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Employee Turnover in the Long Term Care Industry AcademyHealth

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Employee Turnover in the Long Term Care Industry AcademyHealth Powered By Docstoc
					   Employee Turnover in the                                Background                                   Turnover in LTC
   Long-
   Long-Term Care Industry:                Employment in nursing and residential care         Decker et al. 2003: turnover is
  2004 NNAS and NNHS Data                  facilities                                         • 70 percent for certified nursing assistants
                                           • grew from 2.0 to 2.7 million between 1992 and    • 50 percent for nurses
               William Even                  2002                                             • 100,000 FTE vacancies at nursing homes
              Miami University             • Projected to grow to                             GAO (2001): turnover among nurse
                                                3.7 million by 2012 (BLS)
                                                                                              aides working in nursing homes is:
                      &                         6 million by 2050 (DHHS).
              David Macpherson                                                                  13-
                                                                                              • 13-18% percent higher than the overall
                                           Florida                                              labor force
           Florida State University        • First in percentage of people over age 75        • 20% higher than other service workers.
                                                8.9 percent in Florida
                                                5.0 percent in California




         Turnover in LTC                               Turnover in LTC                                 Project Objectives

Turnover is costly                          Why is turnover so high?          (HHS 2002,     Does the measure of turnover or data set
• Screening, training, reduced quality      2003)                                            affect conclusions?
  of care.                                  •   wages and benefits                           What factors influence the level of
• Replacement cost for nursing home         •   working conditions                           turnover?
                               (Pillemer
  assistant = 4 months salary (Pillemer     •   training
  1996)                                                                                      How does exposure to turnover differ
                                            •   staffing levels
                                                                                             across race and gender for nursing home
                                            •   potential for career advancement             residents?
                                                                                                                       Figure 1: Turnover Measures                                                               Figure 2: Job Tenure for Workers Employed at Least 1 Yr
          2004 National Nursing Assistant Survey                                                    50.73




                                                                                                                                                                                                              20
                                                                                                                                                         80
                                                                                   50
                                                                                                                                                                        72.02

                         (NNAS)




                                                                              20 30 40




                                                                                                                                                            60
                                                                                                                 29.68




                                                                               Percent




                                                                                                                                                    Percent
          Supplement to 2004 National Nursing Home Survey




                                                                                                                                                     40




                                                                                                                                                                                                              15
          (NNHS)                                                                                                             16.81                                                                 24.22




                                                                                                                                                         20
           • 3,017 Nursing Assistants surveyed at 582 nursing homes




                                                                                   10
                                                                                                                                           2.776                                        3.758

          Four turnover measures




                                                                                                                                                                                                           Percent
                                                                                   0




                                                                                                                                                         0
                                                                                                  a lot    some     a little   none                                       no thinking about it yes
           • How much turnover is there of nursing assistants at




                                                                                                                                                                                                            10
                                                                                            How much turnover of NAs is there at facility                           Is NA Looking for a Different Job

             facility?




                                                                                   60
                                                                                                       54.81
           • How likely is it that NA leaves current job during next
             year?




                                                                                     40




                                                                                                                                                                                                              5
                                                                                Percent
           • Is NA currently looking for different job, either as a                                                      27.44

             nursing assistant or something else?                                                                                       17.75




                                                                              20
           • Job tenure (in months)




                                                                                                                                                                                                              0
                                                                                   0
                                                                                                     not likelysomewhat likelyvery likely                                                                            0           5           10           15          20            25
                                                                                           How likely will NA leave current job in next year                                                                                                      Years




    Figure 3: How Much Does Turnover Interfere With NAs Job                                           Figure 4: Reason Turnover Affects Job
                                                                                                                                                                                                                             Turnover Analysis of NNAS
   40




                                                                                                                                                                            63.87
                                                                                   80




                                                                                                                                                       60
                                                                                                                                     70.23


                                                                                                                                                                                                                     Methodology:
                                                                                      60




                      33.93
                                                                              Percent




                                                                                                                                                   Percent
                                                                                                                                                       40
                                                                                                                                                                                                36.13
                                                                                                                                                                                                                     • Logit for Looking for Different Job, How Much Turnover at
                                                                               40




                                      29.53
                                                                                                                                                                                                                       Facility, How Likely Will Leave Job in Next Year, How Much
   30




                                                                                                               29.77

                                                                                                                                                       20                                                              Does Turnover Interfere
                                                                                   20




                                                                                                                                                                                                                     Demographic Characteristics:
Percent




                                                                                   0




                                                                                                                                                       0


                                                                      21.23
                                                                                                               No                    Yes                                    No              Yes
                                                                                                                                                                                                                     •   Age and Age^2
 20




                                                                                                                Workload                                         Must Spend Time Training Other NAs

