Understand the Determinants and Quality Implications of Agency Staff Use in Nursing Homes: A Mixed Methods Study
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PROJECT SUMMARY/ABSTRACT The use of temporary contract workers from staffing agencies has become a new normal for nursing homes. In 2018-2019, only 23% of nursing homes used any agency staff, contributing to 3% of nursing staff work hours. This percentage increased to 49% in 2022 and has remained high. Yet, the impact of agency staff on health outcomes is unclear. Agency staff might be better trained and more experienced. But agency staff use can decrease continuity of care and impact the morale of employed staff. Our preliminary analyses found that agency staff use is associated with functional declines, falls, pressure ulcers, and emergency department visits. Also, the association between agency staff use and falls is stronger among residents with Alzheimer’s disease and related dementias (ADRD). By linking Payroll-Based Journal (PBJ) staffing data with national Medicare and resident assessment data, and interviewing nursing home workers and Medicaid officials, we propose a convergent parallel mixed methods study to understand the determinants and quality implications of agency staff use in nursing homes. The specific aims are: Aim 1) To examine the patterns and best practices for agency staff use in nursing homes; Aim 2) To evaluate whether agency staff use is associated with ADRD-related outcomes among long-stay residents and whether staff continuity mediates this association; and Aim 3) To explore how state Medicaid staffing incentives factor into agency staff patterns. Aims 1 and 2 will study an estimated 2,447,000 long-stay residents in 14,727 nursing homes from 2022 Q3 to 2025 Q4 using national Medicare, Minimum Data Set, and PBJ data. Aim 1 will characterize patterns (intensity and continuity) of agency staff using PBJ data, as well as conduct 20 role-specific focus groups with nursing home leadership and staff to understand the best practices for agency staff use. Aim 2 will perform separate two-way fixed-effects models to evaluate the associations of agency staff use with ADRD-related outcomes, such as changes in physical function (primary), aggressive behavior, falls, and hospitalizations. Causal mediation analysis will examine whether the associations can be explained by staff continuity. Aim 3 will utilize Difference in-Differences methods to separately examine the association of Medicaid staffing incentives in Illinois (2022), Maine (2025), and New Jersey (2025) with agency staff patterns. We will also conduct 9 interviews with Medicaid officials to understand the role of staffing incentives in agency staff patterns. This project will improve how agency staff are used so as to optimize quality of care and health outcomes in nursing homes.
