Guest Columns

Cracking the code to seven years of Five-Star ratings success

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Steven Littlehale
Steven Littlehale

Since the inception of the Five-Star Quality Rating program in December 2008, there have been 113 Skilled Nursing Facilities (SNFs) that have earned and maintained an overall 5-star score. Who are these exceedingly high performers and how do they do it? Are their practices something you can emulate? Or, are they just lucky, living in a better ZIP code, or perhaps managing an “easier case-mix”?

Does it surprise you to learn that they are disproportionately nonprofit SNFs? It shouldn't. Nonprofit facilities outperform for-profit facilities in terms of survey outcomes (Health Inspection Rating).

In fact, in terms of “total survey points”, nonprofits average 44.84 versus the for-profits' average of 63.49. Since Five-Star is mostly driven by survey performance, you would rightly expect more nonprofits in this select group, and that is precisely what we see.

Of the 113 SNFs, 66 are nonprofits. However, before we dismiss this finding as being merely an artifact of the survey process, let's consider the other findings and acknowledge that 47 for-profit SNFs that are in this elite group.

Ninety-six percent of SNFs in this group of 113 earned 5 stars not by their survey performance alone, but by the extra lift the staffing and/or quality domain affords. Recall that a SNF has an opportunity to earn an extra point toward its overall Five-Star score if their staffing domain is 4 or 5 and greater than their health inspection rating. Also, an additional point can be earned if its quality domain is a 5.

In addition, facilities can lose their overall 5-star status by performing poorly on staffing and quality. Sixty-nine SNFs earned their way to 5-star honors by picking up an additional point from staffing, 16 SNFs earned their way through a 5 in Quality, and 21 earned a two-point lift through both staffing and quality. It's not just about survey.

Many SNFs approach Five-Star as a numbers game, and in fact it is. But ignoring what the numbers represent is missing the point ... and if you miss the point, you miss out on a point and, ultimately, membership into this select group!

A characteristic that jumps out from the data is that these 5-star facilities far exceed the cut-off points needed for a 5 in both the staffing and quality domains. It's common to see these SNFs making it well over a threshold by a much more significant margin than the non-5-star facilities.

SNFs with seven years of 5-star status appear to be focused primarily on providing quality care and not “making the grade.”

One more interesting finding was that the case-mix adjusted rehospitalization rate for this elite group was lower than the others by almost 4%.  Clearly, doing good vs. looking good seems to be a winning strategy for these 113 SNFs!

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.