I and many others have complained that the 5 star system for skilled nursing is worthless. There is now proof.
Back in February, US News and World Reports published their annual list of the best Nursing Homes, claiming that California had a higher percentage of quality skilled nursing facilities than any other state. I cried foul in an article titled April Fools in February? – US News and World Reports 2013 Best Nursing Homes Report. A few days ago JAMDA published a paper titled The Association Between Quality of Care and Quality of Life in Long-Stay Nursing Home Residents With Preserved Cognition in which they found there was no correlation between quality of life and a high Five-Star rating. (See http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/FSQRS.html for details on the CMS program.) This is an important finding that should make consumers afraid and make operators of great skilled nursing facilities mad as hell. Here is why:
- When a consumer sees a high Five-Star rating, they would reasonably assume it would mean a superior experience for their loved one when, in fact, there is no evidence that this is true.
- It forces skilled nursing operators to spend their energy and efforts on getting or keeping a coveted 5 on the Five-Star rating which is ultimately a “check off the tasks” mentality. This means the tasks become more important than the residents. In reality it becomes a non-person-centered care approach.
Other Important Findings
There were three other findings that were significant:
- The higher the physical impairment, the lower the quality of life. This would suggest two things: (1) That skilled buildings should put significant effort into maximizing residents’ physical abilities;and, that (2) operators should focus on adaptive technologies, devices and methods to give residents the maximum possible physical freedom.
- The study also found that the high levels of depression correlated with a lower quality of life. This finding is sobering and intriguing. While the initial “go to” would likely be anti-depressant medications under the assumption (reasonable) that being a long term skilled nursing resident is, by it’s very nature, depressing. But serious and substantial thought should be given to the question of what can be done to make it a less depressing experience.
Implications for Person-Centered Care
The one thing that was absent (at least specifically) was a suggestion that quality of life is tied to the level of personal choice or control over what happens day-to-day and moment-to-moment in residents’ lives. The reason I find this curious is that, within the person-centered care movement, the ability to have more control is treated as the lynchpin of the concept. This would suggest that maybe person-centered care is more complicated or even something different altogether. Or perhaps, once a resident’s physical and emotional states are maximized they can enjoy the benefits of making personal choices.
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Fascinating Steve. Thanks for sharing news of this study!
From LinkedIn Groups:
Steve I may beg to disagree with you on this one. We must make sure we are not using the results of any system in a way they were not intended to be used, or, extending their use beyond their measure to provide meaningful insights. Quality of life is an intrinsic quality. To some (particularly seniors) it means autonomy, independence, being able to take acceptable risks to do the things I used to do, etc. The word “quality” in terms of long term care has been defined in numerous ways, yet, there is no unanimity of agreement on any one single definition. Quality of care in the five star system is a measure of how effective they are at implementing process. Again,seniors view quality of care more in the vein of quality of life. Adult children tend to view quality of care as receiving the contracted services, on time, and done right and at cost. So seniors and their adult children view “quality of care” much differently. I will be the first to agree that it seems a bit odd how a facility that I volunteer at can be 4 star when I view it as 2-3 star and another facility I’m familiar with and have visited several times is rated 3 star and I view it as 4-5 star. So there must be some subjectivity and possibly auditor bias on the part of those that perform the site evaluations. But what I think has value is supporting these ratings is a criteria against which a facility can be measured and those measures can be translated into non-conformity findings. So to view the 5 star system as a system that should accurately describe an intrinsic concept such as quality of life would seem to be faloneous at best. Now on the other hand, if we view the 5 star system as a compliance based system that measures the degree of conformity with the standard being applied to all facilities equally, then we have a useful tool. One could reasonably expect that a 2 star facility more than likely has more nonconformances against the standard than a 5 star facility and therefore we can say that it is likely that if you place your loved one in a 2 star facility and you view quality of life as a compliance to standards issue, then you won’t be very happy there. So in summary, I tell people to shop the rating, cost per month, read the difficiencies, and interview the facility on quality of life issues such as autonomy, independence, ability to take risk in order to do the things you did when you were young, understand what was important for you to be able to do when you lived at home and can you do those things there, etc. If you wish I can send you an excellent article on this topic and an excerpt from my thesis where I discussed “quality”.
By Thomas M. Lorenz
So a quick question. We are a technology company, you would know us well as we are the guys who make the little beepers you see in all the restaurants when you wait for your table. At any rate we are also in the medical world and I find this whole Nursing Home, Personal Care Home and Assisted Living business very interesting.
So on the 5 star rating deal. The one area I am really interested to hear about is the staffing part. So how do they know how much time each member of the staff spends with each resident or lack of time for that matter. Is there value in a technology that would track every single interaction as “an event” then time stamp the event so you know exactly how many contact points there were in a given time period and the length of time for each and total time over any period specified? Seems like so much of this is on the honor system and if you had a way to measure this it would be valuable information. Additionally I would think you would want this managed offsite so there would be no issue of “tampering”. Love to hear your feedback or anyone in the industry, We think this is an interesting gap that could be fixed very quickly and more importantly very inexpensive for the facility. Cheers RF
Russ, I’m interested in learning more about your ideas for technology that could track interactions between staff and residents. Is there some way you can contact me?
For Steve, the most objective reporting of the citations and complaints a SNF has received is on the site of the California Advocates for Nursing Home Reform (CANHR) website. There is no facility self-reporting and no politics involved in the reviews. They are publicly available by county and can be very helpful in eliminating the worst homes.
As for Russ, there are relevant laws that regulate the amount of time licensed and other staff are to spend with residents. However, I would expect forceful pushback from facilities if you proposed actually measuring the time spent. There are huge variables, such as emergent situations, staff turnover and difficulty finding caregivers. I say this as a former nursing home worker, first as an aide, then as an RN and ultimately as a lawyer who sued a few of the these homes for neglect. Technology would out the truth: many place do not conform with the law and do not want to have this measured objectively.
As an adult child of a mother who was at a nursing home who received the 5 star while I was there, I have some comments. The “check off” mentality was very apparent when the auditors came. The level of tension was so high, you could cut it with a knife. The sad thing was staff was not allowed to have a vacation for the 4 to 5 months that the audit could occur in. This was a great, small facility and the people took wonderful care of my mother. But, I was there every day to be with her. There was not enough staff right after lunch and right after dinner when people all had the same needs. It was a physical impossibility. Some patients required much more time of the CNA than others. When there was an infection and they had to gown up, it took them a lot longer with some patients. So a gizmo that would tell a person how much time they spent with someone, wouldn’t show the whole story. Also, when medicare cut the 15% in 2011, I believe, may have been 2010, there was a decline in the amount of outside activities and evening activities offered to the patients. That was sad.
All, some great insights into perspectives from differing needs.
Steve, my company found innovation to/for: “operators should focus on adaptive technologies, devices and methods to give residents the maximum possible physical freedom.” & “innovating to better serve Seniors”. Unfortunately for both loved one & caregiver, most in the USA have not embraced this technology yet. Be it awareness, availability, or uncertainty about translating the technology to daily use, I have been amazed that a few facilities would not get 1 or 2 if only to transfer patients safely, to/from wherever they are going. Having personally just joined the ranks of the “elderly”, this concerns me greatly. Steve, perhaps after viewing the 4 min. video on my website, you could enlighten me. by Don Hamlin