5. Public Reporting as a Quality Improvement Strategy

Long-Term Care Services
Prior systematic reviews of public reporting do not contain studies of reporting on the quality
of long-term care services either because the searches predated major national initiatives in
public reporting of the quality measure for this setting, or the search strategy, inclusion criteria,
and types of designs allowed precluded inclusion of studies of public reporting about long-term
care (e.g., Fung, 15 Marshall, 221 and Ketelaar 222 ) The Centers for Medicare and Medicaid Services
(CMS) began posting quality data on the Medicare Nursing Home Compare Web site in 2002
and on Home Health Compare in fall 2003.
Selecting a long-term care (LTC) service may be substantially different than selecting other
health care services. Decisions about LTC may be likely to involve family members. They may
be made during a hospitalization to expedite discharge with the involvement of discharge
planners or social workers. Alternatively people may be admitted from the community when
disease progression and functional impairments require more than outpatient management.
Nursing homes (NHs) (alternatively referred to as nursing facilities or skilled nursing facilities)
and home health agencies admit people from hospitals and the community. Nursing homes
provide postacute care to people who are expected to improve (referred to as short-stay residents)
as well as care for long-stay residents with degenerative or debilitating conditions who are likely
to need care for an extended period. Similarly, home health agencies provide postacute care and
also admit people from the community with long-term chronic care needs.
Long-term care organizations and individuals that provide care (collectively referred to as
“providers”) and quality improvement efforts might also differ from acute care and health plans.
As the market areas are different for LTC, the choices may be greater when there is some
substitution among types of services (NH, home health, assisted living, etc.). Conversely, the
choices may also be more limited when only one provider is available in a geographic area or a
location near family is more important than any other consideration. Many LTC service
providers are for-profit yet public payers (Medicare and Medicaid) are major sources of revenue.
For this reason and due to a history of financial crime, unsafe conditions, and abuse, long-term
care services have traditionally been heavily regulated. Combined with the need to serve two
very different populations, short-stay and long-stay residents, these factors create a challenging
environment. While the underlying theory of how public reporting may lead to quality
improvement is the same across settings, the different environment and history may affect its
potential impact on long-term care differently than how public reporting affects hospitals,
individual clinicians, and health plans.
We identified 23 quantitative observational studies and six qualitative studies that met our
inclusion criteria and corresponded to our Key Questions. The observational studies are
described and analyzed first. This is followed by a summary of the qualitative studies.
Overview of Findings
Quality of Care (Key Question 1)
• Some QMs, but not all, improved after public reporting (seven studies).
o Measures for short-stay residents of nursing homes showed improvement across
studies (two studies). 13,58
100