Choosing a Nursing Home: What Do Consumers Want to Know, and Do Preferences Vary across Race/Ethnicity?

Abstract

Objective

To identify what consumers want to know about nursing homes (NHs) before choosing one and to determine whether information preferences vary across race/ethnicity.

Data Sources/Study Setting

Primary data were collected in Greater Boston (January 2013–February 2014) from community‐dwelling, white, black, and Latino adults aged 65+ and 40–64 years, who had personal/familial experience with a NH admission or concerns about one.

Study Design

Eleven focus groups and 30 interviews were conducted separately by race/ethnicity and age group.

Principal Findings

Participants wanted detailed information on the facility, policies, staff, and residents, such as location, staff treatment of residents, and resident conditions. They wanted a sense of the NH gestalt and were interested in feedback/reviews from residents/families. Black and Latino participants were especially interested in resident and staff racial/ethnic concordance and facility cultural sensitivity. Latino participants wanted information on staff and resident language concordance.

Conclusions

Consumers want more information about NHs than what is currently available from resources like Nursing Home Compare. Report card makers can use these results to enhance their websites, and they should consider the distinct needs of different racial/ethnic groups. Future research should test methods for collecting and reporting resident and family feedback/reviews.

The health care market has embraced public reporting, and The Centers for Medicare and Medicaid (CMS) alone has report card websites for hospitals, home‐health providers, nursing homes (NHs), dialysis facilities, and physicians, with more to come for other providers like hospice and inpatient rehabilitation facilities. A number of states have their own report card websites, and the private market also has several offerings, including Healthgrades and The Leapfrog Group. These websites typically provide general information on the provider, as well as details about the quality of care. In the case of NHs, the CMS website Nursing Home Compare (NHC, www.medicare.gov/nhcompare) is the most comprehensive national website where users can find information on every Medicare/Medicaid certified NH in the United States.

The idea behind report cards is to provide consumers with quality information so they can choose higher quality providers, thereby encouraging poor performing providers to improve or leave the market (Zinn et al. 2005; Stevenson 2006). Providers themselves also use the measures to benchmark their performance against competitors and peers (Marshall et al. 2000; Mor 2005; Stevenson 2006). Furthermore, the reports provide important information to help inform patient conversations with providers.

Prior studies have reviewed the availability of nursing home public report card websites, identified the scope and detail of information, and evaluated the utility of available information (Mukamel and Spector 2003; Castle 2005a; Castle, Diesel, and Ferguson‐Rome 2011). A comprehensive review of state report cards in 2010 found that 25 states had at least one nursing home report card website, and it covered a range of content, including general facility information, staffing levels, services offered, and a variety of quality indicators (Castle, Diesel, and Ferguson‐Rome 2011). Harrington et al. (2003) developed a model for what information should be included in report card websites and identified these areas as key: facility characteristics and ownership; resident characteristics; staffing indicators; financial indicators; deficiencies, complaints, and enforcement actions; and clinical quality indicators.

Several NHC studies found that NHs showed marked improvement in quality after implementation of NHC (Zinn et al. 2005; Mukamel et al. 2008; Werner, Konetzka, and Kruse 2009a; Werner et al. 2009b). Surveys found that NH administrators view the report cards and some report taking action to improve quality based on report results (Castle 2005b; Mukamel et al. 2007, 2008). Nevertheless, research shows that most consumers remain unaware of report card websites (Castle 2005a; Totten et al. 2012).

Key to the success of any public reporting initiative is ensuring content in the report card is relevant for consumers (Assurance 1998; Shaller et al. 2003). Indeed, some argue that irrelevant content is part of why consumer use of report cards remains so low (Shaller, Kanouse, and Schlesinger 2014). Outside of NH care, researchers have used focus groups to elicit and understand consumer preferences to help guide the development of quality measures and reports (McGee et al. 1999; Sofaer 2002; Sofaer et al. 2005). However, little is known about what kinds of information consumers want or need when making a NH selection. Using focus groups with short‐stay residents, family members of long‐stay residents, and information intermediaries (discharge planners and community organizations), one study identified the most important factors used by consumers for selecting a particular NH (Shugarman and Brown 2006). They found that the most important selection factors for residents were recommendations from family/friends, prior experience with the NH from family/friends, and appearance of the facility. The most important factors for family members of residents were proximity to family, recommendations from family/friends, and how staff treat/interact with residents.

