Soliciting feedback

Getting feedback from residents, families and visitors to nursing homes has become a rapidly growing aggressively competitive market place.  There are three broad groups competing in what has recently become a  very complex and confusing system for both the not-for-profit providers and the community.

1. The family as represented by government and members of NACA,  They are responsible for designing this complicated market and they have done this behind our backs.  They have a vested interest in protecting it.
2. Consultants of various sorts serving the sector.  They have seen additional opportunities in servicing the confused and struggling customers of this system.  They could have a vested interest in maintaining its complexity.
3. Independent groups comprising:
   1. Individuals who are concerned at what is happening and are motivated to help prospective residents find suitable facilities as well as providers willing to address problems and wanting feedback to guide them.
   2. An entrepreneur who sees web feedback as a potential global market.
   3. An international not-for-profit providing web feedback in health and aged care in the UK expanding into Australia.
   4. A multinational US web feedback company focusing on the tablet and smartphone market that also provides feedback on aged care facilities.

My interest is in the problems in this system and what the proposed Community Aged care Hub could do to address them.

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The family

The family are promoting a positive image of aged care by associating aged care with going on holiday, finding accommodation and dining out.  They are porting the sort of reviews done when going out for a good time and applying them to aged care which is a trifle different.

COTA/NRMA/Gallup polls

COTA the seniors group that is a member of NACA and works with the government in structuring our aged care system, has joined with NRMA to develop an OWL rating of 1 to 3 in which nursing homes, which are good enough and pay enough, can display in much the same way that hotels, caravan parks and restaurants do.  It is rather more suited to retirement villages than nursing homes, but both are included.

It is interesting that this project went ahead when all of the submissions to the ACCC assessment of the application to certify the OWL ratings logo came from state residents associations that were critical and opposed to the scheme. Although others were invited by letter only three submissions were made.  It suggests that this was more about serving providers than residents - or perhaps about creating positive stories to counter the widespread concern about what is happening in the sector.

I am critical at the way the Gallup surveys which have merit are being organised. The OWL ratings promote and encourage the good homes to improve their performance. It concerns me because it is voluntary and those homes that perform poorly are automatically excluded. These facilities are where the problems lie.  As the submissions indicate the questions are skewed and do not addequately reflect what prospective residents need to know when they make life changing decisions.

From a consumer point of view, it is more important to know the bad ones to stay away from. Many want to be near family and the local homes may not be rated by these surveys. Once you are in a nursing home, it is too late.  It is simply too difficult to move. It is not like other services.  This caters to the very rich rather than to the average person looking for somewhere safe near family and friends.

I am also worried that the providers will be supplying the names and details of the people to be interviewed.  This creates a situation where there is a strong temptation to game the system by selecting those who will give positive feedback and excluding those who have complained.  This has been a major problem in survey systems.

MyAgedCare offers trip adviser services

The Government has carried the image of holiday time one step further.  Since 2014, it has been promising to offer a trip adviser service on its heavily criticised MyAgedCare website.  While that has been met with some enthusiasm by a few, serious critics in the UK and Australia see the application of this complex and relatively unreliable system to aged care as ridiculous  and inappropriate.

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Industry consultants and advisers

Aged Care Ratings and Aged Care Online

A director of a consulting business advising providers, a director of a business in the “Placement Industry” (which helps potential residents find a nursing home), and a director from Aged Care Online, (a company publishing information about aged care and about individual nursing homes) have founded Aged Care Ratings.

Facilities rate themselves on a 5 star system and if they want to put this on their websites and letterheads with a logo then they pay a fee to have it verified and then certified by Aged Care ratings. The rating does not include standards of care or quality of life.

Aged Care Online invites short reviews from residents and families on its web site. It publishes a listing of all the aged care facilities in Australia with any information the facility has provided including beds on offer and pricing. It the facility has been rated, the star logo is displayed and if any reviews are available they are displayed. Contact details are provided.

DPS publishing

DPS publishing works with the industry and publishes information brochures that the providers use. In December 2015, they indicated that they were considering “implementing user reviews” on their web site.

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Independent web based feedback sites

This more limited system does not collect nearly as much information as the Gallup poles collected by NRMA and COTA.   Although they do not collect as much information, I think that these sites could serve the bulk of people looking for an aged care facility much better.

These sites are already popular in the UK where they have had more experience. There is a rating system and feedback is supplied anonymously on the web sites.  It is often structured to get comment on specific issues but also allow free comment.  Providers of care are supplied with this information so that they can respond, take remedial action and address community concerns. This is an excellent idea and potentially very helpful for providers committed to improving their services. The feedback supplied is also a valuable resource for those deciding which nursing home to enter.

