OBJECTIVE:Assess home health care (HHC) agency coverage in Puerto Rico (PR), a U.S. territory, and compare PR agencies with those in the U.S. (excluding PR) and in a subset of counties outside of PR with high Puerto Rican populations (CHPRPs). METHODS:PR HHC coverage was mapped using data from 2020 U.S. Census ZIP Code Tabulation Area (ZCTA) and publicly available Centers for Medicare and Medicaid Services (CMS) files. Descriptive statistics on HHC agencies, patients and Medicare beneficiaries were calculated from publicly available CMS data. Pearson's χ2, Fisher's exact, or t tests were used to compare PR agencies with U.S. (excluding PR) and CHPRP agencies. RESULTS:Nearly all PR ZCTAs were served by ≥7 HHC agencies. Compared with U.S. and CHPRP agencies, those in PR have higher nonprofit ownership, higher Medicare Advantage (MA) enrollment, and better fall prevention and quality of patient care, but lower performance in timely HHC initiation, patient influenza vaccination, and patient experience. CONCLUSION:PR HHC agencies excel in patient improvement metrics, with opportunities to strengthen patient experience and preventive care. Future research should examine factors underlying observed differences, and MA enrollee access to and use of HHC.

Nursing staff including registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) are critical to nursing home (NH) operations but account for approximately 27% of net revenues. Understanding how nursing staff wages affect financial performance is particularly important as policy efforts seek to expand NH minimum staffing hours. Drawing from efficiency wage theory, which posits that employers may pay above-market wages to enhance worker productivity and retention, this study examined the relationship between nursing staff wages and NH financial performance. We used secondary datasets, including Payroll-Based Journal data and Medicare cost reports (N = 37 933 facility-year observations, 2020-2022). The dependent variable was operating margin, while the independent variables were facility-level RN, LPN, and CNA wages. An instrumental variable (IV) approach was used to address potential endogeneity in RN wages, with county-level average wages (excluding the index facility) serving as the instrument. The first stage modeled RN wages as a function of the instrument, and the second stage estimated the effect of predicted wages on operating margin. Ordinary least squares models were used for LPN and CNA wages, for which endogeneity was not detected. A $1 increase in RN wages was associated with a 0.70 percentage-point decrease in operating margin ( P = .01, 95% CI [−1.27, −0.14]). For LPNs, a $1 increase was associated with a 0.17-point decrease ( P < .001, 95% CI [−0.20, −0.13]), and for CNAs, a 0.31-point decrease ( P < .001, 95% CI [−0.37, −0.26]). These findings underscore the tension between workforce investment and financial sustainability in an industry that operates in a resource-constrained environment. Policy interventions such as wage subsidies or higher Medicaid reimbursements may be necessary to balance staffing investments with financial viability.

BACKGROUND AND OBJECTIVES:Turnover among nursing staff (registered nurses, licensed practical nurses, and certified nursing assistants [CNAs]) is a long-standing challenge in nursing homes with significant implications for quality of care. This study aimed to examine the relationship between nursing staff wages and turnover. RESEARCH DESIGN AND METHODS:We used national data from 2021 to 2023, linking multiple datasets including the Payroll-Based Journal and Medicare Cost Reports (n = 37,254). Turnover was modeled separately for each nursing staff type as a fractional outcome bounded between 0 and 1. The primary predictor variable was facility-level average hourly wage for each staff type. To address potential endogeneity and reverse causality, we used a two-stage residual inclusion instrumental variables approach with county-level average wages (excluding the index facility) as the instrument. Models controlled for facility-level organizational and county-level market characteristics, with fixed effects for county and year and cluster-robust standard errors at the facility level. RESULTS:Higher CNA wages were significantly associated with lower turnover (β = -0.35, 95% CI [-0.59, -0.11], p = .005), indicating a 0.35 percentage point reduction in turnover per $1 increase in hourly wage. Wages were not significantly associated with turnover among licensed nurses. DISCUSSION AND IMPLICATIONS:Findings suggest that wage increases may be most effective for CNAs, while retaining licensed nurses likely requires complementary organizational and nonmonetary strategies. While nursing homes should strive to offer competitive wages to their staff, targeted reimbursement reforms may be necessary to overcome financial constraints.

