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Consumers reveal obstacles to using nursing home quality ratings

Study: Lack of awareness and trust limit value of federal rating system

April 4, 2016

A study of dozens of people who placed a relative or friend in a nursing home in the previous six months found that few people were aware of the Nursing Home Compare website, published online by the Centers for Medicare and Medicaid Services (CMS) to help families find the best and closest available care facility.

The study published Monday, April 4, 2016, in the April issue of the journal Health Affairs, also showed that those who viewed the website often did not trust it, at least initially. Many were interested in questions that the website did not answer, such as how to find a nursing home that was affordable, offered multiple activities for residents and had beds available for people who rely on Medicaid. Most of those interviewed understood the importance of staffing, but showed little interest in the website's core clinical-quality measures such as pain management, the use of restraints, and prevention of pressure sores, infections and falls.

"This website could become a handy, useful tool, offering consumers a starting point to select high-quality providers," said study author Tamara Konetzka, PhD, professor of public health sciences at the University of Chicago and lead author of the study. "But before people can turn to it, they need to know it is available. And before they trust it, they need to see clearly where the data come from."

Even then, for residents who rely on Medicaid, obstacles to choosing high-quality nursing homes -- such as distance to those facilities -- may remain.

CMS launched the five-star version of their web-based Nursing Home Compare (NHC) in December 2008 to help families find the best available nursing home. The system is designed to combine multiple measures into a simplified five-star rating. Five stars mean "much above average." One star indicates "much below average."

"The five-star ratings allow consumers to compare nursing homes considering multiple attributes at once, much like Amazon and Yelp ratings," said co-author Marcelo Perraillon, PhD, assistant professor of health, systems, management & policy at the Colorado School of Public Health.

NHC collects data from all CMS-certified nursing homes in the United States and splits the information into three categories: results from periodic health inspections, staffing ratios per resident and a cluster of clinical quality measures. Then, they combine the data to produce an overall rating.

Despite enthusiasm by many when shown the Nursing Home Compare example, many of the 63 study subjects were "skeptical about the source and accuracy of the data and thought that the nursing homes themselves might have control over the site," the authors wrote.

The skeptics were not far off. The inspection ratings are based on surveyor reports. "Those are considered to be more objective," Konetzka said. "But the staffing data and the quality measures are based on self-reported data supplied by nursing home managers. There is more skepticism about these measures."

The skeptics were not far off. The inspection ratings are based on surveyor reports. "Those are considered to be more objective," Konetzka said. "But the staffing data and the quality measures are based on self-reported data supplied by nursing home managers. There is more skepticism about these measures."

A quick survey shows many nursing homes with an overall one-star inspection rating are rated as four or five stars for clinical quality, based on their self-reported data.

To counterbalance this discrepancy, the system gives much greater weight to inspection ratings, Konetzka points out, so overall ratings tend to mirror the inspection rating.

CMS is beginning to collect payroll data, she said, which should increase the accuracy of staffing ratings starting in the second half of 2016. They are also adding new quality measures, "but some underlying reliability problems may remain," Konetzka said.

A lot has changed since the five-star system was introduced online more than seven years ago, the authors note. Studies from 2003 and 2006 mention limited use of the Internet by families choosing a nursing home. But a decade later, the current study found that "almost all respondents had access to the Internet and used it in their decision-making process." The current study also found greater emphasis on costs and on how to gain access to high-quality nursing homes for those dependent on Medicaid, who make up 60 percent of nursing home residents.

Konetzka and Perraillon suggest ways to overcome some of NHC's problems, such as the lack of awareness. They acknowledge it is expensive to advertise a product that people may not anticipate needing, but the widespread growth of the Internet, with a boost from traditional information sources such as family, friends and health care providers, should slowly raise awareness. That may help consumers distinguish between verified data and corporate boasting.

The study authors urge CMS to highlight their role in collecting the data for Nursing Home Compare and to make it clear that federal regulators, and not the nursing homes, maintain the website and, increasingly, collect the data. CMS could also improve the website's appeal, they suggest, by adding more information about costs, inserting opinions from nursing-home residents about the quality of their experience and quantifying the availability of activities for residents.

"For the website to gain acceptability and use, CMS should keep improving the accuracy of the underlying data," Perraillon said. "Nursing Home Compare should continue evolving."

The authors also encourage families to find a nursing home that meets their loved one's particular needs and to visit several nursing homes to see how they treat residents. One nursing home resident they surveyed recommended surprise visits.

"The five-star system is one-size-fits-all. It doesn't distinguish between particular types of needs, such as dementia or cancer," Konetzka said. Some nursing homes cater to particular religious or ethnic groups, which may improve the social life and comfort level of residents, which "may even trump some clinical-quality concerns," she said.

On the whole, "there is still some noise in this system," Konetzka said, but with the proposed improvements, "I believe there is more and more signal within that noise."

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