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What is missing from Five Star?

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Ilene Warner-Maron
Ilene Warner-Maron

The Centers for Medicare & Medicaid Services introduced the Five Star Quality Rating System of long-term care facilities in 2008 with the aim of improving consumerism in the selection of nursing homes. The three key components of the Five Star include health inspections, staffing and quality measures reported through MDS collection.

The rating system has gone through additional changes recently with the addition of psychotropic medications for short and long-stay admissions as an additional quality indicator. CMS plans to collect information directly from facility payroll records in order to calculate the nursing staff hours, rather than to rely on nursing homes' reports of the data. The calculation of the staffing star favors facilities with higher register nurses, adversely affecting the standing of nursing homes located in geographic areas with chronic RN shortages.

We must ask: Does the Five Star Rating system, in its current form, ensure that consumers can distinguish between a high functioning and a poorly functioning facility? Consider the following:

  1. One of the best predictors of care is the permanency of nursing staff, yet nursing turnover rates are not currently considered a quality indicator and are not used to determine the Five Star Rating;
  2. A resident's perception of quality may be very different from that of a surveyor or CMS. Residents may describe quality in terms of having certified nursing assistants with permanent assignments or having the ability to complete a menu;
  3. Data is collected regarding the development of pressure ulcers, however in some instances such as residents with multiple organ failure, metastatic cancer or the inability to maintain nutrition despite appropriate interventions, a pressure ulcer may develop. There is no provision in the Five Star to separate the avoidable from the unavoidable pressure ulcer;
  4. Facilities with higher proportions of residents on hospice may have more residents develop pressure ulcers as part of the terminal process. In addition, there may be more residents with complaints of moderate to severe pain associated with their diagnoses. Since pain is a quality measure, there may be an increased number of residents with pain that could potential affect the rating. There is no distention made between hospice and non-hospital residents regarding their reports of pain;
  5. With the closure of state psychiatric hospitals over the past decade, finding facilities for residents with mental health and physical health issues has been increasingly difficult. The inclusion of the use of psychotropic agents as a quality measure may discourage facilities from admitting prospective residents with mental health issues on long-standing psychotropic therapy in order to avoid adversely affecting their quality measures and their Five Star Rating. Exceptions include schizophrenia, Tourette's syndrome and Huntington's disease. But bipolar disease, psychotic depression and other major psychiatric diagnoses are not included in the exceptions. This may further marginalize residents with psychiatric illness.
  6. To address the issue of recruiting and retaining RNs, facilities will need to rethink the process. Consider working directly with schools of nursing as clinical sites, making the experience of working with older adults in this setting as positive as possible; use recruitment bonuses with financial incentives for months of service; access social media for recruitment; host nursing CEU programs at the facility on a topic of interest that includes a wide variety of settings such as falls or pressure ulcers.  
  7. Long-term care facilities will need to increase the level of education, support and supervision of their LPNs in the absence of RNs.  Begin by examining the types of residents, diagnoses, treatments, medications and care needs to determine the existing knowledge gaps. Direct in-service education towards filling this gap while publicizing the facility's support of LPN education and development in the community.
The Five Star Rating System may be an important tool for consumers who have the time and resources to research long-term care facilities and it may decrease individuals' reliance on the hospital discharge planner to access an appropriate bed for the patient, however consumers need to be aware that the rating system still requires them to personally visit facilities to get a feel for the type of care that is actually being provided.  

Long-term care facilities need to be aware of the unintended consequences of the rating system and CMS policy makers need to take into consideration the ramifications of the Five Star Rating System on facilities with at risk populations.

Ilene Warner-Maron, Ph.D., RN-BC, NHA, has been practicing nursing for 33 years, specializing in the care of geriatric patients. She is an assistant professor at Philadelphia College of Osteopathic Medicine in the department of Interdisciplinary Health Services.



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