End-of-Life Care in Nursing Homes: The High Cost of Staff Turnover

By Tilden, Virginia P.; Thompson, Sarah A. et al. | Nursing Economics, May/June 2012 | Go to article overview

End-of-Life Care in Nursing Homes: The High Cost of Staff Turnover


Tilden, Virginia P., Thompson, Sarah A., Gajewski, Byron J., Bott, Marjorie J., Nursing Economics


EXECUTIVE SUMMARY

*Nursing home staffturnover results in high cost - both economic and personal - and has a negative impact on the quality of care provided to residents at the end of life.

*Reducing staffturnover in nursing homes would benefit both the cost to the U.S. health care system, and, most importantly, the care residents receive in the vulnerable period leading to death.

*There is rising pressure on nursing homes to improve their palliative and end-of-life care practices and reduce transfers to hospital for situations and conditions that can be safely managed on site.

*Nursing care staffdeserve an investment in the specific training necessary for them to give the highest quality care to dying residents.

*This training should be multifaceted and include the physiological, psychological, spiritual, interpersonal, and cultural (including ethnic) aspects of dying.

*Empowerment with these necessary knowledge, skills, and attitudes will not only result in better care for residents but likely also will reduce the burnout and frustration staffexperience in caring for residents near death.

ACCORDING TO THE CENTERS for Medicare & Medicaid Services (CMS, 2011), national health care ex - penditures are projected to increase from the current record high of over 17% of the Gross National Product to over 19% by 2020. Of the many factors that contribute to the high and rising costs of health care in the United States, those associated with nursing home care are some of the largest and most problematic (Dartmouth Atlas of Health Care, 2012). In 2010, combined CMS expenditures for the elderly and disabled totaled $73 billion, and they are estimated to be over $120 billion by 2020. Costs associated with the last year of life compose approximately one-quarter of total CMS outlay (CMS, 2011). Nursing home care overall, combined with specific end-of-life care in nursing homes, total a large and expanding percent of the nation's health care budget. One aspect of those costs, nursing home staffturnover, and the significant effect of turnover on the quality of care provided to residents at the endof- life, is discussed.

Background

Low job satisfaction and high staffturnover prevail throughout the nursing home industry, driving costs up and quality down. Despite variation in how turnover is calculated (Mukamel et al., 2009), there is ample evidence that turnover rates for clinical care staffin nursing homes range between 55% and 75% (Castle, 2006). Certified nursing assistants (CNAs), the largest segment of the workforce and the group delivering the largest percent of direct care, turn over at the highest rate, often approaching 100%. The Paraprofessional Health Care Insti tute (2001) estimates CNA turnover costs the industry $2.5 billion per year. In one case study, the Oakland, California-based Medical Hill Rehabilitation Center conservatively estimated CNA re - placement costs in 2006 at $1,961 per person. With an annual CNA turnover rate of 94%, this center estimated its replacement cost for CNAs alone was over $100,000 a year (Farrell & Dawson, 2007). Calculating those costs to today's dollars would likely in crease the amount by 50%.

Seavey (2004) conducted a meta-analysis of the retention and turnover literature and concluded that a minimum direct cost of turnover per person was $2,500. Direct costs include those associated with separation, advertising and recruitment, orientation and training, temporary agency workers, increased injuries, and closed beds. In addition, indirect costs (e.g., loss of residents to other facilities, inefficient use of RN staffwhile training new employees) add to the economic impact of turnover. Most importantly, the quality of care for residents deteriorates with turnover due to reduced employee morale, deterioration of organizational culture, loss of experienced and knowledgeable workers, and loss of consistent staffand agency practices (Jones & Gates, 2007; Stone & Dawson, 2008). …

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