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. Author manuscript; available in PMC: 2022 May 31.
Published in final edited form as: J Appl Gerontol. 2018 Aug 17;39(4):385–392. doi: 10.1177/0733464818790381

Family Satisfaction With Nursing Home Care: Findings and Implications From Two State Comparison

Tetyana P Shippee 1, Weiwen Ng 1, Amy Restorick Roberts 2, John R Bowblis 2
PMCID: PMC9154313  NIHMSID: NIHMS1804931  PMID: 30117352

Abstract

Family satisfaction, while recognized as important, is frequently missing from validated measures of long-term care quality. This is the first study to compare family satisfaction across two states using validated measures and to compare the organizational and structural factors associated with higher family satisfaction with nursing home care. Data sources are family satisfaction surveys from Minnesota (MN) and Ohio (OH), linked to facility characteristics from Certification and Survey Provider Enhanced Reports (CASPER) for both states (N = 378 facilities for MN; N = 926 facilities for OH). Activities and food were among lowest rated items in both states. Relationships with staff were the highest rated domain. Higher occupancy rates, smaller facility size, and non-profit ownership consistently predicted better satisfaction in both states. Our findings show consistent organizational factors associated with family satisfaction and provide further evidence to the validity of family satisfaction as a person-centered measure of quality. This lays the foundation for tool development on the national level.

Keywords: family satisfaction, nursing home care, organizational factors, measure development

Introduction

Much attention has been given to the quality of care provided to nursing home (NH) residents (Castle, 2008; Castle & Ferguson, 2010; Zimmerman, 2003), with a host of measures publically available on the NH Compare website to better inform consumers (Centers for Medicare and Medicaid Services, 2018). Yet, one area that has been lacking is the inclusion of validated measures of consumer and family satisfaction (Williams, Straker, & Applebaum, 2016). While quality of care is important, satisfaction is highly valued by consumers as a metric of quality (Shippee, 2012).

To address this gap, providers and payers have been urging for greater inclusion of validated measures of NH satisfaction, both in terms of resident and family satisfaction. Unlike other settings, there is no governing body repository of existing validated measures for NH family and resident satisfaction. Much of this work has been happening in individual states (with the National Quality Forum as an example), but the focus has not been on long-term care. It is essential that instruments that are used to assess patient-reported outcomes in long-term care are evaluated for their reliability and validity for relevant populations prior to their use as meaningful and trustworthy assessment tools.

Family members play a key role as consumers of long-term care and as an important source of information about quality in NHs (Frentzel et al., 2012). Previous work has shown that family and resident satisfaction are distinct concepts (Kane et al., 2005; Shippee, Henning-Smith, Gaugler, Held, & Kane, 2017), and that family satisfaction complements other measures of NH quality (Li, Li, & Tang, 2016). Therefore, understanding which facility factors influence family member satisfaction can guide performance improvement programs and promote efforts to include satisfaction along with other publically reported quality measures.

To broaden our understanding of organizational and structural factors that are associated with family satisfaction, this study examines family satisfaction from two states: Minnesota (MN) and Ohio (OH). Data from these two states are used because both states have been leading the national efforts in this area and, to our knowledge, are the only two states with validated measures of family satisfaction as demonstrated through peer review (Shippee et al., 2017; Straker, Chow, Kalaw, & Pan, 2013; Williams et al., 2016). This study addresses a gap in the literature on NH family satisfaction in several ways. First, we adapt Donabedian’s conceptual model, which specifies that organizational and market structure should influence an NH’s ability to engage in good processes of care, which themselves should contribute to better family satisfaction (Castle & Ferguson, 2010; Donabedian, 1988). Structural variables we analyze are staffing levels, ownership, and market characteristics. Second, we compare the role of the same facility-level factors on family satisfaction reports across two states, which is an important contribution missing from previous studies and an important analysis from the policy perspective. Third, we use validated tools to measure family satisfaction.

