Shapley Jr R, Weech-Maldonado R, Davlyatov G, Orewa GN, Patterson J, Borkowski N
Background: The 2019 introduction of the Patient Driven Payment Model (PDPM) marked a major shift in reimbursement for U.S. skilled nursing facilities (SNFs). Unlike the previous prospective payment system (PPS), which encouraged high therapy service volumes, PDPM aligns payments with resident needs and care complexity. It broadens case-mix adjustments to include non-therapy ancillary services and speech-language pathology while reducing financial incentives linked to therapy volume. Prior research has explored nursing and therapist staffing changes since the implementation of PDPM in 2019. However, to date there have been no studies that have examined the effects of PDPM on both nursing and therapist staffing intensity, before, during, and after coronavirus disease 2019 (COVID-19). As such, our national study contributes to the literature by providing a comprehensive analysis of nursing and therapy staffing changes from January 2018 to December 2023, and segmenting the staffing data into five periods: pre-PDPM (January 2018 to September 2019), post-PDPM/pre-COVID (October 2019 to February 2020), COVID first wave/peak (March 2020 to December 2020), COVID vaccine introduction (January 2021 to December 2021), and COVID endemic management (January 2022 to December 2023).
Methods: Data sources included the Payroll-Based Journal, SNFs Care Compare, Long-Term Care Focus (LTCFocus), Medicare Cost Reports, Area Health Resource Files, DHHS Provider Relief Fund, SNF’s COVID-19 Public File, and CDC COVID-19 Data Tracker. The study sample included 80,721 SNF-years, representing 931,865 year-month observations. Random effects models were used to analyze changes in nurse and therapy staffing intensity across the five time periods.
Results: Our findings reveal an initial increase in registered nurse (RN) staffing during the post-PDPM/pre-COVID and COVID peak periods, followed by a decline after the COVID vaccine introduction. Licensed practical nurse (LPN) and certified nursing assistant (CNA) staffing intensity also declined, notably after the vaccine rollout. Therapy staffing for occupational, physical, and speech therapists decreased beginning in the post-PDPM/pre-COVID period, while occupational and physical therapy assistants saw declines starting with the COVID peak. For-profit and chain-affiliated SNFs experienced greater increases in therapy staffing and larger reductions in nursing staffing than not-for-profit and independent facilities. Despite increased SNF occupancy by the pandemic’s end, staffing intensity continued to decline, and Coronavirus Aid, Relief, and Economic Security (CARES) funding had no significant impact on staffing levels.
Conclusions: PDPM and the COVID-19 pandemic led to significant declines in both nursing and therapy staffing intensity. Although RN nurse staffing initially increased following PDPM’s introduction, this trend reversed during the pandemic, likely due to workforce shortages and COVID-19-related challenges. The reduction in therapy staffing may have been influenced by changes in PDPM’s therapy reimbursement structure and lower occupancy rates during the pandemic. SNF management must adapt to these changes, balancing staffing with new reimbursement structures to ensure patient care quality. Policymakers should consider nuanced reimbursement models that support both the admission of clinically complex patients and adequate staffing for high-quality care.