For many years, hospital social workers and discharge planners have had few tools at their disposal to determine the relative quality of skilled nursing facilities (SNFs) when seeking to assist a patient or their family with a placement.
Yes, hospital staff are plugged into their communities and hear a lot about local providers of choice. And, like any citizen, they can review inspection reports, but most often the determinants of placement are based on factors like location and proximity to family, quality of food, building aesthetics, word of mouth or personal relationships.
Publicly available data, specifically the Centers for Medicare and Medicaid Services' Five-Star Quality Rating System, help to put information to work in a way that not only benefits consumers but also other providers. At its core, Five-Star is simple and easy to use, designed to enable comparisons between nearby facilities so that the "best" placement can be made.
But does Five-Star really capture the "best" – and isn't the "best" SNF different for each individual? While it's certainly a useful tool for learning about facilities and making comparisons, it has significant limitations that can stymie efforts to find truly the "best" placement for meeting the medical and functional needs of the individual. It falls short of being an indispensable discharge planning tool for hospitals, and in today's value-based environment, placement in a facility where the patient can have good outcomes and avoid unnecessary re-hospitalizations is more important than ever before.
As we look toward data-driven systems, processes and solutions to better integrate as a means of improving patient outcomes and safety, we need to demand from tools like public rating systems the same quality: the ability to transcend provider types and provide precise, actionable information.
Here are five reasons why Five-Star falls short of that standard:
1. Within Five-Star, results from state inspections (called surveys) is the tail wagging the dog. Survey results do not necessarily align with the true indicators of quality, or at least the indicators of quality that might be relevant to a patient's particular needs. For instance, where there is so much focus currently on reducing hospital readmission, Five-Star does not correlate in any way to re-hospitalization data.
2. States are responsible for surveys and they vary widely. Some states are much more rigorous than others, and even within states, there can be significant variations in the level of scrutiny among regional offices. One regional office might be much more onerous than the next and this inherently undermines ratings.
3. Five-Star does not take into account that all people needing SNF care are unique. Some require short-term complex rehab before returning home, while others need long-term placement and will remain. Nor does Five-Star acknowledge that SNFs often specialize in one type of care versus another. Ultimately Five-Star does not align a patient's needs with the "right" SNF to meet those needs. The result is an apples-to-oranges comparison and a poor placement.
4. The rating system takes into account three years' worth of data, which means that a facility might already have fixed what was driving a lower score a couple of years ago. A single substantiated family grievance from up to three years ago could have an outsize impact on the survey score and, ultimately, the rating. The ratings are not updated on a real-time basis and therefore lose their relevance for families and practitioners looking for the most up-to-date nursing home information. The management team in an underperforming facility may have been replaced after a bad survey and, conversely, the team running a top-rated facility may be gone by the time a consumer is considering that facility. In short, the lookback period is too long.
5. Five-Star has no natural connection to the "triple aim" of improved patient experience of care (including quality and satisfaction), better population health, and lower health care cost per capita. The triple aim is the vanguard in health care quality today. Patient experience is not measured in the Five-Star system, and that is so important to an individual's success at a nursing facility. Neither is efficiency, which can drive measureable reductions in health care costs.
The Five-Star Quality Rating System was a step in the right direction by enabling better decision-making and adding some much needed transparency; however, it falls short of its stated goals. And, what's worse is that current utilization far exceeds the original intention, and application, of the system. There are much better tools to align patient needs with the best SNF.
The challenge now is to improve upon this framework by incorporating real-time, relevant measures that truly pinpoint the relative strengths and weaknesses of nursing homes, so that ACOs and hospitals can make the decisions that best improve patient outcomes.
Steven Littlehale is Executive Vice President and Chief Clinical Officer at PointRight, a Cambridge, Mass.-based provider of predictive analytics solutions to thousands of post-acute providers, hospitals, ACOs and payers.
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