Veteran in Fight for Better Nursing Home Care Makes the Case Against Chains

June 2012Kate Darby Rauch

In February 2012, the Tampa Bay Times reported on a successful $200 million wrongful death suit against a nursing home. The plaintiff’s mother had tumbled down a stairwell in her wheelchair, dying of her injuries.

The story cites UCSF School of Nursing Professor Emerita Charlene Harrington’s recent study, which correlated large, for-profit, corporate nursing home chains with low nurse staffing levels and poor-quality care. It’s the first study focusing on the nation’s largest nursing home chains, and to complete her work, Harrington had to untangle the individual homes’ complicated webs of ownership.

“It’s like tracking a problem mortgage when you don’t know who owns the bank,” Harrington said in the article.

Indeed, the son of the Tampa victim has yet to collect a dime as his lawyers engage in a multiyear, multistate effort at tracking accountability.

Charlene Harrington (photo by Elisabeth Fall) When asked about the case, Harrington sighs deeply. She can’t recall Tampa specifically without referring to her research, she explains – there are too many similar stories.

Each one propels Harrington’s career mission of documenting nursing home quality, using data to show the link between fewer nurses and poorer care – and making the data accessible and understandable, not only for people looking for nursing homes, but also to improve government oversight. Her testimony at the state and federal levels has played a significant role in raising nursing home standards, including passage of the 1987 Federal Nursing Home Reform Act.

“No one wants to think about nursing homes,” Harrington says. She points to a decline in funding for geriatric research, budget cuts by the government agencies that regulate long-term care, and society’s general aversion to the sensitive subject of aging and physical decline.

This despite a generation of Baby Boomers that is rapidly expanding the number of older Americans, from 12.4 percent of the population in 2000 to a projected 19 percent in 2030, according to the U.S. Administration on Aging.

“The whole country is in a state of denial,” says Harrington. “No one thinks they’ll need a nursing home, which is fine. But when people do, we need to know they’ll have adequate care.”

A Trend to Watch

Harrington’s recent study, published in Health Services Research in February 2012, found that between 2003 and 2008, the nation’s top 10 for-profit nursing chains logged 30 percent fewer staff nursing hours and were cited for 36 percent more deficiencies or care violations and 41 percent more serious deficiencies than government-run homes.

Deficiencies include falls, infections, unsanitary conditions, weight loss, pressure sores, mistreatment and other serious and potentially harmful problems.

For-profit corporate nursing home ownership is a growing trend in the United States, which makes these patterns particularly significant, Harrington says. According to her, the 10 largest chains operate 2,000 of the nation’s nursing homes today, controlling about 13 percent of nursing beds.

“The chains set the pace for the nursing home community because they’re financially successful, so it’s important to look at what they do,” says Harrington.

A report by the Medicare Payment Advisory Commission (MedPAC), an independent congressional agency, found that the average nursing home profit margin in 2010 was 18.5 percent; however, there was a wide disparity between the margins of nonprofits (9.5 percent) and for-profits (20.7 percent).

But financial success comes at the expense of patient care, contends Harrington.

“The problem isn’t necessarily that they’re for-profit,” she says. “It’s that they’re trying to make huge profits off a labor-intensive industry, and the only way to do that is to cut staffing and that really hurts the quality.”

“We agree staffing is important, yet staffing extends beyond RN ratios,” says Greg Crist, vice president of public affairs for the American Health Care Association, a nonprofit federation of affiliated state health organizations, representing more than 11,000 nonprofit and for-profit nursing facility, assisted living, developmentally disabled and subacute care providers. “We also feel that perspectives on quality should extend farther and include outcomes focused on, say, the percent of individuals who return home, who maintain or improve function, or who are satisfied with the care they receive. That offers a more complete picture of quality in our centers.”

Harrington wouldn’t disagree about needing a more complete picture, but she has noted that skilled nursing care, compared to less skilled care, is correlated with fewer deficiencies.

Lack of Transparency

The study analysis was particularly tricky, Harrington says, because federal monitoring occurs at the individual home, not the corporate, level – and regulators don’t lump data together under ownership.

