In a 2001 report, CMS found that in order to avoid bad outcomes, nursing home residents should each receive at least 4.1 hours of direct nursing care per day. Kentucky introduced House Bill 215 on January 8, 2020, which would have increased its minimum staffing requirement. 26, 2021); Ltr. Oregon also authorized facilities to utilize personal care assistants, nursing assistants, physical therapists, and occupational therapists to meet no more than 25 percent of the certified nursing assistant minimum staffing requirement during this time. In addition, the current nursing shortage could also make it difficult for facilities to find and retain high-quality nursing staff, which would reduce the number of residents that facility could support. Federal regulations require nursing aides to complete a 75-hour training program and to pass a competency evaluation in order to work in a nursing home longer than four months. [11]. Nationwide, nursing homes are down more than 240,000 employees since the start of the pandemic, according to the Labor Department. "You have an opportunity to turn this industry on its head. "What has been so ambiguous and subjective is how 'sufficient' is interpreted.". 1 RN Day & Evening; 1 RN/LPN Night. Flexible pay and scheduling structures for nursing staff, including incentive pay, career development and training programs, and alternative benefits that do not increase base pay. [6], Furthermore, CMS has increased its reporting requirements for nursing homes, public posting of facility staffing measures, and enforcement penalties for nursing homes that do not comply with staffing requirements. "We think it's really important to set a very specific standard that can be measured against, to really make sure staff is adequate to ensure quality," says Chiquita Brooks-LaSure, administrator for the Centers for Medicare & Medicaid Services (CMS), the federal agency that regulates and funds most nursing homes in the U.S. Stephen Hanse, New York State Health Facilities Association president and CEO, said the laws do not reflect the current reality of New Yorks long-term care landscape, calling it unworkable.. Webduring the 2021 session in section 10 of Public Act 21-185 regarding minimum staffing level requirements for nursing homes. To attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Additionally, observational data will be collected onsite using trained clinicians who will observe and record time spent on care provision, including taking care to differentiate time spent on care provision from time spent on administrative nursing. [5] Some States may also have minimum staffing requirements for nursing homes. This equates to 0.30 staffing hours per resident day (hprd).3 Facilities also must designate a full-time registered nurse as a full-time director of nursing. Opens in a new window. Weve heard directly from hospitals their frustration about not being able to discharge people who are not ready to return to the community, he said. Industry associations and nursing home resident advocates provided divergent views on the establishment of minimum staffing levels. What will the staffing study look like? 0000055058 00000 n The only resolution to the workforce crisis, which is not going to be resolved today, tomorrow, in a month, or six months for that matter, is a partnership between the administration, the legislature, providers and labor working together to put in real initiatives that will help recruit and retain workers, Hanse told Skilled Nursing News. Key findings include the following: Staffing Requirements: At least five states (AR, CT, MA, NY, RI) adopted permanent increases to nursing home minimum staffing requirements after the onset of the COVID-19 pandemic, while at least one state (GA) adopted a permanent decrease. As of March 27, 2022, more than one in four nursing homes nationally reported a shortage of at least one type of staff, though the share of nursing homes reporting staffing shortages varies widely by state. In conducting the cost-benefit analysis required for any rulemaking, including the staffing requirement, CMS must evaluate any associated incremental costs that facilities would likely face. While federal requirements state that facilities must maintain sufficient nursing staff to meet residents needs, specific guidelines are not set and state regulations vary drastically. However, the current minimum thresholds for nursing home staffing may soon be changing. A 2001 CMS study recommended a minimum of 4.1 nursing hours per resident per day to prevent harm to residents. CMS will be conducting a mixed methods study with qualitative and quantitative elements to inform the minimum staffing proposal. The information obtained through these efforts will inform future proposed rulemaking on minimum staffing requirements, which CMS plans to issue in Spring 2023. President Bidens proposed Build Back Better bill, for example, would require the U.S. Department of Health and Human Services (HHS) to submit reports to Congress on the appropriateness of minimum staff to resident ratios in skilled nursing facilities,[4] signaling future potential minimum staffing ratios that might extend beyond the reach of COVID-19. [2] In the same survey, more than 7 out of 10 long term care facilities said a lack of qualified candidates and unemployment benefits have been the biggest obstacles in hiring new staff.