to determine what exact nursing inputs will relate to specified resident outcomes. There is information emerging, however, that will help establish a set of relationships between resident needs, staffing, and quality.

There has been considerable controversy over the past years about the minimum staff required to meet resident needs. A significant tension has existed between consumer and professional groups who propose increased numbers of registered nurses (RNs) and total staff, and payers, primarily state Medicaid agencies, who are concerned about the cost to the public of paying for additional staff. It is important to recognize that while minimum staffing levels are particularly tied to Medicaid payment, Medicare is an increasingly significant payment source through expansion to subacute services. It is likely, given the current funding crisis in the Medicaid and Medicare programs, that financing for nursing home care will be increasingly problematic, especially if these programs are cut. Financing of nursing home care will require potentially a new funding structure. If money were not an issue, there would be no need to constrain staff, and every nursing home resident could have their own RN care 24 hours a day.

Many states have established a minimum standard for nursing time per resident per day. Federal requirements state that an RN must be present in a facility for 8 hours a day, 7 days a week, regardless of the size of the facility. It is difficult to argue against the need for a minimum number of staff members with defined capabilities to carry out the basic functions of nursing home care. However, the notion of a minimum number applied uniformly to all facilities is complicated by the fact that nursing homes have differing case-mix populations needing different levels of nursing expertise and different amounts of care. The problem with the concept of minimum staff is that it becomes translated to mean the maximum staff for payment purposes. In addition to the actual minimum levels, there is a more general requirement that there be sufficient staff to provide the required care to residents. However, there has been little guidance as to what ''sufficient" staff actually means. The definition of sufficient has been operationalized in conflicting ways. The regulatory agencies hold nursing homes to a standard of "highest practicable level" for resident care, yet the payment agencies provide funding for staffing at minimum levels.

Quality of care has received increasing attention over the past 5 years, yet there has been relatively limited research examining the relationship of staffing to quality. There is some consensus about a limited number of indicators of quality care, but in general there remain issues of definition of quality. For instance, should the emphasis on quality measurements be on process or outcome? Who should define quality: the regulators, residents, family, or staff? Is there a consensus about measures of quality among these groups of stakeholders?

Nursing Home Environment

As the lines between the hospital, nursing home, and home care blur, the



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