An Analysis of the Quality Dimension in the Nursing Homes Across the United States
Understanding Nursing Homes (NHs) Quality ratings can be complicated. Medicare has three sets of criteria to assess NHs to be identified as Medicare or Medicaid or as dual-certified, and for a single final “overall star rating” that can be used to compare NH quality locally and nationally. Out of the three criteria, Health Inspections (surveys) as a criterion is like a foundation or a roof to the house whichever analogy you like the most. It forms the basis from which NHs are evaluated for the other two criteria in arriving at a cumulative final overall star rating. Further adding another dimension to the quality ratings, health inspections are also the basis for tagging NHs into two categories-Special Focus Facility (SFF)-these nursing homes have a prolonged history of serious patient safety and quality problems and the more recent, controversial Abuse Icon-these facilities have been cited for abuse where patients were actually harmed and or for having conditions for potential harm either in the past 12 months or for a longer duration
A Primer on How NHs are Evaluated for the Star Ratings
The Three Criterion (on the top) for Evaluating & Comparing (the means on the bottom) the Nursing Home Quality via Star Ratings
Special Focus Facility (SFF) and SFF Candidate nursing homes are those that on an average have-
Twice the number of problems / deficiencies in delivery of care
More problems that are considered as “serious” (including harm or injury) and
These problems are systemic in nature and have not been resolved for at least three years
In computing the overall star rating for a NH, CMS begins with the baseline health inspections criteria star rating. A single star is then added for staffing and then for quality each, if their respective criterion scores are five stars, or a star is deducted for each criterion if the respective criterion score is one star. The overall star rating cannot be over five or under one (max-min) stars.
If the health inspection criterion star rating (which is the baseline criteria) for a NH is a single star, then the maximum allowable overall star rating after adding the staffing and quality ratings will be restricted to a two-star rating. In other words, if a NH receives a single star from the health inspection rating, through the actual site-surveys by trained, local (state-based) professionals; it could imply serious quality issues and so the staffing and quality measures ratings, no matter how good they are, will not carry the NH to receive anything over a star rating of two.
Because the health inspection surveys are on-site and local, the criterion evaluates and compares nursing homes within the state in arriving at a weighted score and then a star rating is derived from it for all nursing homes. The health inspection star rating is used as the foundational score to add or deduct the scores of the other two criteria.
The top 10% performers within the state will receive a health inspection star rating of five while the bottom 20% performers within the state will receive a single star rating. 70% of the NHs within the state will have a health inspection star rating between two and four.
CMS identifies and places NHs with a history of serious problems on a list of SFF Candidates who then assume the SFF status when officially enrolled in a program to address and remediate these issues or face progressive steps including termination of Medicare and Medicaid contracts.
NHs with an SFF status (enrolled in the program) do not receive star ratings in any of the three criterion domains and will not have an overall star rating either
A Roadmap to the Analysis
The analysis presented henceforth will generally follow the following roadmap-
All counties (in 38 states and 173 counties) in the United States with an average health inspection star rating of a 1 and an average overall star rating of a 1 or a 2
Counties (in 47 states and 81 counties) with a single NH provider and no star ratings (no health inspection and overall star ratings)-SFF
Counties (in 34 states and 123 counties) with a single NH provider and an average health inspection star rating of 1
Counties (13 states and 17 counties) with a single NH provider, with an average health inspection star rating of a 1 and either on SFF (none) or SFF candidate status
Counties (in 1 state and 1 county) with a single NH provider, with an average health inspection star rating of 1, either on SFF or SFF candidate status and a 20% or less average available bed capacity
Current NHs (524 NHs in 49 states) on SFF / Candidate status (and States with multiple counties where NH providers on SFF or SFF candidate Status)
Future potential SFF / candidate NHs (2505 NHs in 50 states)
Counties (in 37 states and 156 counties) with the best of the best NHs (a 5-star average health inspection star rating)
Counties with an average NH bed size of under 100 count (in 34 states and 109 counties) and with an average NH bed count of over 100 beds (in 24 states and 64 counties) and an average health inspection star rating of 1
Counties with NHs in the United States with an Average Health Inspection Star Rating of One
CAHISR1There are a total of 15,190 (15,166 not including DC, Guam and PR) Medicare and Medicaid certified NHs in the United States. In looking at the counties with an average health inspection star rating of 1, there are 173 such counties across 38 states with a total of 281 NHs within them in the United States, and an overall star rating is either a 1 or a 2.