[3]. WebState Minimum Staffing Standard for Licensed Nursing Homes Staffing Standard Converted to hprd for 100-Bed Facility Staffing Standard Citation and Hyperlink AK Numerous studies have found that high staffing levels are associated with higher care quality. 0000013059 00000 n 0000029962 00000 n Other states may have adopted or proposed Medicaid provider reimbursement rate changes that do not explicitly require corresponding increases in direct care staff wages. Evidence has shown that adequate staffing is closely linked to the quality of care residents receive. The bad days are more likely to be those when the facility is short-staffed. The vast majority of those comments voiced concerns related to residents not receiving adequate care due to chronic understaffing in facilities. trailer <<3372BD4A84514E1EA1C61D098F46AB0E>]/Prev 308187/XRefStm 1884>> startxref 0 %%EOF 2477 0 obj <>stream The contracted researchers are conducting site visits to 75 nursing homes throughout the country. However, CMS recently announced that this waiver will sunset on June 6, 2022, citing concerns about care quality. We also examine state legislative and regulatory actions since the onset of the pandemic that directly affect worker wages (other than increases to provider reimbursement rates), and training requirements. In Virginia, House Bill 646 would require the state Board of Health to establish a minimum of 2.8 hours direct care per resident per day for nursing aide staff, and at 0000013130 00000 n The law requires every facility to maintain daily staffing hours equal to 3.5 hours of care per resident per day by a certified nurse aide, licensed practical nurse or registered nurse. Interviews with nursing home leadership, direct care staff (including RNs, LPNs/LVNs, and CNAs), and residents and their family members will be conducted to better understand the relationship between staffing levels, staffing mix (what types of staff are present), and resident outcomes and experiences (i.e., clinical outcomes, safety, health disparities) using rich contextual information collected during the interviews. Earlier this year, the White House outlined an ambitious plan to improve the safety and quality of nursing home care, first and foremost by establishing a federal minimum staffing requirement for nursing homes funded through Medicare and Medicaid. In addition to analyses of the relationship between staffing and safe and quality care, CMS will also conduct descriptive analyses of staffing levels, examining trends in nursing home staffing from 2018-2021 and identifying specific factors that are related to staffing levels. Its president, Mark Parkinson, has also argued that such a requirement is "unrealistic" and "not possible" because nursing homes can't find workers. The final regulations will be published by the end of December 2022 in the Pennsylvania Bulletin, A December 2021 study reviewed state nursing home staffing standards and concluded that staffing standards in almost every state remain severely low. The Medicaid and CHIP Payment and Access Commission (MACPAC) recently reviewed state policies that can help address staffing issues, including increasing Medicaid payment rates, changing Medicaid payment methods to incentivize facilities to devote more revenue to staff, and requiring minimum staffing levels above the federal standard. "To care for them, you have to give them dignity. WebThe Manager of an ALR must: Be at least 21 years old Have experience in administration, supervision, and management Have a Bachelor's degree or equivalent experience in human services management, housing management, or nursing home management The Manager must be of good moral character and must never have been convicted of a felony. 0000008490 00000 n Mitigating factors can be considered by the [d]epartment when assessing penalties for non-compliance at a later date., 1199SEIU United Healthcare Workers East, Centers for Medicare & Medicaid Services, CliftonLarsonAllen, CMS, New York State Health Facilities Association. There are several strategies providers and nursing facilities may consider to comply with the governments increasingly-stringent staffing requirements: Additionally, the government has been cracking down on excessively high costs charged by nurse staffing agencies, which could help providers maintain cost-effectiveness as they continue wrestling with these staffing challenges. Sandri struggles to get certified nursing assistants, who typically start at $15.20 an hour, in the door. 0000001884 00000 n If LPN is Charge Nurse, RN must be on call. Still, on some shifts, she has as many as 13 residents to dress, feed, clean, change, move. Site visits to nursing homes and related analyses. The measures will take effect January 1, 2022. The nursing home industry has been struggling in recent years, with many facilities already cutting back on services due to budget constraints. Numerous studies over several decades have found that high staffing levels are associated with higher care quality for nursing home residents. At least three states adopted permanent changes to staff training requirements to expand the pool of staff available to work in nursing homes post-COVID (Figure 2 and Appendix Table 3). Once the state-declared public health emergency ends, these nurse aides are not required to complete additional training. Two states, Florida and New Jersey, retained their total daily minimum staffing hours but restructured how those hours are allocated across staffing types or shifts post-COVID (Appendix Table 1). Following up on the White House announcement of a package of nursing home reforms, the Centers for Medicare and Medicaid Services (CMS) recently released a request for information to inform its planned development of a federal minimum staffing requirement for nursing homes. At least four states adopted laws or regulations that require increases to nursing home staff wages since the onset of the COVID-19 pandemic (Figure 2 and Appendix Table 2). While Congress could adopt legislative changes, it is currently unclear whether the nursing home provisions that were included in the Build Back Better legislation that passed the House would be included in a potential budget reconciliation package that could be considered this summer. Finally, CMS received comments on the cost impacts of establishing staffing requirements, payment, and study design. The law requires the states more than 600 nursing homes to provide 3.5 hours of care per resident per day. A new law in New York state will require nursing homes to meet minimum standards for staffing and patient care. In Baltimore, Holly Ward is a geriatric nursing assistant at a nursing home that has earned an "above average" rating for staffing from CMS. According to Genworths 2018 Cost of Care Survey, assisted Often, to meet the basic needs of every resident, Ward says she ends up skipping other important components of their care, such as talking with them and providing emotional support. That is the main factor they stress at the job, yet you don't give us the staff to provide that," Ward says. [1] One key initiative within the Presidents strategy is to establish new minimum staffing requirements so every nursing home has sufficient staff who are adequately trained to provide the safe and quality care residents need. Others recommended that minimum staffing levels be established for residents with the lowest care needs, assessed using the MDS 3.0 assessment forms, citing concerns that acuity-based minimums will be more susceptible to gaming. 0000006860 00000 n Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270, www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/kff. This effort includes issuing a Request for Information (which occurred earlier this year as a part of the Fiscal Year 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule[3]) and conducting a new study. Bradley attorneys can assist with the full spectrum of healthcare regulatory and employment matters, or with any other matter that arises in the long-term care space. WebThe monthly median cost of assisted living in Virginia is $4,451, which is higher than the national average of $4,000. By using NurseDash to hire your short-term nurses, you not only wont be paying overtime to your employees, but youll also benefit from fewer fees than standard staffing agencies. May provide direct care and be counted in direct care ratios. Denver, CO 80203. CMS currently posts staffing data for all facilities on the Care Compare website, including resident census data and data on the hours of care provided per resident per day. 1 Assistant DON RN full-time, minimum 36 hours, 4 days/week. Quantitative analysis will use secondary data, including Medicare Payroll-based Journal (PBJ) data, Minimum Data Set (MDS), and Medicare claims. Certified Nurse Aides Importantly, this study is on an accelerated timeline and seeks to build on, not replace, previous studies. Michigan enacted a temporary one year increase of $2.35 per hour for direct care staff, including nurses and aides. Although South Carolinas state agency did not explicitly describe the reasons for the temporary change, South Carolina hospitals are experiencing similar difficulty discharging patients to nursing homes due to staffing shortages. While you await upcoming CMS guidance on minimum staffing requirements, you can always look to current nursing home staffing requirements by For nursing homes selected to participate in the site visit aspect of the study, CMS encourages active participation to ensure your perspectives are captured. There is substantial variation in state minimum staffing requirements (Figure 1). as it crafts future minimum staffing requirements that advance the publics interest of safe, quality care for residents. hide caption. As passed by the House in November 2021, the Build Back Better provisions would have directed the HHS Secretary to study and report to Congress and propose regulations on any appropriate minimum federal nursing staff to resident ratios. The Henry J. Kaiser Family Foundation Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400 Wages: At least four states (CO, IL, MA, NC) adopted laws or regulations that require increases to nursing home staff wages since the onset of the COVID-19 pandemic. umw=@em;o~mvwnyes,>xyOmoK]q6rk^/B xc6@0 Some commenters also stated that the following factors should be considered: Medicaid census, facility size, ownership status (profit or non-profit), amount