There are currently or soon will be, several competing groups in Australia asking people to go to their web sites to give feedback. The number of competing sites is going to markedly reduce the number of people responding to each web site and so the validity and usefulness of the information for consumers.

Some of these sites are community focussed and driven by dedicated individuals.  My impression is that genuinely concerned individuals worried about what is happening in nursing homes have started some of these web sites. Some have experienced problems themselves.

Others profess the same concerns but are primarily focused on this as a market. They are commercial entities and driven by market principles -  wanting to grow and make large amounts of money out of it.  Some are multinationals.

Not all the sites are fully transparent about their backers and funders.  With at least 5 groups, it looks like a competitive marketplace.  I can't help asking why we need so many and whether this is something that should be profit driven. The monney for all this has to come from the aged residents either directly or indirectly and will only push up the total cost of aged care further.

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Potential problems for all these sites

There are multiple issues :

• Because negative information is challenging and costly for providers and recruitment of feedback will depend on support from providers, I am worried that pressure may be put on the websites to help keep some of the feedback in 'the family' and not publish it.
• If they are to get sufficient numbers under the present system, all of these websites will depend on the cooperation of providers in directing residents, family and staff to the web sites.  The providers can decide which website they will support and this may not be the one that serves the consumers best.
• My worry is that providers will feel threatened by the public availability of adverse comment and may prefer the Gallup pole surveys where they have more control and where adverse feedback may not be published.
• Poor providers are less likely to cooperate, but if there is a clear single system that consumers are directed to, then there will be strong pressure on them to go there.
• There are many ways that less motivated providers can game these systems by filtering who they recruit to provide the feedback. Alternately, they might support those that provide advertising opportunities and who will exert more control over what is published. Those that don't do what the providers want, may not succeed.  The feedback sites themselves are in a position to manipulate results in order to boost advertising and extort money from providers.  All of these things have, or are alleged to have happened elsewhere.

When the sites were examined in April 2016, two independent sites dominated and the others were not doing very much.  Both of these require reviewers to register with them and give details so are in a position to monitor and vet inappropriate use.  The number of reviewers can be influenced by how carefully they vet and select reviewers. I looked through the site collecting several hundred reviews from each.

The extent to which the aged care sector is covered by reviews was not obvious, but it is clear that the bulk of facilities in Australia have not been reviewed.  About two thirds of reviewed sites were only reviewed by one person and of those reviewed, only 5 to 8% had more than 3 reviewers rating the system.  This can only mean that providers are not supporting them and are not encouraging people to review their facilities.

Aged Care Report Card has the most sophisticated web site, has an advisory panel drawn from a seniors group, nursing bodies and some independent businesses.  They are sponsored by similar groups and use some of these groups to help them recruit reviewers.

Aged Care Reviews is a commercial enterprise started by entrepreneurs and with a board of businesses directors.  It is funded by investors.  While the figures are unreliable, they suggest that it has a larger share of the feedback business and this may be due the additional funds they have available to market their services.

Rorting: Web feedback sites have become very popular in the wider marketplace and large numbers of people use them to evaluate services or products before buying. These systems are being extensively rorted in the USA, in the UK and in Australia. Providers themselves, or commercial entities they employ are providing a flood of positive (for their employer) and negative (for the employers competitors) feedback reviews. These distort the services and render them valueless and deceptive. I give examples on the linked page.

It has probably happened in health care in the UK, but I could not find confirmed reports of this happening in aged care. Comments by community groups in the UK and by one provider in Australia who has withdrawn from the process suggest that it may already be occurring.

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The Community Aged Care Hub

The proposed hub would be working in the nursing homes in each region helping them to collect objective data transparently.  The major weakness in the system that allows rorting is in the openness for anyone to participate.  The other weakness is the vulnerability of the sites to commercial pressures and their ability to vet or censure critical comments because of this.  Their dependence on advertising sits poorly with their intention to provide information objectively.

The hub, rather than the providers could assume responsibility for collecting formal feedback by supervising surveys or by recruiting people to go to a web site to give feedback, so ensuring that the sample is representative and fair.

This would ensure that both satisfied and dissatisfied people were encouraged to do reviews and that a balanced selection of people participated. It would support those web sites that serve providers wanting to improve and it would work with providers in doing this. There would be little prospect for gaming the system. It would be important for the site to please the community as well as the providers. There would be more pressure on providers to participate.  Because a community organisation would be selecting and working with the websites, the leverage and potential control by providers would be eliminated.

The hub would support websites that supply families and researchers with accurate and unbiased information. They would use this information and would integrate it with other information when giving advice and support to families making decisions. They would be cooperating with researchers.

Because this information would be important for the hub in advising and helping families they will ensure that sufficient numbers participate to make the information accurate and useful.

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