Consumers' use of internet-based nursing home report cards

Two Decades of Nursing Home Compare: What Have We Learned?

Approximately two decades ago, federally mandated public reporting began for U.S. nursing homes through a system now known as Nursing Home Compare. The goals were to provide information to enable consumers to choose higher quality nursing homes and to incent providers to improve the quality of care delivered. We conduct a systematic review of the literature on responses to Nursing Home Compare and its effectiveness in meeting these goals. We find evidence of modest but meaningful response by both consumers and providers. However, we also find evidence that some improvement in scores does not reflect true quality improvement, that disparities by race and income have increased, that risk-adjustment of the measures is likely inadequate, and that several key domains of quality are not represented. Our results support moderate success of Nursing Home Compare in achieving intended goals but also reveal the need for continued refinement.

Staff Perceptions of Key Factors Guiding Nursing Home Search and Selection Within the Veterans Health Administration

Background and Objectives

Veterans enter nursing homes (NHs) for short-term postacute, rehabilitation, respite, or end-of-life care. They also enter NHs on a long-term basis due to frailty, disability, functional deficits, and cognitive impairment. Little is known about how a particular NH is chosen once the decision to enter a NH has been made. This study identified VA staff perceptions of the key factors influencing the search and selection of NHs within the Veterans Health Administration (VHA).

Research Design and Methods

Data derived from 35 semistructured interviews with discharge planning and contracting staff from 12 Veterans Affairs Medical Centers (VAMCs).

Results

VA staff placed a premium on Veteran and family preferences in the NH selection process, though VA staff knowledge and familiarity with placement options established the general parameters within which NH placement decisions were made. Geographic proximity to Veterans' homes and families was a major factor in NH choice. Other key considerations included Veterans' specialty care needs (psychiatric, postacute, ventilator) and Veteran/facility demographics (age, race/ethnicity, Veteran status). VA staff tried to remain neutral in NH selection, thus instructing families to visit facilities and review publicly available quality data. VA staff report that amenities (private rooms, activities, smoking) and aesthetics (cleanliness, smell, layout, décor) often outweighed objective quality indicators in Veteran and family decision making.

Discussion and Implications

Findings suggest that VAMCs facilitate Veteran and family decision making around NH selection. They also suggest that VAMCs endeavor to identify and recruit a broader array of higher quality NHs to better match the specific needs of Veterans and families to the choice set available.

Patients Are Not Given Quality-Of-Care Data About Skilled Nursing Facilities When Discharged From Hospitals

Hospitals are now being held at least partly accountable for Medicare patients' care after discharge, as a result of regulations and incentives imposed by the Affordable Care Act. However, little is known about how patients select a postacute care facility. We used a multiple case study approach to explore both how patients requiring postacute care decide which skilled nursing facility to select and the role of hospital staff members in this decision. We interviewed 138 staff members of sixteen hospitals and twenty-five skilled nursing facilities and 98 patients in fourteen of the skilled nursing facilities. Most patients described receiving only lists of skilled nursing facilities from hospital staff members, while staff members reported not sharing data about facilities' quality with patients because they believed that patient choice regulations precluded them from doing so. Consequently, patients' choices were rarely based on readily available quality data. Proposed changes to the Medicare conditions of participation for hospitals that pertain to discharge planning could rectify this problem. In addition, less strict interpretations of choice requirements would give hospitals flexibility in the discharge planning process and allow them to refer patients to higher-quality facilities.

Personalizing Nursing Home Compare and the Discharge from Hospitals to Nursing Homes

OBJECTIVE

To test whether use of a personalized report card, Nursing Home Compare Plus (NHCPlus), embedded in a reengineered discharge process, can lead to better outcomes than the usual discharge process from hospitals to nursing homes.

DATA SOURCES/SETTING

Primary data collected in the Departments of Medicine and Surgery at a University Medical Center between March 2014 and August 2015.

STUDY DESIGN

A randomized controlled trial in which patients in the intervention group were given NHCPlus. Participants included 225 patients or their family members/surrogates.

DATA COLLECTION

Key strokes of NHCPlus users were recorded to obtain information about usage. Users were surveyed about usability and satisfaction with NHCPlus. All participants were surveyed at discharge from the hospital. Survey data were merged with medical records.

PRINCIPAL FINDINGS

About 85 percent of users indicated satisfaction with NHCPlus. Compared to controls, intervention patients were more satisfied with the choice process (by 40 percent of the standard deviation p < .01), more likely to go to higher ranked five-star nursing homes (OR = 1.8, p < .05), traveled to further nursing homes (IRR = 1.27, p < .10), and had shorter hospital stays (IRR = 0.84, p < .05).

CONCLUSIONS

Personalizing report cards and reengineering the discharge process may improve quality and may lower costs compared to the usual discharge process.

Does mandating nursing home participation in quality reporting make a difference? Evidence from Massachusetts

BACKGROUND

Quality report cards have been shown to be effective in influencing patients' referrals and promoting quality improvement in some instances and not others. In this study, we investigate one of the mechanisms that may detract from their effectiveness: voluntary versus mandatory participation of nursing homes in public quality reporting.

