Association of Racial and Ethnic Composition with Staff Levels in Nursing Homes: 2013-2019

Objectives: The nursing home (NH) population has become increasingly diverse, yet many facilities remain de facto racially segregated. This study examines whether a high proportion of Black, Indigenous, and People of Color (BIPOC) residents is associated with nursing staff levels. Design: We constructed a longitudinal cohort of NHs (2013-2019) by linking Certification and Survey Provider Enhanced Reports, LTCFocUS.org, Medicare Cost Reports, and Payroll-Based Journal data. Separate multivariable random effects linear regressions were conducted. Setting and Participants: 14,075 Medicare- and Medicaid-certified NHs in the United States. Methods: The proportion of BIPOC residents was categorized as the 10% of nursing homes serving the highest minority residents in each state each year (High-BIPOC) and the remaining 90% (Low-BIPOC). Total nursing staff levels in hours per resident-day (HPRD) included both hours paid (2013-2019) and hours worked (2017-2019). The total staff included registered nurses, licensed practical nurses, and certified nurse aides. Results: The unadjusted difference in total staff levels between High-BIPOC and Low-BIPOC NHs increased from −0.23 HPRD (4.19 vs 4.42) in 2013 to −0.35 HPRD (3.94 vs 4.29) in 2019 for hours paid. The difference in hours worked increased from −0.19 (3.55 vs 3.74) in 2017 to −0.23 (3.50 vs 3.73) in 2019. The difference became smaller but remained significant after controlling for covariates (−0.037 HPRD for hours paid, and −0.038 for hours worked). Analyses of individual staff types found lower levels of registered nurses and certified nurse aides (but not licensed practical nurses) among High-BIPOC nursing homes. Findings were robust to treating racial and ethnic composition as a continuous variable or excluding payer mix from the models. Conclusions and Implications: NHs with high concentrations of minority residents reported lower nursing staff levels. Improving staffing in NHs serving primarily marginalized racial and ethnic groups remains a policy priority.