Comparing Disaster-Related Surge Staffing Practices Across Rural and Non-Rural Nursing Homes

Clarifying whether rural and non-rural nursing homes implement different disaster-related staffing approaches is vital to developing targeted preparedness strategies.

In this retrospective cohort study of 361 nursing homes exposed to Hurricane Michael (2018), we used a comparative interrupted time series design to assess changes in staffing intensity and composition from 30 days before landfall to 7 days after. We examined three outcomes using the Centers for Medicare & Medicaid Services (CMS) Payroll Based Journal: total staffing intensity (hours per resident per day), licensure composition (percentage of registered nurses (RN) and licensed practical nurses (LPN)), and employment composition (percentage of routine staff who are not independent contractors). We evaluated staffing intensity with linear mixed-effects models and licensure and employment composition using linear probability models. We report point estimates and 95% confidence intervals (CI).

Of 361 nursing homes, 39.9% were rural. At baseline, rural facilities had 8% (0.92; 95% CI 0.87-0.96) lower total staffing intensity compared to non-rural facilities. In the post-event period, rural facilities increased total staffing by an additional 4% (95% CI 1.02 to 1.06) in the post-event period compared to non-rural facilities. Rural facilities increased their routine staff representation (0.46% points; 95% CI 0.14 to 0.78) but decreased licensed staff representation (-1.00% points; 95% CI -1.39 to 0.61) compared to the post-disaster staffing changes in non-rural facilities.

Distinct disaster-related staffing approaches may heighten baseline staffing differences between rural and non-rural nursing homes. Disaster-related staffing intensity increased in rural facilities, with rural facilities starting from a lower baseline. Although rural facilities may have benefited from greater reliance on routine staff, they were unable to augment licensed nurse staffing. These findings offer foundational evidence regarding the influence of baseline staffing practices and local healthcare workforce conditions on disaster-related staffing strategies.