OBJECTIVES

To answer 2 questions: (1) Were the nursing homes choosing not to participate low-quality performers relative to those who chose to participate? (2) Once participation became mandatory, did those that did not voluntarily participate initially, improve more than those that participated voluntarily?

RESEARCH DESIGN

Massachusetts published the Massachusetts Satisfaction Survey report card for nursing homes for the years 2005, 2007, and 2009. Nursing homes' participation was voluntary in 2005 and mandatory in 2007 and 2009. We performed a retrospective statistical analysis of the relationship between nursing homes' decision to participate in quality reporting and 12 quality outcomes: deficiency citations, staffing, and 8 survey domains.

SUBJECTS

A total of 424 Massachusetts nursing homes.

RESULTS

Sixty-seven percent of nursing homes participated in reporting voluntarily. Volunteer nursing homes had better quality for all measures (significant at the 0.05 level or trending toward significance at the 0.10 level for all but 2). Once reporting became mandatory, nonvolunteers improved more than volunteers in all but 2 staffing measures (trending toward significance at the 0.10 level in 5).

CONCLUSIONS

Report cards are more effective if nursing homes' participation is mandated. Nonmandatory reporting systems, as those implemented by some states and professional associations, lead to missed opportunities for quality improvements.

The public gets what the public wants: experiences of public reporting in long-term care in Europe

INTRODUCTION

Public reporting of quality in long-term care is advocated on the basis of allowing providers to improve their performance by benchmarking and supporting users to choose the best providers. Both mechanisms are intended to drive improvements in quality. However, there is relatively scarce comparative research on the experiences and impact of public reporting on quality in long-term care in Europe.

METHODS

Using information gathered from key informants by means of a structured questionnaire and country profiles, this paper discusses experiences with public reporting mechanisms in seven European countries and available information on their impact on quality in long-term care.

RESULTS

Countries surveyed included a variety of public reporting schemes, ranging from pilot programmes to statutory mechanisms. Public reporting mechanisms more often focus on institutional care. Inspections carried out as part of a legal quality assurance framework are the main source of information gathering, supplemented by provider self-assessments in the context of internal quality management and user satisfaction surveys. Information on quality goes well beyond structural indicators to also include indicators on quality of life of users. Information is displayed using numerical scores (percentages), but also measures such as ratings (similar to school grades) and ticks and crosses. Only one country corrects for case-mix. The internet is the preferred medium of displaying information.

DISCUSSION

There was little evidence to show whether public reporting has a significant impact on driving users' choices of provider. Studies reported low awareness of quality indicators among potential end users and information was not always displayed in a convenient format, e.g. through complicated numerical scores. There is scarce evidence of public reporting directly causing improved quality, although the relative youth and the pilot characteristics of some of the schemes covered here could also have contributed to downplay their impact. The establishment of public reporting mechanisms did however contribute to shaping the discussion on quality measurement in several of the countries surveyed.

CONCLUSIONS

The findings presented in this paper highlight the need to consider some factors in the discussion of the impact of public reporting in long-term care, namely, the organisation of care markets, frequently characterised by limited competition; the circumstances under which user choice takes place, often made under conditions of duress; and the leadership conditions needed to bring about improvements in quality in different care settings.

Making difficult decisions: the role of quality of care in choosing a nursing home

OBJECTIVES

We investigated how quality of care affects choosing a nursing home.

METHODS

We examined nursing home choice in California, Ohio, New York, and Texas in 2001, a period before the federal Nursing Home Compare report card was published. Thus, consumers were less able to observe clinical quality or clinical quality was masked. We modeled nursing home choice by estimating a conditional multinomial logit model.

RESULTS

In all states, consumers were more likely to choose nursing homes of high hotel services quality but not clinical care quality. Nursing home choice was also significantly associated with shorter distance from prior residence, not-for-profit status, and larger facility size.

CONCLUSIONS

In the absence of quality report cards, consumers choose a nursing home on the basis of the quality dimensions that are easy for them to observe, evaluate, and apply to their situation. Future research should focus on identifying the quality information that offers the most value added to consumers.

Reporting quality of nursing home care by an internet report card

OBJECTIVE

This study was designed to test an internet report card containing information about quality indicators (e.g., pressure ulcers, falls) as well as assessments of consumer satisfaction and of quality of care by the Netherlands Health Care Inspectorate in nursing homes.

METHODS

Employing a laboratory-type experimental design, 278 current and future consumers and representatives of nursing homes were asked to make quality assessments based on report cards of imaginary nursing homes. They were also asked their opinions of the report cards.

RESULTS

The participants were positive about the internet report card and considered it satisfactory. However, they did make some suggestions for improvement, such as using more understandable terminology. It also became evident that the information on the card must be complete; the omission of information resulted in more negative views of the nursing home.

CONCLUSION

The results show that an internet report card can be a useful tool that enables consumers to assess the quality of nursing home care. Further research is needed to examine whether the report card will actually be used by consumers to make decisions regarding nursing home care.

PRACTICE IMPLICATIONS

The internet report card is a practical tool that can empower consumers, as it facilitates comparisons between nursing homes.