Association of Racial and Ethnic Composition with Staff Levels in Nursing Homes: 2013-2019

Abstract

Objectives

The nursing home (NH) population has become increasingly diverse, yet many facilities remain de facto racially segregated. This study examines whether a high proportion of Black, Indigenous, and People of Color (BIPOC) residents is associated with nursing staff levels.

Design

We constructed a longitudinal cohort of NHs (2013-2019) by linking Certification and Survey Provider Enhanced Reports, LTCFocUS.org, Medicare Cost Reports, and Payroll-Based Journal data. Separate multivariable random effects linear regressions were conducted.

Setting and Participants

14,075 Medicare- and Medicaid-certified NHs in the United States.

Methods

The proportion of BIPOC residents was categorized as the 10% of nursing homes serving the highest minority residents in each state each year (High-BIPOC) and the remaining 90% (Low-BIPOC). Total nursing staff levels in hours per resident-day (HPRD) included both hours paid (2013-2019) and hours worked (2017-2019). The total staff included registered nurses, licensed practical nurses, and certified nurse aides.

Results

The unadjusted difference in total staff levels between High-BIPOC and Low-BIPOC NHs increased from −0.23 HPRD (4.19 vs 4.42) in 2013 to −0.35 HPRD (3.94 vs 4.29) in 2019 for hours paid. The difference in hours worked increased from −0.19 (3.55 vs 3.74) in 2017 to −0.23 (3.50 vs 3.73) in 2019. The difference became smaller but remained significant after controlling for covariates (−0.037 HPRD for hours paid, and −0.038 for hours worked). Analyses of individual staff types found lower levels of registered nurses and certified nurse aides (but not licensed practical nurses) among High-BIPOC nursing homes. Findings were robust to treating racial and ethnic composition as a continuous variable or excluding payer mix from the models.

Conclusions and Implications

NHs with high concentrations of minority residents reported lower nursing staff levels. Improving staffing in NHs serving primarily marginalized racial and ethnic groups remains a policy priority.