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By Margaret M. Conner-Levin, MSW

Where do mandated staffing ratios fit in value-based care? Do lower staffing ratios for clinical professionals improve the quality of care? The data isn’t clear about the benefits of lower staffing ratios and there is a wide range of state-specific regulations related to clinical staffing ratios.

Across the health and human service market, staffing ratios play a big role, but look very different depending on the type of organization, type of program, and the state where the program in operating. For residential and inpatient care for behavioral health and intellectual and developmental disability (I/DD) services for children and adults, staff ratios are a historically integral component to program description and design. There are no federal regulations, and these ratios are outlined by each states as a part of their licensing and operations standards. Ratios are found for 24-hour residential sites and inpatient psychiatric care, but not for outpatient-based care.

In community-based behavioral health residential care, the compliment of staff by education and experience is what is mandated through state regulation (i.e., one BA-level staff for each eight-hour awake shift and one master’s level clinical professionals for every 24-hour period). This is the states’ oversight activity to insure public safety and presumably provide a minimum standard of care. Broadly across the industry—including nursing homes, 24-hour behavioral health facilities, and 24-hour I/DD facilities—ratios exist as determined by the type of facility license issued. This is determined by acuity of population served, number of beds, age of consumers, and environment of care. Formulas vary by state but generally follow a 1:5 (staff-to-consumer) ratio during waking hours. For example, sampling the category of community-based residential care in three states (New Jersey, Illinois, and Texas) shows:

  1. New Jersey—On awake hours, a 1:6 ratio must be met. On overnight hours a 1:12 ratio must be met (see Manual of Requirements For Children’s Group Homes).
  2. Illinois—A 1:5 ratio must be met, or a 2:6 for six or more consumers (see Department of Children and Family Services Requirements For Licensure).
  3. Texas—No minimum ratios (see Compendium of Residential Care and Assisted Living Regulations and Policy)

In each of these examples staff is defined as a direct care support worker with a high school education. In looking across state regulations for community-based residential care the phrase, “Minimum staffing required to meet the needs of the population” is common along with definition of qualifications to fill roles such as manager, social worker, psychiatrist, and residential care worker.

Contrast this to the health care field where, though not standardized or regulated at the federal level, some states do require specific nurse staffing ratios for inpatient hospitals and inpatient rehabilitation facilities. A total of 14 states have some form of nurse staffing regulations. Of these states, California is the only one that has both mandated and implemented staff-to-consumer ratios (see American Nurses Association: Nurse Staffing).

In nursing homes and skilled nursing facilities, there are some basic federal discipline-specific requirements related to nurse staffing. The Centers for Medicare and Medicaid Services (CMS) guidelines for skilled nursing facilities and nursing homes that accept Medicare and Medicaid require facilities to provide licensed nurses 24 hours a day, which are “sufficient” staff to meet the needs of each resident and a registered nurse (RN) a minimum of eight consecutive hours per day, seven days a week (see Staffing Requirements: The Revised Requirements of Participation). Most states have additional staffing requirements addressed through regulations and licensing standards (see Nursing Home Staffing Standards In State Statutes & Regulations). These staffing requirements are more often in the form of discipline-specific requirements for a specified number of hours. For example, there may be state regulations for skilled nursing facilities that must be staffed by a full-time master’s level social worker for 100 or more beds. For less beds, social work functions can be carried out by a variety of staff.

With this variety of regulations and lack of clear definitions, staffing ratios have become a political issue. There are two bills at the federal level, one in the House of Representatives and one in the Senate mandating nursing ratios in acute care settings including skilled nursing care facilities, psychiatric facilities, and rehabilitation facilities (see National Campaign for Safe RN-to-Patient Staffing Ratios). Most recently we saw a ballot initiative placing limits on the number of consumers that a nurse would have responsibility for, fail to pass with voters after a record-breaking $25 million was spent by the Massachusetts Health & Hospital Association to defeat it. According to the MHA, the initiative would have reduced access to services and significantly increased cost of health care (see Hospitals spend record $25M to defeat nurse patient ratio ballot question). In contrast, the Massachusetts Nurses Association spent $12 million to advocate in favor of the ballot initiative. This is just one example of the opposing forces that are continuously at odds when it comes to staff-to-consumer ratios. The reasoning of the opposition is that if staffing ratios are mandated and unable to be met, units will “limit” the number of consumers admitted, causing a negative cascading effect on care, while those in favor of mandated ratios say that it will enable better quality consumer care.

