Nursing home quality scorecards don't tell the whole score

November 21, 2011 — The scoring system government agencies use to rate nursing home quality does not provide an adequate evaluation because they do not take into account the degree of cognitive impairment of their patient populations and whether facilities include a specialized dementia unit according to a new study.

Focusing on statistics from Minnesota, researchers from Indiana University School of Medicine and the Regenstrief Institute report on the inadequacy of quality of care indicators for nursing home residents with behavioral and psychological systems related to dementia in a study published in the November 2011 issue of theJournal of the American Medical Directors Association.

"Measuring quality of care is complicated, but we really need to do a better job," says Arif Nazir, M.D., assistant professor of medicine at the IU School of Medicine and the study's first author. A geriatrician, Dr. Nazir serves as the president of the Indiana Medical Directors Association. Medical directors are physicians who provide care to those residing in nursing homes and other long-term care facilities. "We are a society that looks to scores for everything from cars to hotels, but for nursing homes, scorecards aren't the endgame."

The 80-and-above age group is the fastest growing segment of the U.S. population. One out of every five individuals in this age group is in a nursing home or will require nursing home placement in the future, the majority due to dementia.

Poor ratings may cause facilities with the most experience with dementia to be overlooked or rejected by those seeking placement for a family member who needs these services. A low score is given, for example, for worsening of behavioral and psychological symptoms associated with cognitive impairment. However, this decline is due to the natural progression of the disease, and not necessarily because quality of care is poor according to the study.

"Since quality measures for dementia behaviors are not appropriately evaluated, that throws the entire rating system off," Dr. Nazir said. "A facility with a large number of cognitively impaired residents and with staff members who are trained to help them will receive a lower score than a facility with fewer cognitively impaired residents. The scoring system for nursing homes doesn't accurately evaluate the quality of care provided to individuals with dementia, and it needs to be changed."

In addition to looking at scorecards, he suggests families also investigate the patient-to-staff ratio; whether prompt quality medical care is available to residents when needed; cleanliness of the facility; and proximity to family members who may visit. He also recommends consulting the checklist on the U.S. government website http://www.medicare.gov/NHCompare for other considerations before making a nursing home placement decision.

He strongly counsels against using only the one-to-five-star ratings (indicating much below average to much above average) on the federal and state websites to make a placement decision.

Nursing homes' quality indicators are used for regulation and facility quality improvement as well as public reporting. "Our study stresses the importance of having nursing home quality indicators tailored to the special needs of dementia residents, including the quality of their lives as well as their physical needs," said study co-author and sociologist Greg Arling, Ph.D., associate professor of medicine at the IU School of Medicine, Regenstrief Institute investigator and IU Center for Aging Research center scientist.

"The federal nursing home quality reporting system is currently being revised. It will be interesting to see how these revisions impact the way degree of cognitive impairment and specialized Alzherimer's units are rated," Dr. Arling said.

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"Monitoring Quality of Care for Nursing Home Residents With Behavioral and Psychological Symptoms Related to Dementia" was funded by the Alzheimer's Association. In addition to Dr. Nazir and Dr. Arling, co-authors are Anthony Perkins, M.S., of the IU Center for Aging Research and Malaz Boustani, M.D., M.P.H., of the IU School of Medicine, the Regenstrief Institute, and the IU Center for Aging Research.

The IU School of Medicine and the Regenstrief Institute are on the campus of Indiana University-Purdue University Indianapolis.