Inside the Black Box of Improving on Nursing Home Quality Measures

Abstract

Nursing Home Compare (NHC) reports quality measures (QMs) for nursing homes (NHs) as part of its 5-star rating system. Most of the QMs are based on facility self-reported data, prompting questions about their validity. To better understand how NHs interact with the QMs, we used qualitative methods, including semistructured interviews with NH personnel ( n = 110), NH provider association representatives ( n = 23), and observations of organizational processes in 12 NHs in three states. We found that most NHs are working to improve the quality of care they provide, not merely their QM scores. However, our interviews and observations revealed limitations with the QMs, suggesting that the QMs—on their own—may not accurately reflect the quality of care NHs provide. Our findings suggest several changes to improve NHC, including adding information related to resident and family experience, providing greater risk adjustment, and providing incentives for NHs that serve socially and medically complex residents.

Medicare payment policy in skilled nursing facilities: Lessons from a history of mixed success

“…A study of five common Medicare hospital diagnoses found that SNF days for patients with a stroke declined immediately after the BBA, whereas overall use of inpatient rehabilitation and long‐term hospital care increased 15 . Qualitative research has revealed that SNFs did engage in patient selection strategies to admit fewer high‐risk patients under PPS 25 . However, SNF length of stay was relatively unchanged compared to the pre‐PPS period, which was unsurprising as the SNF PPS reimbursed SNFs on a per diem and not an episode basis 8,18 .…”

“…15 Qualitative research has revealed that SNFs did engage in patient selection strategies to admit fewer high-risk patients under PPS. 25 However, SNF length of stay was relatively unchanged compared to the pre-PPS period, which was unsurprising as the SNF PPS reimbursed SNFs on a per diem and not an episode basis. 8,18 Additional early process changes incentivized by the SNF PPS included a move toward bringing therapy services in-house rather than employing contract therapy companies, allowing SNFs more control over the cost of therapy services as they navigated uncertainty.…”

Expanded role of nurses in Swiss nursing homes and their engagement in quality improvement: A cross‐sectional study

“…When (Lee & Wendling, 2004 ) surveyed Kansas' NHs about the extent of their quality improvement program, they concluded that few NHs had systematic quality improvement programs in place. More recently, Davila et al ( 2021 ) found that the majority of NH directors reported carrying out “data‐focused strategies” to improve quality outcomes. However, methodological differences make comparisons with our data difficult.…”

Silver Opportunity: Building Integrated Services for Older Adults around Primary Health Care

“…In the United States, the federal government requires all Medicare-or Medicaid-certified nursing homes (about 15,000 in total) to routinely report detailed resident demographic, health, functioning, and treatment information using the uniform MDS (which ironically contains more than 400 data items) for resident assessment, care planning, payment, and public reporting purposes. Despite the enormous costs of collecting these data as well as developing and maintaining numerous nursing-home quality measures (Mor 2011), the impact of using these data for improving quality and consumer experience is mixed (Davila et al 2021;Konetzka et al 2022). In health care more broadly, between 2008 and 2018, the federal government invested more than US$1.3 billion in quality measure development, with approximately 2,300 measures developed, of which 788 (34 percent) are being used in government-mandated quality, reporting, and payment programs (Wadhera et al 2020).…”