New QC research refutes some common notions.

Gives JCAHO-accredited, 'poor population' SNFs another look

QUALITY IS USUALLY THE NUMBER-ONE FACTOR FOR FAMILIES searching for the "right" nursing home for a loved one. In the search for quality, unfortunately, people too often resort to some common, untested assumptions. Two common assumptions are: (1) that facilities accredited by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) always outperform their peers in terms of quality; and, (2) that facilities with primarily Medicaid populations always underperform their peers. Recent quality-of-care research refutes these two assumptions, demonstrating that JCAHO accreditation is not always proof that a nursing home provides the highest quality of care, and nursing homes with primarily poor populations frequently outperform their peers on quality. [1]

How do JCAHO facilities rate?

JCAHO is a private organization whose mission is to develop "professionally based standards" that it applies to health care facilities nationwide. [2] JCAHO inspections differ from government survey inspections. Unlike state and HCFA inspections, JCAHO inspections are announced in advance. JCAHO inspections may be conducted by an individual, whereas government surveys usually are performed by a team of inspectors.

In addition, nursing homes pay JCAHO to perform inspections. According to its mission, JCAHO "helps nursing homes, skilled nursing facilities, and long term care pharmacies to integrate quality improvement principles in their daily operations, and improve resident health." [2] How does this mission relate to the overall quality of the facilities JCAHO has accredited?

Consistent with common assumptions, more JCAHO-accredited nursing homes historically outperformed their peers in terms of quality ratings. Forty-one percent achieved above-average ratings, whereas 28 percent received below-average ratings. [3] The fact that so many (28 percent) accredited facilities underperformed their peers is surprising. Accordingly, the assumption that accreditation is tantamount to highest quality is certainly not the rule--more than a quarter of the accredited facilities scored in the bottom third of all facilities nationwide.

Terry Arnold, geriatric care manager for Houston-based Life Care Consultants, expressed doubts about the importance of JCAHO accreditation. "When making a recommendation for my clients, I never consider JCAHO as an indicator of a provider's level of quality," she said. "JCAHO's surveys simply are not thorough enough to rely upon. There are far better criteria to consider when making a decision for placement." While JCAHO accreditation serves many purposes, it would be misleading for consumers automatically to conclude that a facility is a high flier simply because it has paid for and achieved accreditation status.

How do SNFs with primarily Medicaid-paying populations rate?

According to National Eldercare Referral Systems Inc., 68 percent of the residents at the typical nursing facility cannot afford to pay for care and services and thus receive Medicaid support. Created by Title XIX of the Social Security Act, the Medicaid program is "a jointly funded cooperative venture between the Federal and State governments to assist states in the provision of adequate medical care to eligible needy persons." HCFA calls Medicaid "the largest program providing medical and health-related services to America's poorest people." While the federal government outlines the standards for the appropriation of Medicaid funds, the states establish their own standards for eligibility, decide the extent of Medicaid services to be provided, and administer their own Medicaid programs. [4]

"Quality-of-life issues are undoubtedly impacted by Medicaid reimbursement," says Joshua Zuckerman, executive director of the Pleasant Bay Nursing and Rehabilitation Center in Brewster, Mass. Zuckerman believes that, "When it comes to providing care to another human being, payor source should have nothing to do with it." He acknowledges that, despite a nursing home's best efforts, "there is just no way a facility with a high Medicaid census has the money to provide the niceties that a facility with a good private pay mix can provide." Consistent with this point of view, people generally associate low quality with facilities that house primarily poorer residents (e.g., that poor people do not receive good care). What does the evidence reflect?

Once again, the common assumptions hold true but do not establish an absolute rule regarding quality of care compared to payment source. While it is twice as likely that a primarily private pay nursing home will rate well in terms of quality, nonetheless 27 percent receive the lowest ratings.

For primarily Medicaid populated nursing homes, only slightly more nursing homes underperform (39 percent) as opposed to outperform (34 percent). Surprisingly, people who cannot afford care who are living in facilities with 90 to 100 percent Medicaid-supported populations are very likely to live in the state's best-performing facilities. [5]

Conclusions

For families, we all wish it were simple--that choosing an accredited nursing home or one with a primarily private-pay population will guarantee great care--but it is not that simple. Families still need to consider and weigh many factors, from objective quality ratings to word-of-mouth recommendations, to determine which nursing home to choose. The research reflects that JCAHO accreditation should not necessarily be viewed as a "feather in the cap." Also, surprisingly, nursing homes with residents who cannot afford care frequently outperform their peers in terms of quality.

For nursing homes, the proliferation of accredited providers has diluted the significance of accreditation in many ways. Neither a facility's accreditation status nor its population's primary payment status is a dependable indicator of a facility's historical quality-of-care performance. That being said, the best course of action remains creating satisfied customers.

Robert N. Bua, an attorney, licensed nursing home administrator and author, founded CareScout.com. He is a member of the National Academy of Elder Law Attorneys, Professional Association of Geriatric Care Managers, and the American College of Health Care Administrators.

References:

(1.) Research was conducted by National Eldercare Referral Systems Inc. ("CareScout.com") based upon historical analysis of HCFA survey inspection results for approximately 17,000 certified nursing homes across the United States according to data collected as of July 2000.

(2.) The Joint Commission for Accreditation of Health Care Organizations. 15 November 2000. [less than]http://www.jcaho.org/whatwedo_html[greater than].

(3.) Research was conducted using all JCAHO accredited, certified nursing homes as of July 2000 (approximately 2,660 facilities).

(4.) Health Care Financing Administration. 16 November 2000. [less than]http://hcfa.hhs.gov/medicaid/mover.htm[greater than] and [less than]http://hcfa.hhs.gov/medicaid/mcdsta95.htm[greater than].

(5.) Of the nursing facilities analyzed, 89.9 percent provided care for Medicaid-supported residents.

                           Quality levels of
                         JCAHO-accredited SNFs
Above average ratings  41%
Average ratings        31%
Below average ratings  28%
Note: Table made from pie chart
                    Quality levels of nursing homes
                     with high Medicaid populations
Above average ratings  34%
Average ratings        27%
Below average ratings  39%
Note: Table made from pie chart
                  Quality levels of nursing homes with
                        low Medicaid populations
Above average ratings  48%
Average ratings        25%
Below average ratings  27%
Note: Table made from pie chart

How SNFs were rated

Using proprietary methodology (see [less than]www.CareScout.com[greater than]), nursing homes were rated based on their performance in up to four years of government survey inspections. HCFA data and inspection results were weighed according to the severity of different types of violations--for example, a health deficiency such as the failure to treat pressure sores properly is weighed more heavily than a failure to provide a resident with adequate closet space. Scope and severity were also factored. Facilities that historically outperformed their peers statewide received "AAA," "AA," and "A" ratings (approximately the top 35 percent facilities) while facilities that historically underperfomed their peers statewide received "C" and "D" ratings (the bottom 35 percent).

JCAHO-accredited homes include all levels of accreditation within the long term care category and accredited homes were compared based upon their respective ratings. Nursing homes with an average of 90 to 100 percent of residents receiving Medicaid were considered to be facilities with "primarily Medicaid" populations. Nursing homes with an average of 0 to 25 percent of residents receiving Medicaid were considered as being "primarily private pay" (private pay, long term care insurance, Medicare, or alternative methods of payment) facilities.