Selective Admission Decisions and Quality-Measure Scores in Desirable, Highly Resourced Nursing Homes

Context: Nursing homes are graded for quality, with antipsychotic use a key quality-measure contributing to CMS’s ‘5 Star’ facility rating. Some nursing homes have drastically improved their antipsychotic quality-measure score, while others have not. Little is known about why this is so, though all unsafe long-stay prescribing follows social determinants of health (SDOH), and lower-resourced facilities with an inferior payor mix in poorer communities are at greatest risk. “Cherry-picking” admissions is illegal and discriminatory but remains a known unintended consequence of reimbursement capitation. The role of selective admissions in long-stay quality-measure performance manipulation is poorly understood.

Objective: Evaluate the perspectives of facility admissions personnel regarding the role of selective admission decisions and subsequent nursing home care/outcomes focusing on the antipsychotic quality-measure.

Study Design and Analysis: Semi-structured interviews of 14 nursing-home admissions decision-makers regarding selective admissions processes and related outcomes. All decision-makers employed at highly resourced Virginia nursing homes with selective admissions and enhanced nursing/staff. All 6 facilities > 95% white. 2/3: urban; 2/3: not-for-profit. Analysis: Immersion/crystallization.

Results: ‘All’ facilities are selective in admissions, though desirable facilities have more options. Processes include chart reviews, hospital visits, and interviews. Quality-measures are perceived as imperfect measures of quality and vulnerable to manipulation. Non-pharmacologic alternatives to psychoactives are not covered by insurance and only available to well-resourced facilities. Screening potential residents for high care needs is prioritized, though current/past use of psychoactives, symptoms difficult to manage without psychoactives, and red-flags for quality-measure deficiencies are also evaluated. Screening is often framed as ensuring a good ‘fit.’ I.E., a patient requiring antipsychotics would be deemed a poor fit for a facility that does not endorse antipsychotic use.

Conclusions: Facilities improve quality-measure scores by avoiding patients likely to trigger a quality-measure deficiency and facilities can lower their antipsychotic prescribing rate by never admitting patients likely to require these drugs. Quality measures not adjusted for risk or SDOH may increase existing care disparities and exacerbate disadvantages of vulnerable population.