The issue of formally requiring patient surveys for nursing homes, similar to surveys mandated in other segments of health care, has long been a source of debate – one getting stirred up again after federal policy makers decided to nix patient satisfaction measures from the recently issued final prospective payment rule for 2024.

The Centers for Medicare & Medicaid Services (CMS) rejected making patient satisfaction a measure in the SNF Quality Reporting Program (QRP) through the CoreQ: Short Stay Discharge, after floating the idea as part of the proposed rule for 2024. The initiative lacked support during the comment period, the federal agency said.

The extra funding and time associated with a patient satisfaction measure, and fears of even more burdensome regulation, defeated efforts to make the measure mandatory, experts told Skilled Nursing News (SNN).

That said, these types of patient satisfaction measures are useful for improving quality of care, avoiding citations and litigation, with many nursing homes implementing them privately through third parties.

“The big question is, why is [a patient satisfaction measure] not mandated for nursing homes?” asked Steven Littlehale, chief innovation officer at Zimmet Healthcare Services Group. “And what’s very interesting is that the CAHPS nursing home survey has been developed and studied forever. So it’s already been out there for a long time.”

The CAHPS [Consumer Assessment of Healthcare Providers and Systems] for hospitals, and more recently for home health, are mandatory for those providers. In fact, since 2007, certain hospitals failing to publicly report CAHPS results may receive a reduced annual payment update.

The stakes

All parties involved understand that there is a lot at stake. Aside from compromising quality of care, the absence of mandated patient satisfaction surveys means that those nursing homes that do not or cannot afford to conduct private third party surveys also have a bigger likelihood of losing lawsuits and being cited for deficiencies.

And to that end, nursing home operators who spoke to SNN endorsed measuring patient satisfaction.

“[We] are committed to providing high-quality, safe care for our residents, and we support the use of consumer satisfaction surveys to measure resident satisfaction,” said Nate Schema, president and CEO of The Evangelical Lutheran Good Samaritan Society, the largest not-for-profit provider of senior care and services in the United States. ​​”Consumer satisfaction surveys are one example of a more meaningful solution that would improve quality care. This kind of process helps to promote resident and family choice and incentivize skilled nursing facilities to provide high quality care.”

But short of a patient satisfaction survey implemented by the federal or state government, some nursing homes – especially those that are small and lack the resources of a larger organization – can be left grappling to find answers in the aftermath of citations or litigation.

“If I had to address with a nursing home why they have so many complaint deficiencies compared to other people in their market, then I would talk to them and say, ‘Well, what are you doing privately to survey family members and residents about satisfaction?’ because we wouldn’t have a meaningful benchmark to see how you’re doing compared to others,’” Littlehale said.

That said, among the drawbacks that nursing homes cite to making the CoreQ or CAHPS mandatory is that doing so might create more paperwork and burdens without sufficient federal funding backing the endeavor. This, even as many large providers in competitive regional markets such as the East Coast continue to conduct such surveys privately through third parties.

Additionally, CMS does require residents’ perspectives to be taken into account.

“The quality assurance process requirements that we are under by CMS require us to have a quality feedback loop that includes the residents’ voice,” Tina Sandri, ​​CEO of Forest Hills of D.C., told SNN. “It doesn’t specify that we have to use XYZ company or that CMS should personally oversee the survey process, but we are mandated to have it.”

Besides, Sandri said, “Everybody in health care is looking at … customer satisfaction. If you’re not, you’re kind of behind the times because it’s all about the consumer voice.”

Providers also say that there are many different ways that patient satisfaction gets measured in the nursing home sector indirectly when they participate in value-based care and payment models. Still, nursing home operators are not consistently reaping financial rewards by sharing meaningfully in the savings generated by such models, including accountable care organizations. So, participating in value-based care also is not necessarily providing the funding needed to support third-party patient satisfaction surveys.

Nevertheless, it’s in the best interest of organizations to conduct surveys through third parties, Sandri said.

