Starry Ideas for Long-term Care

Recently CMS released a nursing home rating system aimed at simplifying facility comparisons. This "star" system resembles that familiar from use in the hospitality and entertainment industries.  However, unlike hotels, nursing homes receive their ratings based on 3 key measures and an overall quality rating. State inspections, performance on core quality measures and staffing levels over a three year window make up the basis of this rating.

The overall rating is calculated by determining the health inspection rating, adding or subtracting stars based on staffing levels and the addition or subtraction of a star for the quality measures rating. [1] These ratings will receive monthly updates in their on line format.

Individual ratings score a nursing home facility on the scale of one star to five stars, with 5 being the ceiling. Quality improvement remains the overall goal of the ranking system-with lower-scoring facilities having their data widely publicized. Conversely, the best rated facilities will gain a competitive edge through recognition in the scores. As noted on the CMS website, historically, "inspections don't identify nursing homes that give outstanding care." [2] While any financial impact has yet to be realized, the intent behind CMS's adoption is clear: quality of care will be paramount going forward.

Since 2002, CMS has implemented quality measures based on resident assessments. These data come from structured, routine assessments of a patient's medical, social and psychological status. According to Medicare's web site, "these assessment data have been converted to develop quality measures that give consumers another source of information that shows how well nursing homes are caring for their residents' physical and clinical needs." [3]  Ultimately the assessments are used to develop care plans and track patient outcomes. Basing a nursing home's comparative score on these observations is established practice for CMS. The association of a "star" representing nursing home performance on these areas remains the only substantial change to the operation. For years, these same facilities have had inspection results reported to the Medicare program via state inspections; those reports are publicly available.

As CMS and other federal programs move toward a more consumer-centric and cost-effective atmosphere, LTC industry leaders speak out against such measures. Overall the media reports cite LTC insiders as cautioning health care consumers against basing judgment on these scores alone, never mind that the star system only symbolizes an aggregation of data available elsewhere through CMS. The Nursing Home Compare web site clearly encourages those researching nursing homes to use additional tools in home selection. [4] Industry leadership has also openly criticized the reliability of reported scores based on data the nursing homes, themselves, provide to the Medicare program.

American Health Care Association (AHCA), which represents 11,000 non-profit and proprietary facilities, lists a news release on its website that states, in part, "today's survey system does not specifically measure quality  it assesses compliance with federal and state regulations." [5] AHCA is a professional trade association affiliated with long term care facilities. In addition to their national organization, state level associations also exist.

Despite a reluctance to embrace such a new rating system, nursing homes must understand that some data are self-reported and several quality measures directly influenced by local processes-hence, making arguments on data accuracy a double edged sword. Although that individual control over reporting leaves room for inaccuracy or error, these new ratings likely push the industry toward greater uniformity and reliability in capture and data provision. Rather than simply dismissing current data collection methods, this move should drive refinement in those processes.

In defense of the CMS methodology, the onsite state inspection surveys are conducted in an objective fashion by trained personnel. The protocol used in the inspections has a proven success rate and supervision carried out by a federal agency. The comprehensive nature of the reviews creates a meaningful foundation through which nursing home compliance and performance can be easily ascertained. CMS consulted a technical expert panel to assist with development of the five star ratings.

Oddly, CMS did not include customer satisfaction in the rating system. Nursing home industry experts insist that satisfaction acts as the real key to facility performance. However, none of those faulting CMS's new consumer accessible rankings offers solutions for carrying out objective satisfaction surveys. The concept of satisfaction surveys also did not appear in Medicare's announcement. State inspections rely on some element of resident interview, though that may vary by the inspecting body.

The Fort Worth Star-Telegram reported that nationwide, 12 percent of nursing homes received five stars and 22 percent of facilities were rated at one star. [6] Along with a nursing home's star rating, CMS also allows prospective residents to view additional details on facility performance.

Medicare increasingly becomes cost-savvy in its policies and payment methods. What we see demonstrated in the LTC community simply reflects the belt tightening seen across business lines. For example, hospital quality data, too, is readily available for public review at the Hospital Compare Web site. In recent years CMS has rolled out several enterprises promoting health care quality and cost-containment, including MS-DRGs and physician voluntary quality reporting. Nursing homes get no exception from CMS this year and as a result will have to adopt performance improvement measures similar to their acute care counterparts.

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[6] Perotin, Maria M. "Federal agency releases nursing home rating system" Star-Telegram (December 18, 2008).

Mr. Shields currently maintains appointment as the HIMS Supervisor at the VA Medical Center in Louisville, Kentucky. His experience runs across 8 years in health care, a variety of specialties and coding perspectives. Kevin has history as an adjunct instructor for coding and HIT programs, time in independent audit contracting, revenue cycle consulting, medical review for a Tricare PRO and remote contract coding. He has authored articles for AAPC Coding Edge, and Advance for Health Information Professionals. In addition, Kevin participates in the AHIMA ACE (Action Community for e-HIM Excellence), Ingenix Coding & Referential Advisory Board, and just recently joined the BC Advantage Editorial Board. He has also taken part in HIE stakeholder focus groups, CAC studies, a national dialysis workgroup within VA, and proctors exams for local AAPC chapters. Kevin also attends Weber State University, completing a degree in Health Information Technology (HIT).