To our knowledge, this is the first effort to use data from two states to compare factors that are associated with family satisfaction in NHs. The two-state comparison is important from the stand-point of study design and policy. It is difficult to know the transferability of findings about particular aspects of family satisfaction when they are limited to one state and could be driven by the state’s Medicaid reimbursement rates and other policies. For example, in our application, MN uses rate equalization to private pay rates whereas OH has now fully implemented a prospective payment system that resulted in lower average rates (Bowblis & Applebaum, 2017). The benefit of the comparative analysis is the ability to directly test whether factors that indicate higher family satisfaction in one state (MN) match factors associated with higher satisfaction in another state (OH). This approach moves the literature forward by improving the generalizability of findings to support consistent practice and policy implications.

We ask the following questions:

  • Research Question 1:

    What factors are associated with higher family satisfaction in MN and OH?

  • Research Question 2:

    Which factors are similar and different across these states and are these differences statistically significant?

Method

Data

Data for this study came from family satisfaction interviews conducted in MN in 2013 (Kane, 2008; Shippee et al., 2017; Vital Research, 2010) and OH in 2012 (Ejaz, Straker, Fox, & Swami, 2003; Straker et al., 2013). Both data sets reflect each NH’s average score on each survey question1 and were collected by third parties for each state, for the purposes of public reporting.2 The survey scores were merged with facility-level data from the Certification and Survey Provider Enhanced Reports (CASPER). OH has an average of 28.6 respondents per facility, compared with 37.3 respondents in MN. We aggregated family satisfaction items to the facility level by obtaining the facility mean. This resulted in a sample of 378 facility-level observations for MN and 926 facility-level observations for OH, after excluding nine facilities for erroneous staffing data.3

Family Satisfaction Measures

We identified six questions in each state’s survey that covered similar content, had similar wording, and measured a key domain of satisfaction. These six questions included perceived staff attitudes toward the resident,4 food choices, activities, facility cleanliness, autonomy (if residents could make decisions regarding their care), and how strongly the respondent would recommend the facility to others. The specific wording of each question for each state is in Appendix B.

Organizational and structural factors.

Organization and structural factors are grouped into three categories: staffing, payer and case-mix, and facility/market characteristics. We include the level of staffing for various types of staff: registered nurses (RN), licensed practical nurses (LPN), certified nursing assistants (CNA), therapists, activities staff, and ancillary service staff (e.g., housekeeping, dietitians). Staffing variables are measured as hours per resident day (HPRD). Payer-mix variables include the percentage of residents covered by different payer sources (e.g., Medicare, Medicaid, and private pay). To measure residents’ level of physical need, case-mix includes the facility acuity index (Feng, Grabowski, Intrator, & Mor, 2006) and prevalence of dementia, depression, and other psychiatric conditions. Facility structural variables are size, occupancy rate, ownership (non-profit, for-profit, and government), presence of a dementia special care unit, and whether the NH is affiliated with a chain, hospital-based, or part of a continuing care retirement community. At a market level, we include geographic location (metropolitan, micropolitan, rural, or isolated) and indicator variables for the level of competitiveness in the county.5

Respondent characteristics.

Family member engagement and relationship to the resident are associated with family satisfaction scores (Shippee et al., 2017). We included facility-level measures for the following respondent characteristics which were common across both states: respondent relationship (e.g., spouse, child), gender of respondent, and frequency of responder visits.

Analytic Approach

We estimated separate ordinary least squares regression models for MN and OH to determine which organizational and structural factors influence family satisfaction. Our two primary outcome variables are a summary score—an average of all six questions, and if the respondent would recommend the facility, which we refer to as global satisfaction. As a robustness check, we also examined the five domain-specific questions.

MN and OH used slightly different scales to measure family satisfaction (1 through 5 in MN and 1 through 4 in OH). To make both states comparable, we transformed satisfaction scores by calculating a Z-score for each facility within each state, that is, we measured the effect of all variables of interest on the standard deviation from each state’s grand mean. We then performed Chow (1960) tests to determine if the factors that predict family satisfaction in MN are statistically different from OH. As a robustness test, we estimated an additional model with an interaction term for OH with every variable, and obtained equivalent results.

