Advancing Excellence: Very Few Nursing Homes are “Full Active Participants” and Nearly Half of Them Provide Poor Care

In September 2006, the nursing home industry announced a voluntary quality improvement campaign – Advancing Excellence in America’s Nursing Homes.[1]  The campaign, now in its ninth year and third phase, describes its mission: “to make nursing homes better places to live, work, and visit.”[2]  The Center for Medicare Advocacy (Center) was skeptical about the campaign when it was announced in 2006,[3] expressing concerns with the campaign’s minimal goals and repetition of similar and ineffective voluntary improvement initiatives.  Since 2006, the Center’s skepticism has continued.  In 2012, the Center found that facilities providing the poorest quality of care, identified by the Centers for Medicare & Medicaid Services (CMS) as Special Focus Facilities, participated in the campaign to the same extent as other facilities.[4]

Now, for the first time, the campaign reports the level of participation by facilities that register for the campaign.  Analysis of this information indicates that relatively few facilities are actively involved.  Even more troubling, the Center’s review of facilities in five states finds that the highest level of participation by facilities is not correlated with providing high quality care, as reported on Nursing Home Compare.  In fact, as shown below, the opposite is the case.  Nearly half the “full active participant” facilities provide care that CMS describes as “below average” or “much below average.”

Campaign Participation is Limited

Until May 2015, the campaign announced only the names and, by state and nationally, the number of facilities that registered to participate in the campaign.  Since May, the campaign has identified each facility’s actual level of participation, using one of five icons.[5]  Facilities identified as “full active participants” (the highest level of participation) are described as having selected goals and consistently reported their progress to the campaign for the most recent six months.  Four other categories of participation have icons that reflect various levels of participation – i.e., they submitted some data on some of the goals they selected for some period of time.  Facilities that registered for the campaign but have not engaged in any other way do not have any icon by their name.

The Center’s review of five states finds that the level of full participation in the campaign is extremely minimal.  Although the campaign homepage now reports that 62.6% of facilities nationwide participate in the campaign,[6] few facilities are full active participants and the overwhelming majority have done no more than register.

Facilities’ level of participation in Advancing Excellence

State	Number of registered facilities	Full active participants, number	Full active participants, percentage	Registered only, number	Registered only, percentage
California	560	11	2%	538	96%
Connecticut	200	6	3%	174	87%
Georgia	360	24	7%	306	85%
Maine	110	5	5%	77	70%
Tennessee	250	14	6%	217	87%
Total	1480	60	4%	1312	89%

“Full Active Participation” Does Not Correlate to High Quality of Care

The Center looked at CMS’s website Nursing Home Compare to see how the full active participants in five states fared.  Nursing Home Compare scores each facility participating in Medicare or Medicaid, or both, on three separate dimensions – health surveys, staffing, and quality measures – and calculates an overall composite score.  Scores are one to five stars for each dimension and for the overall score; one star is the lowest rating and five stars, the highest.

The overall star rating has the health survey rating as its core, but it can be adjusted upwards or downwards, based on the staffing and quality measures, both of which are self-reported and not audited.  In August 2014, The New York Times reported that facilities “game” their star ratings, particularly their quality measures.[7]  Following this investigative report, CMS announced plans to revise Nursing Home Compare[8] and recalibrated the ratings for the quality measures.[9]

Only 43 of the 60 “full active participants” are found on Nursing Home Compare.  At least 11 of the 17 facilities whose ratings are not reported on Nursing Home Compare are Veterans Administration facilities.

As shown below, “full active participation” facilities are represented in each of the star ratings categories on Nursing Home Compare.

Overall and Health Star Ratings for Full Active Participants in Advancing Excellence

State	Number of facilities on Nursing Home Compare	Overall star rating	Health star rating
California10	2	3 stars: 1 facility 5 stars: 1 facility	2 stars: 1 facility 4 stars: 1 facility
Connecticut11	5	3 stars: 2 facilities 5 stars: 3 facilities	3 stars: 2 facilities 4 stars: 2 facilities 5 stars: 1 facility
Georgia12	19	1 star: 6 facilities 2 stars: 5 facilities 3 stars: 3 facilities 4 stars: 4 facilities 5 stars: 1 facility	1 star: 5 facilities 2 stars: 5 facilities 3 stars: 3 facilities 4 stars: 4 facilities 5 stars: 2 facilities
Maine	5	1 star: 1 facility 3 stars: 1 facility 4 stars: 1 facility 5 stars: 2 facilities	1 star: 1 facility 2 stars: 2 facilities 4 stars: 2 facilities
Tennessee13	12	1 star: 4 facilities 2 stars: 1 facility 3 stars: 3 facilities 4 stars: 1 facility 5 stars: 3 facilities	1 star: 4 facilities 2 stars: 1 facility 3 stars: 4 facilities 4 stars: 1 facility 5 stars: 2 facilities
Total	43

As shown below, 40% of full active participant facilities have overall star ratings of 1 or 2, “much below average” and “below average,” respectively, in Nursing Home Compare’s definitions; 44% of full active participant facilities have health star ratings of 1 or 2.

Only 23% of full active participant facilities have overall star ratings of 5 stars; only 12% of full active participant facilities have health star ratings of 5 stars.

• Overall star ratings
  • 1 star (“much below average”): 11 facilities (26%)
  • 2 stars (“below average”): 6 facilities (14%)
  • 3 stars (“average”): 10 facilities (23%)
  • 4 stars (“above average”): 6 facilities (14%)
  • 5 stars (“much above average”): 10 facilities (23%)
• Health star ratings
  • 1 star (“much below average”): 10 facilities (23%)
  • 2 stars (“below average”): 9 facilities (21%)
  • 3 stars (“average”): 9 facilities (21%)
  • 4 stars (“above average”): 10 facilities (23%)
  • 5 stars (“much above average”): 5 facilities (12%)

Ten of the 43 facilities received 5 stars in the overall rating, but only five of the 43 facilities received 5 stars in the health domain, indicating that self-reported staffing and quality measures continue to boost facilities’ composite scores.

A Caveat

The Government Accountability Office has repeatedly reported over the past two decades that the federal regulatory system understates and undercodes deficiencies and is overly permissive and tolerant of poor care.[14]  As a consequence, the quality of care actually provided to residents is likely even poorer than the findings above suggest.  In addition, some researchers report that rating systems are able to accurately identify only poorer quality nursing facilities, leading them to suggest more limited public reporting.[15]  Applying these researchers’ findings means that the 1 and 2 star facilities most likely do provide poor care but that the 5 star facilities still may not provide good care despite their rating.

​Conclusion

After more than eight and a half years, Advancing Excellence has not been broadly adopted by the nursing home industry.  Even more importantly, the campaign has not improved quality of care and quality of life for residents, as reported on Nursing Home Compare.  Advancing Excellence is not a substitute for the regulatory system.  It is time for CMS and states to fully use the regulatory enforcement system: it is time to enforce the law.