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In September 2006, the nursing home industry announced a voluntary quality improvement campaign – Advancing Excellence in America’s Nursing Homes.[1]  The campaign, now in its ninth year and third phase, describes its mission: “to make nursing homes better places to live, work, and visit.”[2]  The Center for Medicare Advocacy (Center) was skeptical about the campaign when it was announced in 2006,[3] expressing concerns with the campaign’s minimal goals and repetition of similar and ineffective voluntary improvement initiatives.  Since 2006, the Center’s skepticism has continued.  In 2012, the Center found that facilities providing the poorest quality of care, identified by the Centers for Medicare & Medicaid Services (CMS) as Special Focus Facilities, participated in the campaign to the same extent as other facilities.[4] 

Now, for the first time, the campaign reports the level of participation by facilities that register for the campaign.  Analysis of this information indicates that relatively few facilities are actively involved.  Even more troubling, the Center’s review of facilities in five states finds that the highest level of participation by facilities is not correlated with providing high quality care, as reported on Nursing Home Compare.  In fact, as shown below, the opposite is the case.  Nearly half the “full active participant” facilities provide care that CMS describes as “below average” or “much below average.”

Campaign Participation is Limited

Until May 2015, the campaign announced only the names and, by state and nationally, the number of facilities that registered to participate in the campaign.  Since May, the campaign has identified each facility’s actual level of participation, using one of five icons.[5]  Facilities identified as “full active participants” (the highest level of participation) are described as having selected goals and consistently reported their progress to the campaign for the most recent six months.  Four other categories of participation have icons that reflect various levels of participation – i.e., they submitted some data on some of the goals they selected for some period of time.  Facilities that registered for the campaign but have not engaged in any other way do not have any icon by their name. 

The Center’s review of five states finds that the level of full participation in the campaign is extremely minimal.  Although the campaign homepage now reports that 62.6% of facilities nationwide participate in the campaign,[6] few facilities are full active participants and the overwhelming majority have done no more than register.

Facilities’ level of participation in Advancing Excellence

State

Number of registered facilities

Full active participants, number

Full active participants, percentage

Registered only, number

Registered only, percentage

California

  560

11

  2%

  538

96%

Connecticut

  200

  6

  3%

  174

87%

Georgia

  360

24

  7%

  306

85%

Maine

  110

  5

  5%

    77

70%

Tennessee

  250

14

  6%

  217

87%

Total

1480

60

  4%

1312

89%

"Full Active Participation" Does Not Correlate to High Quality of Care

The Center looked at CMS’s website Nursing Home Compare to see how the full active participants in five states fared.  Nursing Home Compare scores each facility participating in Medicare or Medicaid, or both, on three separate dimensions – health surveys, staffing, and quality measures – and calculates an overall composite score.  Scores are one to five stars for each dimension and for the overall score; one star is the lowest rating and five stars, the highest.

The overall star rating has the health survey rating as its core, but it can be adjusted upwards or downwards, based on the staffing and quality measures, both of which are self-reported and not audited.  In August 2014, The New York Times reported that facilities “game” their star ratings, particularly their quality measures.[7]  Following this investigative report, CMS announced plans to revise Nursing Home Compare[8] and recalibrated the ratings for the quality measures.[9]

Only 43 of the 60 “full active participants” are found on Nursing Home Compare.  At least 11 of the 17 facilities whose ratings are not reported on Nursing Home Compare are Veterans Administration facilities.

As shown below, “full active participation” facilities are represented in each of the star ratings categories on Nursing Home Compare

Overall and Health Star Ratings for Full Active Participants in Advancing Excellence

State

Number of facilities on Nursing Home Compare

Overall star rating

Health star rating

California10

2

3 stars: 1 facility

5 stars: 1 facility

2 stars: 1 facility

4 stars: 1 facility

Connecticut11

5

3 stars: 2 facilities

5 stars: 3 facilities

3 stars: 2 facilities

4 stars: 2 facilities

5 stars: 1 facility

Georgia12

19

1 star: 6 facilities

2 stars: 5 facilities

3 stars: 3 facilities

4 stars: 4 facilities

5 stars: 1 facility

1 star: 5 facilities

2 stars: 5 facilities

3 stars: 3 facilities

4 stars: 4 facilities

5 stars: 2 facilities

Maine

5

1 star: 1 facility

3 stars: 1 facility

4 stars: 1 facility

5 stars: 2 facilities

1 star: 1 facility

2 stars: 2 facilities

4 stars: 2 facilities

Tennessee13

12

1 star: 4 facilities

2 stars: 1 facility

3 stars: 3 facilities

4 stars: 1 facility

5 stars: 3 facilities

 

1 star: 4 facilities

2 stars: 1 facility

3 stars: 4 facilities

4 stars: 1 facility

5 stars: 2 facilities

Total

43

 

 

As shown below, 40% of full active participant facilities have overall star ratings of 1 or 2, "much below average" and "below average," respectively, in Nursing Home Compare’s definitions; 44% of full active participant facilities have health star ratings of 1 or 2. 

Only 23% of full active participant facilities have overall star ratings of 5 stars; only 12% of full active participant facilities have health star ratings of 5 stars.

