How to Evaluate Quality Measures for Nursing Homes

Making the decision to entrust the care of a loved one to a nursing home is a significant and often challenging choice. The quality of care provided in these facilities can profoundly impact the well-being of individuals requiring more specialized care. However, for the average person, navigating the complex landscape of nursing home evaluations can be daunting, as recognizing indicators of a high-quality care environment requires specialized knowledge. Moreover, the distinction between short-term and long-term care further complicates the decision-making process. Fortunately, valuable tools offered by the Center for Medicare and Medicaid Services (CMS) can help families evaluate quality measures to make informed choices. By understanding the critical nature of this decision, the inherent challenges in evaluating care facilities, and the nuanced differences between short and long-term care, individuals can leverage these CMS resources to ensure their loved ones receive the highest standard of care in a nursing home setting.

Historically, the term "nursing home" has been broadly used to describe facilities catering to senior living needs, encompassing both short-term rehabilitation and long-term care. However, contemporary definitions increasingly recognize a specialized subset known as skilled nursing facilities. Skilled nursing facilities focus on providing intensive, specialized medical care and rehabilitation services for individuals recovering from surgery, illness, or injury. In contrast, nursing homes, in a more modern context, tend to emphasize long-term care for seniors who may require assistance with activities of daily living. While the terminology has shifted, both skilled nursing facilities and nursing homes provide the same level of services and are often used interchangeably. They remain integral components of the continuum of care for seniors, offering tailored services to meet the diverse needs of an aging population.

Administered by the Centers for Medicare & Medicaid Services (CMS), the nursing home rating system plays a pivotal role in guiding individuals and families through the challenging process of choosing a care facility. The overall rating of a nursing home is tied to its performance across three critical areas: health inspections, staff numbers, and quality of care metrics. The highest rating a community can earn is five stars; the lowest is one star.

Health inspections

Health inspections constitute a crucial component of the nursing home rating system, offering a comprehensive evaluation of a facility and nursing staff's compliance with health and safety standards. Conducted by CMS annually, these inspections meticulously assess various aspects of a nursing home's operations, including hygiene, infection control, medication management, and overall adherence to regulatory guidelines. Trained surveyors visit facilities to conduct unannounced inspections, providing an unbiased snapshot of the environment and care practices. The results of health inspections contribute significantly to a nursing home's overall rating, offering families valuable insights into the facility's commitment to maintaining a safe and healthy living environment for residents. This emphasis on health inspections underscores the importance of regulatory compliance in ensuring the well-being of those entrusted to nursing home care.

Staffing levels

Staffing levels represent another critical dimension in the nursing home rating system, reflecting the adequacy of licensed practical nurses and licensed vocational nurses to meet the diverse needs of residents. CMS assesses staffing levels as a key factor in determining a facility's overall rating. While the number of staff members is a tangible metric, it's essential to note that some research suggests staffing levels alone may not be a definitive indicator of quality care. Instead, factors such as organizational processes and structural elements play pivotal roles in shaping the care environment. The emphasis on processes and structure recognizes that the effectiveness of care delivery goes beyond numerical ratios. Elements like staff training, communication, and facility protocols contribute significantly to the overall quality of care. Therefore, while staffing levels remain a crucial consideration, a more holistic understanding of a nursing home's processes and structure is increasingly recognized as fundamental to providing high-quality care to residents.

Quality of care metrics

Quality of care metrics constitute the final pillar in the nursing home rating system, offering a nuanced evaluation of the overall well-being and satisfaction of residents. These CMS metrics encompass a range of factors that directly impact the quality of life for individuals in long-term care. Metrics often include the prevalence of pressure ulcers, the appropriate use of antipsychotic medications, and the effectiveness of pain management protocols, among others. By delving into these specific indicators, CMS aims to provide families with a comprehensive understanding of the care practices within a facility. It is worth noting that these metrics offer valuable insights into aspects of care that extend beyond the sheer presence of staff or adherence to regulatory standards. As such, they contribute significantly to a more holistic assessment of the quality of care a nursing home provides, ensuring that the well-being and individual needs of residents are at the forefront of the evaluation process.

