When it comes time to place a loved one in a nursing home, or to select a facility for their own care, many Americans find themselves in unfamiliar territory.

A new Commonwealth Fund–supported nursing home guide published in the September issue of Consumer Reports is likely to make this process less stressful—by identifying the highest- and lowest-performing nursing homes in each state and offering tips on how consumers can evaluate the homes that fall in the middle. The investigative report, "Nursing Homes: Business As Usual," written by Trudy Lieberman, director of the Center for Consumer Health Choices, also serves as a wake-up call for the 12 nursing homes in the nation that have been cited for poor care by Consumer Reports for five years in a row, as well as for the state agencies responsible for monitoring quality of care in these facilities.

How to Choose a Good Home

For its report, Consumer Reports analyzed the three most recent state inspection reports for the 16,000 nursing homes across the U.S. and examined staffing levels and quality indicators, such as how many residents develop pressure sores when they have no risk factors for them; the proportion of residents who spent most of their time in bed; and the proportion of residents who experienced a decline in their ability to move about independently.

The Nursing Home Quality Monitor, available online as a clickable state map, is a database of homes to consider—and homes to avoid—in each state. The monitor also indicates if a home is for-profit, non-profit, or government-owned, and whether it's part of a chain or independently owned. These are key facts to know, as the Consumer Reports analysis found that non-profit homes are more likely to provide good care than for-profits. Researchers also learned that independently run homes are more likely to provide good care than chains.

Other recommendations for individuals or families searching for a nursing home include:

• Visit the homes. Once you've selected a few homes, make unannounced visits at different times of the day.

• Read each home's state inspection survey. This report, called Form 2567, should be accessible to all visitors. Difficulty obtaining the report may suggest the home is trying to cover up negative information. A long report often indicates a facility has many deficiencies.

• Ask about top-level turnover. Frequent changes in the administrator and the director of nursing positions could be an indication of poor care.

Why Hasn't the Industry Improved?

The number of poorly performing homes Consumer Reports uncovered shows that bad care is still a problem in this country, despite the passage of a 1987 federal law designed to improve nursing home care for the elderly. The report suggests that enforcement may be part of the problem. According to the Centers for Medicare and Medicaid Services, deficiency citations written by inspectors today are less likely to contain codes that indicate severe problems than they were in 2003.

Additionally, the report points out that state agencies have been slow to impose or collect fines from poorly performing homes. For example, eight of the 12 five-time repeaters on this year's list of poorly performing homes were not fined by the state between 1999 and 2004.

Moving Toward Resident-Centered Care

So how can we get the nursing home industry at large to buy into high-quality care that prioritizes the needs of residents? It's clear that legislation and regulations alone will not drive the change toward resident-centered care. Consumers must push industry to provide the kind of care America 's elders deserve.

The Picker/Commonwealth Quality of Care for Frail Elders program supports the development and spread of culture change in nursing homes by helping to form and test models, such as nonprofit nursing home collaborative Wellspring Innovative Solutions for Integrated Health Care, the Mississippi-based Green House Project, and the Meadowlark Hills retirement community in Manhattan, Kansas. The Frail Elders program also fosters leadership organizations, such as The Pioneer Network, and supports resident-centered care policy initiatives.

The program has also identified projects that empower consumers. The recently released book, 20 Common Nursing Home Problems and How to Solve Them, by Fund grantee Eric Carlson of the National Senior Citizen's Law Center, was highlighted in a Wall Street Journal article and has become an important resource for state and local long-term care ombudsman, who assist nursing home residents and their families.

By becoming consumer-savvy and demanding good, resident-centered care, nursing home residents and their families will help create demand for facilities that not only properly care for residents, but also make them as comfortable and independent as possible.

As always, we'd like to hear from you. Send your feedback to mjk@cmwf.org.

August 2006

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