Although the study provides valuable insight into how residents and families selected a particular facility, it did not identify the breadth of information a consumer would want if faced with that decision. Furthermore, although the study included diverse community members, it did not examine how factors varied across the different race/ethnicity groups included in the study. It may be that preferences about content differ, or that certain NH features or services are more salient to one group as compared with another. This is an increasingly important question in elder care, given the growing diversity of the elder population and the rising use of NH care by racial and ethnic minorities (Vincent and Velkoff 2010; Feng et al. 2011; Centers for Medicare and Medicaid Services 2013). Ensuring that the information provided in NHC meets the needs of consumers is an important step in increasing value and relevance of the report cards. Our study aims to address some of these important questions, specifically: (1) What kinds of information do consumers want and need when making a NH selection? (2) Do these preferences vary across racial/ethnic groups?

Methods

We used a qualitative research design, conducting focus groups and structured interviews to answer the research questions (Morgan 1996; Sofaer 1999; Rakow 2011). Given that this was one of the first studies to identify nursing home information preferences, a focus group format was appropriate, as it allows a researcher to identify the range of opinions and to collect new ideas and meanings that develop over the course of group interaction (Sofaer 1999; Rakow 2011). Additionally, focus groups are seen as ways to help “give voice” to groups with less power by collecting their opinions and interpretations in a scientific way (Morgan 1996; Rakow 2011). We conducted the focus groups first to identify these ranges, and then conducted more in‐depth interviews, where we could probe more for ideas and explanations that surfaced during the focus groups (Sofaer 1999).

Our target population was older adults aged 65 years and older and younger adults aged 40–64 years who were non‐Latino black, non‐Latino white, or Latino any race and resided in the Greater Boston area. These two age groups were chosen to represent two of the likely user types of nursing home report cards: older adults who may have experience/concerns related to themselves, and younger adults who may have experience/concerns related to a parent or older family member. All potential participants were asked to self‐identify their race and ethnicity and age group during the screening process. We used purposive sampling to include participants based on age and race/ethnicity (Horsburgh 2003). We included only community‐dwelling adults (i.e., excluded persons residing in institutions) and required that participants have either a personal or familial experience with NHs, or have a concern for NH need for themselves or a loved one in the future. We included people with experience or a concern as we would be able to discuss which types of information are important in a concrete manner. We did not distinguish between people with long‐term versus postacute experience/concerns. Although information preferences may vary across these two types of users, most sites are geared toward all users, and thus we wanted to capture all types of preferences.

Participants were recruited through senior centers, community organizations, church groups, and senior housing locations, and we advertised through list‐serves and community newsletters. All participants received a $35 gift card as compensation for their time. We held focus groups in private rooms in the locations from which participants were recruited or nearby, and we provided host organizations a $200 gift card in appreciation for their assistance.

We conducted the focus groups and interviews between January 2013 and February 2014. Groups were held separate by race/ethnicity and age group to increase our ability to compare results by population group and facilitate participant comfort (Morgan 1996). The focus group facilitators and interviewers matched participants on race/ethnicity to also aid participant comfort and encourage open communication. The Latino focus groups and interviews were conducted in Spanish, per request of participants, and all materials were translated into Spanish, using translation and back‐translation. Focus groups and interviews lasted approximately 90 and 60 minutes, respectively.