                                                      15.31                                                                                                                                                          •            (-
                                                                                                                                                                                                                         Female (-)
                                                                                                               84.52                                                        85.43
                                                                                                                                                                                                                     •   Hispanic (+)
                                                                                   80




                                                                                                                                                       80




                                                                                                                                                                                                                     •   African-
                                                                                                                                                                                                                         African-American
   10




                                                                                    60




                                                                                                                                                         60




                                                                                                                                                                                                                     •   Asian
                                                                              Percent




                                                                                                                                                   Percent




                                                                                                                                                                                                                     •   Years of Schooling
                                                                               40




                                                                                                                                                    40




                                                                                                                                                                                                                     •   English Main Language
                                                                                   20




                                                                                                                                                       20




                                                                                                                                     15.48                                                      14.57

                                                                                                                                                                                                                     •   Spanish Main Language
   0




                                                                                   0




                                                                                                                                                       0




                     a lot          some             a little          none
                How much does turnover interfere with NAs ability to do job                                 No             Yes                                                  No              Yes                  •   U.S. Citizen
                                                                                                     Affects Workplace Morale                                                        Other
          Turnover Analysis of NNAS                                                           Turnover Analysis of NNAS                                                                                                                Turnover Analysis of NNAS
 • Married
 • Divorced or Separated (+)                                                   Tenure/Working Conditions:                                                                                                               Facility Characteristics:
                                                                                 •               (-
                                                                                         Tenure (-)                                                                                                                       •   Occupancy Rate
Training:                                                                        •       Work Mandatory Overtime (+)
 •   Received Training Before 1987                                                                                                                                                                                        •   Percent of Patients on Medicare
                                                                                 •       Desire to Work More Hours (+)
 •   Employer Paid All Training Costs                                            •       Desire to Work Fewer Hours (+)                                                                                                   •   Percent of Patients on Medicaid
 •   Employer Paid for Some Training                                             •       # Times Injured at Facility                                                                                                      •   Does Facility Have a Waiting List?
 •   Trained in Nursing Facility                                                 •                                (-
                                                                                         Time Off for Good Work (-)                                                                                                       •                              (-
                                                                                                                                                                                                                              Director of Nursing Tenure (-)
 •   Trained in Community College                                                •       Percent Union                                                                                                                    •   Medical Director Tenure
Compensation:                                                                  Facility Characteristics:                                                                                                                  •                                      (-
                                                                                                                                                                                                                              Nursing Hours Per Patient Per Day (-)
 •                 (-
     Hourly Wage (-)                                                             •       Facility Part of Chain
 •   In Pension Plan                                                             •       For Profit Facility
                                                                                 •       Clusters of Beds for Alzheimer's and Related Dementias (+)
 •   In Health Insurance
                                                                                 •                                          (Non-
                                                                                         Cluster of Beds for Behavior Unit (Non-Alzheimer's)
 •            (-
     Bonuses (-)
                                                                                 •       Cluster of Beds for Rehabilitation
                                                                                 •       Number of Beds




                                                                      Figure 5: Percent of Workers Leaving in Past 3 Months                                                                                                       Figure 6: Percent of FTE Positions Vacant
                                                         0 10 20 30 40 50 60




                                                                                                                                0 10 20 30 40 50 60




                                                                                                                                                                                                  0 10 20 30 40 50 60




                                                                                                                                                                                                                                                                   0 10 20 30 40 50 60
              2004 NNHS Data
                                                               Percent




                                                                                                                                      Percent




                                                                                                                                                                                                         Percent




                                                                                                                                                                                                                                                                          Percent
Survey of 1174 facilities
Three turnover measures
• Percent of FTE workers who left in prior 3                                         0      20        40
                                                                                                           RN
                                                                                                                60   80   100                             0        20       40
                                                                                                                                                                              LPN
                                                                                                                                                                                  60   80   100
                                                                                                                                                                                                                              0      20       40   60   80   100                              0       20       40    60   80   100
  months                                                                       Median is 0 percent                                                    Median is 6 percent
                                                                                                                                                                                                                        Median is 0 percent
                                                                                                                                                                                                                                                RN
                                                                                                                                                                                                                                                                                         Median is 1 percent
                                                                                                                                                                                                                                                                                                                 LPN


       left percent=(number FT workers who left +
                                                         0 10 20 30 40 50 60




       .5*number PT workers who left)/number of FTEs




                                                                                                                                                                                                  0 10 20 30 40 50 60
• Percent of FTE positions vacant
                                                               Percent




                                                                                                                                                                                                         Percent
• Percent of workers with at least one year of
  job tenure
Analyze Data with Tobit models                                                       0      20        40
                                                                                                       CNA
                                                                                                           60        80   100
                                                                                                                                                                                                                              0      20       40   60   80   100
                                                                               Median is 11 percent                                                                                                                                            CNA
                                                                                                                                                                                                                        Median is 3 percent
                                                       Note: left percent=(number FT workers who left + .5*number PT workers who left)/number of FTEs
          Figure 7: Percent with at Least One Year of Job Tenure
                                                                                                                                                  Turnover Analysis of NNHS                                                         Turnover Analysis of NNHS
5 10 15 20 25 30