Nursing homes are under immense pressure to improve quality. The purpose of this study was to determine if there is a relationship between registered nurse (RN) skill mix (proportion of RN hours among all nursing staff hours) and higher quality measure (QM) star ratings. Data sets from 2021-2022 were utilized from the American Community Survey, Centers for Medicare and Medicaid Services (CMS), Medicare Cost Reports, Payroll-Based Journal, and Care Compare. The final analytic sample was 14,556 unique nursing homes. Ordered logistic regression was used to examine the relationship between RN skill mix (independent variable) and QM star ratings (dependent variable). The study found that RN skill mix is positively associated with QM star ratings. For a 1% increase in RN proportion, the odds of being in a higher QM star rating category increase by 4% (OR = 1.04, p < .001). This study fills two significant gaps in prior literature by relying on more accurate nurse labor hours through electronic payroll records vs. self-reported data, and by using the government standard of 15 quality measures vs. a few selected metrics. The results have implications for policymakers to incentivize improved quality, and for nursing home administrators to improve QM star ratings.

A key determinant of nursing home (NH) performance, particularly quality, is the adequacy and the expertise of nursing staff [registered (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs)]. Nursing staff serve as primary caregivers in NHs, directly influencing resident care and outcomes. Yet, burnout remains a significant concern, and NHs experience extraordinary levels of turnover. Extended work hours among nursing staff may be an important factor contributing to this challenge. While existing research shows that prolonged work hours can negatively affect healthcare workers’ well-being—leading to poorer quality outcomes and higher turnover rates—little is known about how extended nursing staff work hours specifically affect NH outcomes. NHs differ substantially from acute care settings for various reasons, such residents’ need for sustained and continuous care. Therefore, it is important to understand the implications of extended work hours on resident and staff outcomes in NHs. The overarching goal of this symposium is to explore the antecedents and consequences of extended work hours nursing staff in NHs. As part of the symposium, we have included studies examining how extended work hours relate to quality, turnover, the organizational and environmental factors associated with extended work hours, and overall NH costs. The findings and discussions may offer valuable insights for managerial decision-making and policy and regulatory formulation. They can help address the systemic challenges of nursing staffing in NHs and improve NH performance, particularly regarding quality of care and turnover.

BACKGROUND:Leadership instability in nursing homes marked by high administrator turnover threatens the well-being of vulnerable residents. Although numerous factors have been implicated, the role of ownership remains unexplored. PURPOSES:Based upon the tenets from institutional theory and strategic management theory, the primary goal of this study was to examine the impact of ownership on administrator turnover. METHODOLOGY/APPROACH:Data were derived from different sources: LTCFocus.org , Nursing Home Five-Star Quality Rating System, and Area Health Resources Files (2021-2022). The dependent variable was administrator turnover categorized as follows: 0 = no administrators left, 1 = one administrator left, and 2 = two or more administrators left. The primary independent variable was ownership/chain affiliation categorized as four possible interactions of for-profit (FP) status and chain affiliation: not-for-profit (NFP) independent, FP independent, NFP chain, and FP chain. An ordinal logistic regression model was used, and predicted turnover probabilities were calculated across the four ownership categories. RESULTS:The primary hypothesis was supported and compared to NFP independent, FP chain, FP independent, and NFP chain nursing homes that exhibited approximately 2.3, 1.7, and 1.4 times higher odds of administrator turnover. Predicted probabilities confirmed these trends: FP chain nursing homes had the lowest retention, with a 42% probability of no turnover, 32% for one administrator leaving, and 26% for two or more leaving. In contrast, NFP independent facilities had the highest retention rates, with a 62% chance of no turnover, 25% for one leaving, and 13% for two or more. Differences between groups were statistically significant ( p < .001). CONCLUSION:FP chain ownership was associated with the highest administrator turnover rates, whereas NFP facilities experienced the lowest. FP independent and NFP chain homes had intermediate probabilities of administrator turnover. PRACTICE IMPLICATIONS:Tailoring management strategies to the specific ownership structure may reduce administrator turnover and ensure consistent resident care.