We began the focus groups and interviews by asking participants about their experiences with NHs. We then asked participants to think about what kind of information they would want to know about NHs, if they were in a situation when they or a loved one needed to enter an NH. The focus group and interview discussions were audio‐recorded, transcribed, translated into English as needed, and loaded into AtlasTi. In addition to collecting the qualitative data during research activities, we also asked participants to complete a short demographic/background survey that asked about age, race/ethnicity, income, and computer use.

Our analysis involved several steps. We started by developing a coding scheme with potential themes. We then test‐coded several focus group transcripts, where the entire research team coded the same transcript and met to review and add new codes and resolve differences. We used a team of three coders to code the remaining focus groups and interviews. This smaller team met weekly to review interpretations and resolve discrepancies. We worked through the transcripts systematically by type (e.g., focus group or interview) and group (race‐age), and all coders worked with each type in parallel with the other coders, to discuss common issues or themes that emerged by type. As we started each race group, the three coders and the researcher who worked with that racial/ethnic group test‐coded a transcript and met to review codes. After all transcripts were coded, we analyzed the data to identify the range of preferences, common themes across and within race‐groups, and themes unique to each group. To determine how common preferences varied across race/ethnicity, we identified the most common themes within each group and identified how these themes differed across groups. It should be noted that the number of participants in each focus group differed and the number of comments within each focus group differed. As a result, it is not possible to compare quantities of comments across groups, as such comparisons could be misleading.

Findings

Sample Characteristics

We conducted 11 focus groups and 30 interviews with a total of 105 participants (38 black, 40 Latino, and 27 white) (see Table 1). Participants ranged in age from 42 to 89 years, and the majority of participants were female (see Table 2). Overall about a third of participants had a college degree or higher, and 70 percent reported income of less than $50,000 year. Educational attainment and income differed across the race/ethnic groups, with Latinos having a much larger proportion of participants with incomes less than $50,000 and without a college degree.

Table 1.

Number of Participants in Focus Groups, Interviews, and Overall, by Race/Ethnicity

Race/Ethnicity	Focus Group Participants	Interview Participants	Overall
White, non‐Latino	17	10	27
Black, non‐Latino	28	10	38
Latino, any race	30	10	40
Total	75	30	105

Table 2.

Participants' Characteristics by Race/Ethnicity

Characteristics (%)	All	White	Black	Latino
Female	75.2	85.2	81.6	62.5
Mean age, years (range)	66.1 (42–89)	66.4 (42–88)	65.4 (45–89)	66.4 (42–85)
College/advanced degree	30.00	55.56	47.37	22.50
Annual income of less than $50,000	69.52	51.86	52.63	97.50
Has Internet access at home	62.14	70.37	80.56	40.00
How frequently do you go online: never	37.37	11.54	25.71	55.26
English is primary language	60.00	92.59	100.00	0.00
Speaks English well or very well (self‐described)	72.12	92.59	100.00	22.50
English is preferred language for reading medical or health care information	65.00	96.15	100.00	12.82

In our interviews and focus groups, we found that the majority of participants had some experience with NHs, whether through their own admission to a home or an admission of a close friend or family member. There were several participants who also had experience working in an NH. Few participants had no personal or familial experience with NHs, and these participants were most often Latinos. However, Latinos often mentioned visiting nonfamily members in NHs, through a church group, for example.

Information Consumers Want before Choosing a Nursing Home

Participants provided a wealth of information concerning topics they felt would be helpful to know ahead of time before choosing an NH for themselves or a loved one. We were able to categorize nearly all topics into one of five broad themes: facility, staff, residents, experience, and gestalt (see Table 3).

Table 3.