Findings

Table 1 provides descriptive statistics with unstandardized satisfaction scores. While we cannot directly compare satisfaction scores across the two states in part due to different scales, we find similar patterns across domains within both states: family members’ satisfaction with staff attitudes toward the resident was rated the highest, but satisfaction with food and with activity choices were rated the lowest in both states.

Table 1.

Descriptive Statistics for MN and OH Family Satisfaction Measures and Facility Characteristics.

Minnesota (N = 378)
 Ohio (N = 926)
M
SD
M
SD
Dependent variables (mean scores) Range = 1–5 Range = 1–4 p value
Perception of staff attitudes/respect 4.229 0.245 3.755 0.130
 Food choices 3.668 0.290 3.200 0.288
 Activities are interesting 3.834 0.292 3.145 0.242
 Facility cleanliness 4.086 0.353 3.604 0.243
 Autonomy 4.089 0.235 3.419 0.235
 Would recommend facility 4.159 0.401 3.522 0.325
 Mean of 6 comparable questions 4.011 0.260 3.441 0.201
Staffing direct care hours per resident-day
 Registered nurse 0.520 0.434 0.431 0.362 .000
 Licensed practical nurse 0.747 0.278 0.888 0.304 .000
 Certified nursing assistant 2.203 0.593 2.274 0.645 .066
 Physical, occupational, or speech therapist 0.358 0.395 0.448 0.336 .000
 Recreational therapy or activities 0.252 0.112 0.210 0.107 .000
 Dietitian, food service, and housekeeping 1.355 0.454 1.280 0.544 .019
Payer- and case-mix
 Medicare patient days 0.107 0.113 0.131 0.108 .000
 Medicaid patient days 0.542 0.180 0.622 0.186 .000
 Private pay patient days 0.351 0.148 0.248 0.133 .000
 Acuity index 9.070 1.368 9.685 1.248 .000
 Dementia prevalence 0.468 0.152 0.470 0.172 .840
 Major psychiatric condition prevalence 0.290 0.175 0.340 0.187 .000
 Depression prevalence 0.534 0.193 0.592 0.203 .000
Facility and market characteristics
 Total beds 80.315 47.153 97.297 45.268 .000
 Occupancy ratio 0.890 0.090 0.850 0.110 .000
 Dementia special care unit 0.254 0.436 0.188 0.391 .008
 Chain affiliation 0.537 0.499 0.640 0.480 .001
 Hospital affiliation 0.122 0.327 0.016 0.126 .000
 Continuing Care Retirement Community affiliation 0.074 0.262 0.140 0.348 .001
 Ownership
  Non-profit 0.616 0.486 0.190 0.392
  For-profit 0.296 0.457 0.790 0.407
  Government 0.087 0.282 0.019 0.138 .000
 Market concentration
  Highly competitive 0.222 0.416 0.496 0.500
  Competitive 0.119 0.324 0.409 0.492
  Moderate concentration 0.220 0.414 0.079 0.269
  High concentration or monopoly 0.439 0.496 0.016 0.126 .000
 Geographic location
  Metropolitan 0.431 0.495 0.717 0.450
  Micropolitan 0.159 0.365 0.184 0.387
  Rural 0.143 0.350 0.073 0.261
  Isolated 0.267 0.442 0.026 0.159 .000
Family member characteristics (%)
 Children 0.549 0.142 0.507 0.192 .000
 Spouses 0.155 0.082 0.134 0.099 .000
 All other relatives 0.287 0.156 0.360 0.195 .000
 Female 0.656 0.099 0.690 0.111 .000
 Visit at least weekly 0.683 0.151 0.753 0.165 .000
 Visit at least monthly 0.226 0.123 0.186 0.130 .000
 Visit less than monthly 0.083 0.077 0.061 0.083 .000
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There are significant differences between MN and OH in terms of organizational and structural factors. OH has lower staffing levels for RNs, therapists, and activities and ancillary service staff, but higher staffing levels for LPNs and CNAs. OH NHs have more residents on government programs, have greater physical need, and are more likely to have depression or a major psychiatric illness compared with MN NHs. In terms of facility structural characteristics, OH NHs have more beds, and are more likely to be chain-affiliated, for-profit owned, and freestanding. OH NHs are also more likely to be in urban and more competitive markets than MN NHs.