  • Overall star ratings
    • 1 star (“much below average”): 11 facilities (26%)
    • 2 stars (“below average”): 6 facilities (14%)
    • 3 stars (“average”): 10 facilities (23%)
    • 4 stars (“above average”): 6 facilities (14%)
    • 5 stars (“much above average”): 10 facilities (23%)
  • Health star ratings
    • 1 star (“much below average”): 10 facilities (23%)
    • 2 stars (“below average”): 9 facilities (21%)
    • 3 stars (“average”): 9 facilities (21%)
    • 4 stars (“above average”): 10 facilities (23%)
    • 5 stars (“much above average”): 5 facilities (12%)

Ten of the 43 facilities received 5 stars in the overall rating, but only five of the 43 facilities received 5 stars in the health domain, indicating that self-reported staffing and quality measures continue to boost facilities’ composite scores.

A Caveat

The Government Accountability Office has repeatedly reported over the past two decades that the federal regulatory system understates and undercodes deficiencies and is overly permissive and tolerant of poor care.[14]  As a consequence, the quality of care actually provided to residents is likely even poorer than the findings above suggest.  In addition, some researchers report that rating systems are able to accurately identify only poorer quality nursing facilities, leading them to suggest more limited public reporting.[15]  Applying these researchers’ findings means that the 1 and 2 star facilities most likely do provide poor care but that the 5 star facilities still may not provide good care despite their rating.

​Conclusion

After more than eight and a half years, Advancing Excellence has not been broadly adopted by the nursing home industry.  Even more importantly, the campaign has not improved quality of care and quality of life for residents, as reported on Nursing Home CompareAdvancing Excellence is not a substitute for the regulatory system.  It is time for CMS and states to fully use the regulatory enforcement system: it is time to enforce the law.


[1] The website is https://www.nhqualitycampaign.org/
[2]https://www.nhqualitycampaign.org/about.aspx
[3] Center, “The ‘New’ Nursing Home Campaign: Déjà vu All Over Again” (Alert, Sep. 21, 2006), http://www.medicareadvocacy.org/old-site/InfoByTopic/SkilledNursingFacility/SNF_QualityCampaign.htm
[4] Center, “Voluntary Nursing Home Improvement Campaign Does Not Work” (Alert, Jan. 11, 2012), http://www.medicareadvocacy.org/voluntary-nursing-home-improvement-campaign-does-not-work/.
[5] https://www.nhqualitycampaign.org/findParticipants.aspx#.  . 
[6] https://www.nhqualitycampaign.org/default.aspx,
[7] Katie Thomas, “Ratings Allow Nursing Homes To Game System; Medicare’s Five Stars; Data Taken at Face Value Often Fails to Reflect Real Conditions,” The New York Times (Aug. 25, 2014), http://www.nytimes.com/2014/08/25/business/medicare-star-ratings-allow-nursing-homes-to-game-the-system.html?_r=0.
[8] Center, “Administration Plans Major Improvements to Nursing Home Compare” (Alert, Oct. 16, 2014), http://www.medicareadvocacy.org/administration-plans-major-improvements-to-nursing-home-compare/.
[9] Center, “Changes to Nursing Home Compare and the Five Star Quality Rating System; Two-Thirds of Nursing Facilities Nationwide Will See Decline in Their Quality Measures; One-Third of Facilities Will See Decline in Their Overall Score” (Alert, Feb. 26, 2015), http://www.medicareadvocacy.org/changes-to-nursing-home-compare-and-the-five-star-quality-rating-system/.
[10] Of California’s 11 full active participants, only two appear on Nursing Home Compare.
[11] Of Connecticut’s six full active participants, only five appear on Nursing Home Compare.
[12] Of Georgia’s 24 full active participants, only 19 appear on Nursing Home Compare.
[13]  Of Tennessee’s 14 full active participants, only 12 appear on Nursing Home Compare.
[14] GAO, Some Improvement Seen in Understatement of Serious Deficiencies, but Implications for the Longer-Term Trend Are Unclear, GAO-10-434R (Apr. 28, 2010), http://www.gao.gov/assets/100/96704.pdf; GAO, Addressing the Factors Underlying Understatement of Serious Care Problems Requires Sustained CMS and State Commitment, GAO-10-70 (Nov. 24, 2009), http://www.gao.gov/assets/300/298953.pdf; GAO, Federal Monitoring Surveys Demonstrate Continued Understatement of Serious Care Problems and CMS Oversight Weaknesses, GAO-08-517 (May 9, 2008), http://www.gao.gov/assets/280/275154.pdf; GAO, Stronger Complaint and Enforcement Practices Needed to Better Ensure Adequate Care, T-HEHS-99-89 (Mar. 22, 1999), http://www.gao.gov/assets/110/107832.pdf ; GAO, Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards, HEHS-99-46 (Mar. 18, 1999), http://www.gao.gov/assets/230/227015.pdf.
[15] Charles Phillips, Catherine Hawes, Trudy Lieberman, Mary Jane Koren, “Where should Momma go?  Current nursing home performance measurement strategies and a less ambitious approach,” BMC Health Ser. Res. 2007; 7:93,  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1920506//

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