How to find and use new federal ratings for rehab services at nursing homes

Reviewed by James Ives, M.Psych. (Editor)May 16 2019

For the first time, the federal government is shining a spotlight on the quality of rehabilitation care at nursing homes — services used by nearly 2 million older adults each year.

Medicare's Nursing Home Compare website now includes a "star rating" (a composite measure of quality) for rehab services — skilled nursing care and physical, occupational or speech therapy for people recovering from a hospitalization. The site also breaks out 13 measures of the quality of rehab care, offering a more robust view of facilities' performance.

Independent experts and industry representatives welcomed the changes, saying they could help seniors make better decisions about where to seek care after a hospital stay. This matters because high-quality care can help older adults regain the ability to live independently, while low-quality care can compromise seniors' recovery.

"It's a very positive move," said David Grabowski, a professor of health care policy at Harvard Medical School. He noted that previous ratings haven't distinguished between two groups in nursing homes with different characteristics and needs — temporary residents getting short-term rehabilitation and permanent residents too ill or frail to live independently.

Temporary residents are trying to regain the ability to care for themselves and return home as soon as possible, he noted. By contrast, permanent residents aren't expecting improvements: Their goal is to maintain the best quality of life.

Three separate ratings for the quality of residents' care now appear on the Nursing Home Compare website: one for overall quality (a composite measure); another one for "short-stay" patients (people who reside in facilities for 100 days or less, getting skilled nursing services and physical, occupational or speech therapy) and a third for "long-stay" patients (people who reside in facilities for more than 100 days).

Ratings for short-stay patients — available for 13,799 nursing homes — vary considerably, according to a Kaiser Health News analysis of data published by the government in late April. Nationally, 30% of nursing homes with a rating received five stars, the highest possible. Another 21% got a four-star rating, signifying above-average care. Twenty percent got three stars, an average performance. Seventeen percent got two stars, a worse-than-average score. And 13% got one star, a bottom-of-the-barrel score. (Altogether, 1,764 nursing homes did not receive ratings for short-stay patients.)

Here's information about how to find and use the new Nursing Home Compare data, as well as insights from Kaiser Health News' analysis:

Finding data about rehabilitation. Enter your geographic location on Nursing Home Compare's home page, and a list of facilities will come up. You can select three at a time to review. Once you've done so, hit the "compare now" button at the top of the list. (To see more facilities, you'll need to repeat the process.)

A new page will appear with several tabs. Click on the one marked "quality of resident care." The three overall star ratings described above will appear for the facilities you've selected.

Below this information, two options are listed on the left side: "short-stay residents" and "long-stay residents." Click on "short-stay residents." Now you'll see 13 measures with actual numbers included (most but not all of the time), as well as state and national averages.

Understanding the star rating. Six measures are used to calculate star ratings for the quality of rehab care for short-stay patients. Two of them concern emergency room visits and rehospitalizations, potential indicators of problematic care. Another two examine how well pain was controlled and bedsores were managed. One measure looks at how many patients became better able to move around on their own, an important element of recovery. Yet another examines the rate at which antipsychotic medications were newly prescribed. (These drugs can have significant side effects and are not recommended for older adults with dementia.)

One measure of great interest to seniors is the percentage of residents who return successfully home after a short nursing home stay. But actual numbers aren't available on the Nursing Home Compare website this time around: Instead, facilities are listed as below average, average or above average. The national average, reported in April, was 48.6%, indicating room for improvement.

Tracking variations in performance. Some facilities outperform others by large margins on measures of quality of care for short-stay residents. And some facilities have high scores in some areas, but not in others.

For instance, the nursing home at Westminster Village, a high-end continuing care retirement community in Scottsdale, Ariz., had the highest score for rehospitalizations — 39.9% — out of 68 facilities in and around Phoenix. (By contrast, the lowest score in the Phoenix area was 15.4% and the state average was 23.5%.) It also had the highest rate of helping residents improve their ability to move around on their own — 88.6%. (The lowest score was 37.6% and the state average was 63.6%.)

In an email, Lesley Midkiff, marketing director at Westminster Village, said that the facility's staff is vigilant about sending residents back to the hospital if health issues arise. At the same time, she said, staffers "push the residents just enough to regain independence and recover quickly from their short term stays." Both priorities have the "residents' best interest" in mind, she said.

If a facility has an average or low quality score, Dr. David Gifford, a senior vice president at the American Health Care Association, a nursing home industry group, recommended that people look closely at various measures and try to figure out where the institution fell short. Call the facility and ask them to explain, he said. Also, review Nursing Home Compare's information about staffing and health inspections, Gifford suggested, and visit the facility if possible.

Variations within nursing homes. The newly published Nursing Home Compare data also shows that institutions aren't always equally adept at caring for short-stay and long-stay residents.

Disparities in facilities' ratings for short- and long-stay patients are common. Of 13,351 nursing homes that received both ratings, 32% received the same star ratings for the quality of care received by short-stay and long-stay residents. Another 32% of facilities received higher star ratings for short-stay residents, while 36% got higher ratings for long-stay residents. About one-third of the time, these rating categories were one star apart, but in another third of cases, they varied by two or more stars — a significant discrepancy. (This analysis does not include 2,212 nursing homes for which data was missing.)

In Phoenix, Desert Terrace Healthcare Center, which bills itself on its website as the city's "premier location for short-term rehabilitation and long-term care," is one such facility. Its quality-of-care rating for short-term residents was two stars, while its rating for long-term residents was five stars. Notably, hospital admissions and ER visits for short-stay patients were higher than the state average, while the portion of short-stay residents whose mobility improved was lower than average.

In an email, Jeremy Bowen, the facility's administrator, wrote that the facility had a good record of managing pain and bedsores and limiting antipsychotic prescriptions for short-stay patients. Factors such as hospital readmissions depend on community resources and patients' understanding of their health needs, which are difficult to control, he noted.

Sierra Winds, part of a continuing care community in Peoria, Ariz., has a similar split in quality ratings (two stars for short-stay residents, five stars for long-stay residents). On four of six measures used to calculate star ratings for short-stay residents, it performed worse than the state average.

"Sierra Winds remains committed to providing the highest quality care and services to its residents," wrote Shannon Brown, the facility's executive director, in an email. "We are proud of our 4-star rating with CMS [the Centers for Medicare & Medicaid Services]."

That's the facility's overall rating (this includes data about staffing and health inspections). But it doesn't address the split in scores for short-stay and long-stay patients, which raises a red flag and should certainly cause seniors and their families to ask follow-up questions.

"If I'm a patient looking for a place for a short-term rehab stay, I really want to know how patients who look like me did," said Dr. Rachel Werner, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania and a quality-measurement expert.

KHN senior correspondent Jordan Rau contributed to this report.

We're eager to hear from readers about questions you'd like answered, problems you've been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.