Table 2 reports the regression results for the two outcomes of family satisfaction: the summary score of six items and global satisfaction item. These measures are converted to Z-scores to allow for comparisons.

Table 2.

Standardized Coefficients and Chow Tests From OLS Regression Modeling for Overall Satisfaction.

Mean of six comparable questions
 Would recommend facility
Minnesota Ohio Minnesota Ohio
Staffing hours/resident-day
 Registered nurse −0.033 0.105 0.179 0.214*
 Licensed practical nurse 0.266a −0.181a 0.16 −0.163
 Certified nursing assistant 0.034 0.178*** 0.033 0.189***
 Physical, occupational, or speech therapist 0.138 −0.128 −0.022 −0.205
 Recreational therapy or activities 0.860** 0.489 0.858** 0.208
 Dietitian, food service, and housekeeping 0.071 0.029 0.024 −0.004
Payer- and case-mix
 Medicare patient daysb 0.073 0.011 0.018 0.012
 Medicaid patient daysb −0.04 −0.055* −0.058 −0.045
 Acuity index −0.039 −0.050** −0.034 −0.042*
 Dementia prevalenceb 0.06 0.075*** 0.046 0.084***
 Major psychiatric condition prevalenceb 0.035 0.019 0.035 0.012
 Depression prevalenceb −0.043c 0.018c −0.021 0.015
Facility and market characteristics
 Total beds, each 10 −0.031** −0.021** −0.017 −0.018**
 Occupancy ratiob 0.252***a 0.097***a 0.244***c 0.126***c
 Dementia special care unit −0.220* −0.021 −0.123 −0.01
 Chain affiliation −0.123 −0.307*** −0.159* −0.194**
 Hospital affiliation 0.116 −0.222 0.149 −0.15
 Continuing care retirement community affiliation −0.046 −0.129 0.076 −0.072
 Ownership, ref. non-profit
  For-profit −0.342** −0.412*** −0.507*** −0.408***
  Government 0.209 0.1 0.146 0.13
 Market competition, ref. very competitive
  Competitive −0.05 0.218** −0.019 0.237***
  Moderate concentration 0.27 0.411*** 0.237 0.390***
  High concentration or monopoly 0.033 0.245 0.126 0.450**
 Location, ref. metropolitan
  Micropolitan 0.055 0.196** 0.119 0.200**
  Rural 0.063 0.143 −0.003 0.138
  Isolated 0.287* 0.364** 0.264* 0.199
Respondent characteristicsd
 Children 0.153** 0.071** 0.150** 0.100***
 Spouses 0.007 −0.009 0.062 0
 Female −0.046 −0.028 −0.007 −0.047
 Visit at least weekly −0.066 0.006 −0.009 0.004
 Visit at least monthly −0.095 0.013 −0.087 −0.015
Intercept −2.124* −0.571 −2.749** −0.999
N 378 926
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Note. Minnesota N = 378, Ohio N = 926. OLS = ordinary least squares.

a

Chow test for difference in coefficients between states <.05.

b

Betas for effect of each 10 percentage points. For respondent characteristics, applies to all betas.

c

Chow test for difference in coefficients between states <.1.

d

All respondent characteristics are the proportion of the respondents who have each characteristic.

For individual states’ coefficients:

*

p < .1.

**

p < .05.

***

p < .01.

Across these two measures of satisfaction and for both states, family members in NHs that have fewer beds, have higher occupancy rates, are operated by a not-for-profit, and are in isolated areas reported higher satisfaction compared with their peers. Family members in MN NHs report higher satisfaction for both measures in facilities that have higher level of activities staff whereas higher levels of RN and CNA staffing are positively associated with at least one satisfaction measure in OH. Family members in OH NHs report higher satisfaction if the NH has fewer Medicaid residents, lower average physical acuity, and greater prevalence of dementia, and is located in a less competitive market. While we identify some differences in factors that are associated with higher satisfaction in each state, most of the coefficient estimates for MN and OH are consistent, indicating that some of the lack of statistical significance in MN may be due to smaller sample size.