These assessments, conducted annually by CMS, form the basis for determining Medicare's ratings. Health inspections scrutinize a facility's compliance with regulatory standards, while staff numbers reflect the adequacy of personnel to meet residents' needs. Quality of care metrics delve into various aspects resident care, such as the prevalence of pressure ulcers and the appropriate use of antipsychotic medications. By employing a comprehensive approach that considers these key factors, CMS provides a valuable and transparent tool for families seeking to make informed decisions about the quality of care their loved ones will receive in a nursing home setting.

However, the relevance of the quality rating depends on the specific needs and preferences of individuals and their families. For those seeking short-term rehabilitative care, metrics related to therapy outcomes and recovery support may be of utmost importance. Conversely, individuals considering long-term care may prioritize metrics reflecting the facility's ability to provide sustained comfort, social engagement, and comprehensive medical management. Recognizing this nuanced perspective is crucial, as it allows families to tailor their decision-making process based on the specific care requirements and expectations that align with either short-term recovery goals or long-term residential needs.

6 nursing home quality metrics for short stay residents

CMS uses a small set of key indicators when evaluating the effectiveness of short-term care facilities. These metrics offer insights into the recovery outcomes, transitional support, and overall satisfaction of individuals undergoing temporary care, presenting a comprehensive picture of the facility's performance in meeting the immediate and specific needs of short-term residents.

• Hospitalization rate: Measures the percentage of residents previously hospitalized before entering a nursing home who experienced unplanned re-hospitalizations within 30 days. This metric gauges the facility's efficacy in preventing avoidable hospital stays during the initial month of residence.
• Emergency room visits: Assesses the percentage of residents requiring emergency room visits within the first 30 days of nursing home placement for outpatient care. This metric provides insight into the facility's capacity to address medical needs without resorting to emergency services during the early stages of residency.
• Antipsychotic medication usage: Examines the percentage of residents who were not previously prescribed antipsychotic medication but were given one. Given the FDA's warning about increased risks, this metric emphasizes the importance of judicious use and alternative behavioral management strategies. It underscores the need for appropriate medication administration only when necessary.
• Pressure ulcers (bed sores): Evaluates the percentage of residents developing new or worsening pressure ulcers. This metric sheds light on the facility's success in preventing and managing these conditions, crucial for short-term residents recovering from surgery or illness. Pressure ulcers often result from inadequate movement, emphasizing the importance of repositioning to alleviate long-term pressure on the skin.
• Improvement in independence: Assesses the percentage of nursing home residents exhibiting enhanced independence in activities such as walking, transferring (e.g., getting out of bed and sitting in a chair), and moving within the facility. This metric reflects the success of rehabilitation services in improving residents' functional abilities and overall mobility.
• Transitions to at-home or community living: Examines the rate at which residents were successfully transitioned back to living at home or in the community, measured by the absence of unexpected hospitalizations or deaths within 31 days of nursing home discharge. This metric underscores the facility's commitment to facilitating smooth transitions and providing ongoing support beyond the short-term stay.

9 Nursing home quality measures for long stay residents

In gauging the quality of care provided in long-term care facilities, there are specific nursing home quality indicators that offer insight into the well-being, safety, and overall experience of residents over extended periods. As you will see, some of these metrics are similar to, if not the same, as found in the quality measures for short-term stays.

