Health Impacts of Nursing Home Staffing

Introduction

Adequate staffing is critical to the effective operation of health care facilities. This is particularly true in nursing homes, where the Centers for Medicare & Medicaid Services considers staffing to have “the greatest impact on the quality of care nursing homes deliver.”¹ Yet, most nursing homes staff below the levels that clinicians, researchers, and advocates consider adequate.² Various state and federal proposals have aimed to raise staffing through payment reforms and staffing regulations, including the Centers for Medicare & Medicaid Services’ recent attempt to set more stringent staffing standards.³

To understand the impacts of such policies on patient health, we study a recent Illinois payment reform aimed at increasing staffing at Medicaid-serving facilities. This policy incentivized greater staffing by providing facilities with bonus Medicaid reimbursements up to $38.68 per Medicaid resident-day based on acuity-adjusted staffing levels. In previous work, we found that this reform increased nurse staffing by 12.2% relative to baseline.⁴ Herein, we examine the reform’s impact on patient health.

Methods

We used linked Medicare claims and Minimum Data Set assessments from the second quarter of 2021 to the third quarter of 2023 to examine mortality, hospitalization, and emergency department visits among nursing home residents. As nursing home care aims to promote and aid residents’ independence in activities of daily living (ADLs), we also examined ADL scores, with lower values implying greater independence. Because the policy primarily targeted Medicaid-focused facilities serving long-stay patients, we restricted the sample to quarterly and annual health assessments for long-term residents (N = 2 558 611).

We estimated 2 difference-in-differences models comparing changes in health outcomes before and after the reform for patients in treated Illinois facilities (ie, those with above-median Medicaid shares prior to the reform) against 2 distinct control groups: (1) high-Medicaid facilities in other states (across-state analysis) and (2) low-Medicaid facilities in Illinois (within-state analysis). We present event study and pooled difference-in-differences estimates from these models. All estimates adjust for patient health and demographic characteristics (eMethods in Supplement 1 provides additional details).

This study was approved by the National Bureau of Economic Research institutional review board, which waived need for participant consent. This study followed the STROBE reporting guidelines.

Results

Data depicts the event study estimates resulting from both the across-state and within-state analyses. The patterns do not suggest violation of the requisite parallel trends assumption, supporting the validity of both control groups as counterfactuals for Medicaid-focused nursing homes in Illinois.

Olenski A, Shen K, Ruffini K, Gandhi A. Health Impacts of Nursing Home Staffing. JAMA Health Forum. 2026;7(1):e256272. doi:10.1001/jamahealthforum.2025.6272