Nicholas Castle interviewed nursing home residents and family members in two states about their decision-making process. 9 Two key prior studies used qualitative methods to explore nursing home choice. One quantitative study found that before nursing home quality was publicly reported, consumers chose nursing homes based on shorter distance from home, nonprofit status (potentially as a signal for higher quality), and nonclinical amenities, but not on clinical quality. More generally, little is known about how consumers choose nursing homes and the role of information about quality in that choice. This limits the ability to distinguish the most effective ways in which public reporting could be improved. However, most studies of consumer response to health care report cards have been purely quantitative, with no ability to incorporate consumer-reported experience into interpretation of results or explore what information consumers use when selecting a nursing home. Response could break down in multiple ways: Consumers may not know about the public reports, have access to them, understand them, or trust them they may not value the information relative to other considerations or they may face obstacles to accessing the high-quality providers they would prefer. Why consumers (or their agents, such as discharge planners or family members) do not respond more strongly and consistently to reported information about quality and avoid low-quality providers is still a matter of speculation. These disparities have been directly linked to payment source, with high-Medicaid population nursing homes being of lower quality. Prior research indicates that people of low socioeconomic status are more likely than others to be admitted to the worst nursing homes, 5 which have lower nurse staffing ratios, have more serious regulatory deficiencies, and are more likely to be terminated from the Medicaid program compared to higher-rated nursing homes. Nursing homes are funded largely by public payers, with approximately two-thirds of residents in a typical facility on Medicaid. 2, 3 Consumers’ responses also varied by socioeconomic status. In the nursing home setting, the evidence that consumers use publicly reported information to choose higher-quality providers is mixed. 1 In response, public reporting of health care quality has become a prominent part of the quality improvement landscape. It has long been argued that consumers have limited ability to judge the quality of health care and to distinguish among providers of different quality levels. Useful additions to Nursing Home Compare might include measures of the availability of activities, information about cost, and consumer satisfaction. Our findings suggest that efforts to expand the use of Nursing Home Compare should focus on awareness and trust. Consumers had a positive reaction when shown Nursing Home Compare however, its use appeared to be limited by lack of awareness and, to some extent, initial lack of trust of the data. We found that consumers were receptive to using Internet-based information about quality as one source of information but that choice was limited by the need for specialized services, proximity to family or health care providers, and availability of Medicaid beds. We used a qualitative assessment of how consumers select nursing homes and of the role of information about quality, using semistructured interviews of people who recently placed a family member or friend in a nursing home. Questions remain, however, as to how well consumers use this rating system as well as other sources of information in choosing nursing home placement. In December 2008 the Centers for Medicare and Medicaid Services (CMS) launched a five-star rating system of nursing homes as part of Nursing Home Compare, a web-based report card detailing quality of care at all CMS-certified nursing homes.
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