 residents. Study data were from both the California and Los Angeles Departments of Public Health and as well as news organizations on nursing homes reporting COVID-19 infections between March and May 4, 2020. Results indicate that nursing homes with total RN staffing levels under the recommended minimum standard (0.75 hours per resident day) had a two times greater probability of having COVID-19 resident infections. Nursing homes with lower Medicare five-star ratings on total nurse and RN staffing levels (adjusted for acuity), higher total health deficiencies, and more beds had a higher probability of having COVID-19 residents. Nursing homes with low RN and total staffing levels appear to leave residents vulnerable to COVID-19 infections. Establishing minimum staffing standards at the federal and state levels could prevent this in the future.