With considerable fanfare, the Centers for Medicare and Medicaid Services just released a new five-star quality rating system for nursing homes. As the Boston Globe was quick to point out, this evaluation gave Massachusetts a lower percentage of five-star and a higher percentage of one-star nursing homes than neighboring New Hampshire, Connecticut or Maine.
All rating systems are subject to criticism and this latest version of Nursing Home Compare is no exception. Can the overall quality of a facility be inferred from just three measures (health inspections, staffing ratios, and quality indicators), where the quality indicators rely on self-reported data and are not corrected for the severity of illness of the patients in the facility? But what is indisputable is that nursing homes in Massachusetts vary enormously. Facilities awarded five stars are probably pretty good and those with one star are probably pretty poor. What, then, should the state do to promote better quality?
The prevailing approach to ensuring quality relies on an extensive system of federal regulations that are enforced by the state Department of Public Health. Teams of surveyors make unscheduled inspections to determine whether facilities are in compliance with the regulations and issue citations for any “deficiencies.”
The results of these surveys are public and may result in penalties ranging from fines to loss of Medicaid and Medicare certification. Nursing home regulations, together with a federally mandated resident assessment system, have been associated with a rise in the overall quality of care, but clearly there is more work to be done.
How should Massachusetts promote further improvement? Perhaps it is time to move from a punitive system to one that offers incentives for achieving quality. An interesting experiment that bears watching is underway in Minnesota, which has introduced pay-for-performance into nursing homes. But pay-for-performance tends to encourage institutions to concentrate only on those areas in which they know they will be measured, to the detriment of other areas. And by rewarding facilities for outcomes rather than for improvement, they decrease reimbursement to precisely those sites that need an infusion of funds to do a better job.
Over the long run, Massachusetts can hope to improve nursing homes by making a career in long-term care attractive. Physician interest in nursing home care has grown: medical directors of nursing homes now have their own professional society and an academic journal. Nurse practitioners are playing an increasing role as primary care clinicians in the nursing home, where they contribute to better medical care and decreased hospitalization rates along with a high degree of family satisfaction. The last frontier is the nursing assistant, who continues to be poorly paid, have limited opportunities for advancement, and to suffer from high rates of job-related injury.
The Massachusetts Act to Promote Cost Containment, signed into law in August, 2008, commits the state to a major effort to attract primary care physicians and nurses through enhanced educational opportunities and loan forgiveness programs. We need to broaden that initiative by developing a career ladder for nursing assistants, creating a variety of positions between the Certified Nursing Assistant (who typically receives 75 hours of classroom training and 100 hours of on-the-job training) and the Registered Nurse (who may have spent 4-5 years getting a Bachelor of Science in Nursing). Only when all those caring for nursing home residents take pride in their work, when they receive respect for what they do and have autonomy in their jobs, can we expect both quality of care and quality of life to improve in nursing facilities.
Muriel Gillick is a geriatrician at Harvard Vanguard Medical Associates and a Clinical Professor of Ambulatory Care and Prevention at Harvard Medical School.
This program aired on December 31, 2008. The audio for this program is not available.