Lisa R. Shugarman and Rena Garland
This report was prepared under contract #HHS-100-03-0023 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the RAND Corporation. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Linda Bergofsky, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail addresses is: Linda.Bergofsky@hhs.gov.
The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.
More than a million elders enter a nursing facility each year, yet little is known about how consumers of skilled and long-term nursing care select the facility to which they or their loved ones will be admitted. Many members of the Baby Boomer generation are currently faced with long-term care (LTC) decisions for their parents, and those on the leading edge of the generation will soon be dealing with these issues themselves. The aging of the population points to the increasing need for useful and reliable information resources available to consumers about their health and social care options, including nursing homes. There are numerous resources available to the public to support the decision-making process through federal and state governments as well as private sources. However, there is some skepticism both about the ability of elders and their families to understand and translate that information into a decision, and about whether the information available is relevant to the decision-making process. While these resources are widely available through the Internet, phone, and in print, there is little information about if and how they are used to support the decision-making process.
The purpose of this study, commissioned by the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services, was to use qualitative methods to: (1) systematically review the existence and accessibility of Internet-based resources intended to support the decision to enter a nursing facility and select the appropriate facility for ones needs and preferences; (2) examine how consumers select a nursing home; (3) explore if and how existing information resources are used in the decision-making process; and (4) identify gaps in needed information resources.
The goal of this report is to present a review of a subset of the Internet sites that may be used to inform a consumers selection of a nursing facility. As part of this content review, we reviewed 29 websites; 13 websites were national in scope and 16 were state-specific. The following states were considered in our search for and review of websites: California, Iowa, Florida, Ohio, Virginia and Maryland.
APPROACH AND METHODS
To identify and examine the accessibility of consumer information on nursing home selection, an Internet search was conducted for information resources on nursing home selection and the accessibility of the sites and the information they provided were examined. We selected six states for the review of state-specific website content by balancing three considerations: perceived depth of information resources in each state (i.e., information rich or information poor), logistical feasibility for holding follow-up focus groups, and variation in state demography (i.e., age of population, racial diversity, and urban/rural mix). The states selected were California, Iowa, Florida, Ohio, Virginia, and Maryland.
Internet sites selected for review were based on an initial set of websites with a national focus identified by ASPE. Additional websites were identified using popular Internet search engines (e.g., Google, Yahoo, MSN). State-specific websites were identified through the state resource links from the Medicare.gov site as well as those cited in a recent review of state-specific websites published in the peer-reviewed literature (Castle 2003). We reviewed all sites for accessibility (e.g., how easily they could be identified using common search terms) and navigability (e.g., how easily one might be able to find relevant resources on the site). We also considered how the websites were designed to enhance accessibility for viewers with disabilities using a web-based diagnostic tool that can identify problems with the functionality of those websites. Finally, the content readability of each site was measured to determine how accessible the information on the site might be to different literacy levels. Finally, we described the contents of the selected websites, including the types of educational information provided, languages in which information is available and specific descriptive information about facilities that is available on the site, in addition to other characteristics.
FINDINGS FROM WEBSITE CONTENT REVIEW
In total, we reviewed 29 websites; 13 websites were national in scope and 16 were state-specific. Most of the websites we reviewed included some type of descriptive information about nursing homes. The most commonly included descriptive characteristics were type of ownership, Medicare/Medicaid certification, number of beds, presence of special care or dementia units, and provision of special services or activities; with respect to content, few differences were observed between the state-specific and the national sites. Four national websites and six of the state-specific websites provided any form of quality information. About one-third of sites provided a mechanism to compare facilities. Every site provided some educational materials/resources. Just over half of the sites included instructions on how to search for a nursing facility; this information varied in content and quality; some provided portable document files (PDFs) that consumers could print out and take with them, while others provided more cursory information. Over two-thirds of the sites provided some form of a nursing home checklist that consumers could use as they visit facilities. Approximately 60 percent of the sites provided some information about how to pay for LTC. Over a third of the sites included information about residents rights, and over 70 percent included information on ombudsmen programs. Finally, 75 percent included links to other state resources and most included links to Nursing Home Compare.
In general, all of the Internet searches conducted as part of our assessment of the accessibility of most sites produced useful websites, regardless of the search terms used; Finding a nursing home or Finding a nursing facility, which may be the most commonly used search terms, produced a number of relevant websites. Most of the documents/websites we selected for the test of navigability were easily found. However, many of the sites reviewed had structural problems that affected their functionality, such as broken web links and graphics that did not have appropriate alternative text to aid those with various disabilities in reviewing their content. About one-quarter of sites were available in a language other than English. In addition, most content was found to be at the college reading level, far higher than the average reading level of the public (Kirsch, Jungeblut et al. 1993; National Center for Education Statistics 2003).
SUMMARY AND CONCLUSIONS
This content review summarizes the information for a set of Internet resources that may be useful in supporting a consumers selection of a nursing facility or a caregiver's selection of a facility for a loved one. The review was not intended to be comprehensive; however the sites reviewed here represent most of the sites with a national focus and state-specific sites for the states considered in our review. At the end of this report, we provide a synthesis of findings from the focus group findings reported in a separate volume of this report (Shugarman and Brown 2006) with the findings from the web content review. In the companion volume of this report, we propose a set of actionable items and areas for future research that may result in information resources that better match the needs of consumers seeking a nursing home and improve their accessibility as well.