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Market Decisions Research’s work with the Maryland Health Care Commission (MHCC) began in 2005, when we were contracted to conduct a pilot family satisfaction survey for nursing homes in Maryland using a customized version of a survey instrument we had developed for Massachusetts.

Our work was part of the MHCC’s family experience of care initiative that began with the pilot survey that was intended to guide the start of an annual process. The purpose of the initiative is to measure the experience and satisfaction of family members and other designated responsible parties of residents in Maryland’s nursing homes. More specifically, the objectives are to provide:

1.  Measures of responsible party experience and satisfaction;

2.  Comparisons on experience and satisfaction measures between nursing homes in Maryland;

3.  Comparisons between nursing home peer groups, including geographical region, facility size, and ownership type;

4.  To compare results over time.

The impetus for the MHCC’s family experience of care initiative was a growing emphasis on patient-centered care and the intention of the Agency for Health Care Quality (AHRQ), which is part of the U.S. Department of Health & Human Services, to gather family feedback. Although the survey is not unique to Maryland—Ohio and Rhode Island conduct similar surveys—the MHCC was the one of the first state agencies to conduct this type of survey.

In 2007, we conducted this research using a new survey instrument that had been developed by U. S. Agency for Healthcare Research and Quality (AHRQ) and adapted by the MHCC. We have administered this survey almost every year since, and will be administering it annually through 2023.

Mail Survey Experience

MDR has extensive experience with both large scale and smaller mail surveys.  Often these are coordinated with online and telephone data collection. Examples include,

Massachusetts Nursing Home Satisfaction Survey

• Annual mail survey with telephone follow-up

• 27,500 completed surveys

Colorado Judicial Performance Survey

• Annual online or mailed survey for respondents without email addresses

• 12,000 completed surveys

Massachusetts PROMISES Patient Survey

• Mailed pre and post quality intervention

• 3,600 completed surveys

Our Process in Maryland

The research involves family members of residents at 222 nursing homes throughout Maryland, or as many as 27,500 potential respondents. We contact nursing homes and ask them to provide a list of residents, the designated responsible parties of each of their current residents, and the residents’ intake dates and payment method. A responsible party is most often a family member, such as a spouse, child, or sibling, but can also be someone who is unrelated to the resident, such as a caretaker or a social worker. It’s important to note that because responsible parties of residents with a stay of less than 100 days aren’t surveyed, the experience and satisfaction of the responsible parties of residents with short-term skilled nursing care or rehabilitation needs aren’t captured by this survey.

One of the most challenging tasks for the project is getting the nursing homes to provide accurate, complete contact information for the tens of thousands of potential respondents. Once we have screened the sample to ensure eligibility, we administer a three-phase mail survey consisting of a personalized survey packet, a follow-up/reminder post card, and a second survey mailing to non-responders. The packet each potential respondent receives consists of a personalized letter explaining the purpose of the survey and requesting participation, as well as the actual questionnaire and a postage-paid business reply envelope.

After the mail-survey phases are completed, reminder calls are made to non-responders to encourage participation and, if preferred, to complete the survey by telephone.

Advanced Data Analysis

Following data collection, a complex set of analyses is used to examine results at the state level, by identified peer groups, and at the facility level. After administering the survey, we develop a statewide research report for the MHCC, as well as a facility-specific report and interpretive guide that is distributed to each participating nursing home. Both individual facility and statewide results are shared with nursing home administrators and corporate staff to help facilities identify areas for quality improvement and to make comparisons with other similar facilities.

The survey has an impact on the nursing homes because the data is shared with Maryland Medicaid for the Pay-For-Performance program that awards nursing homes that perform highly on certain quality indicators. The survey data is one of the factors that helps with determining reimbursement rates for the nursing homes.

Overall, satisfaction with family members’ care has remained relatively steady from 2013 to 2016, statewide. Nursing homes are compared to the state average using three peer groups: region (Western, Eastern Shore, Southern, Central, and Montgomery County); nursing home size (≤ 80 beds, 81-120, 121-160, and ≥ 161 beds), and ownership status (non-profit or for-profit). Compared to the state average, Western Maryland nursing homes, smaller nursing homes ( ≤ 80 beds), and non-profit nursing homes had significantly higher satisfaction scores.

The MHCC has a consumer website, Maryland Health Care Quality Reports that includes, among other things, guidance for choosing a nursing home, as well as results of past surveys and quality reports. The website provides access to a nursing home checklist with questions to consider when looking for a nursing home and the MHCC Consumer Guide to Long Term Care, an interactive web tool containing information about an array of long-term care services, including nursing homes and community support services such as senior centers, transportation, and technology assistance. The facility-specific results are posted to assist consumers in making informed decisions when selecting a nursing home.

“Long-term care is the most used of our consumer websites,” said Julie Deppe, Program Manager, Long Term Care Quality Initiatives, MHCC Center for Quality Measurement and Reporting. Part of Deppe’s job is to work with consumers who call the MHCC with questions related to the survey.

“Families are often very eager to share their experiences through the survey,” added Deppe.

Dynamic Reports and Recommendations

At the conclusion of the survey process, we file a report with the MHCC that includes our recommendations for improvements.

“Our approach has been fine-tuned over time,” said Jennifer Oliver, MDR Vice President of Operations, who manages all aspects of the project. “For example, changes to the survey were made in 2018, based on our recommendations after the 2016 survey.”

Previously, there was only one survey question about food: If you helped the resident with eating or drinking during any of your visits, how often did you help with eating or drinking because the nurses or nursing assistants were not available to help or made the resident wait too long?

We suggested that additional questions would enrich the survey. Two questions were added.

In the last 6 months, how often was the resident served a variety of food (e.g., fresh vegetables and fruits, lean meats, fish)?  ¨ Always ¨ Usually ¨ Sometimes ¨ Never ¨ Does Not Apply

In the last 6 months, how often was the food served to the resident high quality (i.e., attractive, appetizing, and nutritious)? ¨ Always ¨ Usually ¨ Sometimes ¨ Never ¨ Does Not Apply

Another change was made to the survey in 2018. A Spanish-language version was developed and administered.

“Facilities requested the Spanish-language version of the survey,” said Stacy Howes, PhD, Chief, Long Term Care and Health Plan Quality Initiatives, MHCC Center for Quality Measurement and Reporting. “Market Decisions Research helped us to make that happen. They consistently produce excellent, reliable, and timely work.”