Two years after the Bush administration began publicly grading nursing homes in an effort to improve quality, a Boston Globe analysis of federal records indicates progress in some areas of patient care, but no gains in others.
Fewer residents are suffering from untreated pain and fewer are being placed in physical restraints, according to the analysis. But the posting of quality scores on the Internet for each of the nation's 16,500 nursing facilities -- designed to marshal public pressure to spur change -- had no significant impact on the portion of residents with pressure sores. Nor did it increase the share of residents who were able to walk, or feed themselves, or use the bathroom on their own.
The unevenness of the results extended across the country, with thousands of homes declining on one or more of the quality measures. Many homes improved in one aspect of care, only to decline in another.
The results were similarly mixed in Massachusetts' 480 nursing homes. There was more progress than nationally in reducing pain, but the percent of residents in physical restraints was unchanged.
''The jury's still out," said Alice Hedt, executive director of the National Citizens' Coalition for Nursing Home Reform. She and other advocates are concerned that because the program is voluntary, the worst homes may not get involved. They suggest that widespread improvement will occur only with better training and more staff.
Under the quality initiative, which is costing $120 million for the first three years, the government posts updated scores every three months that reflect the percent of residents suffering from 15 largely preventable problems. The Globe studied the eight categories that were measured in both 2002 and 2004.
The government is paying consultants to teach 2,400 homes how to provide better care, focusing mainly on reducing pain and pressure sores. In those homes, which volunteered for the help, government officials say there was more improvement, but will not publicly identify the homes.
Federal officials had hoped that an initiative relying on market forces would achieve what the government's longstanding enforcement system had not. That system -- based on annual inspections and penalties for troubled homes -- is inconsistent and ineffective in closing poor-quality homes, a federal consultant reported in April.
But nursing home specialists question whether the modest gains indicated by the Globe's analysis result from the initiative and reflect real changes in quality.
Many homes were able to reduce residents' pain by working with well-established plans to recognize and treat suffering. Similarly, the reduction in restraints is a continuation of a 15-year campaign ordered by Congress. In contrast, the problem of pressure sores got slightly worse, although many of the consultants focused on it.
Meanwhile, major questions remain about the validity of the scores. The numbers are based on data provided by the homes and are at least six months old when posted. Some academics who study quality say the scores seem to reflect the sickness of residents, rather than the care, although the government says it tries to adjust for the mix of patients. Moreover, the Globe found that the scores do not correlate with the results of government inspections of nursing homes.
The initiative also ignores the reality of how most people choose nursing homes -- in a hurry, guided by hospital discharge planners. Nursing home administrators say they are rarely asked about the scores, indicating there is little public pressure to improve.
Some question whether there can be significant change without sending consultants into every nursing home to train workers, which would cost substantially more.
''It takes more than just feedback" to improve quality, said Marilyn Rantz, a professor at the University of Missouri at Columbia who studies nursing homes.
The fate of the program is important, not only for the nation's 1.6 million nursing home residents, but also because it is the first major quality improvement effort launched by the agency that oversees the Medicare and Medicaid programs, which pay for care for millions of seniors and low-income people. The government has since launched efforts to improve home health care and hospital care using public report cards.
Assessing the initiative in an interview, Dr. Mark McClellan, administrator of the Centers for Medicare & Medicaid Services, said there are more nursing homes delivering high-quality care.
''We've made a tremendous amount of progress, and we've got a lot of work left to do," McClellan said. ''There are still a number of institutions that have chronic problems."
But another federal official involved with the program said the government was disappointed that progress was not more widespread. McClellan's staff made the official available to the Globe as a spokesman but said he could not be quoted by name.
State's top gainer
Sea View Retreat, a small, family-owned nursing home in Rowley, illustrates how the initiative can work. In 2002, Sea View ranked near the bottom in Massachusetts on the quality measures. It now scores among the best, according to the Globe's analysis, having achieved the biggest gain among the state's homes.
Owner Stephen Comley II said Sea View was shocked by how badly it compared with other nursing homes in 2002 because it had been getting high marks during state inspections.
''We thought [the scores] were wrong," the former director of nursing, MaryEllen Mighill, said.
But the management committed the home to improving the scores. The staff gave residents more freedom without jeopardizing their safety, switching from chairs with fixed trays that served as restraints to recliners or chairs with bolsters. The percent of their 62 residents with restraints fell from 11 to 2.
They trained staff to recognize and treat pain appropriately, overcoming nurses' fear of giving morphine and using charts showing faces in stages of distress to judge pain in nonverbal residents. They reported 2 percent of residents with chronic pain this year, down from 21 percent in 2002.