Summary of Information Consumers Want before Choosing a Nursing Home, Organized by Major Theme

Nursing home/policy information

Location, closeness to family, access to public transportation, and parking availability

Cleanliness, hygiene

Details on food: quality, ability to meet special dietary needs, nutritional value, choices, cultural appropriateness/options

Recreational activities: variety, ability to engage residents in activities

Pricing, affordability, cost to resident/family

Visitation and outing policies

Availability of religious services, chapels, and activities

Beds per room

Laundry policies

Ability to care for residents with special care needs (e.g., Alzheimer's, dementia, chronic disease)

Whether residents with special care needs were separated or integrated with other residents

Safety, security, and emergency policies for residents and visitors

Medication/pharmacy policies: substitution policies, use of sedatives and antipsychotics, “over” medication policies

Details about staff

Staff treatment of residents

Staff trainings, certifications, and background checks

Cultural sensitivity of staff and languages spoken by staff

Staffing levels or ratios; use of per diem workers; turnover; night/weekend staffing

Staff responsiveness to resident need

Availability of primary care providers, specialists, mental health professionals, social workers, physical therapists, and dieticians

Information about residents

Racial/ethnic background of residents

Common languages spoken by residents

Religious backgrounds of residents

Experience

Feedback from current/previous residents and families

Satisfaction surveys of current/previous residents and families

Reviews: anecdotes like Yelp or Amazon

Gestalt

What's it like here?

Information on the Facility and Its Policies

The most commonly mentioned facility information participants were interested in was the location of the facility: it was mentioned in every focus group and nearly every interview and was coded 44 times. Participants said they would want to know proximity to family/loved ones and accessibility to public transportation. As a younger black (YB) participant explains, “… in terms of friends, family visiting, how accessible is the place? That was a prime thing for my aunt, because her daughter did not have a car so the transportation had to be on a transit system.”

Mentioned in all focus groups and many interviews, cleanliness of the facility was identified as something participants would want to know ahead of time. Participants referenced wanting to know if the place was visibly clean and smelled clean, or as one YB participant called it, the “sniff test.” Participants were also interested in knowing detailed information about the food. A number of participants also mentioned feeding policies as being important, saying they would like to know whether the NH made it a policy to assign nursing staff to patiently assist a resident with eating, if needed:

… I have a friend who kept her mother at home and she would eat a full meal if you fed her and you took the time, it could take about an hour … And in a nursing home I don't think that's going to happen because (those) who support it are poorly paid … (Older black [OB] participant)

Recreational activities were cited in 24 instances, where participants would want to know that residents do not “just sit there all day” (YB participant) and are not in “a place to be locked up all the time” (older Latino [OL] participant). Variety was frequently mentioned, with a younger white (YW) participant noting that “Not everybody's gonna watch television. Not everybody's gonna want to play Bingo … so there needs to be a good variety of things.”

Participants were also interested in knowing details about pricing, cost to residents/families, affordability, and acceptance of different insurance types (e.g., Medicare and Medicaid):

I just know one thing I would want to know is how the finances actually work. It could just be the way I am approaching it but it just doesn't seem to be clear. Each one's different that I talked to. (YW participant)

We also found that participants wanted assurances that they would be able to visit their loved ones at any time “without asking for permission” (OL participant) and that visiting policies would not restrict their ability to take a loved one on an outing.

Participants were interested in learning about a variety of policies, often related to their own/family's needs or prior experiences. One participant gave an example that illustrates the importance of getting a full picture of a facility's policies:

One of the things they said, “Oh no, we don't restrain. No matter what. We don't restrain anybody.” So that was great to us, you know … But they will pump you up with drugs. (YB participant)

Information on Staff

Participants also frequently mentioned staff‐related topics and most commonly said they would want to get a sense of how well staff treated residents before making a selection of NHs; this topic was coded in 65 instances. Participants used words like caring, respect, dignity, and compassion to describe what they wanted to see:

Respect. And not to be treated like I was a stupid, senior person. You know? (Older white [OW] participant)

They were also interested in seeing details on staff training and qualifications and would want to know whether staff had specific training in dealing with frail elders and those with cognitive issues:

If dementia's involved, I want to know if the staff has had training by the Alzheimer's Association because a lot of times they'll say that their staff has special training but there's a big range in the type of training … (YW participant)

Participants recognized the special demands of caring for frail elders and said they would want to know that the staff at the facility had the disposition to handle these challenges while remaining kind:

… that the staff is kind, and gentle with the patients, because sometimes these patients can be obnoxious, and there's no doubt about it. And it takes a strong disposition sometimes for the person who's providing this service not to become ticked off. (OB participant)

They were also keenly interested in knowing that staffing levels were adequate to care for residents. A younger Latino (YL) participant likened it to a classroom: “if there are many students for only one teacher, the quality of education is not the same.”

