Guest Columns

What makes a Five-Star nursing home?

Debra Larkin
Debra Larkin

This year, Presbyterian Village at Hollidaysburg became the only five-star quality rated nursing home in Blair County, PA. It is one of the few nursing homes of its kind in the state. With the strict evaluation of so many different factors going into the rating, it can be a tall task to earn the highly sought five stars.

In order for our industry as a whole to provide the best possible care for our nation's seniors, it's crucial to know and understand the areas in which we all can improve and most importantly, how to innovate and create opportunities to grow within each category.  

The Centers for Medicare & Medicaid Services evaluate senior living and care providers on three categories: Staffing levels, quality measures and health inspection. Each category holding a different weight in the Five Star system.

Our approach to meeting and exceeding the set standards is to focus on a central theme: How can we make our care delivery person-centered and have the highest outcomes that best suits each individual resident? Here's how we were able to achieve the rating at Presbyterian Village at Hollidaysburg.

Staffing: Be flexible in order to meet the greatest need

In order to improve our rating within the category of overall staffing, our nursing leadership recognized RN staffing specifically was the area in which we could improve most. We took a look at the overall amount of time the RN staff spent providing  care and revealed this group had the highest volume of activity. To start, we increased our hours per patient day.

With the state standard for PPD being 2.7, our determination in this area to rise above to 3.6 PPD has proven to increase quality and made us significantly more qualified for the Five Star rating.

My advice for others is that if there is a specific area of staffing that needs more attention, be flexible with your budget to make improvements a reality. Ultimately, having these extra hours does have an offset because it improves the overall quality of care that is provided to patients. With each increased hour of clinical care a resident is now receiving, our community is stronger and better than before.

Quality measures: Regular, proactive care plan reviews

Within the overall nursing home rating, 24 different quality categories are individually measured by CMS. It's important to prioritize and focus on the areas facing the most challenges when compared to the state or national level.

One area we had flagged for improvement was our use of antipsychotic drugs. With the intention of lowering the use of antipsychotic drugs in mind, we adjusted our policies to follow a course of treatment that started with alternative intervention methods.

For our patients in need of long-term care, our medical director now starts their evaluation immediately with a psychiatric diagnosis. We found in some cases there was not a supporting diagnosis for the existing prescription of antipsychotic drugs. By starting with non-pharmacological interventions, we successfully lowered our antipsychotic drug use. Don't be afraid to revisit existing diagnoses, especially if you are assessing a patient with an established treatment plan from a previous care provider.

To achieve our same goal of modernizing drug interventions, the health center also adjusted our entire pain control model. Instead of prescribing medication to patients “as needed” for pain, we transitioned into providing pain management on a routine basis. This put us in a more proactive state than being largely reactive. With a consistent dosage we created a consistent pattern in the body that is one step ahead of whatever the medication is treating.  

The key to success in areas of quality measurement is having a cohesive working relationship between the director of nursing and the medical director at the community. In my experience, the physician must be on board and supportive of the treatment plans the nurses are executing at the ground level. When both have a unified strategy and common goal in mind, the steps to achieving a five-star rating is streamlined in an invaluable way.

The final ingredient to success in this area was prioritizing an effort to significantly decrease the occurrence of Urinary Tract Infections among our patients. Using a bladder scanning technology, we went from an 8% occurrence rate to less than 1%. Using advanced technology allowed us to identify patterns in a patient's urination habits and tracking trends. With this knowledge, we began working with the patients to retrain their bladder, ultimately improving their quality of life and care.

When is comes to quality measures, regularly revisit the technologies and processes you are using to treat patients and constantly look to implement improvements –  especially in the areas that are deficient in the rating system per CMS.

Health inspection: Be authentic and transparent

As often lamented across our industry, surveys in any nursing center setting are typically not a pleasant process. After evaluating your staffing levels and quality measures, there is one anecdotal factor that may benefit the inspection process: transparency.

It is critical to be as transparent and honest as possible with a survey agency, as it bodes well for the whole community. Being honest and building a level of trust allows the survey agency to see how genuine you are in wanting to provide the best care possible.

The philosophy we've followed at Presbyterian Village at Hollidaysburg in order to achieve our Five-Star rating has always been to constantly evolve and strive for innovative and creative ways to provide the best care possible. If you adopt this “best foot forward” approach across your skilled nursing center, actions become habit and it becomes ingrained into daily operations.

But sometimes it doesn't have to be new, flashy or innovative. For example, creating a corporate-wide culture of prioritizing the delivery of authentic care from the ground up makes for a successful operation, perhaps even a five-star operation.

Debra Larkin is the executive director at Presbyterian Village at Hollidaysburg.

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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