Impacts of Skilled Nursing Facility Change of Ownership on Staffing: A Staggered Difference-in-Difference Analysis

Skilled nursing facilities (SNFs) are experiencing significant regulatory scrutiny. Recent federal rules established guidelines for increased transparency in reporting of changes in SNF ownership and controversial minimum staffing levels for nurse occupations. This study examined whether SNF changes in ownership were independently associated with changes in levels of nurse, non-nurse, administrator, and contract staff.

Staggered difference-in-differences analysis using SNF ownership and staffing data from January 2018 to June 2023.

11,543 SNFs.

Outcomes were patient census and the following staffing variables: staffing hours per patient-day (HPPD) for all patient care staff, nurse staffing HPPD, non-nurse staffing HPPD, administrator staffing hours, and percentage of staff employed as contractors. We compared outcomes before and after ownership change for SNFs that changed ownership, using SNFs that never changed ownership as a control group. We adjusted for care quality, rural location, ownership, payer mix, occupancy, chain status, and state.

Between January 2018 and June 2023, a total of 2508 SNFs (21.7%) changed ownership. The change in ownership average treatment effects were a census increase of 2.36 patients per day and a 0.07-HPPD decline in overall staffing, driven by a 0.09-HPPD decline in nurse staffing (-2.23% relative to control group means). Conversely, ownership change was associated with a 0.02-HPPD increase in non-nurse staffing (2.12% relative to control group means), a 0.52-hour (6.43%) increase in administrator staffing, and no change in contractor staffing.

We found that SNF ownership changes were associated with declines in overall patient care staffing, driven by nurse staffing declines. As nurse occupations comprise more than 80% of staff time in SNFs, results support concerns that SNF ownership changes may negatively impact staffing operations and suggest that SNFs undergoing changes in ownership may have increased difficulty meeting potential new nurse minimum staffing standards.