Guest Columns

The Five Star Report, once again, in the SNF spotlight

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Steven Littlehale
Steven Littlehale

The Five Star Quality Rating System takes the spotlight on the front page of the New York Times and the top of the news cycle. The ranking member of the House Committee on Oversight and Government Reform's comments guarantee that the subject will continue to burn brightly. Rep. Elijah E. Cummings' letter to Congress generates additional discussion and review of the rating system that has become so widely used by so many.

Regardless of any of the program's weaknesses, it cannot be ignored that providers have used this metric to establish goals and measure improvement — and improved they have.

I remain mostly concerned, not at the actions of a few providers, but how misleading the rating system is to consumers. It does have the benefit of being easily understood by the general public in its transparency and does mimic other star-based rating systems. However, it assumes that all people entering a skilled nursing facility are the same.

In the existing system, a person in need of short-term care for, say, cardiac rehabilitation would be inclined to select the same four- or five-star SNF as a long-stay person with dementia. Now, you know that SNFs cannot possibly be “the best” for every type of person, so I hope that industry leaders are encouraged to reform Five Star to include more alignment of resident needs to facility strengths.

Since its introduction, SNF providers have improved in the Five Star overall, so why all the fuss by the media and politicians? The New York Times article made a significant leap — from data being self-reported to all SNFs game the system. The risks to a provider if they were to manipulate their data far surpass any short term Five Star Rating benefit.

Our experience has been that most providers use the Five Star information and our associated tools to work toward improving the metrics that drive the measures. I will concede that even though the data is often being purposely manipulated, it is also often inaccurate and not always in ways that benefit the provider.

Surveys are the most influential component of the Five Star Rating System and carry the greatest weight in determining the overall rating. Yet, how surveys are conducted and their outcomes vary considerably by geographic location, proprietary status and resident case mix.  In fact, your ZIP code remains the best predictor of your survey results! The system attempts to control for this variation by using the state vs. the nation as the benchmark, but that doesn't go far enough as considerable variation is seen within the states themselves.

The New York Times article points out that the staffing domain is driven by self-reported data. Clearly, education about which staff to include or exclude and systems to ensure accuracy of the self-reported data must be in place. I don't doubt that some providers bulk up staffing to prepare for survey, but overall, I've seen more organizations unintentionally NOT include staff that they rightly should. Some organizations lean on their payroll software to supply this data. While that's convenient approach, it likely does not count salaried staff that might pick up an additional shift or corporate consultants in the building providing support that qualifies to be counted on the 671. Or their payroll system might not automatically count contract staff.

A simple electronic payroll data feed is not the easy answer to accuracy in reporting.

The MDS assessment provides the source data for the Quality Domain. Erroneous MDS data impacts more than just Five Star. It also impacts the care planning and Medicare reimbursement and Medicaid in many states. For these reasons, it is a rare facility that does not have an interdisciplinary team completing the MDS assessment and multiple layers of review or monitoring for accuracy- getting it wrong has enormous clinical, quality and financial implications.

Although the Five Star Report is not perfect, it has achieved some of its basic goals. SNF providers are focused on their public data profile, and working hard to improve all aspects — state inspections, staffing and quality outcomes. The skilled nursing industry has responded with full intentions to demonstrate a quality focus as they care for America's growing senior population.

I'd like to propose that industry leaders and stakeholders present to the government a better alternative to ensure consumers make the best selection and have the tools to monitor care on an ongoing basis.

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.


Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.

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