In the Literature
When deciding on a nursing home for a family member, consumers often rely on information from ranking systems that are based solely on quantitative measures of questionable importance, say the authors of "Where Should Momma Go? Current Nursing Home Performance Measurement Strategies and a Less Ambitious Approach" (BMC Health Services Research, June 25, 2007). To better inform consumers, the authors recommend an alternative approach to identifying the best and worst homes that relies on multiple dimensions of quality measured over time.
Attempts to differentiate good from bad nursing homes have been stymied by several factors, including the multifaceted nature of quality, diversity within the nursing home population, and difficulty in gauging if variation in resident outcomes is driven by a home's performance.
These barriers "create fundamental problems in our ability to provide consumers with meaningful evaluations," the Commonwealth Fund-supported researchers say. Performance measurement systems can best be used to identify the small number of homes that fall at the low end of the quality spectrum, and may even provide some information about top-ranking homes. But they do not tell us if the many homes that fall in the middle are good options.
Over the years, Consumer Reports has published a series of Nursing Home Watch Lists identifying the "worst 10 percent" of nursing homes in each state, based solely on a review of annual state inspection surveys. In 2006, the Watch Lists were replaced with the Quality Monitor, which uses a new approach that takes into account multiple dimensions of quality over time and uses those results to identify homes that score very badly or very well.
The Quality Monitor examines three dimensions of quality: nurse staffing levels, deficiencies cited in the three most recent state inspection surveys, and quality indicators established by the Centers for Medicare and Medicaid Services. Within each state, homes in the best and worst 10 percent on each dimension are identified. The list of top-ranked homes includes those that are among the best 10 percent on at least two of the three dimensions. The list of bottom-ranked homes includes those in the worst 10 percent on at least two dimensions.
While this "less ambitious" approach may prove helpful to consumers, regulators, and policymakers, it does not remedy every shortcoming. For instance, current measurement systems do not include the views of residents and their families. And while these systems provide information about the "average" resident, in truth, no resident is average. "All residents have special, individual needs. So our ability to provide information about which homes are best for specific individuals is very limited."
The bottom line, the authors advise, is that "information from any performance measurement website or report is no substitute for multiple visits to a home at different times of the day to personally assess quality."