Federal Research Initiatives: Driving Quality Improvement in Nursing Homes

Health care quality initiatives, whether designed and implemented by the Federal government, healthcare researchers, provider groups, or other groups, are developed to improve health care safety, quality, and value in a variety of settings and domains and for a variety of different topics and populations. Improved transparency through public reporting of health care quality data is a critical component associated with these initiatives.

The Centers for Medicare & Medicaid Services (CMS) launched the Five-Star Quality Rating System in 2008 as an enhancement to the Nursing Home Compare Web site. CMS calculates a rating for each Medicare- and/or Medicaid-certified nursing home in the United States. The ratings, which take the form of one to five stars, are calculated in three domains: health inspection results, staffing levels, and quality measures (QMs). An overall rating ranging from one to five stars is also calculated. The star ratings correspond to levels of performance with one star indicating the poorest performance and five stars indicating the highest performance. CMS developed the ratings to provide consumers with easy-to-understand quality information and to drive quality improvement in nursing homes (Abt Associates, 2014; CMS, 2017).

While the distribution of health inspection ratings is fixed, there has been marked increase in the proportion of four- and five-star ratings in the other domains (i.e., staffing, QMs, and overall ratings) since the inception of the rating system. The proportion of one-star nursing homes in these areas has also significantly declined. The changes in the QM rating have especially dramatic since CMS added the QM ratings derived from the Minimum Data Set, Version 3.0 to the Five-Star Quality Rating System in July 2012. Because of these dramatic changes, CMS reset the QM rating distribution in April 2015. Concurrently, CMS made changes to the rules used to generate ratings in the staffing domain (Abt Associates, 2016).

Sparked by a 2011 Office of the Inspector General (OIG) report and concerns over the high rate of antipsychotic medication use in nursing homes, particularly for residents with dementia, CMS established the National Partnership to Improve Dementia Care in Nursing Homes in 2012. In July 2012, as part of this important effort, CMS added two QMs assessing antipsychotic medication use in nursing homes to Nursing Home Compare: the percent of long-stay residents receiving an antipsychotic medication and the percent of short-stay residents newly receiving an antipsychotic medication (Tritz, Laughman, & O’Donnell, 2016). CMS incorporated the quality measures into the Five-Star Quality Rating System in the first quarter of 2015 (CMS, 2016; Tritz et al., 2016)

By the end of 2013, nursing home providers nationwide exceeded CMS’s initial goal of a 15 percent reduction in the prevalence of antipsychotic medication. The usage of these medications in long-stay nursing home residents nationwide fell from 23.8 percent at the end of 2011 to 20.2 percent at the end of 2013 (representing a 15.1 percent decrease). Positive downward trends in the use of these medications continue. In fact, CMS reported the achievement of a 27 percent decrease in the prevalence of antipsychotic medication use in long-stay nursing home residents between inception of the National Partnership and the third quarter of Fiscal Year 2015 (Tritz et al., 2016).

This session will provide a brief background of the Nursing Home Compare Five-Star Quality Rating System, trends from seven years of Five-Star data, an overview of a national initiative to decrease the level of antipsychotic medication use in nursing homes, and a discussion of the impact of the initiative.