CALTCM White Paper on Nursing Home Staffing

Mary Madison, RN, RAC-CT, CDP 
Clinical Consultant – Briggs Healthcare

The California Association of Long Term Care Medicine (CALTCM) “is the medical voice for long term care in California. Our public policy committee developed this White Paper with the intention of making recommendations based on evidence-based literature. CALTCM’s Board of Directors approved this White Paper.  It was not our intention to debate the financial impact of our recommendations or where nursing staff will come from, given the current huge workforce shortage issues. We stand for quality care in nursing homes. We absolutely understand many of the issues that have put nursing home care in the precarious state that the COVID-19 pandemic has tragically highlighted. Those issues need to be debated and those problems addressed, but that does not change the existing evidence. Our White Paper presents the evidence. We’re ready and willing to have a debate over the evidence, though we think it’s more important to have a vigorous discussion on how to finance these recommendations and find the nurses and nursing assistants needed to fulfill these requirements.”

“The COVID-19 pandemic has brought attention to pre-existing quality issues and inequities and disparities that exist in nursing homes across the country. Multiple research studies have shown a positive relationship between the quality of nursing home care and staffing, especially for certified nursing assistants (CNAs) and registered nurses (RNs), but also for total nurse staffing. Prior to the pandemic, low nurse staffing levels were known to be associated with poor quality of care as well as abuse and neglect. The impact of disparities in nursing homes was also evident before the pandemic. Racial and ethnic minorities tend to reside in nursing homes with limited financial resources, low staffing levels and a high number of deficiencies. One study showed that only 9% of White nursing home residents live in “lower-tier” homes, compared to an estimated 40% of Black nursing home residents. A recent study found that nursing homes with the highest proportions of non-White residents experienced COVID-19 death counts that were 3.3-fold higher than those in facilities with the highest proportions of White residents. There is ample evidence-based literature documenting negative outcomes during the pandemic related to disparities. Now is not the time for additional “studies” to assess the importance of appropriate staffing levels. The combination of inadequate staffing and disparities can only lead to more tragic situations and outcomes, such as those recently seen during the latest hurricane in Louisiana.”  (This citation is found, along with the corresponding references, in the White Paper’s Overview.)

I encourage you to review and digest this White Paper as it drives home some excellent points, not only about California but our nation and its nursing home.

Ensure that nursing homes adjust staffing levels to meet the acuity needs of residents.

Since 2019, CMS Medicare prospective payment system requires that Minimum Data Set (MDS) assessments use the Patient Driven Payment Model (PDPM). Resident acuity is classified into 6 basic nursing acuity levels consistent with the (PDPM) categories from highest to lowest:

  1. Extensive Services
  2. Special Care High
  3. Special Care Low
  4. Clinically Complex
  5. Behavioral Symptoms
  6. Reduced Physical Functioning.

These categories identify both the licensed nursing care needs and the CNA care needs. In order to meet federal nurse staffing standards, nursing homes need to identify their average resident acuity. They can do this by aggregating the PDPM nursing acuity needs of residents and dividing it by the average census. Each facility should then adjust its staffing to a level commensurate with the resident needs as recommended. Recommended staffing hours and ratios have been developed and published to guide nursing homes in addressing the average resident acuity in nursing homes.


The Director of Nursing and Director of Staff Development, in collaboration with an engaged, knowledgeable, and competent medical director, should determine appropriate acuity-based staffing levels in nursing homes. The evidence-based literature supports minimum staffing levels with limited exceptions, even in predominantly custodial nursing homes, due to the medical complexity of today’s residents. The exceptions should not drive staffing policy, nor should the challenging workforce shortage issues that we are facing. Policy should be based first and foremost on providing the quality care our residents deserve. Questions about the financing of appropriate staffing levels must be addressed in the context of full transparency. Workforce shortages cannot be a blanket excuse for allowing poor quality of care. The COVID-19 pandemic has tragically demonstrated this fact.

Nurse staffing ratios need to meet the demands of acuity-based resident-centered care within a skilled nursing facility. Assuring a consensus style of leadership, including an engaged and knowledgeable medical director; improving wages and benefits; and respecting and empowering CNAs and RNs within nursing homes will reduce turnover and improve morale.

Staffing shortages can also be positively impacted with changes in requirements to ease the administrative burden for each staff member and enhance the satisfaction of caregiving for vulnerable older adults. Finally, with the stark impact of these issues in nursing homes with a high percentage of residents of color, we believe that staffing requirements should immediately be focused on these facilities.

We close this White Paper by reinforcing the call to action in our opening paragraph. While additional studies may help clarify and focus our precise definitions of minimum staffing levels, and while calling for minimum levels cannot alone solve the staffing crisis, we must act now to ensure adequate staffing of our nursing homes. The current combination of inadequate staffing and disparities can only lead to more tragic situations and outcomes.” 

Definitely food for thought.