As a robustness check, we also examined the five individual domain questions. These results are reported in Table A1 (see Appendix A). While we do find some differences between the two states for some questions,6 most organizational and structural factors associated with higher satisfaction are not statistically different across the two states.

Discussion

This is the first study that uses validated measures of family satisfaction and compares them across two states to identify organizational, payer, and structural factors associated with higher satisfaction. This work is important because payers, policy makers, and providers have called for better measures of consumer satisfaction but research has been lagging in validating and comparing these measures. Our findings move beyond single-state studies of family satisfaction to identify factors that are similar across states. Although our comparison between OH and MN is still limited based on the profiles of these two states, this is the first such examination to date. The use of family satisfaction instruments is highly fragmented (Castle, 2007). Many facilities use their own surveys, yet Maryland and Rhode Island are the only other states that we are aware of that field a statewide survey (Castle, Diesel, & Ferguson-Rome, 2010; Li et al., 2016). The American Health Care Association has sponsored a very short (three-item) satisfaction instrument (National Quality Forum, 2017). Thus, our comparison of MN’s and OH’s measures of multiple domains of family satisfaction adds to the existing literature.

MN and OH are the two states that have led national efforts to measure and report family satisfaction of NHs and are uniquely positioned to inform this work. Our results indicate the consistency of most organizational and structural factors associated with family satisfaction across these two states, supporting previous state-specific findings (Shippee et al., 2017). This is an important contribution to the literature, demonstrating the construct validity of these two family satisfaction measures.

Staffing was a consistent organizational factor associated with higher family satisfaction, with families more satisfied in facilities that have higher RN, CNA, and activities staffing. Higher Medicare payer-mix and lower acuity levels were also associated with higher satisfaction. Structural characteristics were also associated with higher satisfaction, and included smaller size, higher occupancy, not being owned by a for-profit, or being affiliated with a chain, and rural location.

The few factors that were statistically different for MN and OH relate to the role of LPN staffing levels and prevalence of depression, partially reflecting the organizational differences between the two states. We also found that the effect of occupancy rate was larger in MN compared with OH, though the effect was positive in both states.

This study’s limitations include the following: only a minority of questions that were similar across both states could be compared, different response scales required the use of Z-scores for our dependent variables, the surveys were administered in different years (2012 and 2013), and facilities in each state differ on a number of explanatory variables, such as staffing, payer-mix, and case-mix. Also, there may have been unobserved differences in how surveys were administered. In addition, we were not able to compare the relationships between family satisfaction and resident experience and the mediating or moderating roles of structural factors within or between both states. Nonetheless, our study makes an important contribution toward promotion of a publicly reported satisfaction measure on a national basis, such as the state-developed measures used in MN and OH or NH Consumer Assessment of Healthcare Providers and Systems (CAHPS) (Frentzel et al., 2012). Our results clearly show directly comparable factors associated with family satisfaction across these two states, even when these states are very different in terms of state-level NH policies.

Our findings show that family members are generally satisfied with NH quality and consistently rate satisfaction with the perceived attitudes of staff as the highest item across both states, with activities and food consistently lowest. Furthermore, we found consistent effect sizes for key organizational and structural factors associated with family satisfaction. Our comparative work shows the validity of family satisfaction measures and the key role that facility factors play in higher family satisfaction, laying the foundation for tool development on the national level. Indeed, family members are increasingly becoming the key consumers of long-term care for their loved ones and would value having these person-centered measures of satisfaction as metrics of quality.

Acknowledgments

We would like to thank Jane Karnes Straker for contributing her expertise regarding the Ohio Family Satisfaction Survey.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Appendix A

Table A1.

Standardized Coefficients and Chow Tests From Ordinary Least Squares Regression Modeling for Domain Specific Satisfaction.

