Steven Littlehale

The Centers for Medicare & Medicaid Services released improvements to Nursing Home Compare (NHC) in April, with features that included ending the freeze on the health inspection star and quality measure (QM) domain and staffing domain improvements. 

After careful review, I give these improvements two stars, based on a combination of the following three domains: 

  1. Consumer (customer) centricity —This domain measures empathy. Empathy is the ability to anticipate and appreciate/understand and share the feelings of another.
  2. Validity — Validity provides an indication that the reported findings on NHC truly represent the phenomenon CMS is claiming to measure: nursing home quality.
  3. User experience design (UX) — UX is a rating of “ease of use” of the website, and how intuitive and “delightful” it is to interact with.

Consequently, I am asking CMS to take down NHC until this rating improves to at least three stars and until said rating can be sustained in 8 out of 12 calendar months … crickets.

Let’s take a closer look.

Consumer Centricity

Empathy is difficult but not impossible to measure. It can be objective, but ultimately open to individual interpretation, similar to the survey process. Individual survey teams influence survey outcomes. The greatest predictor of survey performance has always been zip code.

Therefore, and following the same logic of Five-Star Survey Domain, empathy is weighted the heaviest, and has the greatest impact in determining my overall rating of two stars. 

Most people come to a skilled nursing home from the emergency room or after a hospital stay. They, and their families, are often in crisis. This awareness should always be a priority as we seek to improve the consumer centricity domain score (and NHC). Here are some recommendations to help achieve this goal:

  1. Define the consumer as the Medicare recipient, in addition to his or her personal advocates. Begin the consumer’s journey on NHC by having him or her answer the follow questions:
  • “Are you looking for a short-term stay?”
  • “Are you looking for a long-term stay?”
  • Or even more simply, “Do you hope to ultimately go home?”

How often are you asked by colleagues, friends and family to help make a choice of a nursing home? I suspect that, like me, you begin with this line of inquiry. With a few follow up questions, a finer point could be achieved to prove the very basic, yet essential, differentiation, which is the fact that there are indeed two categories of care in a nursing home: long-term care and short-term care.

  1. My second recommendation would be a major paradigm shift for CMS and our industry as a whole: to abandon the use of the word “resident” as a catch-all term for all clients. Can’t we call people “people” and not use a term that is, at best, misunderstood, or at worst, loaded with negative connotations — particularly for a short-stay individual? To avoid these emotion-laden implications, I suggest the use of “patient” when the goal is short-term rehab with the intention of a return to home. This would carry forward a caregiving designation that the individual and his or her family have already identified during the hospital stay. We should use the term “resident” only when there is a long-term placement, emphasizing a suggestion of moving into a caring home environment.

CMS already has taken an important step in this direction by separating short- and long-stay measures in the Quality Domain, and using the term “patient” in our new reimbursement model, Patient Driven Payment Model.


Does NHC measure and report on quality in ways that actually help consumers make better and more informed placement decisions? NHC allows you to find and compare nursing homes certified by Medicare and Medicaid. The website contains a plethora of data and measures, all attempting to help the consumer make the most informed decisions possible. However, many outcomes deemed important are given the same visibility as those that are not. Some outcomes, like rehospitalization, appear in several places, all with slightly different meanings. 

There is little evidence in academic literature that indicates that NHC actually helps consumers as intended. On the contrary, what is available in both peer-review literature and trade publications are repeated criticisms and calls for improvement. 

Recommendations to improve the validity domain include the following:

  1. CMS should fund independent studies to measure NHC’s effectiveness.
  2. CMS should then contract for the development of multi-dimensional, yet simple, composite measures that will provide directional guidance for consumers.
  3. Social determinants of health must be considered and how they impact the measures reported in NHC.
  4. A reliable and valid measure for overall satisfaction with nursing home should be added.
  5. Comparative benchmarks should be narrowed to reflect more relevant competitive markets. State benchmarks are helpful but are also often too broad. National data is almost meaningless. “All healthcare is local.”


Wow, where to begin. NHC does not “delight.” However, I’ve been around the site enough to navigate pretty effectively. There are countless paths to “click down,” taking you to similar but not identical information, and more than a few daunting dead-ends.

Are elder consumers and their advocates consulted to help improve NHC? Does CMS listen to the feedback? In 2016, the GAO provided feedback to CMS to improve the design of NHC and add measures of satisfaction. In their report, they wrote:

“… CMS does not have a systematic process for prioritizing and implementing these potential improvements. Rather, CMS officials described a fragmented approach to reviewing and implementing recommended website changes. Federal internal control standards require management to evaluate appropriate actions for improvement. Without having an established process to evaluate and prioritize implementation of improvements, CMS cannot ensure that it is fully meeting its goals for the website…”

Recommendations for UX include the following:

  1. Stop trying to be everything to everyone. Focus on Medicare consumers and send other users of the system elsewhere.
  2. Bring consumers into the design process.
  3. Eliminate the jargon, use familiar terms, and remove acronyms.
  4. Don’t try to turn consumers into regulatory experts, geriatric researchers, or clinicians. 
  5. Links to links to links to links, is a great idea, said no one ever!

Finally, how amazing would it be if a consumer didn’t have to consider his or her healthcare experience in silos at The Affordable Care Act makes great strides to vertically integrate healthcare in the United States. Imagine if all the “” sites did that as well? Only then would CMS get a well-deserved five stars.

Steven Littlehale is a gerontological clinical nurse specialist, and chief clinical officeremeritus at PointRight.