January 03, 2016

For Patient's Sake!

For the last few days I’ve been trying to identify an average skilled nursing facility. Just your typical “rehab,” the place you are likely to be sent after a hospitalization if your are over 65 and had a hip replaced or perhaps a heart attack or a stroke. Some place with dedicated “post-acute” beds, with or without a long term care section where people live out the duration of their lives once they can no longer live independently or in assisted living. Not a “teaching nursing home,” one of a handful of academic institutions that is affiliated with a long term care facility. Not a giant nursing home with 500 or more beds, nor a small ten-bed unit that’s within a hospital. Just a regular SNF, preferably in the Midwest. I’m working on a book about the American health care system, one section of which is about post-acute care, and I’d like a short vignette describing an average SNF. I have plenty of stories of patients’ experiences in a SNF but for purposes of my narrative, I’d like to describe a run-of-the-mill SNF. I’d prefer it not be in the Boston area because my book is already too Boston-centric. And I’ve already featured a hospital in Florida and a physician group practice in California, so for geographic balance, I’d prefer a facility in the middle of the country, preferably in an urban location (most facilities are in cities). It should be a for-profit institution because 70% of SNFs are for-profit. A 150-bed free-standing building in Illinois (Chicago would be good), Michigan (Detroit would be excellent), or Ohio (Cleveland would be perfect), owned by one of the major national chains such as Genesis or HCR ManorCare or Kindred would be ideal. I found quite a few that meet my criteria—but what’s really disturbing is that I can’t find out much about any of them.

I’m going to have to interview the director of nursing or the medical director or the administrator at Average Nursing Home. I may have to visit the facility. But I’d like to get some background information first. And I need to know whom to contact. My problem is that it’s almost impossible to find what I’m looking for and that means it’s almost impossible for prospective patients or their families, too. It means that accountability in these facilities, to which about 20% of older patients go after they leave the hospital, is largely absent. That’s disturbing.

I’ve looked through dozens of websites in the last few days and I have learned quite a bit about nursing home chains. I’ve learned that each chain comes up with a brief and none-too-informative description of its SNFs and essentially uses the same description for every one. They use the same photos, too: evidently there is a generic “dining room photo” and a generic “exercise gym photo.” I’ve learned that they believe that they are marketing the buildings and their equipment, not the people who run the buildings or who provide the clinical care. A bright and clean building with corridors wide enough to accommodate wheelchairs and walkers is nice, and modern exercise apparatus is desirable, but most important are the nurses and the certified nursing assistants who take care of the patients. And there isn’t a word about who actually works at the SNF. The only exception is Genesis Healthcare, the largest of the chains, which has a tab for “staff” on its websites and lists the administrator, director of nursing, admissions director, and sometimes the rehab director, along with some of their credentials. No email addresses, but the facility has an address and a phone number, so it’s possible to track these people down. Even Genesis doesn’t list the medical director, the physician who is required by law to be in charge of assuring that the facility meets certain standards of care.

Maybe I’m just spoiled—I’ve come to realize what an extraordinary wealth of information is readily available for other parts of our health care system, about hospitals and group practices and health insurance companies. Hospital websites, even though they are fundamentally about PR, include the names of the physicians on staff. You can look up how many cardiac surgeons and orthopedists are affiliated with a given hospital and you can find out where they went to medical school or did their residency. You can track down whether they have lost malpractice suits. Local newspapers often have articles about new developments at their community hospitals—new programs, new systems of care, new rankings, and of course new scandals. But about SNFs—hardly a word. When the Department of Justice accused several nursing home chains of bilking Medicare of billions of dollars by charging for “intensive” therapy services from which patients couldn’t possibly benefit—some of them were moribund—that rightly made national news. When a new SNF opened in a small town, that also made the news, principally because it was seen as a source of new jobs. But that’s it. Why? Why is there so little publicly available information about skilled nursing facilities?

If you look at a list of the largest nursing home chains in the US, you will find Genesis Healthcare (#1) is now publicly traded—but only since February, 2015 (it was taken private in 2007). HCR Manorcare (#2) is owned by a private equity firm and both Golden Living (#3) and Life Care Centers of America (#4) are privately held. Kindred (#10) is publicly traded. The private corporations have no incentive to have anything other than a sanitized public image. The publicly traded firms are accountable to their stockholders rather than to patients. If you want to find a facility that is reasonably forthcoming about its operations, you have to look at the non-profits.

This little exercise in futility gave me a far greater appreciation for Nursing Home Compare, Medicare’s website that offers the consumer information about nursing home quality. In the past, I’ve made fun of the five star rating system used by the site and criticized the choice of quality measures: for short stay facilities, the 5 quality indicators used are the proportion of patients who received a flu shot, the proportion who received a pneumonia vaccination, the proportion of patients with a new or worsening pressure ulcer, the proportion of patients newly prescribed an anti-psychotic medication, and the proportion who report moderate to severe pain. I was impressed by a NY Times article in 2014 detailing how nursing homes can game the system and win a five-star rating even when they offer abysmal care. But the latest version of the rating system, which went into effect in February, 2015, relies on actual independent measures of things such as staffing ratios, rather than on the nursing home’s self-report, and is both more reliable and more accurate. 

Nursing Home Compare doesn’t tell the whole story, but it provides an important piece of the story. We need investigative journalists shining a light on this industry and we need more transparency from the institutions themselves. We need to pay more attention to what goes on in skilled nursing facilities, for the patient’s sake.

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