Validation of nurse staffing time associated with a case-mix classification system for long-term care nursing facilities

Abstract

Concern over the adequacy of nurse staffing in long-term care nursing facilities (LTCNF) has been voiced by professional nursing organizations and nursing home advocacy groups for more than twenty years. Studies demonstrating the cost-effectiveness and quality associated with increasing the number of nurses in nursing homes have had little impact on policy. A Health Care Financing Administration (HCFA) funded demonstration project to test a prospective Medicare/Medicaid payment system uses the Resource Utilization Group-Version III (RUG-III) case-mix classification system to determine reimbursement for nursing facilities. The purpose of this study was to determine if the nursing time associated with the RUG-III case-mix classification system is valid for making nurse staffing decisions to provide quality care to nursing home residents. This study used the Delphi technique to obtain consensus on the average nursing time and nurse staffing, by skill level, for nursing home residents classified according to the RUG-III case-mix system. A panel of nurse manager/administrator experts in long-term care, nominated by gerontological nursing and long-term care organizations, reviewed descriptions of residents representing case-mix groups based on the RUG-III classification system. Following the third Delphi round, the panel's estimates of nursing time were compared with the nursing time associated with the RUG-III case-mix classification system. Thirty-seven of the 59 nominees meeting the criteria for the study and agreeing to participate in the study completed all three of the Delphi rounds. Consensus on nursing time for all three nursing skill levels was not achieved for any of the descriptions of residents representing the RUG-III case-mix groups. Throughout the three rounds, the panel members moved toward closer agreement as demonstrated by a decrease in standard deviations. The panels' estimates of nursing time for the 12 Profile Descriptions were significantly higher (p < .003) than the nursing time associated with the RUG-III case-mix groups. The panel members estimated 3 more staff members in a 24-hour period for the 15-bed unit and 4 more staff members for the 40-bed unit than the RUG-III staffing. The results of this study raise questions regarding the usefulness of the nursing time associated with the RUG-III case-mix classification system for making nurse staffing decisions to ensure that the nursing care needs of the residents are adequately met. The panel members' estimates of nursing time for the different case-mix groups and their reasoning for their estimates demonstrated that differing clinical, emotional, technical, and rehabilitation needs of nursing home residents were taken into account when making decisions regarding the resource needs of residents.