Elizabeth M. White, Linda H. Aiken, and Matthew D. McHugh
Introduction/Objective
Medicaid is the largest payer of nursing home (NH) care in the U.S., yet there are long-standing concerns that Medicaid payments are insufficient to cover actual costs of care and contribute to poor care quality. Prior work has shown that low Medicaid reimbursement rates impair administrators’ abilities to employ sufficient nursing staff, but it is unclear how Medicaid funding may contribute to administrators’ abilities to ensure that other elements of safe nursing work environments are in place. In this study, we examined the relationship of nursing home (NH) Medicaid census to nurse ratings of care quality and work environment.
Design/Methodology
Cross-sectional analysis of 2015 linked data from LTCfocus and the RN4CAST-US nurse survey.
Results
Across nurses, 13.5% gave their workplace a poor or failing grade for patient safety, 25.5% rated the quality of nursing care in their workplace as fair or poor, and 31% said that they would not recommend their workplace to family or friends needing care. Controlling for nurse and other organizational characteristics, each 10% increase in a NH’s Medicaid census was associated with a 21% higher odds of nurses grading patient safety as poor or failing (p = .04), a 17% higher odds of nurses rating the quality of nursing care as fair or poor (p = 007), and a 17% higher odds of nurses reporting that they would not recommend their workplace to family or friends. Each 10% increase in an employer’s Medicaid census was associated with an 18% higher odds of nurses reporting poor vs. good work environments (p = .02). The 2 work environment domains that were independently associated with Medicaid census were staffing and/or resource adequacy and nursing foundations for care quality. The latter category reflects whether an organization maintains active quality assurance programs, preceptor programs for new hires, continuing education, consistent patient assignments, up-to-date nursing care plans, and overall high standards for nursing care.
Conclusion/Discussion
Nurses employed in NHs with more Medicaid residents were more likely to give negative assessments of care quality and rate their work environment as poor. These findings add to the body of evidence linking Medicaid funding to care quality in NHs, and illustrate the multidimensional ways in which Medicaid payments may influence NH leaders’ capacity to support their workforce to deliver high-quality care. Various resources exist to aid NH leaders in improving working conditions for their employees, but there is still much work needed to test the efficacy of interventions and understand best strategies for implementation.