Phoebe J PBJ320 Insights

Patterns and perspectives from 9 years of US nursing home payroll-based journal (PBJ) staffing data

1. The COVID Staffing "Spike"

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Phoebe J's Takeaway
Staffing ratios appeared to rise in 2020—but mainly because resident census fell faster than total staffing hours. The apparent increase in staffing ratios during 2020-2021 was largely due to decreased resident census (deaths and discharges) rather than increased staffing hours, with some facilities not reporting data for Q1 2020 during early COVID-19.

2. State Staffing Evolution

Total HPRD
3.0 4.5
Q1 2017
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Phoebe J's Takeaway
Watch how staffing patterns shift across states over time. Each state is colored by its HPRD/Contract Percentage for the quarter. Watch how the colors shift as you animate through time—darker purples indicate higher staffing levels. The animation reveals regional staffing patterns across the US.

3. What Does "Mean" Mean?

Three Ways to Calculate US/State HPRD

HPRD Distribution by Nursing Home

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Phoebe J's Takeaway
When someone says your state's staffing is "3.55 HPRD," ask: by what metric?
  1. National/state staffing ratio (Weighted Mean): Aggregates census and staffing hours so a 600-bed facility counts more than a 30-bed facility.
  2. Median: The typical (middle value) nursing home, less affected by outliers.
  3. Simple Mean: Averages staffing levels by nursing home so a 600-bed facility and a 30-bed facility count the same.
The distribution is right-skewed, with most facilities clustered around 3.0-4.0 HPRD but a long tail extending to higher values. This skewness means the simple mean (3.89) is pulled upward by outliers, while the median (3.67) better represents typical facilities.

4. Contract Staffing

Mean and Median Over Time

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Phoebe J's Takeaway
A small share of facilities rely heavily on agency staff; most use barely any. By either metric, nationwide contract staffing increased significantly during the pandemic but has fallen since 2023.

5. Staffing Ratio by Position

US Staffing by Position (Q1 2025)

RN
RN Admin
RN DON
LPN
LPN Admin
CNA
Med Aide Tech
NAtr

Staffing Breakdown by State

Nurse Aide %
40% 65%
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Phoebe J's Takeaway
Nurse Aides account for Loading...% of nursing staff nationally. However, this varies significantly by state—some states rely more heavily on RNs while others use more nurse aides. The state map shows these regional differences, with yellow shading indicating higher nurse aide percentages. You can toggle to view Total RN % (blue) or Direct Care % (red) to see different staffing patterns across the country.

6. Total vs Direct Care

Total Nurse vs Direct Care

RN Staffing: Total vs Direct Care

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Phoebe J's Takeaway
Total Nurse HPRD (the CMS metric) includes administrators and DONs; Direct Care excludes them. The difference shows how much nursing time is administrative. In Q1 2025, Loading...% of total nursing staff time was administrative/DON, and Loading...% of RN time was administrative/DON.

320 Consulting maintains the PBJ Dashboard, a free public resource tracking federal staffing data across ~15,000 U.S. nursing homes. As seen in Columbia Public Health, Positive Aging, Aging in America News, and WTVR CBS.