There are more (than the 281 included in the county average of a single star in the health inspection survey) NHs in the country, precisely 2,946 (19.4% of the total NHs in the United States) that have a health inspection star rating of 1; of these, 1920 NHs (13% of the NHs in the country) have an overall star rating of 1 and 1026 NHs (7% of the total NHs in the country) with an overall star rating of 2.
Staffing and quality ratings may not have been adequately good to add another star to the 1920 NHs with a single star from the health inspection domain, as they have remained as a single star for the overall star rating, because the lowest overall star rating a NH would receive cannot be lower than a single star which would have been the star rating based on their health inspection rating.
The 2,946 NHs with the lowest health inspection survey scores, with a single star could be the ones that the
Patients and families need to be aware of when making choices
Insurers, hospitals (health systems, ACOs) and providers need to be aware of when referring patients. If your current goals are to improve expected patient clinical outcomes at the best possible cost and avoid harm, being informed and acting on that information timely is the key to attaining that outcome.
Counties in the United States with a Single Nursing Home Provider (and Quality Issues)
In looking at the counties instead of individual NH providers, there are 35 states in the United States within which there are 839 counties with a single NH provider within the county
There are 34 states with a total of 123 counties that have an average health inspection star rating of 1 and or the overall star rating of 1-2.
There are 47 states with a total of 81 counties, on SFF status (no overall star rating because there will be no health inspection star rating)
There are 13 states with a total of 17 counties, with a single NH provider and an average health inspection star rating of one that are also on either SFF or SFF Candidate status
Adams county in ND, with a single NH provider, an average health inspection star rating of 1, on SFF Candidate status and with a 20% or less average available bed capacity within the county.
The situation can be dire, and can pose serious challenges to the patients, families, and providers, leaving no choice other than to use the facility or assume the burden of traveling far to receive care which may not be an option in some cases for a variety of reasons including economic
NHs with an SFF / SFF Candidate Status
The 524 NHs are either a SFF (86) or a SFF candidate (441) in 312 counties across the United States in the 49 states.
Only Alaska does not have a NH provider that is a SFF / SFF Candidate.
Certain counties have multiple SFFs / SFF Candidates.
The only states that do not have multiples SFFs / SFF Candidates are-LA, MD, ND and VA
The SFF candidates (441) can have star ratings (because they are not yet enrolled in the SFF program), and so there are at least that many (441) of them in the group with a health inspection star rating of 1, of which there are a total 2946, the remaining 2505 in all the 50 states are likely going to be placed on the SFF candidate list in the future unless they work towards improving their health inspection survey scores
Counties in the United States with an Average NH Bed Count of Under and Over 100 Beds
In looking at NHs with bed sizes as a variable for quality, we compared the county averages (counties with average bed size) of beds in under 100 beds and over 100 beds categories. More counties (109) with smaller average bed counts (1-99 beds avg per county) have a single star in the health inspection criterion when compared to counties (64) that have NHs with larger bed count (100-196 beds avg per county).
There are 34 states with 109 counties with an average NH bed count of under 100 beds, and 24 states with 64 counties with an average NH bed count over 100 beds (100-196 beds,) with an average health inspection rating of 1
Counties with Excellence (Leaders) in NH Care
Finally, not everything is a "doom" n "gloom" with NH care in the United States. There are NHs in 156 counties across 37 states that are contributing to the county-wide average health inspection star rating of a 5 (which is the max a NH can individually receive) for the cumulative NHs within those counties. Needless to say, there are a lot of NHs that provide excellent care and these leaders could serve to educate their peers and inform on the best practices to look for, to the patients, families and their acute care partners
Note: On 11/4/2022 (original was published on 11/03/2022), A correction was made to the list of single NH providers in a county with an average health inspection star rating of a 1 and either on SFF or SFF candidate list. This also dropped the number of counties that also have a 20 percent or less average available bed capacity.
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