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New Five-Star Rankings: One Way to Check Out a Nursing Home

A web-based rating tool for nursing home selection.

The delicate task of choosing a nursing home for a family member may have become a little easier. People can now check out nursing homes with an online tool that rates the overall quality of a facility’s care with anywhere from one to five stars.

But consumer advocacy groups, while welcoming the new system as a helpful way to identify poorly performing homes, also warn families not to rely wholly on the star ratings when it comes to making a wise choice among the 15,800 nursing homes that participate in Medicare or Medicaid. People should visit nursing homes, talk to doctors and trusted friends and colleagues, and check state assessments based on nursing home inspections before making a final pick, experts say.

To arrive at the star ratings, the Centers for Medicare & Medicaid Services (CMS) uses three categories of data already on its Nursing Home Compare website. The stars are intended to make the site more user-friendly. They focus on three critical areas:

  • Health inspections, which summarize deficiencies the home received in the three most recent inspections.
  • Staffing, which shows the average time nurses and aides spend with each resident daily.
  • Quality measures, a report on the prevalence of pressure ulcers (bedsores), physical restraints, pain and seven other measures affecting residents’ well-being.

Nursing homes are awarded stars in each category, then given an overall rating based on a CMS calculation. Twelve percent of nursing homes nationwide received the top overall rating of five stars (“much above average”), while 22 percent received just one star (“much below average”). Overall, 35 percent were rated above the three-star average and 43 percent below that average. According to CMS, nonprofits and smaller homes tend to have higher ratings, as well as homes in states with higher Medicaid reimbursement rates.

“We think [the system] is a good thing because it is helping people do some comparisons between nursing homes,” says Janet Wells, director of public policy for the National Consumer Voice for Quality Long-Term Care (formerly the National Citizens’ Coalition for Nursing Home Reform), in Washington. “The issues that it ranks nursing homes on are really important, particularly nurse staffing.” Studies have found higher-quality care in homes that provide nurse staffing of at least 4.08 hours on average per resident each day.

In the CMS ratings, though, homes providing fewer hours can still receive a high number of stars, according to the formula CMS uses in its assessments. For example, each of two nursing homes provides 3.5 hours of care per resident, yet home A is awarded three stars for staffing whereas home B gets just one. Why? The system is weighted to reflect the needs of residents in each home, CMS officials say. The sicker the residents, the higher levels of care the home should be providing. So in this example, home B had a case mix that required more hours of care than home A. Thus it received only one star. (See “How ratings are calculated” and the chart below to learn how CMS arrives at the overall rating. On the Nursing Home Compare website, CMS also explains how the ratings work: Click on “Learn More” or on “Five-Star Quality Rating Technical Users’ Guide.”)

The staffing and quality measures used in the ratings are self-reported by nursing homes, not payroll data. CMS does not confirm the reported staffing by comparing it with payroll records, as AARP recommends.

In addition, the ratings don’t “take into account [temporary] agency staffing, known across the nursing home field to decrease quality,” says Lauren Shaham, vice president of communications for the American Association of Homes and Services for the Aging, which is critical of the new system. The ratings count permanent and temporary staff members equally, she says, although the quality they deliver is unequal.

Experts also say, it’s possible that a nursing home could pad the schedule with temporary workers before its annual survey and receive a higher rating.

Unlike a five-star restaurant or hotel, a five-star nursing home is not the Ritz and may have serious problems, others caution. “We do think [the system] is useful in helping consumers quickly identify low-rated nursing homes that they should avoid,” says Michael Connors, advocate for California Advocates for Nursing Home Reform. “But high ratings aren’t a guarantee of quality.”

For example, in 2007-08 California issued citations to 38 nursing homes for the most serious violation—neglect leading to the death of a resident—which carries fines of up to $100,000. Yet of the 35 of these homes that CMS rated, two were awarded five stars and six got four stars under the CMS rating system, according to an AARP Bulletin analysis.

In general, when nursing homes receive citations, they “must file a plan of correction that must be approved by us,” CMS spokeswoman Mary M. Kahn explains. “Once that is approved, we will reinspect to assure the corrective action was indeed taken.” If a home continually shows a pattern of poor performance, she adds, “it is put on our Special Focus Facility list,” meaning that “it is inspected twice as often as other homes.”

But homes placed on the Special Focus Facility list may still receive as many as three stars (meaning “average”) in the quality ratings on the CMS website, according to Rhonda Richards, a senior legislative representative at AARP. In these circumstances, she adds, AARP recommends a one-star (“much below average”) rating. CMS, however, gives Special Focus Facilities credit for improvement, and all facilities get credit for scoring high on staffing or quality measures.

Mitzi E. McFatrich, executive director of Kansas Advocates for Better Care, says her group spot-checked 10 homes and found the star ratings did not accurately reflect the experience of residents. “[Since] we started digging on this site, I have to say we have a lot of concerns,” she says. One well-regarded Kansas home that received two stars (below average), for example, received a PEAK (Promoting Excellent Alternatives in Kansas) award in 2008 from the Kansas Department of Aging. Homes that provide consistent, well-trained staff, a homey environment, freedom to choose when to wake up and what to eat, and regular engagement with the outside world are not identified through this system, McFatrich notes.

“We emphasize that the star rating does not substitute for the consumers’ judgment about which aspects and measures are most important to them,” says Thomas Hamilton, CMS director of the Survey and Certification Group. “The star rating is intended to stimulate thinking but not replace thinking. We encourage consumers to print out the information and take it with them and visit the nursing homes and get direct answers from nursing home staff.”

CMS officials say they will continue to improve the website and hope to add new information over time, such as resident and family satisfaction rates.

Toward that end, the Pioneer Network, based in Rochester, N.Y., which advocates changing the culture of eldercare, is working with CMS to find ways to measure quality of life concerns that are so important to nursing home residents and families. “One has to see the five-star rating as part of a broader initiative to encourage consumers to ask the right questions,” says Bonnie Kantor, executive director of the Pioneer Network. “This is but one measure. Nothing can replace being your own fact-finder.”

How Ratings Are Calculated

The Centers for Medicare & Medicaid Services uses a three-step formula to decide how many stars a nursing home should receive as an overall rating of its quality of care.

Step 1 A nursing home is first assigned a number of stars (1 through 5) according to information from health inspections of the home over three years. This number is the base rating.

Step 2 Stars are added or deducted according to the home’s staff rating, which is based on the average number of hours of care per day residents receive. If the home’s staff rating is 4 or 5 stars, one star is added to the base rating. If staff rating is only one star, then one star is subtracted from the base rating. If staff rating is 2 or 3 stars, the base rating remains the same.

Step 3 Stars are added or subtracted according to how well or poorly the home scores on 10 key quality measures (QM). If its QM rating is 5 stars, one star is added to the rating derived from steps 1 and 2. If the QM rating is only one star, then one star is subtracted from this rating. If the QM measure is 2, 3 or 4 stars, the rating remains the same.

Beth Baker is a freelance writer and the author of Old Age in a New Age: The Promise of Transformative Nursing Homes.

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