Incorporating staffing instability in the nursing home Five-Star Staffing Composite

Staffing is an important indicator of nursing home quality and resident health outcomes. The Five-Star staffing ratings in Nursing Home Care Compare, the report card published by the Centers for Medicare and Medicaid Services, is based on average hours per resident-day and turnover measures. Studies have shown that a new measure of staffing instability, capturing day-to-day staffing variation, is associated with resident outcomes and provides additional information about quality not reflected in the current Five-Star staffing ratings. In this paper we simulate the impact of including the new staffing instability measure on staffing ratings for 13 641 nursing homes nationwide, using data for the third quarter of 2023. We found that, under a conservative scenario, 21% of nursing homes perform well or poorly enough on instability that this addition would change their current staffing rating, providing consumers with additional information about quality for these facilities, with minimal disruptions to the rating system as a whole. We also demonstrate that the choice of weights for each of the measures included in the Five-Star ratings matters. These weights should reflect policy priorities. We conclude that the Centers for Medicare and Medicaid Services can and should add staffing instability to its Five-Star staffing ratings.