Addressing the limitations of nursing home compare

Older adults lose 1-3 percent of their muscle mass each day they spend in a hospital bed, requiring longer stays away from home.

These effects can be mitigated by finding the best level and place of care with greater alacrity. However, data suggests that Nursing Home Compare, the Medicare.gov tool that facilitates provider comparisons, is falling short in helping patients make well-informed care decisions.

The latest U.S. Department of Health and Human Services (HHS) report shows that while the number of nursing home residents decreased, the number of complaints rose 33 percent. A recent Health Affairs blog post highlights difficulties of relying on Nursing Home Compare to select a post-acute care provider. Inequities in the Nursing Home Compare rating system continue to leave providers, consumers, and skilled nursing facilities (SNFs) confused and uncertain about the validity of CMS quality ratings.

Nursing Home Compare was initially launched by the Center for Medicare and Medicaid Services (CMS) in 1998 as a federal website for information about nursing homes. In December 2008, CMS added the Five Star Quality Rating System in an effort to improve quality of care and assist the public in identifying meaningful distinctions among providers.

While CMS has made several updates to Nursing Home Compare and the quality rating system, the complexity of this task is daunting, and many flaws remain.

Lack of a more accurate calculation for risk adjustment
Facilities are rewarded and penalized for quality results based on factors heavily weighted toward medical diagnoses, without adequate inclusion of factors that influence engagement in care at the facility. While medical factors are an important marker of clinical care quality, they aren’t the only performance indicator.

Patients with similar medical diagnoses may present different risks. The current risk adjustment methods lack sufficient correlation between patient needs and facility capabilities. For example, if a facility has two patients with dementia and post-operative hip repair, but one patient has more profound dementia, their ability to transition to a new location and participate in rehabilitation services may be diminished. The facility appears to manage both patients well, but the risks for each patient are significantly different. Such scenarios aren’t well captured under current risk adjustment methodologies.

Rapid turnover
High turnover among nursing home staff creates an opportunity for quality to change more rapidly than the system can reflect. If a five-star facility loses a Director of Nursing and several unit supervisors, the facility’s care quality may be negatively impacted long before it’s reflected in the star ratings. Information regarding facility staff changes should be updated more frequently.

Changing capabilities
In-house and area personnel changes can quickly impact a facility’s capabilities. If the cardiologist treating all heart disease patients retires, the facility may no longer have a bona fide congestive heart failure program. If known, capability changes and notification might change referral patterns and patient choices.

The average Medicare beneficiary will select a nursing home, on average, once or twice in their lifetime. While there are a few repeat patients who will know their preferences, the process for most is like choosing a restaurant in an unfamiliar city. A comprehensive discussion of trade-offs among facilities is essential, as well as eradicating any undue steerage or influence from providers. As facilities strive to meet new assessment processes and requirements, more efficient technology can help mitigate undeserved referral patterns resulting from time lags in understanding on the ground impacts.

Survey process
On-site survey processes remain subjective, and the data isn’t always timely. Despite attempts to standardize, facility concerns and violations are partially surveyor-specific.

While on-site evaluations are critical for maintaining regulatory care standards, the full review process, identification of corrective action plans, and actual correction of cited deficiencies are on the books far longer than is useful. Thus, facilities that have developed problems may continue to receive referrals for months, while referrals to facilities that have corrected care issues may have waned. To meet the goal of pairing patients with the best matched care facility, updates to Nursing Home Compare should be closer to real-time.

Patient experience
Patient experience has not been well integrated and weighted into the current quality rating system. If a patient is comfortable with their care and care team, there is a greater likelihood of better outcomes. Since facilities are inherently biased in surveying the experience of patients currently under their care, unbiased feedback is possible only after patients have been discharged back to the community. Feedback loops are being incorporated into the evaluation process, but there isn’t a standard set of questions, nor is there guidance on when to ask them and how to communicate this feedback to the community.

Continuity of care
How well providers communicate about patient care across the healthcare delivery system is also unmeasured in the current quality rating system. Assuring patients, families and providers that key clinicians are effectively communicating and in close contact improves outcomes, so transitions of care should be assessed. There is strong data to suggest that engaging patients with care providers early on to provide clinical information after discharge to or from a SNF positively impacts patient experience. Measuring the effectiveness of handoffs in clinical communications processes is an important indicator of care continuity.

Nursing Home Compare is a giant leap forward in furthering our understanding of how SNFs compare on certain clinical outcomes, but capabilities change more rapidly than this tool reflects. The long-term care industry has been characterized by rapid turnover and inefficient feedback loops, resulting in imprecise performance indicators and untimely information. These shortcomings must be addressed with metrics that more effectively gauge patient satisfaction and assess critical communication processes that drive better outcomes.

A rating system that depends on a long data measurement cycle hinders potential to recognize ways to shorten hospital and nursing home stays and improve patient outcomes. Technology can address some of these limitations by directing patients to the best level and place of care. For example, decision support tools are helpful in identifying patients able to go directly home, without rehabilitation at a nursing home. Other tools such as The Right Place communication and patient placement platform can help hospitals track patients through the post-acute stay and inform the discharge process with real-time data on facility capabilities and outcomes – and quickly determine where a bed is available. Hospitals can also utilize this platform to maintain referrals to SNF networks for ACOs, Medicare Advantage, and commercial risk contract beneficiaries.

As the population ages, the need for high-quality skilled nursing services will continue to grow. Timely feedback on patient experience and strong upstream and downstream clinical communication ensures providers are on a level playing field with clearly defined capabilities and strengths, with truly risk adjusted outcomes. Without real-time data to inform the post-acute care process, efforts to conceal weaknesses, rather than promote continuous improvements, cause facilities to lose referrals at a time when the industry is being called on to serve more patients, better, and faster than ever.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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