                                                                   5 10 15 20 25 30
    Percent




                                                                       Percent
                                                                                                                                         Compensation:                                  RN       LPN CNA                   Facility Characteristics:                              RN       LPN CNA
                                                                                                                                           Starting Wage                                                                                           Alzheimer’
                                                                                                                                                                                                                               Behavior Beds – Non Alzheimer’s
                                                                                                                                           Health Insurance                                                                    Rehabilitation Beds
        0




                                                                           0
                       0        20        40   60   80   100                              0        20        40    60   80   100
                                            RN                                                                 LPN                         Pension                                           -     -      -                    Number of Beds                                       +           +
                   Median is 75 percent                                               Median is 75 percent
                                                                                                                                         Working Conditions:                                                                   Occupancy Rate                                       +                 -
5 10 15 20 25 30




                                                                                                                                           Percent Working Over Time                         +     +     +                     Percent Medicare
                                                                                                                                           Union                                                   -      -                    Percent Medicaid                                      -                +
    Percent




                                                                                                                                         Facility Characteristics:                                                             Nursing Hours Per Patient Per Day                     -          -     -
                                                                                                                                           Part of a Chain                                   +                                 Does Facility Have a Waiting List?
        0




                       0        20        40   60   80   100                                                                               For Profit Facility                                           +/-
                                                                                                                                                                                                         +/-                   Director Nursing Tenure                               -          -     -
                                           CNA
                   Median is 66 percent                                                                                                    Alzheimer's Beds                                                                    Medical Director Tenure




                            Racial Difference in Means for Residents                                                                            Racial Difference in Means for Residents                                               Staff Turnover by Resident Race
                                                                                                                                                                     Sample Size         Means
                                                                                                                                                                                                                                                         BOTH SEXES
                                                                                                                                                                                      MEN
                                                                                      Both Sexes                                                                                                                                      Sample Sizes                                    No            Controls
                                                                                                                                   Age                               3,355    513     76.0       68.9     7.0*                                                                      Controls
                                                     Sample Size                                        Means
                                                                                                                                   Depressed Mood                    3,302    508     0.56       0.50     0.06
                                                    White              Black                   White            Black    Diff                                                                                                       White        Black      White         Black          Diff         Diff
                                                                                                                                   Total ADLs                        3,322    508     3.90       3.95     -0.06
Age                                                 12,101             1,406                    81.2            74.9     6.3*      Restraints Used                   3,333    509     0.37       0.46     -0.09*                        Percent of Staff Leaving in Last Three Months
Female                                              12,101             1,406                    0.72            0.63    0.09*      Private Health Insurance          3,195    473     0.12       0.06     0.06*         RNs         11046        1233       13.1%        15.9%        -2.8%         -1.8%

Depressed Mood                                      11,958             1,383                    0.62            0.53    0.08*      Medicaid                          3,195    473     0.33       0.55     -0.22*        LPNs        10916        1208       11.7%        13.5%        -1.8%         -1.6%
                                                                                                                                                                                     WOMEN
Total ADLs                                          12,011             1,391                    4.06            4.16     -0.09                                                                                          CNAs        10829        1179       16.8%        15.5%         1.4%          2.2%
                                                                                                                                                                     White   Black   White       Black        Diff
Restraints Used                                     12,037             1,394                    0.38            0.47    -0.08*                                                                                                                       Vacancies as a Percent of FTEs
                                                                                                                                   Age                               8,746    893     83.2       78.3     4.9*
Private Health                                      11,558             1,325                    0.12            0.06    0.06*                                                                                           RNs         11031        1248       11.9%       10.5%        1.4%            2.4%
                                                                                                                                   Depressed Mood                    8,656    875     0.64       0.55     0.08*
Insurance                                                                                                                                                                                                               LPNs        10896        1228        9.7%        7.3%       2.3%*           2.7%*
                                                                                                                                   Total ADLs                        8,689    883     4.12       4.27     -0.15*
Medicaid                                            11,558             1,325                    0.34            0.56    -0.23*                                                                                          CNAs        10843        1201        6.4%        4.7%       1.7%*           1.7%*
                                                                                                                                   Restraints Used                   8,704    885     0.39       0.47     -0.08*
                                                                                                                                   Private Health Insurance          8,363    852     0.12       0.06     0.06*                                                                 physical
                                                                                                                                                                                                                     Controls include age and controls for patient's mental and physical health, length of
                                                                                                                                   Medicaid                          8,363    852     0.34       0.57     -0.23*     stay, payment type, and per diem rate.
                  Staff Turnover by Resident Race                                                            Staff Turnover by Resident Race

