The quality of care provided to nursing home residents has been a persistent concern among clients, their families, and policymakers for decades. To create more transparency related to nursing home quality, the federal government’s Centers for Medicare and Medicaid Services created Nursing Home Compare, an online public reporting system for nursing homes across the country. A School of Public Health researcher recently helped conduct a study to see if nursing homes are genuinely attempting to improve quality of care when working to raise their scores and found it to be true for many facilities.

The study was published in Medical Care Research and Review and co-authored by Associate Professor Tetyana Shippee.

Nursing Home Compare scores use a 5-star rating system that are generated from different scores, including clinical quality measures that are self-reported by the facilities. For example, the clinical quality scores document health events among residents, such as if they develop urinary tract infections. The scores also include data on facility nurse staffing levels and the results of government health inspections.

“Over time, most nursing homes have improved their 5-star ratings,” says Shippee. “Much of this improvement has been driven by the self-reported quality measures rather than through increasing staffing or performing well in regulatory inspections. The fact that the quality measures are largely based on facility self-reported data has prompted questions about their validity.”

To find out if nursing homes are actually working to meaningfully improve their quality of care the researchers conducted interviews with nursing home personnel and in-person observations of the organizational processes used in 12 nursing homes in Illinois, Minnesota, and Pennsylvania.

The researchers found:

• Nursing homes implemented various organizational strategies to improve their quality ratings, ranging from data-focused changes that were relatively simple and required few resources to implement to more complex, clinically oriented strategies that required more resources to put in place. 
• All but one facility used data-focused strategies, such as modifying data collection and reporting processes to improve their scores.
• 10 facilities used more complex clinical strategies, such as employing telehealth services, to demonstrate enhancements to resident care.

“A key takeaway is that most nursing homes are working to improve the quality of care they provide by changing processes or enhancing services; they’re not merely trying to raise their publicly reported quality measures,” says Shippee. “At the same time, our findings highlight some important limitations with the quality measures and provide evidence that concern about the reliability of some of the measures is warranted.”

For example, scores for some measures can be improved primarily by changing how staff collect and report data or by a facility declining to accept more medically or socially complex residents.

Given these limitations, Shippee says that policymakers and government officials should be aware that quality measures on their own may not accurately reflect the quality of care nursing homes provide. Other strategies, such as using value-based purchasing and quality improvement collaboratives, are also important to ensuring nursing homes are truly working to raise their standards of care. 

Many nursing home providers would like the self-reported quality measures to have more weight in the Nursing Home Compare/5-star ratings. 

“However, our results suggest that giving the quality measures more weight in the 5-star ratings would be a mistake from a consumer and policy perspective,” says Shippee. “Our findings suggest several changes to improve Nursing Home Compare/5-star ratings, including adding information related to resident and family experience, adding greater risk adjustment, and providing incentives for nursing homes that serve socially and medically complex residents.”

Shippee is continuing her research into the topic by studying discrepancies between nursing home quality measure scores and the results of facility inspections regularly conducted by the government. She is also examining the organizational structures and processes that differentiate high-performing nursing homes from those with inconsistent or low publicly reported ratings.