Quality care begins with having enough staff available to meet residents’ needs. One tool used to help measure staffing in nursing homes is the Payroll-Based Journal (PBJ), a system developed by the Centers for Medicare & Medicaid Services (CMS).
PBJ requires nursing homes to electronically report staffing information, including the number of hours worked by registered nurses (RNs), licensed practical nurses (LPNs), certified nursing assistance (CNAs), and other direct care staff. This data is submitted quarterly and issued to help calculate each facility’s staffing rating on CMS’s Five-Star Quality Rating System.
For residents and families, staffing levels matter. Research consistently shows that adequate staffing is associated with better resident outcomes, including improved quality of care, fewer avoidable hospitalizations, and greater opportunities for meaningful interaction between residents and caregivers. While staffing numbers do not tell the entire story, they provide valuable insight into a facility’s ability to meet residents’ daily needs.
At the Office of the Kentucky Long-Term Care Ombudsman, we believe there is an opportunity to make staffing information even more meaningful by pairing PBJ data with resident acuity, which is the measure of how much care a specific facility’s residents need. Two facilities may report similar staffing levels, but if one serves a population with greater medical and personal care needs, staffing resources may be stretched much differently. Presenting staffing levels alongside resident acuity could provide families, policymakers, and the public with a more complete picture of a facility’s capacity to deliver quality care.
One approach being discussed in our office is the development of an acuity score that could accompany existing PBJ staffing data. Rather than looking only at the number of hours worked by nursing staff, an acuity score would reflect the complexity of care needed to provide the residents with the appropriate level of care. Information already collected through resident assessments, such as the Minimum Data Set (MDS), could be used to assign weighted values to factors including assistance with activities of daily living, cognitive impairment, behavioral health needs, mobility limitations, and complex medical conditions. These values could then be combined into an overall facility acuity score that is updated regularly.
Implementing an acuity measure would not necessarily require nursing homes to submit additional documentation. Facilities already complete extensive resident assessments through the MDS, so much of the information needed to calculate an acuity score already exists in current methodology could allow CMS and state agencies to generate and publish an acuity rating with existing PBJ staffing data, creating a clearer picture of staffing adequacy without increasing administrative burden on providers.
Greater transparency could benefit everyone involved in long-term care. Residents and families would have access to more meaningful information when choosing a facility. Providers would have an opportunity to demonstrate when higher staffing levels are necessary to meet the needs of residents with more complex conditions. Policymakers and regulators could also use this information to better understand workforce needs, identify trends, and support data-driven decisions aimed at improving quality across the long-term care system.
The Kentucky Long-Term Care Ombudsman Program encourages residents and families to become familiar with publicly available nursing home information, ask questions about staffing during facility visits, and remain actively involved in care planning. Transparency empowers consumers to make informed decisions and supports ongoing efforts to improve the quality of long-term care for all residents.