Some participants also wanted to know about the languages spoken by staff, to assure good communication with their loved one. Staff diversity in race and ethnicity was also of interest for some, as well as staff sensitivity to residents from diverse racial/ethnic backgrounds.

Information on Residents

Some participants wanted to know about other residents and were most often interested in the racial and ethnic backgrounds (20 instances) and common languages spoken by residents (12 instances):

… that would make a difference, wanting to make sure that there were people there that look like the resident I was bringing. (OB participant)

Additionally, a few participants mentioned wanting to know about the diseases, conditions, and care needs of other residents, to ensure their loved one would fit into the community and have their specific needs met.

The Gestalt: What It's Like Here

Another theme that emerged clearly and overlapped with the other themes was the gestalt or “what it's like” at the NH. They wanted to know whether their loved one would be taken care of well—Will they be happy? Will they feel safe? An OW participant said she wanted to know “if the place is friendly and warm.” These are difficult details to ascertain, but they were nonetheless very important to the participants. For example, in explaining what she would want to know about an NH, an OB participant told the following story. This anecdote speaks to issues of staff responsiveness, staff communication/coordination, and facility policy on addressing pain, but also provides an overall sense of what it would be like living in this facility:

So they're sitting in the hallway at a table here and … this patient kept saying “my back,” and probably she said, “I can't stand this anymore” so there was a young girl at the pill cart and she was putting pills in. So she (the patient) went over to her and she said, “I can't stand this pain anymore,” and she (the girl at the cart) said “tell your nurse.” We took my aunt out for a ride, she got an ice cream, and when we came back the woman is still sitting there complaining of the pain … I'm saying all she has to do is call the woman's nurse and say she's complaining, she doesn't have to leave her cart and her pills. I know you can't do that. But get her nurse and let her nurse deal with it instead of letting the woman … (drifts off). (OB participant)

Experience of Residents and Families

Similar to the gestalt, the theme of resident/family experience overlaps partially with the other themes, but it represents a specific way to learn about NHs that was found to be quite important and was coded in 18 instances. Participants wanted to hear feedback from current or former residents and their families, saying they wanted to see “testimonials or other feedback” (YW participant).

I would like to know the opinions of those who have had patients in that nursing home … I always like to check the reviews. (YL participant)

But I have to find out from people who don't work there, because if I go to request that information at the office, they will tell me that it's a wonderful place. (OL participant)

They said surveys of resident and family experiences with a particular NH would be helpful, as would the type of consumer ratings and reviews that you see on Yelp.com. An OL participant suggested a government approach, where “part of the inspection should include interviews with the patients and their relatives.” Another participant suggested a survey should ask residents “if they feel safe … if they feel comfortable, if they would recommend this place to another person” (OL participant). Participants recognized the challenges and potential for gaming in such reviews. Nevertheless, they thought this information would be valuable and necessary information to make a good selection.

I do realize that people who write reviews online are more likely to post a bad review than a good one. But knowing what other people have, you know … Websites like Yelp, it's a good tool. Because when you go to visit, everyone is on their best behavior. (YW participant)

Variation Across Race/Ethnicity

We looked within each race/ethnicity group to identify the most commonly mentioned topics in that group and then compared themes across groups. Table 4 shows the most common topics in each group. We found much overlap in most common themes, but we also found some differences in the topics on which each group focused. We also found some themes were more unique to a particular group.

Table 4.

