Rule Change Could Push Hospitals To Tell Patients About Nursing Home Quality

Nov 28, 2016
Originally published on November 29, 2016 4:42 pm

Hospitals have long been reluctant to share with patients their assessments of which nursing homes are best because of a Medicare requirement that patients' choices can't be restricted.

For years, many hospitals simply have given patients a list of all the skilled nursing facilities near where they live and told them which ones have room for a new patient. Patients have rarely been told which homes have poor quality ratings from Medicare or a history of public health violations, according to researchers and patient advocates.

"Hospitals are not sure enough that it would be seen as appropriate and so they don't want to take the chance that some surveyor will come around to cite them" for violating Medicare's rules, said Nancy Foster, vice president for quality and patient safety at the American Hospital Association.

As a result, patients can unknowingly end up in a nursing home where they suffer bed sores, infections, insufficient staffing or other types of substandard care.

But hospitals' tight-lipped approach to sharing quality information may soon be changed. The Obama administration is rewriting those rules, not just for patients going to nursing homes but also those headed home or to another type of health facility.

Hospitals will still have to provide patients with all nearby options, but the new rule says hospitals "must assist the patients, their families, or the patient's representative in selecting a post-acute care provider by using and sharing data" about quality that is relevant to a particular patient's needs for recovery. The rule was drafted in October 2015.

The administration hasn't said when it will be finalized. Should it not be enacted before the end of President Obama's term, its fate becomes uncertain. President-elect Donald Trump has pledged not to approve new regulations unless two existing ones are eliminated.

The quality requirement might have made a difference for Elizabeth Fee, an 88-year-old San Francisco woman who had been hospitalized for a broken hip. Her hospital, California Pacific Medical Center, told her family about its own nursing home but did not tell them that Medicare had given it one star, its lowest quality rating, Fee's family asserts in court papers.

"I feel we were misled because we believed that Mom was going to a facility that would have given her excellent care," her daughter Laura Rees said. "And what she got was not even close to that, it was like night and day."

A family photo of Elizabeth Fee shortly before her death.
Robert Durell for KHN

At the nursing home, Ms. Fee developed a bowel blockage that went undiagnosed until the morning of the day she died in February 2012. The nursing home and hospital have denied that they provided substandard care and declined to comment. The nursing home closed last year.

Some health systems haven't waited for Medicare's rule change to increase the information they provide patients about prospective nursing homes. In Massachusetts, Partners Healthcare, which runs Massachusetts General and Brigham and Women's hospitals — two teaching hospitals for Harvard University Medical School — endorses 67 nursing homes around the state based on a host of criteria, including state inspections, readmission rates, location and how frequently a doctor or nurse practitioner is at the facility.

Partners believes it doesn't violate Medicare's rules because it gives departing patients a complete list of nursing homes while noting on the list which ones are part of Partner's quality network, said Dr. Chuck Pu, a medical director at Partners. This fall, Partners dropped one of its own nursing homes from its preferred list after it got a poor inspection. "There's no free pass," Pu said.

More careful attention to nursing home quality has been encouraged by existing financial incentives created by the Affordable Care Act that cut payments to hospitals if too many patients are readmitted within a month. "The whole idea of preferred provider networks is really going to escalate in the future," said Brian Fuller, an executive with NaviHealth, a consulting company for hospitals that focuses on patient care after discharge.

Foster, the hospital association executive, said the proposed Medicare rule should make hospitals less wary about giving more detailed guidance. "This signals that it's okay for knowledgeable folks to really engage in that conversation with patients and their families," Foster said.

Kaiser Health News is an editorially independent news service supported by the nonpartisan Kaiser Family Foundation. You can follow Jordan Rau on Twitter: @jordanrau.

Correction: 11/28/16

A previous version of this post incorrectly said Elizabeth Fee, a nursing home patient, died in January 2012. She was admitted to the facility that month, but died in February 2012.

Copyright 2020 Kaiser Health News. To see more, visit Kaiser Health News.


Nursing homes are no longer simply places where the ill and elderly can be cared for at the end of their lives. These days they're also rehab facilities where patients leaving the hospital can continue their recovery. However, finding a safe place to send a patient can be challenging. Many families use the hospital as a reference to a facility. But as Jordan Rau of Kaiser Health News reports, hospitals may not have the patient's best interest in mind when it comes to referring patients to a nursing home, and sometimes the results can be tragic. Jordan Rau joins us in our studio. Welcome.