• Changes in activities of daily living (ADLs): Evaluates the percentage of residents experiencing an increased need for assistance with ADLs, encompassing activities like bathing, dressing, eating, and using the toilet. This metric reflects changes in residents' self-care abilities over time.
• Hospitalization Rate: Measures the number of unplanned hospitalizations per 1,000 long-stay resident days, with long-stay defined as the period following a resident's 100th day in the nursing home. This metric provides insights into the facility's ability to prevent avoidable hospitalizations among long-term residents.
• Emergency room visits: Assesses the number of outpatient emergency room visits per 1,000 long-stay resident days. This metric gauges the frequency of residents requiring emergency care services while residing in the nursing home for an extended duration.
• Changes in movement abilities: Examines the percentage of residents experiencing a deterioration in their ability to move without assistance. This metric sheds light on changes in residents' mobility and independence within the facility.
• Pressure ulcers (bed sores): Evaluates the percentage of high-risk residents with pressure ulcers. This metric focuses on those particularly vulnerable to developing bed sores, emphasizing the importance of preventive measures.
• Catheter usage: Assesses the percentage of residents who have had a catheter inserted and left in within the last seven days. A catheter is a tube used to drain urine from the bladder, and this metric provides insight into recent usage within the facility.
• Urinary tract infections (UTIs): Examines the percentage of residents who had a urinary tract infection within the last 30 days. This metric highlights the prevalence of UTIs, a common concern in long-term care settings.
• Fall-related injuries: Evaluates the percentage of residents who experienced a major injury due to a fall within one full calendar year. This metric underscores the facility's effectiveness in fall prevention strategies and resident safety.
• Antipsychotic medication usage: Assess the percentage of residents given antipsychotic medication. As per FDA guidelines, this metric emphasizes the risk associated with such medications in elderly individuals with dementia, emphasizing the need for alternative behavioral management strategies.

The CMS nursing home quality reports serve as tools for informed decision-making. These reports are easily accessible to the public and provide a wealth of detailed information. Seniorly has made healthcare research easy by providing a summary of the most recent CMS report for every nursing home in the US. You can find these on Seniorly.com.

Red flags in CMS nursing home evaluations

Below you can see an example of a rating for a community that does not score well:

Citations: In the context of CMS reporting, a citation is a formal acknowledgment or documentation of a deficiency or violation identified during a nursing home inspection. When a facility fails to meet specific regulatory standards, the surveyors issue citations to highlight these shortcomings. Citations can range in severity, from less serious issues that pose minimal risk to residents to more critical violations that may jeopardize their health and safety. Each citation includes details about the observed deficiency, its potential impact on residents, and a reference to the specific regulation or standard that was not met. They're an essential component of the CMS reporting system, offering transparency and accountability by publicly disclosing instances where a nursing home falls short of expected standards. Families and stakeholders can use citation information to make informed decisions about the quality of care provided by a facility and the steps taken by the nursing home to address identified issues.

Gap in short stay and long stay quality scores: When there is a significant gap between the short stay and long stay quality scores in a nursing home evaluation, it suggests that the facility is adept at managing ongoing care needs but may face difficulties in delivering the specialized attention required for short-term rehabilitation. Understanding the reasons behind these disparities is crucial for individuals and families seeking appropriate care, as it allows for a more nuanced evaluation of a facility's capabilities across various aspects of resident well-being. It also suggests that the facility may not have properly committed to supporting the level of care it offers.

Low staffing ratings: When the staffing hours per resident per day in a nursing home fall significantly below the state average, it raises concerns about the adequacy of staffing levels to meet the diverse needs of residents. Insufficient staffing can impact the quality of care and overall resident experience, as it may lead to challenges in providing timely assistance, monitoring health conditions, and ensuring meaningful engagement. Residents in such facilities may experience longer response times, limited personalized attention, and potential gaps in essential services. The lower staffing hours could also impact the facility's ability to uphold regulatory standards and maintain a safe and supportive environment. Finally, while staffing is a challenge nationwide in the current climate, a facility that is well below state average may be one that is struggling with leadership issues and may be unable to keep qualified staff. Families and individuals considering a nursing home with staffing levels below the state average should carefully weigh these factors, as they play a critical role in determining the quality of care and the overall well-being of residents in the long term.

Families can also find data on CMS Nursing Home Compare, an online tool that empowers users to compare ratings for different nursing homes across the United States. This user-friendly platform offers a wealth of information, including overall facility ratings and detailed breakdowns of health inspection results, staffing levels, and quality of care metrics.