Background: The 2019 introduction of the Patient Driven Payment Model (PDPM) marked a major shift in reimbursement for U.S. skilled nursing facilities (SNFs). Unlike the previous prospective payment system (PPS), which encouraged high therapy service volumes, PDPM aligns payments with resident needs and care complexity. It broadens case-mix adjustments to include non-therapy ancillary services and speech-language pathology while reducing financial incentives linked to therapy volume. Prior research has explored nursing and therapist staffing changes since the implementation of PDPM in 2019. However, to date there have been no studies that have examined the effects of PDPM on both nursing and therapist staffing intensity, before, during, and after coronavirus disease 2019 (COVID-19). As such, our national study contributes to the literature by providing a comprehensive analysis of nursing and therapy staffing changes from January 2018 to December 2023, and segmenting the staffing data into five periods: pre-PDPM (January 2018 to September 2019), post-PDPM/pre-COVID (October 2019 to February 2020), COVID first wave/peak (March 2020 to December 2020), COVID vaccine introduction (January 2021 to December 2021), and COVID endemic management (January 2022 to December 2023). Methods: Data sources included the Payroll-Based Journal, SNFs Care Compare, Long-Term Care Focus (LTCFocus), Medicare Cost Reports, Area Health Resource Files, DHHS Provider Relief Fund, SNF's COVID-19 Public File, and CDC COVID-19 Data Tracker. The study sample included 80,721 SNF-years, representing 931,865 year-month observations. Random effects models were used to analyze changes in nurse and therapy staffing intensity across the five time periods. Results: Our findings reveal an initial increase in registered nurse (RN) staffing during the post-PDPM/ pre-COVID and COVID peak periods, followed by a decline after the COVID vaccine introduction. Licensed practical nurse (LPN) and certified nursing assistant (CNA) staffing intensity also declined, notably after the vaccine rollout. Therapy staffing for occupational, physical, and speech therapists decreased beginning in the post-PDPM/pre-COVID period, while occupational and physical therapy assistants saw declines starting with the COVID peak. For-profit and chain-affiliated SNFs experienced greater increases in therapy staffing and larger reductions in nursing staffing than not-for-profit and independent facilities. Despite increased SNF occupancy by the pandemic's end, staffing intensity continued to decline, and Coronavirus Aid, Relief, and Economic Security (CARES) funding had no significant impact on staffing levels. Conclusions: PDPM and the COVID-19 pandemic led to significant declines in both nursing and therapy staffing intensity. Although RN nurse staffing initially increased following PDPM's introduction, this trend reversed during the pandemic, likely due to workforce shortages and COVID-19-related challenges. The reduction in therapy staffing may have been influenced by changes in PDPM's therapy reimbursement structure and lower occupancy rates during the pandemic. SNF management must adapt to these changes, balancing staffing with new reimbursement structures to ensure patient care quality. Policymakers should consider nuanced reimbursement models that support both the admission of clinically complex patients and adequate staffing for high-quality care.

Background: Intensivists are physicians who specialize in providing care in the intensive care unit (ICU). The use of intensivists increased dramatically from 2007 to 2010. The purpose of this study is to use agency theory to examine the relationship between the use of intensivists and the efficiency of care provided in the ICU. Methods: This longitudinal study used 2007-2010 data sourced from the American Hospital Association (AHA) Annual Survey and the Healthcare Cost and Utilization Project's (HCUP) State Inpatient Databases (SID) for New York and Washington States. The sample included acute, short-term, general hospitals in New York and Washington State that were categorized as either non-federal governmental, nongovernment not-for-profit or investor-owned for-profit and resulted in between 614 and 625 hospital-year observations, depending on the principal diagnoses being analyzed, over the 4-year period. The study was a panel design and used facility and year fixed effects regression with clustering at the hospital level to explore the association between the use of intensivists and the efficiency of care provided in the ICU. The original analysis measured the use of intensivists as a dichotomous variable, indicating either the use or non-use of intensivists at the hospital and a post hoc analysis measured the use of intensivists as the number of reported intensivists fulltime equivalents (FTEs) per patient day for all ICU patients. Efficiency was operationalized as the average total length of stay (LOS) and the average total cost per patient day for ICU patients for each of the four principal diagnoses of interest, which included acute myocardial infarction (AMI), congestive heart failure (CHF), stroke and pneumonia. These four diagnoses were selected due to the availability of data and the relatively high number of patients who had one of these diagnoses and utilized the ICU during their stay. Results: The study found a nonlinear relationship between the use of intensivists and the average cost per patient day for patients with primary diagnoses of AMI and CHF. For AMI patients, the lowest and the highest levels of intensivist staffing intensity were associated with $245.17 and $425.37 lower cost per patient day, respectively (P=0.07 and 0.06, respectively). For CHF patients, the highest level of intensivist staffing was associated with $339.69 lower average cost per patient day (P=0.01). Conclusions: As providers seek to improve the value of the healthcare provided, one potential strategy to reduce costs is the use of intensivists. This study found that certain intensities of intensivist staffing for certain types of patients is associated with lower average cost per patient day.

