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The Nursing Home Rating System Gets a Reboot

Why so many homes just lost stars and how to choose one wisely

Editor’s note: This article is part of a year-long project about aging well, planning for the changes that aging brings and shaping how society thinks about aging.

Selecting a nursing home — for yourself, a spouse or a parent — is a thorny, often pricey decision. There are roughly 15,000 facilities, the average annual cost for a semi-private room is about $77,000 and, frankly, nursing homes have a less than stellar reputation.

“It’s a very important decision and often made under medical duress, when you only have a short period of time,” says Jeff Kelly Lowenstein, who has investigated nursing homes for The Center for Public Integrity.

Nursing Home Compare

It’s no wonder the Department of Health and Human Service’s free online Nursing Home Compare website gets about 1.5 million visits a year. The site’s Nursing Home Compare tool rates the facilities for quality on a one-to-five star scale.

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Trouble is, Nursing Home Compare has had serious flaws that have made the facilities look like the children of Lake Wobegon (all “above average.”) Roughly 80 percent of the nation’s nursing homes got a four- or five-star rating on their quality measures score — well, they did until last Friday.

How the Ratings Were Tweaked

That’s when the government took a few baby steps to make Nursing Home Compare more reliable, by tweaking its rating methodology to adjust the curve used to measure homes.

For example, it added a measure of anti-psychotic drug use in nursing homes. A home’s score drops if residents use the drugs other than for specific conditions, since the medications can lead to an increases in falls and pressure ulcers. The new methodology also sharpened the scoring method for the star rating based on staffing and made it harder for nursing homes to earn two or more stars for their quality ratings.

Now, only about half of the nursing homes get lofty four-and five-star quality scores. And the star ratings of nearly a third of the homes have dropped, according to The New York Times. In addition, USA Today says, about 61 percent saw their narrower quality-of-care scores drop.

(MORE: Make the Right Choice for Long-Term Care)

Thomas Hamilton, director of survey and certification at the federal Centers for Medicare and Medicaid Services (CMS), which runs Nursing Home Compare, said the current scoring system “raises the standard for nursing homes to achieve a high rating.”

Reviews for the New Ratings

Consumer advocates I spoke with give muted applause to the Nursing Home Compare changes.

“We’ve been concerned for quite some time about the accuracy of the data Nursing Home Compare uses to calculate five-star ratings,” says Robyn Grant, Director of Public Policy and Advocacy for The National Consumer Voice for Quality Long Term Care.

She believes the new scoring method for nursing home staffing “seems to make more sense than the previous method. Overall, the changes will contribute to a system that better reflects reality.” Grant also says she’s glad to see the psychotic medication measurement because those drugs are “a huge issue now in nursing homes; they are way overmedicated.”

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Avery Comarow, Health Rankings Editor for U.S. News, says “the changes aren’t especially substantial, but they are welcome.”

The Gaping Problem That Remains

The recent changes don’t address a big problem with Nursing Home Compare, however: Much of its data, especially staffing data, is self-reported by the nursing homes with no independent verification. “We question the staffing data accuracy,” says Grant. “It inflates the ratings and gives the impression that there is more staff than reality.”

Articles by The New York Times and The Center for Public Integrity say some homes game the system, goosing their staffing-rating scores by bringing on workers just before inspectors come and dropping them afterwards. The Center for Public Integrity also found that staffing figures in nursing home financial reports are often much lower than those they report to the government.

Evvie Munley, the Senior Health Policy Analyst at Leading Age, a group whose members include nursing homes, says the staffing forms are “very confusing” for nursing home employees to complete. “I get calls from homes all the time about this,” she adds.

Nursing Home Compare designers say they hope to start gathering staffing information through nursing home payroll data — by the end of 2016. The Affordable Care Act of 2012 requires converting to payroll-based data collection, but implementation has been glacier.

Kelly Lowenstein is somewhat skeptical that this change will happen by 2016. “A number of advocates and nursing home owners told me they wonder if CMS will be able to pull it off. There’s so much variation in payroll systems,” he says.

But verifiable payroll data collection is something that critics and the nursing home industry would like to see. Credible information on staff turnover “is the single most-important data element I would kill for,” says Comarow. Leading Age’s Munley says: “We’re very supportive of a payroll-based system. It will improve accuracy.”

What the New Ratings Don’t Mean

The new ratings don’t necessarily mean that a nursing home’s quality has slipped if it now has a lower score. In fact, the site warns: “Because of these changes, it is not appropriate to compare a facility’s Quality Measure ratings that appear in February with those that appeared in earlier months.”

But the nursing home industry fears that’s exactly what consumers will do and that they’ll mistakenly believe a facility’s quality has dropped if its score did.

“If centers across the country start losing star ratings overnight, it sends a signal to families and residents that quality is on the decline when it has improved in a meaningful way,” said Mark Parkinson, president and chief executive of the nursing home lobbying group, the American Health Care Association.

How to Choose a Nursing Home

If you or a loved one need to find a nursing home, start with Nursing Home Compare, realizing that it’s an imperfect tool. “I tell people it’s one tool, it’s not the tool,” says Munley. “Use it as a way to frame your questions. I did that when I was looking for a nursing home for my mother.”

Grant agrees. “It’s a starting off point, but we hope it’s never the only factor someone uses to select a nursing home,” she says. “Onsite visits are crucial.”

After finding several local homes worth considering through Nursing Home Compare, visit them numerous times, on different days of the week and different times of the day and night. Look beyond the made-for-public-consumption lobby and first-floor area and venture around to less-traveled areas.

Grant says, if you see data about a home in Nursing Home Compare that causes you concern, ask the administrative staff about it to see how they defend it. Kelly Lowenstein urges looking into any nursing home violations or lawsuits, too.

Also, Grant advises, “come up with your own checklists of what you want in a nursing home” and look for facilities that match. “What kind of accommodation do they give to your needs and preferences? For instance, if you’re a nightowl, can you go to the lobby to watch the late news on TV?”

That might sound like a small thing. But since the home could run nearly $80,000 a year and be a last residence, it ought to be the best possible place.

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