Nursing Home Care for Veterans

Quality Data

VA’s Community Living Center (CLC) Compare Report features a star rating system adapted from Medicare’s Five Star Rating Methodology that gives each facility a rating between 1 and 5 stars. These CLC ratings are based on:

• Health surveys
• Staffing
• Quality of resident care measures

Each of these 3 domains are assigned a star rating, and, in addition, an overall 5-Star rating calculated to allow as close of a comparison to community nursing homes as possible.

The CLC Compare replicates Medicare’s five-star rating method as closely as possible, but is still a “work in progress”. For instance, VA is only able to report 11 out of 16 Medicare quality measures for skilled nursing facilities. We are working on the remaining 5 and plan to release those over the next year once they are available.

Using the star rating with other information

The star rating system can give important information about topics that residents and families find important, but isn’t a substitute for visiting a facility. Residents and families should use the star ratings, together with other sources of information such as a personal visit or a discussion with a clinical provider that understands the resident’s needs and the capabilities of a facility. The Medicare Guide to Choosing a Nursing Home (PDF) and Nursing Home Checklist (PDF) may help with questions to ask when visiting a facility.

What goes into the CLC Compare Report

Health Surveys

Medicare Certified Skilled Nursing Facilities as well as VA Community Living Centers must meet standards set by the federal government to protect residents. Examples of these standards include:

• Hiring enough quality staff to provide adequate care
• Managing medications properly
• Protecting residents from physical and mental abuse
• Storing and preparing food properly

State survey agencies conduct health surveys of Medicare certified facilities about once a year on behalf of the federal government. The health survey team consists of trained surveyors, including at least one registered nurse. VA uses an external organization to survey its CLCs using the same standards required by Medicare. VA’s survey team looks at many aspects of life in the nursing home including, but not limited to:

• The care of residents and the processes used to give that care
• How the staff and residents interact
• The nursing home environment

Surveyors also review the residents' clinical records, interview residents and family members, as well as caregivers and administrative staff.

The survey star rating is based on the last 3 years of onsite surveys, with the greatest weight given to the most recent survey. Star ratings are assigned based on how the Community Living Center scores compare with Medicare nursing homes in the same state. In some cases, VA surveyors may be “tougher graders” than state surveyors, so the star rating comparisons are only approximate.

Staffing

The staffing rating has information about the number of hours of care provided on average to each resident each day by nursing staff, which include registered nurses (RN), licensed practical/vocational nurses (LPN/LVN), and nurse aides (NA). Care hours are derived from automated systems that track staff assignments and care. Total care hours are adjusted for the fact that some residents are sicker and therefore have greater care needs. For example, a Community Nursing Home with residents who had more severe needs would be expected to have more nursing staff than one where the residents do not need as much care. Star ratings are assigned based on how the Community Living Center performs compared with Medicare nursing homes across the nation.

Quality Measures

The quality measure rating has information on different physical and clinical measures for CLC residents. This information is collected by VA Community Living Centers as well as by Medicare Skilled Nursing Facilities for all residents using the latest version of the Resident Assessment Instrument - Minimum Data Set. The information collected includes the residents' health, physical functioning, mental status, and general well-being and offer information about the progress of resident’s physical and clinical needs. Medicare Skilled Nursing Facilities and VA CLCs use the quality measures to review and improve the quality of the care they give to residents. Information is listed for 2 groups of residents:

1. Short-stay residents - those who spent 100 days or less in a nursing home
2. Long-stay residents - those who spent over 100 days in a nursing home

CMS assigns nursing homes a quality of resident care star rating based on their performance on 16 measures, of which VA currently is able to track and report 11. The other 5 are in development and will be released when available.

Quality Measures are not the same as Quality Standards

According to Medicare Nursing Home Compare the quality of resident care measures aren’t benchmarks, thresholds, guidelines, or standards of care. They are snapshot, at a point in time, of the average condition of residents. The measures also may not take into account the special populations that are served by a facility, which may cause higher rates of certain conditions. For example, a CLC that specializes in complex skin and wound care may admit Veterans with severe pressure ulcers that occurred at home or another hospital. If those residents require more than 100 days for healing, those residents will be counted in the numerator of the “Pressure Ulcer among High Risk Long Stay Residents” measure, even if their care in the CLC was entirely appropriate and met medical standards.

Things to Keep in Mind for the Overall Star Rating

No rating system can address all the important considerations that go into a decision about which nursing home/CLC may be best for a particular person. Examples include the extent to which specialty care is provided (such as specialized rehabilitation, hospice care, or care focused on behavioral or cognitive difficulties) or how easy it will be for family members to visit the nursing home resident. Visits from family can improve both the residents' quality of life and quality of care, so it may often be better to select a nursing home or VA CLC that is close over one that may be farther. Veterans and their caregivers should therefore use CMS Star Ratings together with other sources of information, such as a personal visit and tour, to determine the long-term care setting that is most appropriate.