Do not-for-profit nursing homes provide better care?

The decision to move my grandmother to a nursing home was very difficult for my parents. After all, when my grandmother was a girl in "the old country" (her native Germany), families would care for their elders in their home. And my parents did in fact do this for several years. But eventually my grandmother's worsening dementia and health meant that she required more care than my parents could safely provide, and they decided a nursing home was the best option. But then they were faced with another difficult decision: Which nursing home would provide the best-quality care, and how might they determine this?

These are common questions, and not just among concerned family members. Researchers and policy makers are also keen to learn which nursing homes provide the best care—and why. One factor thought to influence care quality is what's called "profit status": whether a facility is a for-profit business or a not-for-profit venture. One school of thought holds that not-for-profit homes deliver better care because this is more central to their mission, and they do not need to divert financial resources to shareholders and taxes. But another view suggests that for-profit nursing homes actually provide superior and more efficient care because they feel added pressure to compete on price and quality.

Many studies have put these opposing theories to the test, and researchers have recently published a review that summarizes their results. Overall, they found that not-for-profit nursing homes deliver higher-quality care than for-profit facilities. (This echoes our own findings from an analysis in 2006.) In the new review, the researchers looked at 82 studies done from 1965 to 2003. Forty found better care at not-for-profit homes, while three studies gave the nod to for-profit facilities. The remaining 39 studies had mixed results.

The researchers also pooled the studies' findings to take a closer look at four measures of care:

• The quality of staffing (the number of staff per resident and the level of staff training)
• The frequency of pressure ulcers (open sores that can develop if someone is left sitting or lying in one position for too long)
• How often physical restraints were used
• How often homes were cited for regulatory problems.

For the first two measures, not-for-profit homes came out ahead, providing better-quality staffing and having a lower rate of pressure ulcers. They also did slightly better on use of restraints and number of regulatory citations, although their edge over for-profit homes was small enough that it could have been due to chance.

Obviously, many factors influence the quality of care at a nursing home, such as staff turnover and budgets. Profit status may be another factor. However, the research doesn't yet tell us how a not-for-profit structure might improve care or, indeed, whether other factors might be giving these facilities an edge.

What you need to know. Profit status is one factor among many to consider when reviewing nursing homes. To get a real sense of a facility, you need to visit it (sometimes unannounced), ask questions, and do your research (for example, review the home's state inspection survey, which should be readily available). There are also many useful guides online to help you pick the best home, including our advice for finding good care. And keep in mind that a not-for-profit status doesn't guarantee quality care, and for-profit doesn't automatically mean there will be problems. Indeed, nearly half the studies in the review didn't give either type of home a clear advantage, which suggests there's a good deal of variation among facilities.

A footnote: My parents eventually selected a not-for-profit facility for my grandmother and were pleased with it overall. But my mom still dropped in several times a week to check on her mother and visit. She found that good care can be even better when a resident has a regular advocate, and the staff were glad for her participation as well.

—Sophie Ramsey, patient editor, BMJ Group

ConsumerReportsHealth.org has partnered with The BMJ Group (British Medical Journal) to monitor the latest medical research and assess the evidence to help you decide which news you should use.

Find out about other senior living and care options and how aging in place communities can help some seniors. Read more on patient-centered care for dementia patients, and see which drugs are most effective for treating dementia (susbcribers only).

Comments

[RAC, PhD]

While reviews of the literature are valuable, the Center for Medicare and Medicaid Services provides a comparison of nursing homes based upon their performance on facility inspections, staffing patterns and 10 quality measures. The fact that the CU study does not reference this currently available consumer friendly data set demonstrates the poor job that CMS has done in making the public aware of this very helpful information which is available at www.medicare.gov/nhcompare/.

[Nursing education]

As a future nursing educator I found this blog to be indispensable. Over the past fifteen years of my nursing career, I have been in virtually every nursing educational setting. For this reason I have collected numerous nursing resources on the subjects of cognitive processes, learning and teaching techniques. This blog by far pulls all the information together, and it will become the most utilized of my collection. The information is laid out in a logical format that starts with the basic concepts, theories, objectives and goals of learning.

[Alex]

"In the new review, the researchers looked at 82 studies done from 1965 to 2003."

Making conclusions about today's quality of care based on data from the sixties, seventies, and eighties? Come on!

I encourage readers to look at some responses to the study here: http://www.bmj.com/cgi/eletters/339/aug04_2/b2732

The point is that the conclusions drawn from this study are sketchy at best, and deceptive at worst.