Most Common Themes within Each Race or Ethnicity Group, Presented in Order of Frequency Topic Was Cited for Each Particular Group

White Participants	Black Participants	Latino Participants
Location Staff responsiveness Staff treatment of residents Staffing levels Staff training/certifications Cleanliness Food	Cleanliness Location Staff treatment of residents Food Staff training/certification Recreational activities	Staff treatment of residents Location Cleanliness Staff languages Resident race/ethnicity Resident language

We found that comments from white participants were fairly evenly distributed across major themes; no particular “hot topic” stood out for this group. White residents frequently mentioned location topics as being important to know, including proximity to home or family. They often mentioned staffing levels and staff responsiveness and wanting to make sure that staff would quickly attend to resident need, often citing negative prior experiences:

Well, there were times, too, he had a stomach problem, too, and he used to want to go to the bathroom, and he'd wait, and he would wait, and wait, and wait. And they just ignored him, you know? (OW participant)

Black participants were interested in wanting to know details about staff trainings and certifications, wanting assurances that all levels of providers were educated and skilled in caring for elders and could meet their health care needs. Black participants wanted to know details about recreational activities, hoping the activities would be of interest to their loved one. For example, a YB participant said that “for most of them, they think Bingo is the bomb, but for our ethnicity, it's—you know, we're involved in much more of the arts … like my aunt was, you know, God, reading, the arts. She considered Bingo a waste of mind, of brain cells. So how diverse are you in those social activities?”

A theme almost universally unique to black participants was wanting to know about security and safety policies, such as how they kept residents secure: “You want to make sure that there are mechanisms in place so that patients cannot leave on their own” (YB participant). They also wanted assurance that visitors would not pose a threat and that facilities had security measures in place. For example, one YB participant asked, “Do I have to press a button and wait for you to admit me in or can anybody just walk up in the joint?” They were also interested in knowing how the facility would handle transporting residents and visitors in the case of emergency.

Latino participants frequently mentioned wanting to know how staff treated residents. This was an important issue for all groups, but it was particularly salient for the Latino participants; it was mentioned in every single Latino focus group and interview, which was not the case for white or black participants. Focus on staff treatment may be out of fear of or experience with discrimination:

It is very important that they are sensitive to our culture. I have noticed that many people who work in the medical field, we are like a package for them. That happens and I don't know why, and you feel discriminated by the way they talk to you or by certain attitudes. (YL participant)

They were also frequently interested in knowing about staff and resident languages, saying that whether a home had bilingual or Latino staff would be important to know before making a choice.

Although all groups mentioned they would be interested in learning about the race and ethnicity of residents before making a selection, this was a common theme for Latino participants, and for black participants to a lesser degree. This would be a way to determine whether their loved one would “feel at home” (OL participant) and connect with other residents.

… it wouldn't be at the top of my list only because I would want to make sure that the facility is a good facility, but I would be interested in the, whether the staff is diverse, whether the patients are diverse in the nursing home. (YB participant)

Discussion

This study sought to identify the types of information consumers want and need when selecting a NH, and to determine whether these information preferences differed among white, black, and Latino consumers. It was easy to elicit opinions and suggestions in all of the focus groups and interviews we conducted. Many participants were impassioned about the topic, based on personal or familial experiences. They also drew on previous knowledge from their communities and the news.

Of note, there was little specific discussion of “quality of care” or “quality measures.” Arguably, part of the reason for this omission is that things like quality of life and dignity are ranked first in people's minds; we saw this in the frequency by which participants mentioned wanting to know how staff treated residents and wanting assurances that their loved ones would be happy in the NH. However, the idea of quality care underlies what many participants were asking for when they said they wanted to make sure their loved ones were “taken care of” and that they wanted a “good place.” Perhaps this reflects differences in conceptualizing quality between lay people and researchers (Sofaer and Firminger 2005).