                 Sample Sizes
                                      WOMEN
                                                                 No        Controls                      Sample Sizes
                                                                                                                                  MEN
                                                                                                                                                             No          Controls
                                                                                                                                                                                                                  Conclusions
                                                               Controls                                                                                    Controls
                                                                                                                                                                                          •Turnover is a significant problem for nursing homes.
               White        Black      White         Black         Diff       Diff                     White         Black        White           Black         Diff        Diff
                                                                                                                                                                                          • Working conditions and compensation affect level of
                   Percent of Staff Leaving in Last Three Months                                             Percent of Staff Leaving in Last Three Months                                turnover
   RNs         8027          798       12.9%        14.5%        -1.7%      -2.4%          RNs          3019          435         13.9%           18.4%      -4.5%        -0.5%
                                                                                                                                                                                          • Little evidence that facility type (size, case mix)
   LPNs        7928          780       11.8%        13.3%        -1.5%      -1.6%          LPNs         2988          428         11.3%           13.9%      -2.6%        -1.5%
                                                                                                                                                                                          affects turnover
   CNAs        7862          765       16.4%        15.0%        1.5%        1.9%          CNAs         2967          414         17.9%           16.4%         1.5%       2.5%
                                                                                                                                                                                          •Significant racial differences in the age, health, and
                                Vacancies as a Percent of FTEs                                                              Vacancies as a Percent of FTEs                                payments methods for nursing home residents
   RNs         8014          801       11.8%       10.3%        1.5%         2.4%          RNs          3017          447         12.3%       10.9%         1.4%           2.2%
                                                                                                                                                                                          • Despite these differences, there are only modest
   LPNs        7911          787        9.8%        7.4%       2.4%*        2.7%*          LPNs         2985          441         9.5%            7.3%     2.2%*          2.6%*
                                                                                                                                                                                          racial differences in resident exposure to turnover.
   CNAs        7873          773        6.3%        4.8%       1.5%*        1.4%*          CNAs         2970          428         6.7%            4.5%     2.2%*          2.2%*

                                                           physical
Controls include age and controls for patient's mental and physical health, length of                                                              physical
                                                                                        Controls include age and controls for patient's mental and physical health, length of
stay, payment type, and per diem rate.                                                  stay, payment type, and per diem rate.