WERTHEIMER: So is it a concern that some nursing homes are now taking rehab patients?

RAU: It used to be that you would do all of your recuperation in a hospital. But as time has gone by, hospitals want to get their patients out quicker. So yes, it's changed a fair amount.

WERTHEIMER: Well, why wouldn't it be possible for hospitals just simply to say, OK, this is the best rehab facility in the area, you should go there?

RAU: You would think it would make sense, but there's been a longstanding Medicare rule that says that hospitals have to give patients full and free choice of where they want to go not just for nursing homes, but for home health facilities, any place. And the hospitals have been very paranoid about being fined for breaking this rule. And as a result, they often will just give you a list of all the places around and the geography. And they won't tell you if a place has a bad record of inspections or infections or other problems.

WERTHEIMER: Now, in the case you followed in California, a family sought the advice of the hospital where their mother had had surgery and then they followed that advice.

RAU: That's right. So Elizabeth Fee was an 88-year-old woman. She went to California Pacific Medical Center, which is one of the best hospitals in San Francisco, for hip surgery. And it went very well. And then afterwards, she was looking to go to a nursing home to get better. And so I talked to her daughter, Laura Rees, and she told me what they were told by the hospital discharge planners.

LAURA REES: They kept pointing to their facility. They told me the quality was very, very good and it was basically like an extension of the hospital. We'd gotten very good care there.

WERTHEIMER: So it sounds like she's anticipating that the quality of care at the nursing home will be the same.

RAU: Yeah, that's right. It actually had the exact same name, California Pacific Medical Center, as the hospital did.

WERTHEIMER: What happened to Mrs. Rees' mother?

RAU: Well, she was there for about two weeks. And unfortunately, she developed an obstructed bowel. It wasn't caught immediately - until, actually, the day that she died - and she died at that point.

WERTHEIMER: Did her daughters understand that something bad was happening, that this was way past recovering?

RAU: You know, they say that they were worried from the beginning. They even had their own private sitter they had hired to watch over her. And I talked to her other daughter, Nancy, and she told me what the experience was like.

NANCY FEE: It fills me with despair because so much was invested in my mother in terms of medical expertise and care and compassion. And it was all just dumped.

WERTHEIMER: I understand that this nursing home was given one star by Medicare.

RAU: Medicare has a score of one to five stars, and you can look it up on their website, Nursing Home Compare. It's based on a lot of different factors - staffing levels, how well patients recuperate, and then also their past inspections. And this particular hospital had been written up several times for not attending to patients properly.

WERTHEIMER: Would the daughters have known that? Should they or could they have known that?

RAU: They certainly would've wanted to know about it. But most people don't know about the website and they say they weren't aware that it even existed. The other thing is that, you know, people aren't thinking about what's going to happen when they get out. I mean, if you're about to go in for surgery, that's where your focus is, and you assume that that's going to be the point of most danger. But the reality is that it's actually these transitions from hospital to nursing home, from hospital to home, where a lot of patient injury takes place.

WERTHEIMER: How hospitals refer patients to nursing homes - is that going to change? Is there any sort of movement afoot to try to fix that problem?

RAU: Well - so the Obama administration has proposed that hospitals have to play a active part in guiding patients to the proper nursing home, and they have to provide objective information about the quality of the homes.

WERTHEIMER: So that they can make a critical decision.

RAU: That's right. The other thing is the Obama administration proposed this regulation, and it hasn't been moving. And their term is ending, so there's still an open question about whether it's actually going to be enacted. But if it goes over into the Trump administration, all bets are off. Donald Trump has said that for every one regulation that is issued by his administration he wants to eliminate two others. So it's certainly possible that it might be in trouble.

WERTHEIMER: In the meantime, what do you suggest?

RAU: Well - so people should go to Nursing Home Compare. They shouldn't just assume that the one that's closest to their home is the best. They should go and visit the home, talk to the families of other patients there, and also just really grill the discharge planners at the hospitals about what their observations are.

WERTHEIMER: So what happened with the Fee family, the daughters who lost their mother?

RAU: Well, the family brought a lawsuit. It's still pending. The doctor in the case has settled, but California Pacific Medical Center has denied and contests all these charges.

WERTHEIMER: That's the hospital that owns the facility.

RAU: That's right.

WERTHEIMER: Jordan Rau is a senior correspondent with Kaiser Health News. Thank you very much.

RAU: Thanks for having me. Transcript provided by NPR, Copyright NPR.