“I wanted to improve the quality in our buildings, and I realized that without using a neutral third party, people who are under our care might not feel comfortable speaking up,” she said. “We want their honest opinion. So in the interest of providing good quality, we provide that neutral voice.”

CoreQ nixed

The CoreQ measure was designed to calculate the percentage of individuals discharged from a SNF within 100 days of admission who were satisfied with their SNF stay. The questionnaire administered would have asked residents to rate their overall satisfaction with their care using a 5-point Likert scale – or a numbered satisfaction scale – on such areas as: quality of staff, quality of care received, recommendation of the facility to friends and family, and how well resident discharge needs were met.

However, CMS decided not to move forward with the CoreQ measure because not all the parties involved agreed that CoreQ would have accurately measured resident satisfaction.

“There isn’t a consensus yet about how to measure resident satisfaction in nursing homes across all stakeholders,” said Brian Ellsworth, VP of public policy and payment transformation at Health Dimension Group.

This, despite the fact that a home health patient satisfaction measure was piloted and is currently being implemented, he said. He believes the home health measure could be a template for an eventual SNF measure, which is a “significant issue to watch.”

The benefits to measuring resident satisfaction – on the condition that it’s accurately measured – are invaluable, Ellsworth said.

“It helps promote resident-centered thinking on the part of nursing homes. A survey can, if detailed enough, provide actionable feedback to providers about care delivery processes and operational issues,” noted Ellsworth. “The problem is, however, that as these data collection instruments get more detailed, they become more burdensome to providers and residents, and response rates can suffer. When that happens, reliability can go down. These are challenging issues that require careful design considerations and thorough testing.”

In some markets, providers self-fund these activities because of competitive pressures, Ellsworth said, while some Medicaid programs are in the early stages of incorporating resident satisfaction measures into quality incentive programs.

Gaining support for a mandatory satisfaction measure on the home health side was easier due to greater financial incentives related to home health value-based purchasing, Ellsworth said.

“[Medicare VBP] affects a larger portion of the revenues than SNF VBP,” Ellsworth explained. “And considering that Medicare is also a bigger payer in home health proportionately, over time providers are likely going to pay more attention to it.”

He thinks that the SNF VBP program should be enlarged to create more meaningful financial incentives to drive quality, aligned with Medicaid and Medicare Advantage programs.

And CoreQ was developed in collaboration with the American Health Care Association (AHCA), so this framework does have industry support, experts said.

“AHCA made a big push for it, so there are many nursing homes that are out there using CoreQ today but, unfortunately, the data is not publicly available,” Littlehale said. “Any nursing home can work with a third party vendor to administer the CoreQ satisfaction survey in place of third party surveys, and many people have done so.”

The missing voice of the patient

Now that the CoreQ has been removed from becoming a part of a federally mandated measure, the industry has lost the opportunity to truly allow the patient voice to guide quality and satisfaction, experts caution.

Patient satisfaction will continue to be measured through private third party surveys not all nursing homes can support, or through using proxy measures, which are inadequate.

“So for my whole career, I’ve had to find proxy measures. So that’s over 30 years of looking at the various measures and trying to say, ‘Well, I think pressure ulcers are important, I think, successful discharge to the community is important,’ but it’s never in the voice of the family member or the residents themselves,” Littehale said.

Other proxies he considers are related to rehospitalizations, weight loss, incidence of pressure ulcers, and food quality, among others. But, he says, these metrics are vastly inadequate in painting a full picture of patient satisfaction.

“Absent a set of a direct satisfaction survey, you are left to sort through a bunch of measures and say, you know, if four out of the five things are pointing in the right direction, we can make a statement about what we think about that facility’s quality,” he said.

And in this regard, nursing homes are lagging other sectors of health care.

“Hospitals and home health each have their own version of this satisfaction survey and it is mandated. So if you go to Hospital Compare or Home Health Compare, you will see reporting of patient satisfaction,” said Littlehale. “Why was such a survey skipped for nursing homes? I’ve asked this question of the appropriate people and then asked industry people. No one really has a clear answer.”