All ETDs from UAB

Advisory Committee Chair

Robert Weech-Maldonado

Advisory Committee Members

David Becker

Ganisher Davlyatov

Sue S Feldman

Justin C Lord

Document Type


Date of Award


Degree Name by School

Doctor of Philosophy (PhD) School of Health Professions


Nursing homes face an ever-changing environment and must adapt to achieve organizational success. Recent events such as the COVID-19 pandemic and the implementation of the Patient-Driven Payment Model (PDPM) reimbursement policy have disrupted nursing homes. PDPM put pressure on nursing homes to change their operations and billing practices. The reimbursement policy changed from Resource Utilization Group (RUG) under the Prospective Payment Model (PPS), to PDPM. PDPM, which encourages more value in skilled nursing facility (SNF) spending, has been explored by various studies with respect to nursing home’s reaction in reducing therapy staffing. Three studies follow that examine PDPM and COVID-19 in the nursing homes industry. The purpose of the first study was to determine whether nursing homes are aligning their nursing and therapy staffing patterns with the new policy incentives and whether the changes are resulting in financial performance. It was found that an increase in one hour of staffing variable particularly RN and PT were associated with an increase in operating margin. The second study which used the resource-based view of the firm to understand the association between the new policy change and nursing home quality of care mediated by nursing staffing intensity before and after the implementation of PDPM found that RN hours per resident day increased while CNA hours per resident day iv decreased. The study also found PDPM had an indirect positive effect of quality of care through RN and negative effect through CNA. COVID-19 pandemic created new and additional challenges for nursing homes, exacerbating the financial pressures that they have already been experiencing. In the third study, the impact of COVID-19 pandemic on nursing homes financial performance was investigated. It was found that nursing homes operating margin dropped about 7% during the pandemic, and operating cost per resident day increased by $58, while operating revenue per resident day only increased by $32. Findings from this study will help inform policy makers and practitioners as to the effect to which the external environmental can impact nursing homes operations, and to help prepare in case of another pandemic as well as monitor nursing homes finances, quality, and staffing.

Available for download on Monday, September 01, 2025