Sometimes you get thinking on something so basic to our industry, it triggers thoughts on why is it so? Counting staff and why CMS counts the way it does is just one of those items.

Since public reporting on staffing began, the focus has been a form of tunnel vision, focused on nurses and CNAs. CMS’s Five-Star Quality Rating System clings to that metric. Two staff types. One narrow lens. But is this lens too stuck in the past, and devoid of the flexibility you see in other business sectors?

CMS and its regulations on staffing are often bogged down at the nurses’ station. What about the physical therapists, occupational therapists, speech-language pathologists, mental health counselors, social workers, activity professionals, and the full team that helps a resident achieve their optimal level of functioning?

Mental Health Staff, Invisible or Not?

Several providers I know work with residents who live with serious mental illness. They invest heavily in behavioral health specialists, licensed mental health counselors, psych NPs, social workers, and more. Most of these professionals show up in PBJ datasets. They exist. You can see them. They’re real. They’re paid. They’re essential.

But because they’re not “nurses” or “aides,” they don’t count in HPRD metrics. And Five-Star doesn’t reflect their presence at all.

So, let’s say you hire a trauma-informed behavioral team to help stabilize your residents and reduce hospitalizations. Great move! You get rewarded for this hire by guess what, a ding on your Five-Star staffing rating. Try explaining that to your state surveyors, board, lender, or REIT—or, most importantly, to your residents’ families.

New Study, Same Old Problem

A recent working paper from the Pension Research Council at the Wharton School looked at the relationship between staffing and antipsychotic use. They found that fewer staffing hours correlated with higher use of antipsychotics.

But hold on. The researchers only counted nursing and CNA hours. Once again, we’re drawing big conclusions from a partial picture and ignoring the many other clinical personnel active in any given facility.

Would the correlation hold up if mental health professionals were counted, or if case mix were considered? Almost certainly. Would the insights be more actionable? Absolutely.

Making Cross-Training a Thing

Residents are fed, safe, and seen.

But those minutes, or hours, spent performing these duties are often impossible to report properly under PBJ rules to be counted in Five-Star staffing, if the care was provided by anyone but a nurse or CNA — which means they vanish. Quality is happening. Care is being provided. It’s just not counted.

It’s time to change the equation, and it’s fairly obvious we are in urgent need of a new staffing model, one that:

• Recognizes the full interdisciplinary team

• Reflects case mix and resident needs

• Gives providers the freedom to design care models that actually work for their population

Let’s stop pretending that quality care begins and ends with nursing. It begins with people: the right people, doing the right work, for the right residents.

When a recreational therapist feeds a resident in the dining room, we call it a “compliance risk,” if not properly trained – plus they wouldn’t count as direct care to residents. There is no incentive in SNF world for cross-training staff. But in another world, i.e., most other business settings, it’s called being helpful and useful, and good.

It’s time we moved forward when it comes to counting staff, and all that ALL staff do to provide quality care.

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.