OBJECTIVE:Nursing staff are central to ensuing high-quality care in nursing homes (NHs), yet their wages often lag behind those in other health care settings. This study aimed to examine whether higher wages for nursing staff-registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs)-were associated with better NH quality. DESIGN:This was an observational study using panel data from 2020 to 2022. SETTING AND PARTICIPANTS:The study included all Centers for Medicare and Medicaid Services-certified US NHs. The analytic data file comprised 37,577 facilities. METHODS:This study used multiple secondary datasets, including the Payroll-Based Journal, Medicare Cost Reports, Care Compare: Five-Star Quality Rating System (Five-Star QRS), and LTCFocus.org. The primary outcome was NH quality, operationalized through the quality domain of the Five-Star QRS. The primary independent variables were the facility-level average hourly wages for RNs, LPNs, and CNAs, adjusted for inflation. To address potential endogeneity, average nursing staff wages at the county level, excluding the index facility, were used as an instrument for wages. RESULTS:A 1-dollar increase in wages for RNs, LPNs, and CNAs was associated with 12% (95% CI, 1.07-1.17), 10% (95% CI, 1.05-1.15), and 8% (95% CI, 1.07-1.45) higher odds, respectively, of obtaining a higher star rating (P < .001). Marginal effects analysis showed that a 1-dollar increase in wages was associated with a 2.4%, 2.0%, and 1.8% higher likelihood of achieving a 5-star rating for RNs, LPNs, and CNAs, respectively. CONCLUSIONS AND IMPLICATIONS:Higher nursing staff wages were associated with increased odds of achieving a higher quality rating. NHs need to offer competitive wages as part of broader efforts to improve quality. Targeted reimbursement strategies may be necessary to support wage increases, especially for facilities serving a high proportion of vulnerable residents.

As competition intensifies in the global medical tourism industry, countries are increasingly seeking effective marketing strategies to enhance their market share. Developing such strategies requires a comprehensive understanding of the expenditure patterns of medical tourists, particularly in emerging destinations with limited historical involvement in medical tourism. This study aims to examine the expenditure characteristics of medical tourists with respect to treatment type, gender, religion, and country of origin. Empirical data were collected from 288 medical tourists (response rate: 82%) receiving healthcare services in Turkey, an emerging hub for medical tourism. Cross-tabulation analyses and chi-square tests of independence revealed statistically significant differences in expenditures based on the aforementioned characteristics. The findings indicate that, on average, female, non-Muslim tourists from developed countries spent more than their male, Muslim, and developing-country counterparts. Additionally, aesthetic treatments accounted for the highest average expenditures among all treatment types. This study offers valuable insights into the expenditure behavior of medical tourists in Turkey, contributing to the broader understanding of competition in the medical tourism sector. These findings can inform the development of strategic roadmaps and targeted marketing approaches in emerging medical tourism markets.

Nursing home (NH) care is labor intensive with total labor costs constituting nearly 70% of an average facility’s operating costs. This study aimed to assess the relationship between nursing staff [registered nurses (RNs), licensed practical nurses (LPNs), certified nursing assistants (CNAs)] extended work hours and NH financial performance, specifically their operating costs. The study utilized four datasets: Care Compare: Five-Star Quality Reporting System, Medicare Cost Reports, LTFocus.org, and the Area Health Resource Files (2020-2022). A multivariable linear regression model with two-way fixed effects (year and state) was employed to analyze the data (N = 38,966). Separate regression models were estimated for RNs, LPNs, and CNAs. The dependent variable was operating costs, which include all costs incurred in direct resident care. The independent variable was extended work hours, measured as the percentage of nursing staff exceeding 50 work hours per week, averaged across the year to calculate the annual facility-level rate. After controlling for appropriate organizational and environmental level factors, the analysis did not find significant association between nursing staff extended work hours and NH operating costs. The findings suggest that extended work hours may be a convenient strategy for NH administrators to meet resident care demands, as it does not appear to significantly impact operating costs in our study. However, relying on extended hours could have unintended consequences, such as increased nursing staff burnout, reduced job satisfaction, and potential declines in care quality. While this approach may seem financially neutral, its long-term effects on resident outcomes and workforce stability warrant closer attention.

