U . S . N e w s & W o r l d R e p o r t 2 0 1 9 - 2 0 B e ...

Methodology Report

U.S. News & World Report 2019-20 Best Nursing Homes

Ratings

October 29, 2019

Zach Adams, ScM Tavia Binger, MSPH

Greta Martin, ScM Anwesha Majumder, MHS

Meera Suresh, ScM Ronan Corgel

Regan Mukai, MPH Anna George, MA Ben Harder

U.S. News & World Report's "Nursing Home Finder" is the sole and exclusive property of U.S. News & World Report, L.P., which owns all rights, including but not limited to copyright, in and to the attached data and material. Any party wishing to cite, reference, publish or otherwise disclose the information contained herein may do so only with the prior written consent of U.S. News. Any U.S. News-approved reference or citation must identify the source as "U.S. News & World Report's Nursing Home Finder" and must include the following credit line: "Copyright ? 2019 U.S. News & World Report, L.P. Data reprinted with permission from U.S. News." For permission to cite or use, contact permissions@.

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Introduction

U.S. News & World Report's Nursing Home Finder is a decision-support tool created to help consumers who are seeking a nursing facility for themselves or a family member in need of either short-term rehabilitation or long-term nursing care. The Best Nursing Homes Ratings reflect U.S. News' analysis of data collected and published by the federal government using a methodology defined by U.S. News; nursing facilities' U.S. News ratings and federal ratings will differ because the U.S. News methodology and federal methodology differ. U.S. News updates ratings on an annual basis. Current ratings were generated based on data publicly available as of August 2019. The Nursing Home Finder is not a substitute for medical advice, and consumers should consult their medical professional when looking for short-term rehabilitation or long-term nursing care.

As a decision-support tool, the Nursing Home Finder has wide potential relevance. On any given day, over 15,000 nursing facilities in the U.S. care for over 1.3 million people1, most of them elderly. One of every ten Americans over the age of 85 is a nursing-home resident, and nearly one-third of older Americans spend time in a nursing home in their final months of life2.

Generally, services offered at nursing facilities fall into two categories: 1. post-acute care, often involving physical rehabilitation therapy, following a hospitalization for surgery, heart attack, stroke, injury or other conditions; and 2. long-term care for residents who are no longer able to live independently and need medical supervision. The Short-Term Rehabilitation rating evaluates nursing homes on the quality of care they provide to patients requiring rehabilitation care during short-term post-acute stays. This year, a new Long-Term Care rating has been developed to evaluate a nursing home's performance in providing services to residents in need of daily assistance with medical and nonmedical needs. The Overall rating reflects a nursing home's care of all residents, both short- and long-term.

Selecting a nursing home for one's self or a loved one should involve an in-depth site visit, preferably more than one at different times and on different days. While ratings cannot substitute for this, there are many homes to choose from, especially in metropolitan areas, and credible ratings can help consumers winnow down the options to a more manageable starting point. As with other industries, multiple organizations rate nursing homes using different criteria and weighting to assess quality, so consumers may want to consult multiple sources when making a nursing care decision.

1 Calculated from the July 2019 CMS Provider Info file. 2 Aragon, K., Covinsky, K., Miao, Y., et al. 2012. JAMA Internal Medicine. Use of the Medicare Posthospitalization Skilled Nursing Benefit in the Last 6 Months of Life. 172(20):1573-1579.

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Background on U.S. News Ratings

U.S. News began publishing online ratings of nursing homes in 2009. Initially, the tool reflected a snapshot of the star ratings posted on Nursing Home Compare (), the consumer website administered by the federal Centers for Medicare & Medicaid Services, or CMS. CMS assigns an overall rating of one to five stars to nursing homes according to their performance in three areas or domains: state-conducted health inspections, nurse staffing and medical quality measures. Homes also receive a CMS star rating in each domain.

In the 2018-19 ratings, U.S. News introduced the Short-Term Rehabilitation rating, the first composite quality score designed for use by post-acute care patients in need of skilled nursing care.

2019-20 methodology changes

For the 2019-20 U.S. News Best Nursing Homes ratings, several changes were made to improve our ability to provide consumer decision support:

Most notably, a new rating specific to long-term care was introduced. This rating evaluates a nursing home's ability to care for residents who need ongoing, daily assistance with both health-related care and non-skilled personal care, such as dressing, eating, and using the bathroom. Long-term residents are defined as residents who are in a nursing home for more than 100 days. A measurement model known as confirmatory factor analysis was used to determine a composite score for the quality of care delivered by each nursing home to long-term residents. See Appendix A for a list of measures included in this rating.

The Short-Term Rehabilitation methodology was updated to include several aspects of quality not previously incorporated, including the consistency of registered nurse staffing, antipsychotic medication usage, and success in preventing falls. See Appendix A for a list of measures included in this rating.

A new approach for the Overall rating now uses the U.S. News Short-Term Rehabilitation rating and Long-Term Care rating from each nursing home in order to generate an Overall rating. Because several substantive changes were made for the 2019-20 U.S. News Best Nursing Homes Overall rating, a home's Overall rating should not be compared against previous years'. For facilities that are eligible to receive both Short-Term and Long-Term ratings, each home's Overall rating was based on the average of the homes Short-Term and Long-Term ratings, where High Performing receives a value of 5, Average receives a value of 3, and Below Average receives a value of 1. Facilities that are only eligible in one category received an Overall rating based entirely on that score. The U.S. News Overall rating was

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previously based on three CMS-issued domain-specific star ratings: staffing, inspections and quality. The current U.S. News methodology no longer incorporates any of the CMS-issued domain-specific ratings or the overall rating from the CMS five-star quality rating system. Furthermore, some measures used in the analysis for both Short-Term Rehabilitation and Long-Term Care ratings are not used in the CMS approach. As such, facilities with five stars in the CMS short- or long-term quality domains did not necessarily receive a High Performing rating in the corresponding U.S. News rating.