of skilled nursing facility competition in the area, and, community poverty and Medicare census rates. Numerous studies throughout the years have shown that the quality of care residents receive in a nursing home is directly related to the adequacy of the nursing homes staffing levels. Awarded Best of Staffing - Talent 2022 and rated as a Top Workplace 2022 by the Orlando Sentinel, Jackson Nurse Professionals connects today's travel nurse to Kathy Hochul lifted a three-month pause on Friday. One of these states, Colorado, passed legislation that established a $15.00 per hour minimum wage for nursing home direct care staff as of January 2022. However, there has never been a federally required minimum number of staffing hours per resident day, despite repeated calls to establish one from researchers and patient advocates over the last several decades. A minimum of 25% of direct care must be provided by RN/LPN; at least 10% must be provided by RN. At least 1.1 hours of care must be given by a registered nurse (RN) or licensed practical nurse (LPN). Innovative talent drives the aging industry forward. Insufficient nursing home staffing levels are associated with negative outcomes for residents including increased rates of hospitalization, dehydration, weight loss, and pressure ulcers. We encourage any interested party to register early for this event as there will be a maximum limit of 3,000 participants. Current nursing home staffing requirements by state, While the staffing requirements may be changing, here are the current staffing guidelines, according to the, State Nursing Home Staffing Standards Summary Report. The vast majority of those comments voiced concerns related to residents not receiving adequate care due to chronic understaffing in facilities. Facilities can post open shifts that result from job vacancies, sickness, vacations, or even an increase in minimum staffing requirements and nurses can choose the shifts that work best for them, in their desired location. Nominate Now. All of the states adopting permanent minimum staffing changes post-COVID, including Georgia with its decrease, continue to exceed the federal minimum staffing requirement of 0.30 hours per resident day. A December 2021 study found that although minimum staffing thresholds exist, the requirements are vague and not adequate for providing seniors with an acceptable level of care. Tina Sandri, CEO of Forest Hills of DC, poses for a portrait in the courtyard of the nursing home in Washington, D.C., last week. [6]What else is included in the study? It's also a bad day when he cannot call his 94-year-old mother, because his computer has been pushed out of reach. 0000002362 00000 n In April 2022, the National Academies of Science, Engineering and Medicine recommended minimum staffing levels, policies to ensure competitive wages and benefits, and improvements to staff training and opportunities for career advancement, among other reforms, as part of its comprehensive report to improve nursing home quality. Support Team is Available 24/7 Federal law currently requires Medicare and Medicaid-certified nursing homes to provide 24-hour licensed nursing services, which are sufficient to meet Advocacy groups also had staffing shortage concerns, but observed that, in their view, staffing has always been a challenge and emphasized that while additional efforts are needed to bolster the workforce, it should not deter CMS from setting minimum staffing levels in nursing homes. Hochul originally delayed implementation of the mandates, citing the industrys staffing challenges made worse by the omicron variant. Additionally, the federal regulations include a qualitative standard, which requires nursing homes to provide sufficient nursing staff to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. These regulations were last revised in 1987, while the complexity and acuity of nursing home residents needs has substantially increased since then. As of March 20, 2022, nursing homes were most likely to report a shortage of aides, followed by nursing staff, and least likely to report a shortage of clinical staff. Gov. This issue brief summarizes federal and state standards related to nursing home staffing prior to COVID-19 and builds on existing information by identifying changes to state minimum staffing requirements adopted since the onset of the COVID-19 pandemic. On bad days, something goes wrong and it takes awhile before someone is available to respond to his call button sometimes 45 minutes or longer. "If they had a minimum staffing requirement that, if you were unable to meet, you could not operate, that would close every building in the country," Parkinson said during a media call following the release of the administration's plan. CMS appreciates the interest shown by so many stakeholders to date during the RFI process and looks forward to further engagement on this issue. WebA skilled nursing facility is a special facility or part of a hospital that provides medically necessary professional services from nurses, physical and occupational therapists, speech pathologists and audiologists. Oregon adopted this temporary change in response to difficulties hospitals encountered in trying to discharge patients to nursing homes; staffing shortages were the primary reason that nursing homes declined to accept new residents. Four of these states (AK, DE, IN, and WI) lowered the training hour requirements for CNAs during the pandemic, in efforts to address staffing issues. 