                                                                                                                Turnover analysis of NNAS                                                                   Turnover analysis of NNAS
                                Appendix                                                Variable                  Likely Leave
                                                                                                                  Job Next Year
                                                                                                                                  Looking for
                                                                                                                                  Different Job
                                                                                                                                                    How Much
                                                                                                                                                    Turnover?
                                                                                                                                                                   How Much
                                                                                                                                                                   Interfere?
                                                                                                                                                                                    Variable                           Likely Leave
                                                                                                                                                                                                                       Job Next Year
                                                                                                                                                                                                                                       Looking for
                                                                                                                                                                                                                                       Different Job
                                                                                                                                                                                                                                                       How Much
                                                                                                                                                                                                                                                       Turnover?
                                                                                                                                                                                                                                                                   How Much
                                                                                                                                                                                                                                                                   Interfere?
                                                                                        Age                       -0.0108         0.0050                                            U.S. Citizen                       -0.0382         0.0728
                                                                                                                  (1.41)          (0.63)                                                                               (0.57)          (1.18)
                                                                                        Age^2/100                 0.0105          -0.0103                                           Married                            0.0033          0.0263
                                                                                                                  (1.10)          (1.04)                                                                               (0.09)          (0.77)
                                                                                        Female                    -0.0549         -0.1501                                           Divorced or Separated              0.0996          0.1497
                                                                                                                  (1.18)          (3.27)                                                                               (2.58)          (3.92)
                                                                                        Hispanic                  -0.1438         -0.1824
                                                                                                                                                                                    Receive Job Training Before 1987   0.0042          -0.0134         0.0343      0.0503
                                                                                                                  (2.18)          (2.61)
                                                                                                                                                                                                                       (0.11)          (0.35)          (1.01)      (0.05)
                                                                                        Black                     0.0483          0.0432
                                                                                                                                                                                    Employer Paid All Training Costs   -0.0437         -0.0446         0.0247      -0.0199
                                                                                                                  (1.45)          (1.38)
                                                                                                                                                                                                                       (1.25)          (1.29)          (0.92)      (0.02)
                                                                                        Asian                     0.0108          0.0207
                                                                                                                                                                                    Employer Paid for Some Training    0.0186          0.0306          0.0398      -0.0932
                                                                                                                  (0.13)          (0.24)
                                                                                                                                                                                                                       (0.33)          (0.56)          (0.89)      (0.09)
                                                                                        Years of Schooling        0.0139          0.0131
                                                                                                                                                                                    Trained in Nursing Facility        0.0293          0.0370          0.0054      0.0518
                                                                                                                  (1.61)          (1.57)
                                                                                                                                                                                                                       (0.82)          (1.04)          (0.19)      (0.05)
                                                                                        English Main Language     -0.0957         -0.1266
                                                                                                                                                                                    Trained in Community College       0.0053          0.0204          0.0021      0.0747
                                                                                                                  (1.39)          (1.77)                                                                               (0.13)          (0.51)          (0.06)      (0.07)
                                                                                        Spanish Main Language     0.0935          0.0611                                            Ln (hourly wage)                   -0.1659         -0.1112         -0.1609     -0.1865
                                                                                                                  (0.83)          (0.56)                                                                               (2.31)          (1.49)          (2.12)      (0.19)
                           Turnover analysis of NNAS                                                                      Turnover analysis of NNAS                                                                      Turnover analysis of NNAS
Variable                          Likely Leave        Looking for     How Much    How Much     Variable                              Likely Leave        Looking for     How Much    How Much     Variable                            Likely Leave        Looking for        How Much      How Much
                                  Job Next Year       Different Job   Turnover?   Interfere?                                         Job Next Year       Different Job   Turnover?   Interfere?                                       Job Next Year       Different Job      Turnover?     Interfere?
Pension Plan                      -0.0387             -0.0234         -0.0503     -0.0021      Bonuses                               -0.0396             -0.0668         0.0170      0.0181       Percent of Patients on Medicare     -0.0293             0.2273             -0.0293       -0.2456
                                  (1.27)              (0.81)          (1.62)      (0.00)                                             (1.27)              (2.14)          (0.66)      (0.02)                                           (0.20)              (1.88)             (0.28)        (0.25)
In Health Insurance Plan          -0.0357             -0.0439         -0.0182     -0.0465      Facility Part of a Chain              -0.0118             -0.0353         -0.0322     0.0146
                                                                                                                                                                                                  Percent of Patients on Medicaid     -0.1250             -0.0389            0.0349        -0.0676
                                  (1.42)              (1.59)          (0.76)      (0.05)                                             (0.41)              (1.26)          (1.13)      (0.01)
                                                                                                                                                                                                                                      (1.5)               (0.57)             (0.44)        (0.07)
Job tenure (in months )           -0.0015             -0.0005         0.0006      0.0004       For Profit Facility                   0.0594              0.0440          -0.0097     0.0264
                                  (2.61)              (0.93)          (1.34)      (0.00)                                                                                                          Does Facility Have Waiting List     0.0417              0.0354             -0.0480       -0.0129
                                                                                                                                     (1.80)              (1.46)          (0.31)      (0.03)
Job Tenure^2/100                  0.0003              -0.0001         -0.0001     0.0000       Clusters of Beds for Alzheimers       -0.0273             0.0176          0.1154      0.0716                                           (1.31)              (1.16)             (1.52)        (0.01)
                                  (1.52)              (0.34)          (0.51)      (0.00)       and Related Dementias                 (0.86)              (0.62)          (3.71)      (0.07)       Director Nursing Tenure             0.0014              0.0009             -0.0052       -0.0032
Work Mandatory Overtime           0.0876              0.0678          0.1110      0.2102                                                                                                                                              (0.60)              (0.44)             (2.40)        (0.00)
                                  (2.51)              (2.06)          (3.56)      (0.21)       Cluster of Beds for Behavior Unit     0.0430              0.0210          -0.0015     -0.0308      Medical Director Tenure             -0.0001             -0.0008            -0.0017       -0.0002
Desire to Work More Hours         0.0285              0.0724          0.0060      -0.0780      (Non-Alzheimers)
                                                                                               (Non-Alzheimers)                      (0.57)              (0.32)          (0.02)      (0.03)
                                                                                                                                                                                                                                      (0.05)              (0.42)             (0.80)        (0.00)
                                  (0.80)              (2.01)          (0.19)      (0.08)
                                                                                                                                                                                                  Percent Union                       0.0202              0.0078             0.0255        -0.0148
Desire to Work Fewer Hours        0.2657              0.3101          0.1011      0.1338       Cluster of Beds for Rehabilitation    0.0249              0.0307          -0.0590     -0.0392
                                                                                                                                                                                                                                      (1.11)              (0.38)             (1.01)        (0.01)
                                  (6.01)              (7.17)          (1.98)      (0.13)                                             (0.51)              (0.73)          (1.36)      (0.04)
                                                                                               Number of Beds                        -0.0003             -0.0001         0.0000      -0.0002      Nursing Hours Per Patient Per Day   -0.0126             -0.0202            -0.0050       -0.0110
# times injured at facility       -0.0006             0.0006          0.0044      0.0101
                                                                                                                                     (1.40)              (0.68)          (0.14)      (0.00)                                           (2.69)              (4.03)             (1.22)        (0.01)
                                  (0.37)              (0.36)          (1.51)      (0.01)
                                                                                               Occupancy Rate                        -0.0131             0.0542          0.1111      -0.1316      Obs                                 1,565               1,565              1,570         1,570
Time off for good work            -0.0318             -0.0032         -0.1053     -0.0962
                                  (0.56)              (0.06)          (3.03)      (0.10)                                             (0.10)              (0.45)          (0.82)      (0.13)