Staff attitudes/respect Food choices Activities are interesting Facility cleanliness Autonomy
MNe OHe MNe OHe MNe OHe MNe OHe MNe OHe
Staffing hours/resident-day
 Registered nurse 0.100 −0.150 −0.286**a 0.207a 0.168 −0.151 −0.234 0.103 −0.094 0.096
 Licensed practical nurse 0.293b −0.26b 0.234 −0.082 0.003 −0.207* 0.234c −0.124c 0.403*b −0.110b
 Certified nursing assistant 0.022 0.161** 0.057 0.134** −0.004 0.115** −0.019c 0.180**c 0.078 0.153**
 Physical, occupational, or speech therapist 0.181 0.294 0.052 −0.315** 0.029 −0.223 0.134c −0.238c 0.316* −0.066
 Recreational therapy or activities 0.374 −0.133 0.607 0.557* 1.610*** 0.973** 0.578 0.323 0.265 0.623*
 Dietitian, food service, and housekeeping 0.018 0.071 0.042 0.003 0.000 0.019 0.253* 0.101 0.016 −0.01
Payer- and case-mix
 Medicare patient days −0.001c −0.190**c 0.088 −0.052 0.111 0.046 0.110* 0.117** 0.036 0.095*
 Medicaid patient days −0.017 −0.089** −0.077* −0.114*** 0.047 −0.013 −0.053 −0.046 −0.044 0.009
 Acuity index −0.083** −0.051* −0.003 −0.061** −0.04 0.007 −0.01 −0.02 −0.025 −0.094***
 Dementia prevalence 0.069* 0.091*** −0.007 0.051** 0.065 0.052** 0.056 0.073*** 0.071 0.015
 Major psychiatric condition prevalence 0.038 0.011 0.042 0.044** 0.05 0.005 0 −0.001 0.013 0.034
 Depression prevalence −0.041 −0.01 −0.050* −0.005 −0.026 0.031* −0.038b 0.022b −0.036b 0.035*b
Facility and market characteristics
 Total beds, each 10 −0.038** −0.019** −0.028** −0.022** −0.002 −0.013* −0.034** −0.019** −0.037** −0.015**
 Occupancy ratio 0.164** 0.064* 0.145** 0.079** 0.234** 0.104** 0.269***b 0.098***b 0.204**b 0.021b
 Dementia special care unit −0.15 −0.004 −0.239*c 0.037c −0.183 −0.044 −0.174 −0.024 −0.225* −0.056
 Chain affiliation −0.087 −0.213** 0.064a −0.364***a −0.114 −0.267*** −0.224** −0.249*** −0.091 −0.232**
 Hospital affiliation 0.084 0.140 0.197 −0.205 0.040 −0.349 0.069 −0.57 0.037 0.039
 Continuing care retirement community affiliation −0.005 −0.042 −0.166 −0.027 −0.239 −0.144 0.166b −0.215**b −0.06 −0.158
 Ownership, ref. non-profit
  For-profit −0.310** −0.250** −0.227 −0.306*** −0.083b −0.423***b −0.421** −0.281*** −0.159 −0.364***
  Government 0.170 −0.05 0.177 −0.097 0.281* 0.130 0.073 0.248* 0.194 0.155
 Market competition, ref. very competitive
  Competitive −0.062 0.251*** −0.163 0.161** 0.145 0.083 0.034 0.200** −0.186 0.133*
  Moderate concentration 0.148c 0.506***c 0.189 0.355** 0.403** 0.259** 0.308* 0.357** 0.060 0.185
  High concentration or monopoly 0.043 0.324 −0.089 0.092 0.203 0.159 0.076 0.389* −0.196 −0.183
 Location, ref. metropolitan
  Micropolitan −0.032 0.141 0.014 0.277*** 0.142 0.105 −0.048 0.168** 0.082 0.092
  Rural −0.075 0.133 0.157 0.201* 0.134 0.050 0.025 0.159 0.078 0.050
  Isolated −0.004 0.086 0.279 0.521** 0.313* 0.308 0.292* 0.247 0.286 0.454**
Respondent characteristicsd
 Children 0.208***b 0.056*b 0.087 0.046 0.127** 0.022 0.119** 0.073** 0.069 0.028
 Spouses 0.174**c 0.023c −0.088 0.018 −0.067 −0.038 0.107 −0.002 −0.156 −0.046
 Female −0.086 −0.047 −0.032 −0.014 −0.058 −0.015 −0.055 −0.025 0.008 −0.001
 Visit at least weekly −0.107 −0.034 −0.128 0.008 0.040 0.023 −0.075 0.014 −0.052 0.026
 Visit at least monthly −0.065 0.035 −0.154 −0.007 0.014 −0.001 −0.057 −0.01 −0.127 0.019
Intercept −0.873 0.601 0.171 0.327 −3.634*** −1.079 −2.197** −1.266** −1.308 −0.021
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Note. Minnesota N = 378, Ohio N = 926.

