161-2010: Measuring Nursing Home Quality: The Five-Star Rating System

Since 1998, the U.S. Centers for Medicare and Medicaid Services (CMS) has maintained a website, Nursing Home Compare, which provides detailed quality information about every certified nursing home in the country. In December 2008, CMS greatly enhanced the usability of the website by adding an easy-to-understand 5-star rating. Each nursing home receives one to five stars based on performance in each of three key quality domains (health inspections, reported staffing levels, and quality measures derived from mandated assessments of resident health and well-being) plus an overall quality rating. Calculation of ratings requires integration of information from both facility and residentlevel data sources. SAS® was used extensively in analysis to support the development of the rating system, and it is currently used to process data to refresh the ratings each month, based on newly collected data in each domain. This presentation describes the integration of data from various sources and the rating algorithms, as well as some of the decisions that were made in the design of the ratings. The presentation also describes how the “5-star team” maintains a consistent process as the rating methodology is refined, and new data are received monthly. INTRODUCTION More than 3 million Americans live in nursing homes in the United States. In 2008, just over 7 percent of the over-65 population and more than 20 percent of the over-85 population had a nursing home stay (CMS, 2009). Many of these are long-term nursing home residents, but an increasing proportion are short-stay or post-acute patients, who spend time in a nursing home for rehabilitation after an acute hospitalization, before returning to the community. While few would argue that the quality of nursing home care has increased markedly since the passage of the Nursing Home Reform Act in 1987, quality of care remains an important concern. Over the past several years, there has been an increased emphasis on providing information to consumers about the performance of medical providers, including nursing homes, to assist them in making choices about providers, including nursing homes. This type of public reporting is intended to improve quality of care by motivating improvements in the quality of individual providers and by increasing the likelihood that patients choose high-quality providers. Nursing Home Compare (http://www.medicare.gov/NHCompare) is one of several “Compare” Websites maintained by the US Department of Health and Human Services to provide information to consumers about individual providers. Since its inception in 1998, Nursing Home Compare has provided an increasing amount of detailed information about nursing home quality. Indeed, the amount of information provided and the way in which the information has been presented may have been somewhat overwhelming and difficult to interpret and synthesize for many prospective nursing home residents and their families. Thus, the Centers for Medicare and Medicaid Services (CMS), which is responsible for the certification and licensure of all nursing homes in the US that receive Medicare and/or Medicaid reimbursement for services, as well as for the content and layout of Nursing Home Compare, decided to make a major change in the way information about nursing homes is displayed on the website. Specifically, they decided to construct summary ratings of nursing home quality using the data already available on the website. The summary ratings are displayed as easily understandable star ratings. Each home is given a 1 to 5 star rating on three distinct domains of quality, as well as an overall rating. CMS first reported these ratings on the Nursing Home Compare website in December 2008 and updates them each month as new data become available. Additionally, CMS carries on several related activities to support the use of the website, both by providers and consumers. For example, each month, an individualized “Provider Preview” report is generated for every nursing home and distributed to providers’ electronic mailboxes so that they can see their ratings in advance of the release of this information to the public via the website. Additionally, CMS operates a telephone “Helpline”, used primarily by providers, to address questions related to the ratings and the underlying data. The remainder of this paper illustrates the rating system on Nursing Home Compare and describes the development of the rating system, including discussion of each of the quality domains; the data processing used to produce the ratings each month; and some of the additional programming and analysis that is done for quality assurance, ongoing review and reporting. SAS has been used extensively throughout the process – for analysis to support the development of the rating algorithms, for the processing of the data each month to generate the ratings, and for producing several different types of reports that are used by providers, state survey agencies and by CMS. 1 Healthcare Providers & Insurers SAS Global Forum 2010