Families' and Residents' Perspectives of the Quality of Nursing Home Care: Implications for Composite Quality Measures

Exploring nursing home resident and their care partner priorities for care using the Action-Project Method

BACKGROUND

Nursing home (NH) residents' experiences are embedded within their relationships to others. Our objectives were to describe how residents and care partners (family or staff members) jointly construct, discuss, and act on care priorities.

METHODS

We used Action-Project Method, a qualitative method focused on action within social context. We recruited 15 residents and 12 care partners (5 family and 7 staff members) from 3 urban NHs in Alberta, Canada. Residents and care partners participated in a video-recorded conversation about their experiences in the NH, then individually reviewed the video-recording to add context to the conversation. Following transcription, preliminary narrative construction, and participant feedback, the research team conducted in-depth analysis to identify participant actions, goals, and projects, including those jointly shared by dyad members.

RESULTS

All participants' intentions could be broadly described as "making time in the NH as good as possible" and projects were grouped into five categories: resident identity, relationships (both presence and absence), advocacy, positivity, and respectful care. Participants often raised issues of short-staffing as a significant barrier to respectful care. Care partners, especially staff, used positivity to redirect residents from difficult topics. Joint projects could be identified in some, but not all, cases.

CONCLUSIONS

We found that maintaining a sense of identity, fostering relationships, and receiving respectful care were important to residents but that short-staffing created barriers. Methods to capture these aspects of the resident experience are needed but should not be influenced by care partners' tendency towards positivity in resident interactions.

Assessment of Consumer Complaint Investigation Scores, Recertification Survey Scores, and Overall Nursing Home Health Inspection Star Quality Rating

IMPORTANCE

The Centers for Medicare & Medicaid Services' Five-Star Quality Rating System combines results from nursing home recertification surveys and complaint investigations into a single indicator for health inspections. This combination may mask complaint investigation results.

OBJECTIVE

To construct and compare star ratings specific to recertification surveys and specific to complaint investigations to discern whether they provide different information.

DESIGN, SETTING, AND PARTICIPANTS

In this quality improvement study, the Nursing Home Compare Five-Star Quality Rating System was used to calculate three 5-star ratings: 1 overall health inspection rating combining recertification survey scores and complaint investigation scores, 1 using only recertification scores, and 1 using only complaint investigation scores. The study included US nursing homes. The sample calculated star ratings for nursing homes in November 2017. This sample included all whose most recent recertification surveys occurred in 2016 up to and including November 2017, and those with 36 months of data from the ASPEN Complaints/Incidents Tracking System and the Certification and Survey Provider Enhanced Reports. Data analyses were completed on different days in 2022, depending on which questions were being addressed.

MAIN OUTCOMES AND MEASURES

Comparison of the 3 star rating distributions. The recertification survey and complaint investigation star ratings were compared with respect to the overall health investigation rating. The recertification and complaint star ratings were cross-tabulated.

RESULTS

Among the 15 499 nursing homes, 19.8% had 1 overall health inspection star, 23.2% had 2, 23.2% had 3, 23.2% had 4, and 9.8% had 5 overall health inspection stars. Most had the same overall and recertification star ratings; for example, 79.4% had 5 overall stars and 5 recertification survey stars. However, overall and complaint-based star ratings were discordant, with a relatively large proportion of nursing homes (25.7%) having no complaint deficiencies and therefore high star ratings.

CONCLUSIONS AND RELEVANCE

In this quality improvement study assessing the 2 components of the Five-Star Quality Rating System, results of recertification surveys were largely similar to health inspection star ratings. However, recertification survey scores differed from complaint inspection scores, suggesting health inspection ratings may not reflect consumers' views of care, services, or other valued amenities. A complaint-focused metric may have utility. However, research is needed concerning the many nursing homes with no or very few complaint deficiencies.

Who Visits Relatives in Nursing Homes? Predictors of at Least Weekly Visiting

OBJECTIVES

Within the context of a single study, assess the relative importance of the 6 factors identified in a 2019 systematic review as associated with the likelihood that family members will visit nursing home residents.

DESIGN

Retrospective statistical analysis of an existing survey data set.

SETTINGS AND PARTICIPANTS

A national survey conducted with 4350 relatives of long-term nursing home residents.

METHODS

Probit models of the probability of visiting a family member at least once weekly, stratified by age of the visitor, were estimated. To account for possible endogeneity of respondent involvement in the choice of nursing home and visit rate, visit rates were estimated using 2-stage residual inclusion in which the first stage explained involvement in nursing home choice.

RESULTS

Involvement in nursing home choice has a substantively and statistically significant positive effect on visit probability for all age groups of respondents. Travel time has a substantively and statistically significant negative association on visit probability for all age groups. Younger women are more likely to visit than younger men. For all but the oldest respondents, higher income and full-time employment contribute to involvement in nursing home choice as does being Black or Hispanic.

CONCLUSIONS AND IMPLICATIONS

As in previous research, travel time is an important determinant of visit rates. The strong association of involvement in nursing home choice with visit probability suggests a strong psychological motivation for visiting. To improve visiting, future research should focus on better understanding of the psychological factors that are associated with it and rely on better data and improved statistical methods. Our findings also suggest that nursing home administrators should consider adopting initiatives to facilitate and empower family members' involvement in nursing home choice, which in turn may lead to increased visitations.