Learnings on star ratings
Associate Professor Stephanie Harrison – an epidemiologist at the Registry of Senior Australians Research Centre, South Australian Health and Medical Research Institute – answers questions on her star ratings research.
What did your star ratings research investigate and why?
Publicly reporting on the quality and safety of aged care services helps make the sector more transparent and accountable. Importantly, it provides people looking for care and their families with a way to compare different providers and make informed choices. Internationally, a number of countries have worked towards public reporting of aged care services to help people choose the best option for their needs. For example, since 2008, the US has used a five-star quality rating system for nursing homes to assess the quality of care provided. Until recently, Australia didn’t have anything similar, making it difficult for people seeking care and their families to compare care providers.
The Royal Commission into Aged Care Quality and Safety recommended introducing a Star Ratings system in Australia in its final report in 2021. Introduced in December 2022, the new system is Australia’s first national resource for the public to compare the quality and safety of aged care homes, marking substantial progress in making the aged care sector more transparent and accountable.
The Australian Star Ratings are based on the summary of providers’ performance across four categories: residents’ experience, compliance to government regulations and standards, meeting mandatory staffing levels, and quality measures. These categories are used to calculate an overall rating, from one to five stars, for each of the 2,600-plus aged care homes across the country. In the first year after the system was introduced, 1,329 aged care homes received a 4- or 5-star rating, an increase of 352.
The quality measures category ratings had the biggest fluctuations over time
We conducted our study because we wanted to explore the changes in star ratings by aged care homes further and understand more about how the ratings have changed, both overall and in each of the individual categories. Also, no research thus far had looked at characteristics of the aged care homes that might be linked to higher star ratings while considering multiple characteristics at once. So, we chose to investigate this further, examining what characteristics of aged care homes are associated with higher ratings and how the overall ratings and individual category ratings have changed over time.
What information did you use to conduct the research?
For our study, we used publicly available data from the Department of Health and Aged Care about the Star Ratings system, which is updated every financial quarter. We looked at data from two reporting periods: the first one, covering October to December 2022, and the most recent one at the time of our study, which was from April to June 2023. We also wanted to explore the characteristics of aged care homes, so we used information published through the Aged Care Service List. The information used for the study is available here.
What characteristics have you found are associated with higher star ratings?
We found that smaller aged care homes – with fewer than 60 residents – were 3.2 times more likely to receive a 4- or 5-star rating compared to larger homes, while medium-sized homes – with 61 to 100 residents – were 1.7 times more likely to receive a 4- or 5-star rating. We also found that government-owned aged care homes, as well as those located in more socioeconomically advantaged areas, were more likely to receive a higher rating. Interestingly, we also found that aged care homes in Queensland were more than twice as likely to receive a 4- or 5-star rating compared to those in New South Wales.
We had anticipated that smaller, government-operated aged care homes would have higher star ratings, and our findings lined up with this. International research has suggested that smaller homes tend to deliver better quality care, which may lead to better outcomes for residents, such as improved quality of life and fewer hospital visits. Previous research in Australia has also suggested that government-operated aged care homes had better results for 31 quality and safety indicators, compared to for-profit and not-for-profit homes.
How did the star ratings change over the period?
As we saw in previous reports, the percentage of aged care homes receiving a 4- or 5-star rating increased over time, from 41 per cent in the October and December 2022 period to 54 per cent in the April to June 2023 period. However, while 25 per cent of homes improved their star rating, 10 per cent declined in their ratings over the same period.
The overall increase in star ratings was mainly driven by improvements in the residents’ experience, compliance, and staffing categories, which makes sense as together these account for 85 per cent of the total rating. Whereas, the quality measures category, which is based on quality indicators for pressure injuries, restrictive practices, falls, unplanned weight loss, and medication management under the National Aged Care Mandatory Quality Indicator Program, only makes up 15 per cent of the overall rating.
Interestingly, the quality measures category ratings had the biggest fluctuations over time. Nearly one-third of aged care homes improved their quality measures rating, while almost another third declined. This suggests there may be some inconsistencies in how homes are performing in these areas over time.
Do you have any recommendations for policy makers?
Our research, along with previous studies, highlights that smaller, government-run aged care homes tend to perform better, which raises concerns about how the growing size and privatisation of aged care homes might impact care quality. We also think that planned initiatives to build, train, and support the aged care workforce, should specifically target disadvantaged areas where resources for delivering high-quality care might be limited in multiple ways.
Also, we believe that we, and policy makers, can learn a lot from high-performing aged care providers. These providers likely have valuable insights and models of care that could be shared across the sector nationally to help others improve. Finally, just as with any quality monitoring program, we recommend that the Star Ratings system be continuously improved and refined. This will help ensure it remains relevant, useful, and meaningful to help people accessing aged care.
Dr Stephanie Harrison is an associate professor in health services and epidemiology at Registry of Senior Australians Research Centre at the South Australian Health and Medical Research Institute
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