By Lina Stepick, Director of Research, PHI. Republished with permission from PHI.

PHI in partnership with the UCSF Health Workforce Research Center on Long-Term Care released a new study showing startling trends in the use of contract CNAs to fill staffing gaps in nursing homes. Researchers found that nursing homes increased their reliance on contract CNAs through staffing agencies in recent years and that contract CNA staffing was associated with worse care quality outcomes.

Certified nursing assistants (CNAs) play a critical role in supporting quality of care and quality of life for nursing home residents. Higher levels of CNA staffing are positively associated with improved care quality and outcomes for nursing home residents — but low wages and other job quality concerns drive high turnover and job vacancy rates within this workforce. One strategy that nursing homes use to fill CNA staffing gaps is to hire CNAs temporarily through staffing agencies.

These CNAs, known as “contract CNAs,” are not full employees of a nursing home but rather work for the nursing home under contract or through a staffing agency. Contract staffing employment arrangements vary across a wide spectrum, ranging from gig work models where contract staff are engaged by the hour or shift to travel nursing agency staffing, which may include contracts lasting several weeks and housing arrangements, amongst various other models. Contract staffing may offer higher hourly wages and greater flexibility for employers and workers, but the practice also raises concerns around rising labor costs, precarious employment, and lack of benefits and worker protections.

Using data from the Centers for Medicare & Medicaid Services (CMS), the study shows that contract CNA staffing rates had already been increasing in nursing homes prior to the onset of the COVID-19 pandemic and that this trend dramatically accelerated in late 2020 through early 2021. Specifically, the proportion of nursing homes using any contract CNAs more than doubled, from 22% in 2017 to 56% in 2022, and the proportion of total CNA hours filled by contract CNAs across all nursing homes increased from 2% in 2017 to 11% in 2022.

We also found that the proportion of CNA hours per resident day (HPRD) — measured as the total number of hours of CNA care divided by the number of nursing home residents — increased dramatically. Across all nursing homes, contract CNA HPRD increased from 3% of total CNA HPRD in 2017 to 18% in 2022. Examining just those nursing homes that used any contract CNAs, the proportion of CNA HPRD filled by contract staff more than doubled from 15% in 2017 to 32% in 2022.

The study also reveals that higher levels of contract CNA staffing were associated with worse care quality outcomes for nursing home residents. Higher proportions of contract CNA HPRD were associated with worse 5-Star quality ratings; higher rates of catheters inserted and left in, urinary tract infections (UTIs), and pressure ulcers; and lower rates of residents making improvements in function. These associations between contract CNA staffing and worse care outcomes held true when controlling for nursing home-level characteristics and state-level unemployment and COVID-19 infection case rates.

This evidence on the expansion of contract CNA staffing and the impact on care quality in nursing homes underscores the urgent need to improve CNA job quality. More competitive wages and benefits, supportive supervision, and safer working conditions — among other improvements — are necessary to attract and retain CNAs to nursing home jobs and, in turn, support continuity of care for residents. At the same time, acknowledging the reality of contract staffing in nursing homes, this research highlights the need for practical guidance for nursing home leaders on how to best train and support mixed CNA teams. All CNAs in nursing homes, whether fully employed or contract staff, provide essential care for residents and must be valued and supported accordingly.