                      Turnover analysis of NNHS: RNS                                                                 Turnover analysis of NNHS: RNS                                                                   Turnover analysis of NNHS: RNS
Variable                                    %Left                 %Vacancy        % Tenure>1    Variable                                       %Left                %Vacancy         % Tenure>1

Starting Wage                               0.000321              0.00126         -0.0624       Cluster of Beds for Rehabilitation             0.00825              0.0342*          -2.839       Variable                                    %Left                 %Vacancy             % Tenure>1

                                            (0.14)                (0.82)          (-0.22)                                                      (0.39)               (1.92)           (-0.77)
                                                                                                # Beds:                                                                                           Percent on Medicare:
Health Insurance                            0.0394                0.0211          7.059
                                                                                                50-
                                                                                                50-99                                          0.0712**             -0.0185          -5.527       10-
                                                                                                                                                                                                  10-19                                       0.00448               0.00764              -2.537
                                            (1.30)                (0.86)          (1.30)
                                                                                                                                               (1.97)               (-0.72)          (-1.29)                                                  (0.23)                (0.52)               (-0.88)
Pension                                     -0.0189               0.000988        9.480***
                                                                                                100-
                                                                                                100-199                                        0.111***             -0.00849         -8.637**     20+                                         0.00930               0.0109               -3.150
                                            (-1.03)               (0.075)         (3.53)
                                                                                                                                               (3.06)               (-0.33)          (-1.97)                                                  (0.37)                (0.54)               (-0.75)
% Working over time                         0.0562                0.0874***       -2.009
                                                                                                200+                                           0.180**              0.0280           0.109        Percent on Medicaid:
                                            (1.56)                (3.95)          (-0.46)
                                                                                                                                               (2.06)               (0.85)           (0.020)      20-
                                                                                                                                                                                                  20-39                                       -0.0546*              0.0130               -2.733
Union                                       0.0177                -0.00269        5.400
                                                                                                Occupancy Rate:                                                                                                                               (-1.90)               (0.40)               (-0.43)
                                            (0.68)                (-0.15)         (1.22)
                                                                                                70-
                                                                                                70-79                                          -0.00628             0.00773          9.953*       40-
                                                                                                                                                                                                  40-59                                       -0.0337               0.0252               -4.064
Facility Part of a Chain                    0.0299*               -0.00954        -8.156***
                                                                                                                                               (-0.16)              (0.24)           (1.80)                                                   (-1.12)               (0.86)               (-0.72)
                                            (1.65)                (-0.67)         (-2.95)
                                                                                                80-
                                                                                                80-89                                          -0.0226              0.0310           14.47***     60-
                                                                                                                                                                                                  60-79                                       -0.0659**             0.0249               -4.649
For Profit Facility                         -0.00149              -0.00777        -1.418
                                                                                                                                               (-0.74)              (1.20)           (3.19)                                                   (-2.12)               (0.89)               (-0.83)
                                            (-0.084)              (-0.49)         (-0.49)
                                                                                                90-
                                                                                                90-94                                          -0.0256              -0.0000422       8.800*       80+                                         -0.0807***            0.00419              -2.211
Clusters of Beds for Alzheimers             0.00504               -0.0116         -1.779
                                                                                                                                               (-0.76)              (-0.0017)        (1.90)                                                   (-2.59)               (0.13)               (-0.35)
                                            (0.29)                (-0.87)         (-0.65)
Clusters of Beds for Behavior               0.0400                0.0135          1.434         95+                                            -0.0589*             -0.000397        14.61***

