Date of Award


Document Type

Campus Access Dissertation

Degree Name

Doctor of Philosophy (PhD)



First Advisor

Jennifer Gaudet Hefele

Second Advisor

Pamela Nadash

Third Advisor

Dan Barch


Strengthening the caregiver workforce has been an important focus for researchers and policy makers aiming to improve quality in nursing homes. Minimum staffing regulations exist for nursing staff but staffing mandates for Physical Therapists (PT) and Occupational Therapists (OT) have yet to be established. Services from PT/OT staff are covered by Medicare for residents requiring skilled care but are not covered by Medicaid for chronic care residents. These professional non-nursing staff possess unique skill sets and knowledge that are characteristically different from nursing staff. Guided by the framework of the Resource Based View of the Firm theory, this study examines the relationship between PT/OT staffing and quality to strengthen minimum staffing policies and to determine the appropriateness of these services for long-stay residents. Data from 2013 to 2016 on over 12,000 nursing homes were linked across four data sets: Nursing Home Compare; Online Survey, Certification, and Reporting and Certification and Survey Provider Enhanced Reporting; Long-term Care: Facts on Care in the U.S; and the Area Health Resources File. Random and fixed effects analyses were conducted on more than 43,000 nursing home observations to identify the effect PT/OT staffing have on long-stay resident outcomes and the 5-star quality measure. The findings provide support that a positive relationship between PT/OT staffing and quality exists but increases in staffing were not directly related to quality improvements after isolating only time-varying differences across facilities. The results also demonstrate a non-linear relationship between PT/OT staffing and quality after stratifying the sample into quartiles based on baseline PT/OT staffing levels; PT/OT staffing effects differed between facilities in the lowest and highest staffing quartiles. This study demonstrates that PT/OT staffing may be important components in improving long-stay resident outcomes and overall quality. Evidence was found in support of minimum staffing requirements for PT/OT staffing and expanding coverage of these services under Medicaid. Future research should look to substantiate these findings using additional quality measures. Studies should also consider interdisciplinary approaches to understand the relationship from a cost perspective and lend further support to policy makers aiming to improve quality and refine staffing policies for nursing homes.


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