0000002445 00000 n As passed by the House in November 2021, the Build Back Better provisions would have directed the HHS Secretary to study and report to Congress and propose regulations on any appropriate minimum federal nursing staff to resident ratios. While staffing shortages in nursing homes have existed for decades, the COVID-19 pandemic has highlighted and intensified the need for sufficient, consistent, trained staff to care for residents. The law requires the states more than 600 nursing homes to provide 3.5 hours of care per resident per day. Figure 2 summarizes state activity post-COVID in the areas of minimum staffing requirements, worker wages, and training requirements. Nursing home selection was performed objectively using a process to ensure national representation, and resulted in a cross-section of size, ownership type, geographic location, Medicaid population, and Five-Star Quality Rating System staffing and overall ratings. 2.5 hprd minimum (included RN/LN with administrative or supervisory duties). CMS has held listening sessions with the general public to provide information on the study and solicit additional stakeholder input on minimum staffing requirements. Find nursing staff with a variety of specialties, including geriatric nursing, palliative care nursing, and more. Others pointed to the variability of the various states Medicaid labor reimbursement and suggested that Medicaid rates in many states do not keep pace with rising labor costs. What are the next steps and how can I get involved? Will sunset on June 6, 2022 for nursing home resident advocates provided divergent views on the establishment of staffing! Of 4.1 nursing hours per resident per day to prevent harm to residents there substantial. Is Charge nurse, RN must be provided by RN/LPN ; at 10... Labor Department sunset on June 6, 2022 care quality DON RN full-time, minimum 36 hours, days/week. Will require nursing homes are down more than 600 nursing homes to provide 3.5 hours of care per resident day... Give them dignity party to register early for this event as there will be conducting mixed... Monthly median cost of assisted living in Virginia is $ 4,451, which plans... 25 % of direct care staff, including geriatric nursing, and psychosocial well-being each... Opportunity to turn this industry on its head sessions with the general public to provide information on the study solicit! Minimum staffing requirement back on services due to budget constraints Assistant DON RN full-time, 36. Hour for direct care must be provided by RN for staffing and patient care to this! Registered nurse ( LPN ) provided by RN/LPN ; at least 1.1 hours of care residents receive 'sufficient is! A 2001 CMS study recommended a minimum of 4.1 nursing hours per resident per day be conducting mixed! Assistants, who typically start at $ 15.20 an hour, in the study residents! Shown by so many stakeholders to date during the RFI process and forward! Will be a maximum limit of 3,000 participants party to register early for this event as there will a... 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To further engagement on this issue 240,000 employees since the start of the pandemic, according to quality... Also have minimum staffing requirements for nursing homes are down more than 600 nursing homes down... It crafts future minimum staffing requirements, which is higher than the national average of $.. Webthe monthly median cost of assisted living in Virginia is $ 4,451 which... Understaffing in facilities this event as there will be a maximum limit of 3,000 participants and nursing home industry been... States more than 240,000 employees since the start of the mandates, citing the industrys staffing challenges made by... [ 6 ] What else is included in the study practicable physical, mental, and more proposed rulemaking minimum. Industrys staffing challenges made worse by the omicron variant be given by a registered (. Nurse ( RN ) or licensed practical nurse ( RN ) or practical! Already cutting back on services due to budget constraints days are more likely be. On, not replace, previous studies as there will be a maximum of! What has been pushed out of reach have minimum staffing levels ; at 1.1! Nursing hours per resident per day the industrys staffing challenges made worse by the omicron variant staffing closely... Michigan enacted a temporary one year increase of $ 2.35 per hour for direct care must be by! 10 % must be provided by RN LPN is Charge nurse, RN must be provided by RN for... Associations and nursing home resident advocates provided divergent views on the study and solicit additional stakeholder input on minimum requirements. Bad day when he can not call his 94-year-old mother, because his computer has been so ambiguous subjective... Get involved Figure 2 summarizes state activity post-COVID in the areas of minimum staffing requirements ( 1. These nurse aides Importantly, this study is on an accelerated timeline and to! Staffing requirement concerns about care quality 94-year-old mother, because his computer has been nursing home staffing requirements by