Our findings were fairly consistent with a previous study that identified the most important NH decision factors (Shugarman and Brown 2006). Like in that study, our participants consistently identified needing to know about the location of the facility to make a choice. Staff treatment of residents, prior experience of family/friends, and staffing information were also identified as important in both studies. There were some differences as well. For instance, cleanliness was mentioned in many focus groups and interviews in our study; however, it seemed less important in that study; and quality of care was commonly mentioned in their study, but not in ours. Furthermore, our findings indicate that people are interested in seeing very detailed information to help support a decision, like feeding, visitation, and medication policies, while there was no mention of these topics in Shugarman's study. Comparing our results to Shugarman's, there is consistency in what information people say they need to make a decision and what factors were most important to the actual decision. However, our findings suggest that people are interested in knowing a broad range of information before choosing a nursing home, even if those pieces of information do not ultimately become the most important decision factor.

Information preferences did vary across the three racial/ethnic groups we included in this study, in terms of which topics were most commonly mentioned within each group. Black and Latino participants were especially interested in knowing about the diversity in race, culture, and language at the facility. This reflects the desire to ensure social comfort and good communication for themselves or a loved one. This information could be important in other health care settings, including physician offices and hospitals. Indeed, numerous studies and briefs underline the importance of racial concordance and cultural competence (Cooper et al. 2003; LaVeist, Nuru‐Jeter, and Jones 2003; Street et al. 2008). However, it may be even more important for consumers when considering a “total institution” like an NH, where all of a person's needs are provided within the institution, including food, shelter, medical care, and community (Goffman 1968). The importance of being able to communicate with staff and other residents affects more than the quality of medical care; it permeates all aspects of a resident's life.

Implications

The findings from the study have important implications for report card makers, policy makers, nursing home owners/managers, and researchers. First, report card makers can use the results of this study to evaluate how their current reports meet the needs of consumers and enhance where needed. For example, according to a review of 25 state NH report card websites, nine websites provide information on what services are available at the facility, five websites provide information on staffing levels, six provide NH rates/prices, and three provide details on resident demographics (Castle, Diesel, and Ferguson‐Rome 2011); all of these are information topics identified as important in our study. Unfortunately, the federal NHC website does not provide information on rates/prices, resident demographics, or services offered. Like the state websites, NHC does provide information on staffing. However, our study determined that consumers want detailed information on staffing, like provider types availability, use of per diem staff, and turnover. Unfortunately, staff–patient ratios or hours per resident‐day are usually the only staffing information available on these websites, along with limited information on provider availability.

Report card makers can also use these findings to enhance content to meet the needs of black and Latino users. For instance, NHC does not currently provide information on resident race/ethnicity. Only one website in the Castle review (www.calnhs.org, now Calqualitycare.org) provides this information (Calqualitycare.org, n.d.). Neither currently provides information on resident languages spoken, which was of particular interest to Latino participants and is collected on resident assessments. Report card makers should consider adding this information, given how important communication can be to both the quality of care and the quality of life a resident experiences (Wilson‐Stronks, Galvez, and Organizations 2007; Joint Commission 2012). Furthermore, report cards should be available in languages other than English. In our study, none of the Latino participants identified English as a primary language. NHC is available in English and Spanish, and addressing language options should be an important step in making report cards accessible to Latinos and other non‐English speakers/readers.

Some information sought by potential users might be more difficult to include, for example, information on staff languages and facility policies. Although it is possible to modify facility assessment tools to include this information, it may be easier to simply provide a link to the facility website on the report card websites, where nursing home owners/managers can offer more detailed information to users, such as medication, food/feeding, and security policies. Castle's review found that four states provide these facility links (Castle, Diesel, and Ferguson‐Rome 2011); however, NHC does not.

A big gap in what consumers want to know about nursing homes exists in terms of understanding the gestalt and accessing resident/family experience. Both of these needs can be met through resident/family satisfaction surveys and the collection of anecdotal data. Six state websites provide family/resident satisfaction data as part of their report card, and seven provide some information on quality of life indicators (Castle, Diesel, and Ferguson‐Rome 2011). This goes a long way in helping consumers in those states get a sense of the NH. However, this important information remains absent on NHC. One possible solution would be for the federal government to mandate the collection and reporting of resident/family satisfaction, similar to what is done for hospitals in Hospital Compare. There is an existing version of this survey for NHs, the CAHPS for Nursing Homes Surveys, and this tool contains a breadth of satisfaction and experience categories that could help paint a picture of “what it's like here” for consumers. However, to our knowledge there is no intention to collect or report this information for all NHs in the near future.

