Executive Summary

For the first time, the Centers for Medicare & Medicaid Services is posting Star Ratings, showing patients’ perception of care, on the Hospital Compare website.

  • Ratings are based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and include individual scores on 12 composite measures based on the HCAHPS responses as well as state and national averages.
  • A big gap between patients who reported receiving discharge instructions (86%) and those who said they understood what to do at home (52%) indicates that hospitals need to revise their discharge teaching and make sure patients understand their treatment plan.
  • Case managers need to take the time to fully assess all patients — not just those going to post-acute facilities — to find out their living situations, their support systems, and their need for resources after they go home.


For the first time, prospective patients can find out what other patients think of your hospital by checking the Hospital Star Ratings on the Center for Medicare & Medicaid Services’ (CMS’) Hospital Compare website.

The Star Ratings, which show patients’ perceptions of the hospital experience, are based on hospital scores from 22 questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which hospitals must send randomly to newly discharged patients. Hospital Compare includes each individual hospital’s ratings on 11 composite scores on HCAHPS measures and the new HCAHPS Summary Star Ratings, which are a combination of all ratings. The website includes state and national averages for each metric.

The metrics posted on Hospital Compare show huge gaps between the percentage of patients who said they were given information about what to do during their recovery at home (86%) and those who said they understood their care when they left the hospital (52%), says Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan Health Care Group, a Newton, MA, healthcare transition management software firm.

Patients are not likely to base their choice of hospitals solely on the Star Ratings, says Linda Sallee, RN, MS, CMAC, ACM, IQCI, director for Huron Healthcare, headquartered in Chicago.

In fact, CMS advises patients to consider many factors in hospital choice, including word-of-mouth information.

People tend to go to hospitals in their community or where their doctor practices, Sallee points out. “But people are becoming more savvy and are paying attention to quality data, so the Star Ratings could have some effect. It would be a good idea for hospitals to pay attention to their scores and take steps to improve,” she adds.

One major reason for improving patient satisfaction is the announcement from CMS in the Inpatient Prospective Payment System proposed rule for fiscal 2016 that it intends to add metrics from three HCAHPS care coordination questions to the Value-Based Purchasing program in fiscal 2018.

The questions focus on patients’ understanding of their care when they left the hospital and ask if the staff took their preferences into consideration in deciding their post-acute care needs; if patients had a good understanding of how to manage their health when they were discharged; and if patients clearly understood the purpose of taking their medications.

“This is just another indication that CMS is serious about improving the discharge process and patient care,” Sallee says.

Birmingham advises hospital case managers to review their hospital’s scores, particularly on the discharge planning and care transition measures, to determine where there is room for improvement.

“When just over half of patients understand their care when they leave the hospital, it indicates that the discharge process needs to be improved. We already knew this, but now it’s been proven that just handing patients a sheaf of papers doesn’t translate into them understanding what to do. It’s time for hospitals to revise the way they assess patients who are appropriate for home health services or home without services to develop a discharge plan,” she says.

HCAHPS surveys aren’t sent to people with skilled nursing facility referrals. The ratings come from patients who were discharged from home, Birmingham points out.

“This indicates that case managers need to spend as much time with patients who are going home as they do with those who are going to a skilled nursing facility. Case managers should assess patients’ needs and develop a discharge plan based on their functional needs and strengths to determine their discharge destination. When it’s home, spend more time with the patient, spend more time with the staff nurses and therapists, if appropriate, to make sure patients understand their role in the discharge plan,” she says.

Case managers haven’t always created a discharge plan for patients being discharged to home, but that needs to change, Sallee says. “Case managers need to give patients going home all those safety nets that will help keep them from coming back to the hospital when the care they need could be provided somewhere else,” she says.

Discharge planning has gotten short shrift in many hospitals because of the time-consuming nature of the process and because many case management departments don’t have enough staff to spend a lot of time with patients, says Toni Cesta, RN, PhD, FAAN, partner and consultant in Dallas-based Case Management Concepts.

“With CMS’ focus on reducing readmissions and improving quality, it’s important to make sure patients understand what they need to do after discharge. If case managers rush in at the last minute to develop a discharge plan, it impacts patients’ perception of the care they are getting as well as having the potential for developing a discharge plan that won’t work,” Cesta adds.

Case managers should assess every patient and take the time to find out their support systems and other situations at home that could impact a safe transition, she says.

Case managers need to broaden their focus and find out what issues patients face when they get home and what resources are available to fill that need, Sallee says. Take the time to dig deeper and find out the situation at home as well as the patient’s needs, she says.

For instance, you may see an elderly patient who is in the hospital for a short stay, but who will need someone to be with him or her 24 hours a day after discharge. “The patient may say that he lives with his daughter, but it may be that everyone in the family works or goes to school and the patient would be alone for a good part of the day. If case managers don’t take the time to find out that detail and have the family make arrangements for a daytime caregiver, the discharge may not be successful,” Sallee says.

“An unsuccessful discharge may cause the patient or the family member who helps the patient complete the HCAHPS give the hospital a low score, which will affect the Star rating,” Birmingham says.

Case managers should develop a good relationship with patients and their families, talk with them in easy-to-understand language about the discharge plan, and get their approval of the plan, Cesta says, adding that Medicare Conditions of Participation mandate involving patients and families in the discharge plan.

Cesta suggests that case managers visit their patients every day during the hospital stay and reinforce and reiterate the discharge plan. “Patients can’t hear everything in one session. You’ve got to teach them multiple times,” she says. When you go into patients’ rooms, sit down and take the time to get to know the patients, she adds.

“When case managers fly in at the end of the hospital stay and have no relationship with the patient, they shouldn’t wonder why their scores are low,” she says.

Case managers have to take the time to sit down and talk to patients and involve them in the discharge plan, says Eric Heil, co-founder and chief executive officer at RightCare, a healthcare information technology company based in Horsham, PA.

He recommends that case managers and nurses talk about the potential discharge plan during conversations with the patient throughout the hospital stay.

“Case managers should talk to patients, find out their preferences and their needs at home, and use the information to create a discharge plan and talk to them about their discharge plan throughout the hospital stay,” he says.

“Integrating conversations about the next level of care into the clinical workflow is critically important. If nurses or case managers wait until the day of discharge to talk about the discharge plan, the patients are likely to feel unprepared,” Heil adds.

Good communication starts with the hospital staff. “If the team members communicate effectively among themselves, they are likely to communicate well with the patients,” he says.

Case managers can do a lot in conjunction with nursing to improve their hospital’s scores on the discharge information questions, says Wanda Pell, MHA, BSN, director, Novia Strategies, a national healthcare consulting firm.

“If patients don’t know they are being discharged until the morning of the discharge, they don’t feel ready,” Pell says. But if the staff sets the expectation for the length of stay in the beginning, the patient and family won’t feel rushed and they are more likely to feel prepared to go home, she adds.