Long-Term Care Survey Alert

Learn the ins and outs of this latest effort to quantify nursing home quality.

The Centers for Medicare & Medicaid Services is rolling out a five-star rating system for nursing homes in December, an initiative that could put your facility on or off consumers' shopping lists. And now's the time to find out how the approach will work so that you can explain it to staff and consumers -- and potentially even boost your initial star rating before it's too late.

The basics: CMS will calculate a facility's number of stars based on information already reported on the Nursing Home Compare website. Specifically, the agency will tap the facility's three most recent years of annual and complaint surveys, a subset of the 19 quality measures posted on the Nursing Home Compare website -- and staffing data, according to the agency's Thomas Hamilton in a lively Open Door Forum on the rating system. These three data sets will be weighted and rolled into an overall quality rating, Hamilton explained. At press time, CMS had yet to disclose its weighting formula or the subset of the QMs used in the rating calculation.

ODF participants had no shortage of questions during the ODF Q&A session about the star-rating system, including:

• How frequently a facility's posted star rating will change. Hamilton noted that overall CMS anticipates updating the five-star rating at least quarterly. And "it's a rolling system" which means that the newer input replaces the oldest information, Hamilton relayed.

• How CMS will audit the information submitted by facilities for accuracy. Hamilton said CMS is looking at that issue and wants to select QMs that are more "resistant" than other QMs to manipulation in a self-reported system. Hamilton also noted that staffing numbers are reported just before the survey process and thus more "amenable" to checking for erroneous reporting. CMS' long-term goal, he said, is to move to more frequent staffing reporting aligned to a facility's payroll system.

A number of providers and industry experts aired concerns about what they said the rating system doesn't measure -- true quality. A five-star rating system is an excellent idea and would be very helpful to consumers, comments Terry Sullivan, executive director, Illinois Council on Long Term Care, who expressed his views at the ODF. But, as he told Hamilton during the Q&A session, the system should be based on something more than basic compliance. If a facility has a lot of low-care patients and doesn't take any risks in providing specialty services, you may have a five-star facility that's really a sparse, basic nursing home, Sullivan tells Eli.

Instead, Sullivan would like to see a star system used to motivate facilities not just to avoid making mistakes but also to get the "creative juices flowing" and ask: what more can we do, such as providing more restorative services and mental health services in Section P of the MDS?

In a letter to CMS shared with Eli, Sullivan outlined a number of MDS-driven quality measures that would better indicate quality outcomes. (For a free copy of an MDS Alert article on Sullivan's proposed measures and how facilities might develop their own measures for internal use, please e-mail your request to the editor at KarenL@eliresearch.)

In terms of staffing numbers, more isn't always necessarily more effective in improving resident outcomes. Sullivan noted that a study conducted in Illinois in the 1990s showed no correlation between nurse and dietary staffing levels and deficiencies in those departments. Interestingly, nursing homes with fewer nursing violations had higher numbers of quality assurance and MDS nurses looking after quality in the facility, he said.

In the view of Seattle-based MDS expert Nathan Lake, RN, BSN, MSHA, the five-star rating system is too simplistic, even though consumers want and need a way to sum up a facility's quality. Yet "now we have a simple rating system that supposedly tells you everything without telling you how the numbers were derived." He also wonders if the approach will encourage people to "just go for the numbers to improve their star rating," noting that there's always that danger when you simplify the scoring.

Attorney Howard Sollins points out that many long-term care companies measure quality using a variety of tools. And wouldn't it be appropriate for CMS to ask providers how they measure quality -- and what tools they use? asks Sollins, a partner in the law firm of Ober/Kaler in Baltimore. "Rather than starting with the assumption that the survey outcomes should be used to generate the rankings, why not engage in a dialogue with providers, consumers and advocates on what they consider quality services?"

A Work in Progress?

As for industry criticisms about use of survey information for the rating system, Hamilton noted that CMS has counted at least 10 states with rating systems for nursing homes on their websites. And most of the states use survey information as their primary basis for rating as do many of the private rating systems.

Hamilton maintained that the basic compliance requirements do provide a window into the quality arena. And the extent of compliance does provide a reasonable scale to at least get a sense of the degree of quality in a nursing home, he said. But he agreed that CMS "resonates" with comments that the compliance requirements don't provide the entire picture. And he appeared open to suggestions from ODF participants about how to improve the rating system over time.

MDS and long-term care industry expert Rena Shephard, MHA, RN, RAC-MT, C-NE, encourages providers to share their ideas with CMS on how to create a meaningful five-star quality rating system. In her experience, "CMS does pay attention in an organized way to everything they receive," says Shephard, who is president and CEO of RRS Healthcare Consulting in San Diego and also founding board chair and executive editor for the American Association of Nurse Assessment Coordinators. "Certainly the agency has some limitations alluded to in the ODF -- for example, they don't have the capability to collect certain types of information." Thus, "some of the suggestions made by providers might be ones for the future."