Jack Meagher has benefited from the extra attention. For years he told his daughter to ''put a pillow over his head" if he ever needed to go into a nursing home. But with a paralyzed leg and the loss of bladder and bowel function, he needed nursing home care.
He arrived at Sea View earlier this year bedridden and considering hospice. Now, the 81-year-old wheels around in a chair to socialize with other residents. Although he spends nearly all day in the wheelchair, he said he has not had one pressure sore. ''I couldn't have done any better" in finding a good home, Meagher said.
In contrast, other homes are downplaying the scores, suggesting that they reflect the illness of the residents and not the care provided.
At Blaire House, a for-profit home in Worcester that paid federal fines every year from 2001 to 2003 for harming residents, managers said they are not disturbed that their scores plunged and that 28 percent of residents are in restraints and 26 percent need more help with daily activities. Blaire House had the largest two-year decline of any home in Massachusetts, according to the Globe analysis, despite getting help from government-paid consultants. Managers said the scores do not signal bad care and may yet get worse because residents, most of whom have dementia, are arriving more disabled.
''Our goal is to make sure these residents are taken care of perfectly," executive director Cynthia Lownes said. Although the staff works to reduce use of restraints, she said lap belts are often needed to keep residents safe.
A learning curve
Some of the problems have proved resistant to change. Nationally, the proportion of residents with pressure sores increased from 8 percent to 9 percent, although the painful problem is often avoidable. Pressure ulcers, which can lead to infections, typically result when residents, whose skin is fragile, eat poorly, drink too little water, do not move about, or are left in clothes wet from urine. Federal officials say that before the quality initiative began, many homes were not checking residents for pressure ulcers on admission, so there is a long learning curve. ''It's not like teaching people to recognize pain and hand out pain pills. It's really improving basic care," said Rantz, of the University of Missouri.
The difficulty in reducing pressure sores is evident at Hunt Nursing & Retirement Home in Danvers. In 2002, 6 percent of the nonprofit home's 120 residents had sores. But that rose to 11 percent this year despite what management said was an aggressive effort to identify residents at risk and provide special care to prevent sores.
One disabled woman developed three deep sores on her rear end last spring, all bleeding and black from dying tissue, according to a report by state inspectors, who cited and fined the home for failing to prevent sores on four residents. The sores developed after nursing home staff left the woman restrained in a wheelchair for hours, inspectors said.
In an interview, officials of Berkshire Healthcare, which owns Hunt, offered no explanation for what happened. But they said many of their residents have pressure sores when admitted. The home is appealing the fine.
Berkshire Healthcare officials said their recent focus on improving care was spurred by a commitment to quality, not the posting of scores or the state's inspections.
''We provide quality care," said Alicia Brown, vice president of clinical services for Berkshire. ''I question what the numbers really mean."
Doubts about accuracy
Questions about the validity and meaning of the numbers were raised from the beginning. Congress' investigative arm, the Government Accountability Office, argued for delaying the initiative in 2002 because of a high error rate in the self-reported data on pain, toilet use, and feeding.
John Schnelle, a professor at the University of California at Los Angeles, studied California nursing homes and found that there was not much difference in the quality of care provided by those with the best and worst scores on pressure sores, restraints, and several other measures. He also found that homes reporting higher levels of pain were actually better at recognizing and treating pain than those with worse pain scores.
Dr. David Gifford, who is directing the consultants working with nursing homes, said the quality measures were validated with visits to nursing homes, and are continually being revised with help from the National Quality Forum, a nonprofit organization promoting healthcare standards.
But the government is now examining the accuracy of the underlying data and a Medicare official said there are enough doubts that they are not ready to punish homes or reward them with higher payments based on the scores.
Although public pressure is supposed to be a major impetus for improvement on the scores, it is not clear that the public is using the information widely to chose nursing homes.
Arthur Roberts has been a resident of two nursing homes in the last year, neither selected with the help of the scores. After bypass surgery, hospital discharge planners sent him to Hunt without consulting the family, said his daughter, Sandra Fourlis. There, she said, staff undermined his dignity by putting him in diapers, instead of retraining him to use the bathroom.
Roberts, 86, went home briefly, but again needed intensive nursing. The family asked his daughter-in-law, a nurse, to help choose a home. Jennifer Roberts said she picked Sea View based on the advice of other medical professionals and a visit to the facility.
''I didn't look at how many patients had infections or any of those statistics," she said. Arthur Roberts is now thriving.
Alice Dembner can be reached at firstname.lastname@example.org.