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Providing nursing home care in an era of increasing scarcity: the case of Pennsylvania

2022 Conference Presentation

8 September 2022

Providing nursing home care in an era of increasing scarcity: the case of Pennsylvania

Pamela Nadash , University of Massachusetts Boston , United Kingdom

Elizabeth Simpson, Molly Wylie, Marc Cohen
University of Massachusetts Boston


Background: In the United States, Medicaid financing of nursing home care provides the strongest safety net for low income older adults, persons who have high-intensity long-term services and supports (LTSS) needs, and consumers with exorbitant LTSS costs; many of whom have to spend down their resources to become eligible for the program. Yet, as important as this service setting is to these populations, nursing homes currently face serious threats to their financial viability. This is particularly true in the context of the COVID-19 pandemic, where the costs of caring for residents in a safe way have increased significantly, even as the ability to recoup these costs from the Medicaid program has been constrained.

Objective: The objective of this research is to assess key supply and demand factors that affect the performance of Pennsylvania's nursing home industry over time (2010-2020).

Methods: This research examines individual long-term care facilities and/or employees and residents in the Commonwealth of Pennsylvania. It draws from several large, national data sources, including Nursing Home Compare,, the U.S. Bureaus of the Census and Labor Statistics, and Certification and Survey Provider Enhanced Reports (CASPER), as well as state-level population projections and Department of Health and Human Services data. An aggregate database with historical data points at the facility, state, and regional level was constructed. Annual total and regional trends were examined from 2010 to 2020. Researchers also made projections where possible and appropriate.

Principal Findings: Despite indications that the demand for LTSS in Pennsylvania will increase over the coming decade and that the Commonwealth's nursing homes are now serving individuals who have increasingly challenging diagnoses, staff hours among direct care workers have remained relatively unchanged over the last ten years, while RN hours have declined slightly. Thus, even as the population has become somewhat more medically complex, total care hours have not changed much and skilled hours have actually declined. Additionally, compensation levels for the direct care workforce have remained relatively flat in nominal terms and declined in real terms, making it more difficult to recruit and retain direct care workers. This study also documents that while certain individual quality metrics have improved in Pennsylvania nursing homes, overall aggregate quality scores have declined. Constant direct care hours to serve a population of more medically complex residents likely contributes to this observation.

Conclusions: Staffing levels and wages at Pennsylvania nursing homes--particularly among direct care staff--are not keeping up with the complexity of nursing home residents' care needs and with increasing demand for institutionally based services. Considering declining quality ratings, shortfalls in hours and wages among Pennsylvania's nursing home staff point to the need for further investment in staffing and staff training, which can only come about in the context of a payment structure necessary to support it.