The Nursing Home Compare star rating system assesses quality of care based on health inspections, staffing and quality of resident care measures. It examines important factors such as emergency preparedness, resident/staff ratios, re-hospitalization rates, falls and antipsychotic use.

After writing about turnover in my last column, I wondered what might happen if high marks were also awarded to facilities for strong staff retention, which has been positively correlated with better care (in this research, for example). From there, I began to imagine an entire rating system based on my view of long-term care.

I think of nursing homes holistically, as microcosms that thrive when each group of participants is thriving. The three groups in each long-term care world are the residents, staff and families. If these contingents are happy, it’s more likely that there will be filled beds, fewer lawsuits and reduced turnover expenses, consequently making CEOs happy.

The supplemental rating system would be based on quality of life rather than on quality of care and it would examine the quality of life of all the participants.

The ratings would review:

  1. Staff turnover — To improve retention, facilities would invest in their staff members not just by reviewing their salaries (because nobody goes into direct care for the money), but also by investing in training, onboarding, teamwork, educational reimbursement and other initiatives (such as offering onsite childcare) that make the organization a good place to work over the long haul.

  1. Resident independence and uniqueness — This facet focuses on how well residents are encouraged and assisted to maintain their interests and connections, reducing depression and creating a more lively, joyful environment. Greater opportunity for resident autonomy would result in decreased “behaviors,” reduced use of medications, improved staff retention, fewer empty beds and positive public relations when skillfully publicized. To accomplish this, therapeutic recreation would be elevated to its proper position as a crucial department charged with designing programs that enhance life for all within the home. A director of volunteers would be hired and supported, psychology services would be well-utilized and the social work department would be staffed in a way that allows social workers to exercise the skills they were trained for rather than being limited to charting admissions and facilitating discharges.

  1. Greater family satisfaction — As I wrote in 7 powerful ways to deliver family-centered care, if we accept that we’re admitting the family rather than the individual to the nursing home, our outlook and programming changes considerably and does so in a way that increases family satisfaction and reduces problematic interactions. Much of the time spent dealing with disgruntled family members is a result of being reactive rather than proactive in our approach. Family-centered care includes ensuring that facility websites provide answers to frequently asked questions about care and links to helpful resources such as “The Savvy Resident’s Guide” and the American Diabetes Association. It includes opportunities for relatives early in the process to connect with experienced families, as well as staff training on family-centered care.

  1. Better deaths — A “good” death includes discussions with residents and their families about their end of life priorities, timely referral to hospice and palliative care services, respectful handling of the remains and an opportunity for those in the long-term care community to mourn. It’s my belief that we’d retain more new staff members if we helped them handle this aspect of long-term care (see “Absenteeism and turnover? Death anxiety could be the cause”) and that strong leadership can improve this aspect of LTC culture.

  1. Community relations — Nursing homes play an important role in local communities. LTC comes into the lives of community members when they’re at their most vulnerable and have the greatest need for and expectation of kindness and expertise. Facilities can improve community relations and care quality through intergenerational programming in partnership with schools, providing volunteer opportunities and by hosting educational and support programs for people with medical conditions. Engaging locals throughout the lifespan can increase the likelihood that the facility is chosen for both care and employment.  

I strongly suspect my supplemental Quality of Life rating system would have a positive impact on most of the areas being assessed by the current star rating system. And in the ultimate test for any of us, I might even enjoy living in a 5-star Quality of Life nursing home.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with over 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at