Federal officials seek to raise the bar for nursing home evaluations

Physical Therapist Cara Goins, left, works with Ponder Geren at Siskin Rehabilitation Hospital on Tuesday, February 24, 2015, as he recovers from a stroke.
Physical Therapist Cara Goins, left, works with Ponder Geren at Siskin Rehabilitation Hospital on Tuesday, February 24, 2015, as he recovers from a stroke.

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Government pushes nursing homes to give patients less anti-psychotics

Picking a nursing home has never been easy.

There is much to consider that the glossy brochures don't reveal: The quality of medical care. The level of staffing. Inspection reports. Any history of penalties.

That's where government care ratings come in. And the oversight process just got tougher, as federal officials seek to raise the bar for nursing home care, an answer to longstanding criticisms that its previous ratings system was unverified and inflated.

A third of the nation's nursing homes saw their overall ratings drop last week after the U.S. Centers for Medicare and Medicaid Services unveiled the changes to its Nursing Home Compare website, which measures 15,000 nursing homes nationwide on a five-star scale.

Of the 34 nursing homes in a 50-mile radius around Chattanooga, eight now have a "much below average" score, or just one star on the five-star scale. Another eight now have two stars -- a "below average" score.

Before the change, about 80 percent of nursing homes received either a four- or five-star rating in the category of quality measures. Now, only about 49 percent of nursing homes have achieved that.

The number of overall one-star ratings has grown from 8.5 percent to 13 percent, and in Chattanooga included big names like several LifeCare Centers of America facilities and Alexian Brothers Village.

"Hopefully this motivates nursing homes to look more closely at themselves, to step up their game and educate their staffs in new ways," said Trudy Mott, the long-term care ombudsman for Southeast Tennessee, which includes 10 counties.

Officials caution that the lower ratings do not necessarily mean changes in the care provided. The new scale is part of a major shift in the way nursing homes are being assessed.

For example, the new scale will rank the use of anti-psychotic medications -- which advocates have long argued are overused by nursing homes to address patient behavior. The new system will also have more checks to track staff levels, a key factor in quality. Instead of simply self-reporting those numbers, nursing homes will be expected to back their staffing levels up with payroll information.

Overall, a higher quality rating will be much more difficult to reach.

Better quality rankings

The changes aim to push nursing homes to make improvements and to bring Americans "more precise and meaningful information on quality when they consider facilities for themselves or a loved one," a news release from CMS said.

The government estimates that 1.5 million people use Nursing Home Compare. But nursing homes watch the ratings even more closely than most consumers, using them to gauge performance and even using the star ratings system in advertising when their scores are good.

Resident advocates have widely cheered the change.

Nursing home leaders, meanwhile, are concerned that consumers will see the lower numbers and misinterpret them.

"Our biggest concern is how consumers evaluate the change, or look at this data three months down the road and they're unaware of these changes," said Jesse Samples, executive director of the Tennessee Health Care Association, which represents nursing homes across the state. "Nothing changes with these facilities. And they've worked hard to get ratings improved, and now the scale has changed."

Nursing home leaders say the new ratings are one part of a larger change in rules and regulations as such facilities look to Medicare to shift payments from fee-for-service to quality of care.

"I think all of us in the nursing home industry are trying to hurry to get a handle on these changes so we can learn the technicalities, so we can make changes accordingly," said Diana Miller, administrator for Siskin Hospital's Subacute Rehabilitation program. The program is a short-stay nursing home where people typically come to rehabilitate from the hospital before returning home or to a long-term facility.

For now, though, Miller is breathing a sigh of relief. Siskin was one of seven nursing homes that achieved a "much higher than average" overall rating.

"I was so thankful. I have been thanking my staff ever since then," she said. "Hopefully it means we're on the right track and we'll be able to work within this new system."

Other local nursing homes that saw much lower ratings under the new system urged consumers to read the new reports carefully.

"There needs to be a measure of quality and raising the standards is a good thing; however, there are some caveats to the system the consumer may not understand," Alexian Village CEO Robin Baschnagel said in a statement.

Alexian Village performed above average on quality measures. But it still got the lowest possible score for its overall rating after a low health inspections score from August 2014. Inspectors found five deficiencies, ranging from how medications were stored to how residents' complaints about food palatability were being addressed.

"We would ask [consumers] to consider the quality measures rating and compare to other facilities," Baschnagel said. "Some facilities may have a better overall ranking, but in comparison to Alexian Village, their quality measures are lacking."

LifeCare Centers of America, which is headquartered in Cleveland, Tenn., also saw some of the lowest local ratings at its Cleveland, Red Bank and Rhea County locations. The centers were primarily hit on quality scores -- which included problems like higher-than-average numbers of urinary tract infections and pressure ulcers, and of residents who were physically restrained.

In a statement, company President Beecher Hunter said Life Care is "still above the national average in overall stars and quality, and we strive to provide excellent care each and every day."

"The safety and well-being of our residents is our highest priority, and we encourage any consumers researching nursing facilities to visit one of our buildings to see the quality care we provide," he said.

Seeing is believing

Advocates agree that the Medicare data cannot outweigh the importance of in-person visits.

Mott travels the region visiting nursing homes, checking on complaints and compliance issues. While she is glad that the federal government brings more accountability, she is wary about how people interpret the ratings.

"You can have a bad rating at a good facility for various reasons, and you can gave a good rating at a bad facility," she said. "The care itself is given by people. And as always, people will be people -- for good and for bad."

Mott recommends families spend time at nursing homes when they're making decisions for their loved ones. Go inside, get a feel for a place, she says. Talk to residents. Talk to staff. Some will be very truthful.

"Some will tell you, 'I wouldn't bring my mom here,' even when they work there," she said.

Mott hopes the changes CMS is bringing will be helpful, but she is more concerned about making changes at the staff level -- bringing payment and training into line so that certified nursing assistants and others on the front lines of care feel better-motivated to do their jobs well.

"I bring different eyes when I go into a nursing home," Mott said. "I am always trying to remind those administrators: This is not your home. You go home every day. This is [the residents'] home, their space, and you're entering into it. You need to respect them."

Contact staff writer Kate Belz at kbelz@timesfreepress.com or 423-757-6673.

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