Nursing-Home Ratings Earn Mixed Reviews
By Elizabeth G. Olson
Kaiser Health News
Tuesday, July 14, 2009
When 81-year-old Sally Darr needed nursing home care after injuring herself in a fall, her family turned to a new federal rating system for help.
The online tool uses movie-review-style ratings — one to five stars — to compare homes based on such measures as number of employees, state health inspection results and how many hours of licensed nursing care are provided each day.
"We had looked at nursing home Web sites, but they don’t give you the whole picture," said Nancy Donaldson, one of Darr’s daughters. Their choice, Inova Cameron Glen Care Center in Reston, "rated four stars pretty much across the board, and it is clean and the staff is very good."
Donaldson is one of millions of people who have visited the Nursing Home Compare site since it was overhauled and the nation’s 15,600 homes were rated in December. But there’s debate among industry and consumer groups about how well it’s meeting the public’s needs. The federal agency that runs the site plans to survey users later this year on exactly that question.
The industry, which had sought to delay the system’s rollout, complained that the grading system was started much too quickly. Nursing homes say the information, gleaned from homes as well as from state inspection reports, misleads families and patients because it doesn’t give an accurate picture of the amount and kind of care in each facility.
A leading consumer group wants the site to provide more details about inspection results and quality-of-care measures. Consumer advocates and industry representatives are calling for changes in the way the ratings assess staffing, which all sides agree is the best indicator of quality of care. Nursing homes say simple counting of workers does not reflect the care patients actually receive, while consumer advocates complain that employee information that comes from homes is unchecked and may contain errors.
‘Out of Whack’
The Centers for Medicare and Medicaid Services (CMS) developed the rating system after criticism from Sen. Ron Wyden (D-Ore.), who said "something is out of whack in this country when it’s easier to find out information about a washing machine than a nursing home." The repackaged site is more visually appealing and "takes a large amount of data and improves access to it substantially," said Thomas Hamilton, director of the agency’s survey and certification group. Although CMS emphasizes that no one should choose a home without visiting it, he says the data can help narrow choices. But Hamilton conceded "there has been a fair amount of misunderstandings" with nursing home operators "about areas like quality measures and staffing."
CMS is talking to the industry, patient advocates and states about changes, including the way the system measures quality of care. For example, homes that specialize in managing pressure sores and pain have more patients with those problems, and that can skew the homes’ ratings, the industry maintains.
In addition to an overall rating, the site provides star ratings for each nursing home in three categories: performance on health inspections in the past three years, ratios of staff to patients, and 10 quality-of-care measures. Consumers can also use the site to call up specific findings from inspections, other details on each home and consumer tips.
Ratings are updated as states complete inspections. Maryland’s ratings mirror the overall national picture: About 20 percent of its nursing homes are listed as five-star and another 20 percent as one-star. Of the 33 facilities in Montgomery County, for example, six received the highest rating and five earned the lowest. Wendy Kronmiller, who oversees inspections of 235 homes as director of Maryland’s Office of Health Care Quality, praised the system as "a great summary." Ratings generally are accurate, she says, particularly in the upper and lower ends of the range. As CMS weighs changes to the system, the first priority will probably be staffing information. Consumer advocates and industry representatives agree that the staffing numbers reflected in ratings don’t capture the fluctuating employment picture at many nursing homes.
Larry Minnix, chief executive of the American Association of Homes and Services for the Aging, a trade group for nonprofit nursing homes, also contends that the current system does not count all categories of caregivers within a facility. As a result, homes may not get credit for the care they actually provide to residents.
Staffing is an important issue for consumers. Janet Chap of Chevy Chase, who consulted the site when her family needed to move her father from Florida to a nursing facility in Cincinnati, said she "gave a lot of weight to the ratio of staff to patients." Congress is considering one change: requiring homes to report their payroll data electronically every two weeks. CMS would use the data to help verify the accuracy of staff reporting.
Grading on a Curve
Other issues may not be so easily resolved. Some in the industry complain that the ratings operate like a grading curve, ensuring that similar percentages of homes will receive the highest and lowest designations. They say that makes it harder for an improving home to rise in the star system.
"Twenty percent of homes have to be one-star no matter what they are doing," said Steve Morrisette, president of the Virginia Health Care Association, which represents many of the state’s 276 nursing homes. CMS maintains there’s adequate opportunity for nursing homes to improve their ratings.
Inspections are another major point of contention among states, patient advocates and the industry. States have varying standards, Hamilton noted, citing as an example different practices concerning use of physical restraints, which are generally discouraged. (The CMS site cautions against comparing homes in one state with those of another.)
Minnix complains that inspection data generally are inconsistent, outdated and misleading. He urges that the process be revamped with better-trained inspectors and more funding. Colleen Ryan Mallon, marketing director for Northern Virginia’s Goodwin nursing homes, says inspectors should be more objective and talk to residents more about the quality of care.
On the consumer side, the NCCNHR, formerly the National Citizens’ Coalition for Nursing Home Reform, wants more state inspection information posted online. That includes specifics on deficiencies — especially those that result in death — and the penalties levied for infractions, said Janet Wells, a spokeswoman for the advocacy group. The coalition also wants verification of self-reported, unaudited information from the homes.
Six months after it launched, the rating system’s impact is unclear. Even though CMS says the site attracts 50,000 daily visitors, both nursing homes and patient advocates suspect many families don’t know about it. Gerald Kasunic, the long-term-care ombudsman for the District, who said he hears little mention of the five-star system, believes it "is a great tool for the next generation" — people accustomed to using the Web.
Right now, he said, many people making decisions about homes "are in a crisis and pressed to make an immediate decision," and some simply "don’t know that the ratings exist online."