Of the roughly 18,000 nursing homes in the US, more than 90 percent accept Medicare or Medicaid, which means they must meet federal standards and be inspected annually. They’re also required to report and post staffing information and deficiencies.

To examine care across chains, Harrington had to sort through business filings to learn what facilities each corporation owns, then cross-reference these lists with federal reporting data. One chain can own hundreds of homes.

Making matters more complicated is the trend-within-a-trend of private equity firms taking over nursing home corporations. Private equity firms – essentially private investment managers with select clients – don’t have the same reporting requirements as public businesses.

“A lot of these nursing home chains were on the stock exchange but have recently been taken over by private equity companies, [which] aren’t under the same scrutiny,” Harrington says. “It’s very hard to find out anything about them.”

Yet Harrington did find out. Her study revealed that after four of the nation’s top nursing home chains were bought by private equity firms, their number of deficiencies jumped.

Fodder for Policy

Janet Wells Janet Wells, who is retiring as director of public policy for the National Consumer Voice for Quality Long-Term Care, a national nonprofit advocacy group, says groups like hers depend on academic research like Harrington’s to use as ammunition in their fight for change.

“We hear stories day after day after day from family members about poor care in the facilities, so [we] can say this anecdotally,” Wells says. “But all of these individual stories don’t make a whole. Charlene’s analysis is really helpful to make the case that we need better tracking and better support for adequate nursing.”

Pat McGinnis, the executive director of the nonprofit California Advocates for Nursing Home Reform (CANHR), says ownership has been an especially hard nut to crack. Yet this is exactly what is needed to determine who is responsible for a resident’s care.

“That’s why Harrington’s research is so important,” McGinnis says. “If you’re looking at a facility, you want to know who owns it; who is responsible. We know quantitatively the large for-profit chains have more deficiencies than the smaller chains, or the mom-and-pops, and certainly than the nonprofits.”

In fact, the Affordable Care Act, the health care reform law, includes several new requirements scheduled to take effect next year to improve nursing home transparency. Harrington’s research was a factor, Wells and McGinnis say.

Among the new requirements:

  • Detailed reporting on what proportion of federal dollars is used for direct care as opposed to administrative costs
  • Ongoing nurse staffing reporting, versus a snapshot report
  • More ownership details

Harrington calls these changes “very, very important,” though she acknowledges that as the new law unfolds, everything is subject to change.

Getting the Word Out

Meanwhile, Harrington hopes her data reach anyone facing the strenuous, sensitive job of finding nursing care for themselves or a loved one.

The federal government has a five-star rating system for Medicare-certified nursing homes, based on several measures, including health inspections, staffing and fire safety. The ratings are available on Nursing Home Compare, an online tool at the Medicare.gov website.

Some states, including California, also have online rating tools. California’s, called Cal Quality Care, is hosted by the nonprofit California HealthCare Foundation and was started by Harrington, who still runs it.

While these tools are imperfect, because not all data are reported, Harrington and Wells believe they help families make wiser choices.

The challenge is getting people to use the tools; raising awareness is an ongoing effort. For example, Harrington and Wells would love to see such rating tools used more by hospital discharge managers, and believe this could lower rates of rehospitalization.

“Most people go from a hospital to a nursing home and have to find a place in 24 or 48 hours,” says Harrington. “A lot of times the hospitals don’t tell consumers there are these websites. Consumers want to find a place close to home for convenience purposes, but they don’t look at the quality.”

Says Wells, “When the government spends years developing a rating system to help people select good nursing homes and then allows hospitals to discharge patients to one- or two-star facilities, it doesn’t make sense.”

Unfortunately, the tools don’t yet name the chains that own homes, though Harrington hopes this will change. If chains continue to rack up more deficiencies, highlighting this fact could steer people to better-run facilities. This, in turn, might motivate owners to do things differently.

“Letting the public know about this problem puts greater pressure on these chains to improve quality,” she says. “As long as they can get away with this and there’s no uprising, they’re going to continue, and that’s why it’s so important this kind of behavior be exposed.”