There are many ways to go about choosing a senior care community for a loved one. Checklists abound, you may be overwhelmed with questions to ask: How do I pay? What percentage of the staff is vaccinated? Is the facility for-profit or not-for-profit? The list goes on. If you want to hone in on one thing, consider staffing.
According to a survey published in September by the American Health Care Association, “86% of nursing homes and 77% of assisted living providers said their workforce situation has gotten worse over the last three months.”
Nursing homes are experiencing a high level of staffing shortages while assisted living residences are experiencing a moderate level.
Staffing Shortages Affect Quality of Care
Back in 2002, I interviewed then program director for the Volunteer Advocacy Program in the New Jersey Ombudsman’s Office for the Institutionalized Elderly Joann Cancel for my book “Who Moved My Dentures?” Here’s what she told me then:
“The biggest problem today is staffing and it applies to all states. Years ago, abuse was the biggest problem in long-term care. It still exists but now the bigger issue is neglect because of inadequate staffing and poor work ethics.”
That was 19 years ago — what has changed? Well the pandemic brought to light a few things. Trust in long-term care has eroded. With that, consideration of long-term care has dropped in preference to aging in place. That had an impact on census, revenue and budgets.
So, what happens? People are let go. Those who stay are asked to do more and burn out. Add to the post-pandemic reevaluation of work, and you find lower paid but essential employees questioning if this is what they want to do for a living every day.
Get Help With Your Decision
Still for many, an organized community of care (continuing care retirement community, assisted living, independent living, skilled nursing) is sometimes a necessary and important consideration when no other care options are available, especially if the older person is isolated from friends and family.
So, as you consider a community of care, consider first getting some help. A geriatric care manager can help you sort through your options. Then consider a registered nurse who can come with you as you tour a place and help you ask the right questions.
Start With Baseline Guidance
Unfortunately, assisted living is less regulated than nursing homes, so hard and fast data is difficult to come by when evaluating staffing. However, the government’s Nursing Home Compare site, weighs staffing when awarding “stars” to facilities. Five stars is considered the highest. This is a good baseline from which to start but not your ending point.
When the Star System was first introduced, staffing was self-reported and the data was unreliable. Places reporting appropriate staffing did not always turn out to be the highest quality places because in reality, the staffing was over-reported. As staffing is probably the single biggest indicator of quality, well, you can see the dilemma.
The Centers for Medicare & Medicaid Services imposed stricter standards for its consumer-facing nursing home ratings in 2019, including new separate ratings for short-term and long-term stays. But U.S. News and World Report recognized the issue one year sooner in its Best Nursing Home ratings.
Finally, research state facility inspection reports too. You can ask to see the state report when you visit a care home.
When staffing is appropriate, the benefits are great:
— Fewer medication errors.
— Lower patient mortality.
— Shorter stays.
— Lower patient care costs associated with readmission.
— Less nurse fatigue and burnout.
— Increased patient satisfaction.
— Higher patient care survey scores.
What to Ask
A lot of the original advice I shared in my book still applies.
CMS regulations require that nursing homes provide eight consecutive hours of RN services on each day and around-the-clock licensed nurse services. The state of New Jersey went further in early 2020 when it enacted legislation that mandated one certified nursing assistant to every eight residents for the day shift; one direct care staff member (registered nurse, licensed nurse practitioner or CNA) to every 10 residents for the evening shift; and one direct care staff member (RN, LPN or CNA) to every 14 residents for the night shift.
With that baseline, ask:
— How many aides per patient are there?
— How many LPN’s and RN’s per patient are there?
— How long has staff been on board? (Facilities with staff who have been in place a long time by and large are facilities that provide better care because they have experience. The facility must be treating its employees with respect if they stay.)
— What is the turnover rate of employees?
— Are temporary staff used? What percentage and how often?
— Is management stable?
— Are there geriatric nurse specialists and others specially trained to care for older adults?
— Does the facility conduct criminal background checks?
Some other considerations:
— Pull a staff member aside and ask him/her what it’s like working there.
— Find out how the staff works together. Are there patient care meetings at the start of the day? Is there a hand off when the shift changes so that the next shift coming in knows exactly what each resident’s personal situation is for that day?
— Does staff make rounds together?
What Else to Look For
Find out the approach a facility takes with regards to resident care. As mentioned, you may want to take a nurse with you when you go to visit a place that you are thinking about.
And ask the right questions: Is there a multidisciplinary approach to care, that is, is there a team approach? Is care individualized for each patient? What kind of quality assurance program do they have in place? How is their data handled? Are medical records computerized? Is there full documentation of what is taking place? What are the checks and balances in place to assure that everything is being done above board? What emergency procedures are in place? What hospital will a resident be taken to if care is needed? How is a resident’s family physician brought into the care team?
Yeah, it’s a lot and probably most of it’s above your pay grade. That’s why it’s important to consult professionals.
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