Patient satisfaction surveys do not always capture the full experience or accurate sentiment that a patient feels (CAHPS User Network 2014), underlining the importance of collecting anecdotes or narratives from current and prior residents/families. Furthermore, context‐based strategies for engaging consumers in decision making suggests including emotional content helps consumers connect with these types of reports, making them more likely to use them (Shaller, Kanouse, and Schlesinger 2014). It may be possible to capture some of this information in the resident assessments conducted on all nursing home residents. The current version of this tool (MDS 3.0) includes resident interviews, where residents are asked directly about how they feel focusing on pain, cognition, mood, and discharge expectations (Saliba et al. 2012). This may be a possible vehicle for collecting patient experience. However, there is an inherent conflict of interest in having an employee of the NH ask a resident about his or her satisfaction and experience. Another possibility is to have state surveyors randomly select residents to interview specifically on their satisfaction and experience as part of the mandated audits of all NHs.

We see these surveys and reviews as essential to meeting consumer information needs to support decision making. This will greatly enhance consumers' ability to narrow down and find facilities that meet their needs regarding staff treatment of residents, cleanliness, staff and management interaction with families, and the general feel of the place. This may be a complex undertaking, but it is one the CMS and states should strongly consider, as this is likely the way of the future. The following review of a NH near Boston, Marion Manor, was taken from the private website Yelp.com, most known for its restaurant reviews:

Wonderful place! Not fancy but clean, friendly and attentive. My Father left Brightview Danvers, just the opposite … fancy, clean only in the areas that nobody uses, help does as little as possible. Seriously love Marian Manor, glad I got the chance to know another. (Yelp.com, n.d.)

This is the type of information participants indicated they would use. However, this is not a randomly selected survey participant and, in fact, we do not even know this reviewer truly had family in this facility. The problem in allowing these private websites to be the only conveyor of this type of information is that these websites are easy to manipulate and may enable posting of deceptive reviews. The CMS can design the collection and presentation of reviews, grounded in solid research methodology, to better convey this important content. We believe this is an important role for public websites to take on.

Limitations

This study is not without limitations. The sample was limited to the greater Boston area, and we did not use a random sample to select participants for this study. As a result, we have limited generalizability and findings must be understood within this context, including that the results may be biased toward an urban population. However, given that this is the first examination of consumer preferences for NH information, we feel that our methods were suitable and justified. We were able to generate a wide range of opinions and topics from participants, which can be later used for a larger, more generalizable study (Sofaer 1999; Myers 2000).

Likewise, our study was limited to only three racial/ethnic groups, and these questions about information preferences should be asked of other racial/ethnic populations. Furthermore, it is important to note that racial/ethnic groups are not homogenous, and preferences and opinions vary within each group as well.

Conclusions

In sum, our work builds on other reviews of websites and assessments of decision making to help identify how well current websites meet consumers' information needs. Additionally, our study makes an important contribution by identifying the ways in which information preferences vary across race and ethnicity. We found that consumers clearly want more information than what is currently available on NHC and other NH report card websites. The CMS and other report card makers can use the findings from this study to make improvements to their websites, and they should pay particular attention to meeting the needs of racial and ethnic minority users, given their growing numbers among the aged. Providing information on previous resident/family experience and the overall gestalt will prove to be the most challenging, but also the most valuable to consumers. Future research should focus on developing and testing methods for collecting consumer review/anecdotal feedback to ensure scientific rigor. These studies would do well to involve diverse consumers in the design of the data collection tools and website features to ensure future enhancements meet consumer need.

Supporting information

Appendix SA1: Author Matrix.