Context: High Medicaid nursing homes are under-resourced and associated with lower resident quality of care. Culture change initiatives, a movement to transition nursing homes to more home-like environments, are a potential process to improve residents’ quality of life and care. Objective: To examine how the number of years of implementing culture change initiatives is associated with nursing home quality among high Medicaid nursing homes in the US. Methods: The study used national survey data from nursing home administrators (n = 348) merged with secondary data sources for the year 2018: LTCfocus.org, Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Quality Rating Program (SNF QRP), and the Area Health Resource File. The dependent variable was the nursing home quality star rating obtained from the CMS SNF QRP. The independent variable represented the number of years of implementation of culture change initiatives. Data were modelled using an ordinal logistic regression with state-level fixed effects (n = 339). Findings: Compared to nursing homes with no culture change/one year or less implementing culture change initiatives, those with six or more years had increased odds of having a higher star rating. Facilities with two to five years of implementing culture change initiatives did not significantly differ from nursing homes with no culture change/one year or less implementing culture change initiatives. Limitations: The culture change measure was self-reported by nursing home administrators. Implications: Results suggest that a more extended implementation period of culture change initiatives may be needed to see quality improvements among high Medicaid nursing homes.

BACKGROUND:Private equity (PE) investment in U.S. nursing homes has increased significantly over the past two decades. The emergence of this novel ownership model has prompted concerns regarding its effects on nursing home performance, especially quality. OBJECTIVE:This systematic review examined the impact of PE ownership on U.S. nursing homes, focusing on quality of care and financial performance. The review was conceptually informed by agency theory and the structure-process-outcome (SPO) framework. METHODS:Following PRISMA guidelines, a systematic search across five databases identified 12 studies published between 2000 and 2024. Eligible studies examined the effects of PE ownership on nursing home quality or financial performance. Data were extracted and synthesized across these two dimensions. RESULTS:Across studies, PE ownership was linked to higher number of deficiencies, increased hospitalization rates, and higher mortality, although some improvements in care processes were noted. Financial outcomes showed initial financial gains but long-term challenges, primarily due to high debt loads. CONCLUSIONS:Findings suggest that PE strategies may prioritize short-term profitability, which may compromise quality of care in some instances. These findings highlight the need for financial transparency, and reimbursement models that incentivize long-term quality.

Background: Nursing homes have long struggled with nursing staff shortages. These staffing gaps have led nursing homes to increasingly rely on agency or contract labor hired through third-party agencies. While agency nursing labor may enable nursing homes to maintain resident care, it costs substantially more than permanent staff. These increased expenses can put downward pressure on nursing home financial performance. Drawing from Resource Dependency Theory and Transaction Cost Economics, this study investigated the association between the use of agency nursing staff and nursing home financial performance. Methods: This study utilized five secondary data sets: Payroll-based Journal (PBJ), Care Compare FiveFiles, and LTCFocus.org for the study period 2018-2022. All Medicare and Medicaid certified U.S. nursing homes were included in the analysis (n=65,821). The dependent variable was operating margin, a widely used financial measure which indicates the entity's operating profitability. Independent variables included the proportion of agency nursing staff hours for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs), while controlling for facility and community characteristics that may affect nursing home financial performance. A multivariable linear regression model with two-way (facility and year) fixed effects was used. Results: Regression analysis indicated that greater reliance on agency nursing staff was significantly associated with lower operating margins across all three categories: RNs [0=-0.32, 95% confidence interval (CI): -0.37, -0.27, P<0.001], LPNs (0=-0.34, 95% CI: -0.39, -0.30, P<0.001) and CNAs (0=-0.37, 95% CI: Conclusions: Agency labor may provide a convenient solution for addressing staffing gaps; however, their use may negatively impact nursing home outcomes, including financial performance. Nursing homes should prioritize the recruitment and retention of permanent nursing staff, with appropriate policy support to address workforce shortages and improve long-term sustainability.