a

Chow test for difference in coefficients between states <.01.

b

Chow test for difference in coefficients between states <.05.

c

Chow test for difference in coefficients between states <.1.

d

All respondent characteristics are the proportion of the respondents who have each characteristic. Betas for effect of each 10 percentage points.

e

Betas for effect of each 10 percentage points. For respondent characteristics, applies to all betas.

For individual states’ coefficients:

*

p < .1.

**

p < .05.

***

p < .01.

Appendix B

Minnesota 2013 Family Satisfaction Survey, Selected Questions and Response Options.

Instructions to respondent: Please tell us about your experiences with the nursing facility and the care given there. Please grade each of the following items where A = excellent; B = very good; C = average; D = below average; and F = failing.

Domains of family satisfaction and item description Excellent A Very good B Average C Below average D Failing F Don’t know/not applicable N/A
Staff attitudes/respect: Item 7: Staff’s attitude toward the resident (respect, concern, caring)
Food choices: Item 9: Menu choice of food available to the resident
Activities are interesting: Item 12: Offering activities that are interesting to the resident
Facility cleanliness: Item 20: Cleanliness of the facility
Autonomy: Item 31; Allowing the resident to choose to receive or refuse care
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Extremely high 5 4 3 2 Extremely low 1
Would recommend facility: Item 37: Rating the nursing facility on a scale where 5 = extremely high and 1 = extremely low, how enthusiastically would you recommend this nursing facility to another family
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Domains of family satisfaction and item description Yes, always Yes, sometimes No, hardly ever No, never Don’t know/not applicable N/A
Staff Attitudes/Respect: Averaged across Items 9, 20, and 21.
Question 9: Does the activities staff treat the resident with respect?
Question 20: Are the nurse aides gentle when they take care of the resident? and
Question 21: Do the nurse aides treat the resident with respect?
Food Choices: Item 29: Can the resident get the foods he or she likes?
Activities are interesting: Item 7: Are the facility activities things that the resident likes to do?
Facility cleanliness: Item 39: Is the facility clean enough?
Autonomy: Item 16: Is the resident encouraged to make decisions about his or her personal care routine?
Would recommend facility: Item 47: Would you recommend this facility to a family member or friend?
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Footnotes

1.

Ohio’s are a raw mean, while Minnesota’s are risk-adjusted with a hierarchical linear model.

2.

In both states, report cards are publicly available (Minnesota Department of Human Services, n.d.; Ohio Department of Aging, n.d.) and the current year’s summary scores for each nursing home (NH) are publicly reported. Individual data, and previous years of facility-level data, may be obtained from each state on a case-by-case basis.

3.

Erroneous staffing levels were identified using the method described in Bowblis (2011).

4.

In the case of perception of staff attitudes toward the resident, Minnesota asked a single question whereas Ohio asked three different questions which were specific to certain types of staff (e.g., “Do the nurse aides treat the resident with respect?” “Are the nurse aides gentle when they take care of the resident?” and “Does the activities staff treat the resident with respect?”). To make Ohio comparable with Minnesota, we calculated the mean of these three questions.

5.

We calculated Herfindahl-Hirschman Indices (HHI) for each county and categorized each county into a level of competition based on the FTC/DOJ Horizontal Merger Guidelines.

6.

Differences include Perceived Staff Attitudes/Respect (% Medicare residents and level of competition), Food Choices (RNs), and Facility Cleanliness (CNAs and therapists).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

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