Abstract: Nursing homes provide critical long-term and post-acute care to older adults, yet persistently low care quality remains a pressing policy issue in this industry. Direct care staffing—provided by certified nursing assistants (CNAs), licensed practical nurses (LPNs), and registered nurses (RNs)—is a key determinant of quality, but there is limited consensus on optimal staffing levels and skill mix. Using daily employee-level nursing home staffing data, this study leverages day-to-day staffing shock caused by employee absences to causally estimate the effects of staffing levels and skill mix on patient outcomes. We find that, on average, nursing homes are only able to replace 82% of lost staff hours when an employee is absent with wide variation around this mean. Instrumenting for potentially endogenous staffing levels with our absence instrument, we find that a 25% increase in the weekly staff-to-resident ratio results in a 15.3% reduction in the share of residents hospitalized and a 15.1% reduction in the share of patients who die in that week, as well as an 11% and 13% reduction in days spent in the hospital and overall spending on inpatient care. Quality effects were largest from increases in CNA staffing levels, consistent with this staff type providing the preponderance of daily hands-on patient care. These findings can directly inform ongoing debates about minimum federal staffing standards recently implemented by the Biden administration and currently being reviewed by the Trump administration.
Bio: David C. Grabowski, PhD, is a professor of health care policy in the Department of Health Care Policy at Harvard Medical School. His research examines the economics of aging with a particular interest in the areas of long-term care and post-acute care. He is a member of the National Academy of Medicine. He has published over 250 peer-reviewed articles, and his work has appeared in leading peer-reviewed journals of economics, health policy, and medicine, including Review of Economics & Statistics, Health Affairs, Journal of Health Economics, and New England Journal of Medicine. His work has been featured by prominent popular press outlets, such as the Wall Street Journal, National Public Radio, Washington Post, and New York Times. He has testified to Congress on seven separate occasions.
Dr. Grabowski’s research has been supported by the National Institute on Aging, the Agency for Healthcare Research and Quality, and the Centers for Medicare and Medicaid Services (CMS). His research has also been funded by several private foundations including the Robert Wood Johnson Foundation, Commonwealth Fund, Arnold Foundation, Donaghue Foundation, and Warren Alpert Foundation.
From 2017 through 2023, Dr. Grabowski was a member of the Medicare Payment Advisory Commission (MedPAC), which is an independent agency established to advise the U.S. Congress on issues affecting the Medicare program. He has also served on several CMS technical expert panels. During the pandemic, he served on the CMS Nursing Home Coronavirus Commission. He was also a member of the National Academy of Sciences, Engineering, and Medicine Committee on the Quality of Care in Nursing Homes. He is an associate editor of the journal Forum for Health Economics and Policy, and he is a member of the editorial boards of American Journal of Health Economics, B.E. Journals in Economic Analysis & Policy, and Journal of the American Medical Directors Association. He was the 2004 recipient of the Thompson Prize for Young Investigators from the Association of University Programs in Health Administration.
Dr. Grabowski received his BA from Duke University and his PhD in public policy from the Irving B. Harris School of Public Policy at the University of Chicago.
