How to Choose a Nursing Home: Count the Stars

If a five-star home is the best, why would anyone would pick one with a single star?

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As I wrote this morning, the main selling point of the federal government's revamped Nursing Home Compare tool is "to provide families with a straightforward assessment of nursing-home quality, with meaningful distinctions between high- and low-performing homes" (lifted from today's press release). Then wouldn't you think that one of those meaningful distinctions would be between homes with the highest (five stars) and those with the lowest (one star) rating overall? Why would anyone even consider a one-star nursing home?

So at this morning's press conference announcing the rollout of the new five-star rating system, I asked Kerry Weems, acting administrator of the Centers for Medicare and Medicaid Services, whether a family looking for a nursing home should automatically eliminate one-star, and perhaps two-star, homes right away. It seemed like a logical conclusion. "Not automatically," he answered. "I would recommend that they think carefully before choosing a one-star home. They should try to understand why that home has one star. A couple of bad health inspections, bad staffing levels—that could be the explanation." But how can you be sure that a home has cleaned up its act?

To be fair, Weems also said, echoing the advice posted on the Nursing Home Compare page, that families should gather as much information as they can and not rely on ratings or, for that matter, on the seemingly hard data behind the ratings. And a lengthy, unscheduled visit is vital.

I had more questions, as many families will. I posed some of mine to CMS before the conference and some afterwards—and just received an answer from a senior spokesperson. Here's a Q&A:

Is there a timetable for further improvements mentioned in various documents, such as specialization (dementia, patients on a ventilator, specialized rehabilitation, etc.), patient satisfaction information, languages spoken, and so on?

These suggestions are being compiled into a set of considerations to be evaluated by the next administration.

Why wouldn't there be an automatic deduction of one or more stars for a home that has been such a poor performer for such a long time that it is labeled a Special Focus Facility?

We want SFF nursing homes to improve their quality and do not wish to penalize them for doing so, especially since we require them to sustain their improvement for about 12 months before they can graduate. And we wish consumers to be aware of the SFF nursing homes in their area that are improving. If memory serves me, we still find that the preponderance of SFFs come out at the one-star level (about 90 out of about 134), but about 30 were able to rate at two stars, and abort 14 at three stars. No SFF has more than three stars.

The stats sent to me this morning show that not all nursing homes provided information for performance in the quality measures or figures for staffing. Why not?

For quality measures, there sometimes are data that are not reported, but the larger issue is whether there are sufficient numbers to be statistically valid. . . . [F]or example, in the measurement of activities of daily living function, we do not include people who are comatose, at end-stage disease, or on hospice.

For staffing, we have quality edits built in to identify suspect or incomplete data. We kick that data out and ask the state survey agencies to follow up. We ask nursing homes to double-check their data and work with us if they see problems. For example, we identified a problem with nine nursing homes in Indiana that are on a campus with other retirement facilities and think that there are denominator problems (some nonnursing home residents included in the count). So we suppress the data and the quality rating until the problems are worked out.

A document posted in June on your Web page suggests that CMS wants to raise consumer awareness of Nursing Home Compare. It cites the 1.3 million page views per month generated by the Hospital Compare site. What is the figure for Nursing Home Compare?

1.1 million page views per month.