Background: Nursing homes (NHs) hold a key role in delivering health care services to older adults with Alzheimer's dementia. Alzheimer's disease special care units (AD SCUs) have been adopted as an organizational strategy to provide specialized care to long-stay residents with AD. The objective of this study was to ascertain the relationship between AD SCU designation and financial performance among NHs. Methods: This study used secondary data from Medicare Skilled Nursing Facility (SNF) Cost Reports [Centers for Medicare & Medicaid Services (CMS)], Area Health Resource Files (AHRF) and Brown University Long-Term Care Focus (LTCFocus), for the years 2006-2019. The dependent variable, NH financial performance, was measured as total margin and operating margin. Panel event study methodology was used to estimate the causal effects of AD SCU adoption for each of the financial variables, controlling for a range of organizational and market covariates. Results: The adoption of AD SCUs was significantly associated with improved total margin of 1.8 percentage points beginning at t=2 (P<0.05) and remained positive and significant through t=4, demonstrating a lagged but sustained improvement in financial performance. Adoption of AD SCUs indicated a stronger and more immediate effect on operating margin; beginning at t=1, operating margin improved by 2.1 percentage points (P<0.01) and peaked at t=2 with a significant increase of 3.3 percentage points (P<0.001). Conclusions: The adoption of AD SCUs was significantly associated with financial performance over time, although the timing and magnitude of these effects differ between total and operating margins. As NHs seek to deliver high-value care, one potential strategy to improve financial performance is the adoption of AD SCUs. These findings provide policymakers and NH administrators with a better understanding of factors influencing NH financial performance and the relationship between AD SCU adoption and NH profitability.

In the past two decades, private equity (PE) acquisitions in nursing homes have surged, driven by financial gain and market consolidation. The increasing presence of PE firms in the U.S. nursing home industry has raised concerns about its impact on care quality and financial performance. This systematic review examined the impact of PE ownership on U.S. nursing homes, focusing on care quality and financial performance using agency theory and the structure-process-outcome framework. Adhering to PRISMA guidelines, a systematic search across five databases, including PubMed, Web of Science, and ABI/Inform. The initial search yielded 343 articles. After removing duplicates, screening for title, abstract, thorough evaluation, and full-text review, 12 studies published between 2000 and 2024 met the inclusion criteria and were included in the study. Data were extracted and synthesized across quality and financial dimensions. PE ownership was linked to higher deficiencies, increased hospitalizations, and higher mortality, though some care processes improved. PE-owned facilities showed initial financial gains but faced long-term financial challenges due to high debt and lease obligations. Staffing changes suggested an increased reliance on lower-skilled staff. PE strategies may prioritize short-term profitability, at the expense of care quality. Cost-cutting measures can undermine staffing and patient outcomes, highlighting the need for stricter staffing regulations, financial transparency, and value-based reimbursement to ensure sustainable, high-quality care. Effective policy interventions are needed to safeguard residents of nursing homes and maintain equitable care standards.

This study investigated the trends in agency nursing staff utilization in United States nursing homes against the backdrop of longstanding staffing challenges exacerbated by the COVID-19 pandemic. It analyzed data from the Centers for Medicare and Medicaid Services Payroll-Based Journal (PBJ), LTCFocus.org, Area Health Resources Files, and Rural-Urban Commuting Area codes covering 80,244 nursing home-year observations (2017-2022). Joinpoint regression analysis revealed that agency labor utilization increased across all nursing staff categories (registered nurses, licensed practical nurses, certified nursing assistants), with a significant upward shift beginning in 2020, coinciding with the onset of the COVID-19 pandemic. The study also noted an interesting pattern of increased agency nursing staff use during weekends, possibly due to reduced availability of full-time staff. Ownership analysis revealed that not-for-profit chain facilities had the highest use of agency labor. We also examined differences in agency nursing staff utilization by nursing home size and location (urban/rural). Additionally, state-level variations in agency staff utilization were noted, highlighting regional differences in reliance on agency labor. Additional research is needed to evaluate the policy and operational implications of agency nursing staff utilization in nursing homes.