Workforce Practices & Organizational Performance in Nursing Homes: Implications for Resident Health and COVID-19 Containment

Abstract

One in three COVID-19 deaths in the United States occurred in a nursing home, raising questions about how nursing home facilities might improve organizational performance on resident health outcomes. Though researchers have linked workforce practices to organizational performance on patient health, it is less clear whether the predictors of organizational performance look different for pandemic infection, relative to other health conditions. To address this gap, this paper links workforce practices with both pre-pandemic resident health conditions and with COVID-19 outcomes. The analysis relies on multivariate and logistic regressions using two novel datasets that link multiple administrative sources before and during the pandemic. It evaluates how workforce practices such as pay, staff hours per resident, outsourcing, and overtime relate to resident health in both contexts. Whereas estimates show that workforce practices for Registered Nurses are the primary driver of resident health before the pandemic, outsourcing is more important to predicting COVID-19 infections and mortality. Specifically, outsourcing care work before the pandemic is associated with a one percentage point decrease in COVID-19 mortality during the crisis, conditional on at least one positive case in the facility. The findings call into question widely made extrapolations from pre-pandemic research on how workforce practices may help predict pandemic spread. By evaluating multiple workforce practices in one model, the findings inform nursing home management decisions in the interest of resident health.