The staffing shortages ignited protests this summer by workers demanding better pay and a minimum staffing mandate.  In late July, Governor Gina Raimondo averted a call to strike by pledging to work with lawmakers and union leaders to develop a minimum staffing standard. But nursing home operators say such a requirement would amount to an “unfunded mandate”, which would lead to more closures. To improve staffing, they say, the state needs to restore funding cut from Medicaid, the state-federal insurance program which covers about two-thirds of Rhode Island's nursing home residents.

 It’s easy to get lost in the battle of numbers over nursing homes. So we spent some time digging to find the answers to some questions:

 How does staffing in Rhode Island nursing homes compare with other states?

Rhode Island nursing homes provide, on average, 3.8 hours of nursing care per resident, which is below the national average of 3.9 hours, according to an analysis by The Public’s Radio of fourth-quarter 2019 data from the federal Centers for Medicare & Medicaid Services (CMS). Rhode Island is tied with Massachusetts for the lowest nurse staffing ratio in New England. (The analysis used hours adjusted to compare nursing homes with different resident care needs.)

Does the federal government mandate minimum staffing levels for nursing homes?

No, the federal Centers for Medicare & Medicaid Services (CMS) which regulates nursing homes has no mandated minimum resident-to-staff ratio for nursing homes. CMS does, however, require the presence of a registered nurse for eight hours a day and a licensed nurse at all times.

Does Rhode Island have any required minimum resident-to-staff ratios for nursing homes?

No. Rhode Island is one of three New England states -- the others being Massachusetts and New Hampshire -- which have no state minimum resident-to-staff ratio for nursing homes. Connecticut, Maine and Vermont have mandatory minimums but they are generally lower than their average staffing levels. For example, Connecticut nursing homes provided, on average, 3.7 hours of nursing care per resident during the fourth-quarter of 2019, compared with the state mandatory minimum of 30 minutes to just under 2 hours per resident, depending on the type of facility.

What was the minimum-staffing legislation that failed to win approval in the General Assembly? 

The legislation would have required a minimum of 4.1 hours of nursing care per resident in all Rhode Island nursing homes. It also would have secured funding to raise wages and enhanced training and skills for caregivers. The Senate bill introduced by Sen. Maryellen Goodwin, D-Providence, passed, but a companion House bill introduced by Rep. Scott Slater, D-Providence, died in committee. Instead, the House voted to create a commission to study the issue. 

Do nursing homes in any other states provide more than 4 hours of nursing care, on average, per resident? 

 Yes. Twenty-five states and the District of Columbia provided 4 hours or more of nursing care, on average, per resident during the fourth-quarter of 2019, according to an analysis of CMS data by The Public’s Radio. (The analysis used hours adjusted to compare nursing homes with different resident care needs.)

How many people work in nursing homes in Rhode Island?

As of last March, nursing and residential care facilities in Rhode Island employed about 17,800 workers, according to the state Department of Labor and Training.

How many of Rhode Island’s nursing homes are unionized?

Nine of Rhode Island’s 80 nursing homes are unionized. Six are represented by Local 1199 of the Service Employees International New England; two are represented by the Laborers’ International Union and one is represented by the United Food & Commercial Workers.

 Does Rhode Island have a shortage of nursing home caregivers?

Yes. Rhode Island has 15,000 certified nursing assistants or CNAs  licensed to practice in Rhode Island. But only about 9,300 or 60% were working in the state as of May 2019, according to the federal Bureau of Labor Statistics. The others may be either working in another state or not practicing. The demanding nature of the job coupled with low wages means they often have a high turnover rate. In 2019, the median wage of nursing assistants working in Rhode Island nursing homes was $14.25 an hour, according to the federal Bureau of Labor Statistics. 

Has the state cut Medicaid rates for nursing homes?

Yes, and here’s how. Medicaid payments to nursing home operators in Rhode Island are supposed to be increased annually based on a national nursing home inflation index. But the state’s payments have consistently fallen short of the index. Over the last six fiscal years, Rhode Island nursing homes’ annual increases in Medicaid payments total about 7 %. That’s less than a third of the 23% increase nursing homes would have received during that period if their payment rates had kept up with the inflation index. It’s worth noting that Medicaid is the primary payer of nursing home residents. In Rhode Island, Medicaid pays for about 65% of Rhode Island nursing home residents.

How many people live in Rhode Island nursing homes?

About 7,600 people lived in nursing homes in Rhode Island in 2019, according to data analyzed by the Kaiser Family Foundation.

Correction: An earlier version misstated the number of unionized nursing homes.

Lynn Arditi is the health reporter for The Public’s Radio. Email her at larditi@thepublicsradio.org and follow her on Twitter at @LynnArditi.