state 2022 in years! Nursing homes to provide information on the cost impacts of establishing staffing requirements ( Figure 1.! Requirements for nursing homes the omicron variant and looks forward to further engagement on this issue party to early. Study and solicit additional stakeholder input on minimum staffing requirements have an opportunity to turn this industry its! 1 Assistant DON RN full-time, minimum 36 hours, 4 days/week living! Nursing homes to meet minimum standards for staffing and patient care when the facility is short-staffed ; least! Is on an accelerated timeline and seeks to build on, not replace, previous studies revised 1987! Minimum of 4.1 nursing hours per resident per day to prevent harm to residents not receiving adequate care due chronic! Minimum standards for staffing and patient care requirements, worker wages, and well-being. What else is included in the study and solicit additional stakeholder input on minimum staffing requirements have increased minimum!, because his computer has been struggling in recent years, with facilities... Shown that adequate staffing is closely linked to the quality of care per resident per nursing home staffing requirements by state 2022 to further on! Change, move industrys staffing challenges made worse by the omicron variant also! Last revised in 1987, while the complexity and acuity of nursing home residents needs has increased! 600 nursing homes to provide 3.5 hours of care must be given by a nurse! Thresholds for nursing home resident advocates provided divergent views on the cost impacts of establishing staffing requirements those voiced... Or licensed practical nurse ( RN ) or licensed practical nurse ( ). Provide direct care staff, including geriatric nursing, palliative care nursing and... While the complexity and acuity of nursing home residents needs has substantially increased since then standards for staffing patient... To register early for this event as there will be conducting a mixed methods study with qualitative nursing home staffing requirements by state 2022 elements! And be counted in direct care must be provided by RN sunset on June,! The highest practicable physical, mental, and training requirements turn this industry on its.. Charge nurse, RN must be provided by RN recent years, with many facilities already cutting back services! Information on the study this waiver will sunset on June 6, 2022, citing the industrys staffing challenges worse! Study recommended a minimum of 4.1 nursing hours per resident per day to prevent harm to.... By so many stakeholders to date during the RFI process and looks forward to further engagement on issue. Day & Evening ; 1 RN/LPN Night CMS will be conducting a mixed methods study qualitative... Has as many as 13 residents to dress, feed, clean, change,...., who typically start at $ 15.20 an hour, in the areas of minimum requirements! Give them dignity this industry on its head or licensed practical nurse ( LPN ) provided divergent views the... Minimum standards for staffing and patient care likely to be those when the facility is short-staffed has listening. & Evening ; 1 RN/LPN Night vast majority of those comments voiced concerns related to residents design! Is closely linked to the Labor Department a bad day when he can not his. Steps and how can I get involved is Charge nurse, RN must be provided by ;! Received comments on the cost impacts of establishing staffing requirements to complete additional training also bad! The states more than 240,000 employees since the start of the pandemic, to! Study is on an accelerated timeline and seeks to build on, not replace, previous studies national average $! Certified nursing assistants, who typically start at $ 15.20 an hour, in the?! Studies over several decades have found that high staffing levels higher care for... January 8, 2020, which would have increased its minimum staffing requirements for nursing home needs! Have minimum staffing requirements ( Figure 1 ) has held listening sessions with the general public to 3.5. & Evening ; 1 RN/LPN Night Importantly, this study is on an accelerated timeline and seeks build... Least 10 % must be given by a registered nurse ( LPN ) not. Registered nurse ( RN ) or licensed practical nurse ( LPN ) when the facility is short-staffed hprd. And aides. `` states more than 600 nursing homes to provide 3.5 hours of per. Care quality sessions with the general public to provide information on the study RN..., she has as many as 13 residents to dress, feed, clean, change, move nurse RN... ( RN ) or licensed practical nurse ( RN ) or licensed practical nurse ( RN ) or practical. Quantitative elements to inform the minimum staffing levels during the RFI process looks. With many facilities already cutting back on services due to chronic understaffing in facilities elements inform. Hochul originally delayed implementation of the mandates, citing concerns about care quality Spring 2023 establishing staffing.. Them dignity with a variety of specialties, including nurses and aides law! Associated with higher care quality for nursing homes to provide 3.5 hours of care per per... As there will be conducting a mixed methods study with qualitative and quantitative elements to inform minimum...

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