                                            (0.62)                (0.46)          (0.20)                                                       (-1.94)              (-0.017)         (3.22)
                    Turnover analysis of NNHS: RNS                                                 Turnover analysis of NNHS: LPNS                                              Turnover analysis of NNHS: LPNS
Variable                             %Left         %Vacancy     % Tenure>1   Variable                             %Left         %Vacancy     % Tenure>1   Variable                             %Left        %Vacancy    % Tenure>1
Nursing Hours Per Patient Per Day:                                           Starting Wage                        0.000881      -0.000195    0.148        Cluster of Beds for Rehabilitation   0.0434       0.0250      -7.241
2-2.99                               -0.157***     -0.0658**    23.73***                                          (0.54)        (-0.13)      (0.41)                                            (1.14)       (0.95)      (-1.61)
                                     (-3.18)       (-2.15)      (3.78)       Health Insurance                     0.0272        0.0218       3.424        # Beds:                              0.00462      0.0236      -1.244
3-3.99                               -0.126***     -0.0507*     18.88***                                          (1.44)        (1.29)       (0.87)       50-99
                                                                                                                                                          50-                                  (0.34)       (1.46)      (-0.38)
                                     (-2.76)       (-1.68)      (3.03)       Pension                              -0.0324***    0.00127      4.159**                                           (1.97)       (-0.72)     (-1.29)
4-4.99                               -0.0944***    -0.0606**    19.18**                                           (-2.87)       (0.13)       (2.03)       100-199
                                                                                                                                                          100-                                 0.0282       0.0225      -8.277**
                                     (-2.85)       (-2.45)      (2.49)       % Working over time                  0.0334        0.0795***    -4.829                                            (1.28)       (1.05)      (-2.18)
5-11.99                              -0.127***     -0.0449      21.54***                                          (1.64)        (5.35)       (-1.37)      200+                                 0.0622***    0.0205      -12.73***
                                     (-4.72)       (-1.57)      (2.73)       Union                                -0.0258*      0.0333*      6.834**                                           (2.81)       (1.04)      (-3.42)
12+                                  -0.118***     -0.0636***   25.44***                                          (-1.86)       (1.84)       (1.98)       Occupancy Rate:                      0.0746**     0.0471*     -5.641
                                     (-4.47)       (-2.81)      (3.11)       Facility Part of a Chain             0.0131        -0.0193*     -4.205*      70-
                                                                                                                                                          70-79                                (2.39)       (1.67)      (-1.17)
Does Facility Have Waiting List      0.00614       -0.0256*     -2.937                                            (1.15)        (-1.81)      (-1.89)                                           (-0.16)      (0.24)      (1.80)
                                     (0.36)        (-1.88)      (-1.10)      For Profit Facility                  0.00765       -0.0215*     -2.142       80-
                                                                                                                                                          80-89                                0.00126      -0.0201     10.88**
Director Nursing Tenure              -0.00803***   -0.00212     2.640***                                          (0.66)        (-1.75)      (-0.89)                                           (0.053)      (-1.06)     (2.52)
                                     (-3.84)       (-1.48)      (9.36)       Clusters of Beds for Alzheimers      0.0106        0.00545      -1.556       90-
                                                                                                                                                          90-94                                -0.0118      -0.0146     6.183
Medical Director Tenure              0.00311*      0.00155      0.265                                             (1.00)        (0.53)       (-0.71)                                           (-0.61)      (-0.86)     (1.61)
                                     (1.95)        (1.40)       (1.13)       Clusters of Beds for Behavior        0.0434        0.0250       -7.241       95+                                  -0.0132      -0.0239     4.346
Observations                         909           909          908                                               (1.14)        (0.95)       (-1.61)                                           (-0.66)      (-1.37)     (1.15)




                   Turnover analysis of NNHS: LPNS                                                 Turnover analysis of NNHS: LPNS                                              Turnover analysis of NNHS: CNAS
                                                                             Variable                             %Left         %Vacancy     % Tenure>1   Variable                             %Left        %Vacancy    %Tenure>1
Variable                             %Left         %Vacancy     % Tenure>1   Nursing Hours Per Patient Per Day:                                           Starting Wage                        -0.00363     -0.00175    0.456*
Percent on Medicare:
                                                                             2-2.99                               -0.0612**     -0.0364*     7.665                                             (-1.59)      (-1.43)     (1.75)
10-
10-19                                0.00232       0.0130       0.564
                                                                                                                  (-2.08)       (-1.75)      (1.59)       Health Insurance                     -0.0363      -0.00238    4.543*
                                     (0.20)        (1.22)       (0.26)
                                                                             3-3.99                               -0.0619**     -0.0463**    6.924                                             (-1.43)      (-0.25)     (1.78)
20+                                  0.00400       0.0235       0.245
                                                                                                                  (-2.19)       (-2.23)      (1.44)       Pension                              -0.000902    0.00817     5.121***
                                     (0.24)        (1.36)       (0.068)
                                                                             4-4.99                               -0.0490*      -0.0675***   4.569                                             (-0.073)     (1.44)      (3.44)
Percent on Medicaid:
                                                                                                                  (-1.91)       (-4.66)      (0.77)       % Working over time                  0.0703**     0.0612***   -5.148*
20-
20-39                                0.0188        0.0173       -6.676
                                                                             5-11.99                              -0.0916***    -0.0184      4.994                                             (2.19)       (4.76)      (-1.75)
                                     (0.75)        (0.62)       (-1.19)
                                                                                                                  (-5.11)       (-0.71)      (0.83)       Union                                -0.0412***   0.00810     4.343**
40-
40-59                                -0.00254      0.0373       -0.0350
                                                                             12+                                  -0.0873***    -0.0428**    9.288*                                            (-3.37)      (0.97)      (2.02)
                                     (-0.12)       (1.45)       (-0.0074)
                                                                                                                  (-5.41)       (-2.55)      (1.71)       Facility Part of a Chain             0.00826      -0.000466   -2.317
60-
60-79                                0.00863       0.0317       -3.303
                                                                             Does Facility Have Waiting List      -0.00686      -0.0113      1.201                                             (0.74)       (-0.080)    (-1.46)
                                     (0.40)        (1.40)       (-0.69)
                                                                                                                  (-0.54)       (-1.04)      (0.55)       For Profit Facility                  0.0327***    -0.0155**   -1.665
80+                                  0.00246       -0.00664     0.0909
                                                                             Director Nursing Tenure              -0.00345***   -0.00163     1.613***                                          (2.96)       (-2.56)     (-1.04)
                                     (0.096)       (-0.30)      (0.017)
                                                                                                                  (-2.93)       (-1.58)      (6.87)       Clusters of Beds for Alzheimers      0.0186*      0.00647     -2.734
                                                                             Medical Director Tenure              -0.00178*     -0.000746    0.270                                             (1.66)       (1.06)      (-1.64)
                                                                                                                  (-1.82)       (-0.85)      (1.37)       Clusters of Beds for Behavior        0.171        0.00633     -8.843***
                                                                             Observations                         914           915          911                                               (1.29)       (0.45)      (-2.84)
                  Turnover analysis of NNHS: CNAS                                         Turnover analysis of NNHS: CNAS                                    Turnover analysis of NNHS: CNAS
Variable                             %Left        %Vacancy   %Tenure>1                                                                     Variable                             %Left        %Vacancy      %Tenure>1

