According to a study published online in advance of print publication in Health Services Research, the largest for-profit nursing homes in the nation deliver considerably lower quality of care as they often have fewer staff nurses compared with non-profit and government-owned nursing homes.

The study, led by University of California, San Francisco (UCSF), of care at nursing homes around the nation, is the first to focus only on staffing and quality at the 10 largest for-profit chains.

First author Charlene Harrington, RN, PhD, professor emeritus of sociology and nursing at the UCSF School of Nursing. Harrington also is director of the UCSF National Center for Personal Assistance Services, explained:

“Poor quality of care is endemic in many nursing homes, but we found that the most serious problems occur in the largest for-profit chains. The top 10 chains have a strategy of keeping labor costs low to increase profits. They are not making quality a priority.”

It is believed that low nurse staffing levels are the strongest predictor of poor nursing home quality.

In the U.S., the ten largest for-profit chains run approximately 2,000 nursing homes, controlling around 13% of nursing home beds in the nation.

Nursing home chains have undergone a significant expansion in recent decades. Several chains were publicly-traded companies until the early 2000s, when five of the largest chains in the nation went bankrupt. The largest nursing home chains became more financially stable after increases in Medicare payments as well as restructuring and ownership changes. More recently, private equity investment firms, which invest funds received from investors, with whom they share profits and losses, purchased some of the largest publicly held chains.

In order to measure quality of care, the investigators compared facility deficiencies and staffing levels at for-profit chains to those at nursing care homes operated by five other ownership groups. The researchers selected the 10 largest chains as they are the most successful in terms of growth and market share and they are influential in the nursing home industry.

The team observed that for-profit nursing care homes aim to keep their expenses down by reducing staffing, especially RN staffing.

Harrington, stated:

“Recent Medicare cuts in payment rates for nursing home residents – by 11 percent in October, 2011 – may further jeopardize the health and safety of residents if the chains respond by reducing staffing and wages.”

In 2008, the 10 largest for-profit nursing home chains were:

  • HCR Manor Care
  • Life Care Centers of America
  • Golden Living
  • Genesis HealthCare Corporation
  • Kindred Healthcare
  • SavaSeniorCare, LLC
  • Sun Health Care Group, Inc.
  • National Health Care Corporation
  • Skilled HealthCare, LLC
  • Extendicare Health Services, Inc.

From 2003 to 2008, for-profit chains had fewer nurse “staffing hours” compared to non-profit and government nursing homes when controlling for other factors. Collectively, total for-profit nursing hours were 30% lower than government and non-profit nursing homes, and these companies also had the sickest residents. Furthermore, the top nursing home chains were significantly below the national average for RN and total nurse staffing, as well as below the minimum nurse staffing advised by experts.

Compared with the best nursing homes, the 10 largest for-profit chains were cited for 41% more serious deficiencies and 36% more deficiencies. Deficiencies include failure to prevent:

  • falls
  • infections
  • resident weight loss
  • pressure sores
  • poor sanitary conditions
  • resident mistreatment
  • and other issues that could considerably harm residents

In addition, the investigation discovered that the four largest for-profit chains had more deficiencies after being purchased by private equity companies between 2003 and 2008. This investigation is the first to associate poor care after purchase by private equity companies.

According to the researchers, more studies should be carried out. They state that greater accountability and quality oversight mechanisms would help enhance nursing home care, together with effective funding incentives and sanctions for low staffing and poor quality.

Written by Grace Rattue