Eligibility Requirements

Eligible nursing homes were first identified from the July 2019 CMS Provider Info file, which became publicly available in August 2019. Facilities with data for at least four of the five short-term claims-based outcome and journal-based staffing measures received a Short-Term Rehabilitation rating in 1 of 3 performance bands. Facilities with at least three of the four long-term claims-based outcome and journal-based staffing measures received a Long-Term Rehabilitation rating in 1 of 3 performance bands. Nursing homes that received either a Short-Term Rehabilitation rating or a Long-Term Care rating were eligible for a U.S. News Overall rating in 1 of 5 performance bands. Figure 1 outlines the eligibility criteria for each rating.

All rated homes accept residents covered by Medicare, Medicaid or both. CMS-certified facilities excluded from the analysis are still displayed with descriptive information about the location and basic characteristics in the Nursing Home Finder (nursinghomes), but without ratings (see Appendix B for more details). Nursing homes absent from the July 2019 CMS Provider Info file are not displayed on Nursing Home Finder, even if their CMS data were included in a prior or subsequent month.

In all, 13,683 nursing homes received a Short-Term rating, 13,685 homes received a Long-Term rating, and 14,853 homes received an Overall rating for the 2019-20 Best Nursing Homes Ratings.

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Figure 1. Eligibility for U.S. News Ratings

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Methods

Data sources

Data for both the short- and long-term ratings were primarily obtained from Nursing Home Compare, the CMS public reporting site3. This included information on outcome and quality measures, health inspections, nurse staffing hours, and other structural measures for each nursing home. Additional staffing measures were constructed using data from the Payroll-Based Journal (PBJ). The 2016 Skilled Nursing Facility Therapy Minutes Public Use File (PUF) was used to obtain information on utilization of services provided to Medicare beneficiaries in nursing homes for the short-term rating. Additional quality measures for the short-term rating were also obtained from the Skilled Nursing Facility Quality Reporting Program (QRP). Data from Brown University's LTCfocus provided information on whether facilities have an Alzheimer's disease Specialty Care Unit, which is currently displayed on the Best Nursing Homes website but not a component of either the short-term rehabilitation rating or long-term care rating4.

Theoretical Framework

Quality of care has no ready definition or definitive metric, and there is no consensus on the best way to measure it, particularly in the nursing home setting. Some aspects of healthcare quality are readily quantified, while others are more challenging to measure. The Short-Term Rehabilitation rating and the Long-Term Care rating, like the Best Hospitals: Procedures & Conditions ratings5, uses the Donabedian paradigm, which reflects a relationship between structure, process and outcomes, to determine a composite measure of quality of care. Avedis Donabedian described this now-widely accepted paradigm in 1966, which has been applied to healthcare as follows:

Structure refers to resources connected with patient care, such as the number of nurses or ownership status of the facility.

Process refers to the way in which diagnoses, treatments, practices to avoid harm to patients and other care are rendered, for example, whether steps known to be effective in preventing infections and medical errors or improving patient health are built into nursing home routine.

Outcomes refers to the results of care, such as whether a patient experiences a

3 Archived data provided by CMS at 4 Create Custom Reports on Long-Term Care. Retrieved from: 5 Martin, G., Majumder, A., Adams, Z., et al. 2019. Methodology: U.S. News & World Report 2019-20 Best Hospitals Procedures & Conditions Ratings.

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hospitalization or an emergency room visit, and whether a patient ultimately returns home following the nursing home stay.

An important goal of this methodology is to give patients a clear bottom line. Notwithstanding the complexity and nuance of measurement and the usefulness of particular types of information, patients deserve an overall conclusion: How well does a nursing home perform compared to other nursing homes in short-term rehabilitation or long-term care? The ratings aggregate the measures into an overall assessment in each type of care by placing homes into one of three composite bands: High Performing, Average, or Below Average.

Structural Measures

Considerable evidence has shown nurse staffing levels in nursing homes are associated with successful resident outcomes, and therefore one of the most important structural measures for evaluating nursing home care6. Well-staffed homes help to provide safe environments with necessary nutrition, appropriate administration of medication, support for various activities of daily living, and a low frequency of accidents or injuries.

Staffing measures used in both short- and long-term rating calculations are based on data collected through the PBJ. The advantage of the PBJ is that it is auditable, increasing the accuracy of the available staffing numbers at each home (notwithstanding rare reported implementation problems7) and reflects average staffing over an entire quarter. Data on the average number of registered nurses, licensed practical nurses, licensed vocational nurses and certified nurse assistants are available through this system. The daily resident population for each nursing home is calculated by CMS using the Minimum Data Set 3.0 (MDS), an assessment reported by all short-term and long-term facilities in the U.S. with beds certified by the federal government. CMS compared the total staffing hours to the average number of residents during the same period to determine the daily minutes of nursing time per resident. These measures are case-mix adjusted based on the distribution of residents by Resource Utilization Group.

The following structural measures, all related to staffing, were used in the ratings:

Nurse staffing. This is a measure of the availability of all nursing staff (including registered nurses, licensed practical nurses, and nurse aides), expressed as the average minutes per resident per day. Many long-term residents need a variety of services that extend beyond medical care, and nursing staff provide them with assistance in

6 Clarke SP, Donaldson NE. Nurse Staffing and Patient Care Quality and Safety. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 25. Available from: 7 Clyne, J.W., and Sloan, K.S. 2018. LeadingAge New York. Letter to Seema Verma RE: Nursing Home Staffing Ratings. Sept. 5.

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