Cluster of Beds for Rehabilitation   -0.0278*     0.00922    0.118       Variable                     %Left        %Vacancy   % Tenure>1   Nursing Hours Per Patient Per Day:

                                     (-1.90)      (1.02)     (0.046)     Percent on Medicare:                                              2-2.99                               -0.119**     -0.0410**     1.558

# Beds:                                                                  10-
                                                                         10-19                        0.0228*      -0.00236   -0.256                                            (-2.18)      (-2.27)       (0.40)
50-99
50-                                  0.0332*      -0.00555   -0.481                                   (1.79)       (-0.38)    (-0.16)      3-3.99                               -0.115**     -0.0400**     1.907
                                     (1.92)       (-0.58)    (-0.20)     20+                          -0.0000716   0.00746    -2.702                                            (-2.27)      (-2.26)       (0.49)
100-
100-199                              0.0522***    -0.0159    -1.599                                   (-0.0041)    (0.80)     (-1.01)      4-4.99                               -0.123***    -0.0492***    0.780
                                     (3.00)       (-1.60)    (-0.65)     Percent on Medicaid:                                                                                   (-3.32)      (-4.41)       (0.17)
200+                                 0.0350       -0.0137    5.064       20-39                                                             5-11.99                              -0.139***    -0.0337**     3.453
                                                                         20-                          0.0248       0.0103     -7.111*
                                     (1.36)       (-1.01)    (1.52)                                                                                                             (-3.86)      (-2.07)       (0.71)
                                                                                                      (1.09)       (0.81)     (-1.82)
Occupancy Rate:                                                                                                                            12+                                  -0.158***    -0.0492***    2.981
                                                                         40-
                                                                         40-59                        0.0467**     0.0236**   -8.013***
70-
70-79                                -0.0123      0.00802    6.964**                                                                                                            (-6.07)      (-4.89)       (0.52)
                                                                                                      (1.99)       (2.02)     (-2.70)
                                     (-0.50)      (0.61)     (2.15)
                                                                         60-
                                                                         60-79                        0.00403      0.0241**   -8.346***    Does Facility Have Waiting List      0.0177       -0.00141      -2.241
80-
80-89                                -0.0243      0.00106    3.950
                                                                                                      (0.19)       (2.21)     (-2.90)                                           (1.61)       (-0.23)       (-1.33)
                                     (-0.98)      (0.097)    (1.34)
                                                                         80+                          -0.00863     0.000804   -4.075       Director Nursing Tenure              -0.00236**   -0.00163***   1.015***
90-
90-94                                -0.0392*     0.00575    6.052**
                                                                                                      (-0.35)      (0.066)    (-1.23)                                           (-2.06)      (-2.65)       (6.38)
                                     (-1.92)      (0.52)     (2.06)
                                                                                                                                           Medical Director Tenure              -0.00110     0.000655      0.101
95+                                  -0.0549***   -0.00587   6.565**
                                                                                                                                                                                (-1.19)      (1.17)        (0.75)
                                     (-2.59)      (-0.54)    (2.15)
                                                                                                                                           Observations                         911          914           907

				
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