One issue is whether the use of technology is going to change how we view staffing ratios. We’ve written about how technology is replacing some health care service functions and making workers more “efficient”—Workforce Problems? Technology As Strategy; The Staffing Equation For Community-Based Services; and Technology As A Workforce Solution. Technology can bridge some of the gaps in staffing by augmenting the delivery of care. Remote monitoring of consumer conditions, medication monitoring systems, electronic appointment reminders, online cognitive therapy, and telehealth are all virtual care options that create efficiencies and can help to amplify staff. As we move into a more value-based financing systems, there is a much bigger bang for your buck by spending health care expertise on innovation and virtual care than simply adding more staffing.

For many executives of provider organizations, standards around staffing issues don’t represent a value-add, but rather another strategic and administrative challenge to overcome—particularly when faced with no increases in fee-for-service (FFS) rates and workforce shortages. As we have discussed before, knowing your numbers and understanding your drivers of cost are critical. Leading and managing by well-defined key performance indicators help drive your strategy for sustainability and growth. This squeeze is part of the formula of strategic decisionmaking for the future and how to achieve the size and scale to sustain an organization with programs that have a design based in a FFS world.

The cost of mandated staffing levels is one of many reasons behavioral health care provider organizations have been slower to jump into value-based care arrangements—fixed costs aren’t correlated with value added. Executives of provider organization are somewhat squeezed between the state regulatory requirements to operate a facility and the costs that are not necessarily compensated in newer reimbursement rates and models. Prescribed staffing ratios serve a purpose, but are best compensated in an FFS model.

Regulation of health care provider organizations is necessary to assure public safety. Reexamining what should be regulated based on the phasing out of FFS reimbursement models and the growth of value-based care models is worth exploration. This brings us back to the question—do mandated staffing ratios add value? I think in terms of timeliness and safety the answer is yes. I think in terms of improving care outcomes the answer is less clear. The compliment of care inputs drive quality and that is reflected by diverse care teams and innovative treatment offerings augmented by technology. Outcome measures should be defined by providers that directly correlate to the delivery of positive outcomes versus prescriptive input such as staffing ratios. In a value-based care environment, mandated staffing ratios hold less relevance.

The question for executive teams to answer is about balance—is it quality versus quantity? Or is it a little bit of both? In a market focused on value and driven by consumerism, it might be beneficial for provider organizations to ramp up their staffing ratios to deliver a more positive consumer experience. Consumers don’t do well with long waits for service, whether waiting for care while on an inpatient unit or waiting for an appointment as an outpatient. Consumer satisfaction, engagement, and progress declines the longer the consumer waits for a positive outcome. Clearly adequate staffing to provide care is necessary; that is not a question. Quality care is experienced when a consumer has a positive outcome as a result of the input, or efforts, of staff to provide care. Quality care is not experienced just because of the numbers of staff seen by a consumer.

A key to creating reasonable staffing levels is giving health care provider organizations input into defining those numbers based on acuity levels, environmental factors, staff skill, technology augmentation, and measured outcomes of care. Offering care that prioritizes safety, compassion, and individuality as the core components drive far better outcomes than administering programs by the numbers.

While staffing levels do play a role in operations of health care and need to remain a part of standards of care, without clear reasoning for the levels they are just numbers to be dealt with.

For more, join us in June in New Orleans at OPEN MINDS Strategy & Innovation Week, where we will take a deep dive into how technology-based care delivery can influence staffing during The OPEN MINDS Consumer Engagement Technologies Summit—featuring Andrea Auxier, Ph.D., Senior Vice President, Product Development, New Directions; Chris Thompson, MHA, Chief Operating Officer, Monarch; Davis Park, Executive Director, Front Porch Center for Innovation & Wellbeing; Larry Smith, CPRSS, Chief Operating Officer, Grand Lake Mental Health Center, Inc.; and Neal A. Bowen, Ph.D., Chief Mental Health Officer, Hidalgo Medical Services.


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