Low-care residents in nursing homes: the impact of market characteristics

Approximately 30% of nursing home residents were recently identified as low-care cases; that is, residents with low levels of acuity. Other institutional venues, board and care homes and assisted living facilities, for example, are often recommended as alternative domiciliaries providing more appropriate and less expensive care for these residents. In this investigation the effect of nine market factors on the prevalence of low-care residents in 14,646 nursing homes are studied. Government regulations, competition from other providers, and the overall munificence of the market are found to influence their prevalence. These results are discussed along with several issues inherent to channeling low-care residents to other care setting.     

Changes in Long-Term Care Markets: Assisted Living Supply and the Prevalence of Low-Care Residents in Nursing Homes

ObjectivesTo assess the effect of changes in assisted living (AL) capacity within a market on prevalence of residents with low care needs in nursing homes.DesignRetrospective, longitudinal analysis of nursing home markets.Setting and participantsTwelve thousand two hundred fifity-one nursing homes in operation during 2007 and 2014.MeasurementsWe analyzed the percentage of residents in a nursing home who qualified as low-care. For each nursing home, we constructed a market consisting of AL communities, Medicare beneficiaries, and competing nursing homes within a 15-mile radius. We estimated the effect of change in AL beds on prevalence of low-care residents using multivariate linear models with year and nursing home fixed effects.ResultsThe supply of AL beds increased by an average 258 beds per nursing home market (standard deviation = 591) during the study period. The prevalence of low-care residents decreased from an average of 13.0% (median 10.5%) to 12.2% (median 9.5%). In adjusted models, a 100-bed increase in AL supply was associated with a decrease in low-care residents of 0.041 percentage points (P = .026), controlling for changes in market and nursing home characteristics, county demographics, and year and nursing home fixed effects. In markets with a high percentage of its Medicare beneficiaries (≥14%) dual eligible for Medicaid, the effect of AL is stronger, with a 0.066–percentage point decrease per 100 AL beds (P = .026) vs a 0.016–percentage point decrease in low-duals markets (P = .48).Conclusions and implicationsOur analysis suggests that some of the growth in AL capacity serves as a substitute for nursing homes for patients with low care needs. Furthermore, the effects are concentrated in markets with an above-average proportion of beneficiaries with dual Medicaid eligibility.     

The Relationship between Older Americans Act Title III State Expenditures and Prevalence of Low‐Care Nursing Home Residents

Objective

To test the relationship between older Americans Act (OAA) program expenditures and the prevalence of low-care residents in nursing homes (NHs).

Data Sources and Collection

Two secondary data sources: State Program Reports (state expenditure data) and NH facility-level data downloaded from http://LTCfocUS.org for 16,030 US NHs (2000–2009).

Study Design

Using a two-way fixed effects model, we examined the relationship between state spending on OAA services and the percentage of low-care residents in NHs, controlling for facility characteristics, market characteristics, and secular trends.

Principal Findings

Results indicate that increased spending on home-delivered meals was associated with fewer residents in NHs with low-care needs.

Conclusions

States that have invested in their community-based service networks, particularly home-delivered meal programs, have proportionally fewer low-care NH residents.Many states are in the throes of transforming their financing and delivery of long-term services and supports (LTSS). Many of these efforts are aimed at increasing Medicaid funding on home and community-based services (HCBS) in an effort to delay or avoid nursing home (NH) placement, and maintaining current non-Medicaid LTSS funding for the near-poor older adults. While much effort has been geared toward evaluating the cost-effectiveness and role of Medicaid funded HCBS in preventing or postponing NH placement, little research has evaluated the value of other state funded non-Medicaid LTSS, such as The Older Americans Act (OAA) programs.The Older Americans Act of 1965 (Pub. L. 89-73, 79 Stat. 218, July 14, 1965) was among the first federal initiatives aimed at providing comprehensive services to help older adults stay as independent as possible in their homes and communities. The major program under the OAA, Title III Grants for State and Community Programs on Aging, provides funding to State Units on Aging (SUA) and local Area Agencies on Aging (AAA) for services that include in-home assistance, home-delivered and congregate meals, respite for family caregivers, preventive health services, and legal services for older adults and their caregivers. While funding from the OAA is small compared with the major source of long-term care (LTC) funding from Medicaid, it provides a safety net for people who might otherwise not qualify for Medicaid financed LTC support. A recent national survey of OAA program participants found that more than 85 percent of those receiving homemaker services, case management, transportation, and home-delivered meals report that these programs helped them remain at home (Altshuler and Schimmel 2010). HCBS can be viewed as a substitute for institutionalization for individuals who do not require skilled 24-hour care. Without these programs, it may be that more individuals would be in NHs with low-care needs.Previous studies have suggested that anywhere from 5 to 30 percent of NH residents have low-care needs and could perhaps be better served in the community (Ikegami, Morris, and Fries 1997; Castle 2002; Mor et al. 2007; Arling et al. 2010; Hahn et al. 2011). States vary greatly in their prevalence of low-care NH residents (Mor et al. 2007). The rates of low-care residents in NHs has been found to be related to variation in Medicaid expenditures on home and community-based services (HCBS) and availability of community alternatives (Castle 2002; Hahn et al. 2011).Because it is believed that the availability of supportive services in the community allows older adults to remain at home and transition from the NH back to the community, we hypothesize that states that invest more money in their OAA programs will have fewer residents in NHs with low-care needs. We took into consideration other factors that have been shown to be related to a NH''s proclivity to provide services to residents with low-care needs, such as the facility''s occupancy rate and characteristics of NH''s resident population. With regard to market characteristics, we believed that competition may influence low-care resident rates in NHs and therefore we included measures of home care capacity and supply of NH beds. In addition, we believed that states with greater investments in their Medicaid HCBS programs would have an increased awareness and ability to sustain low-care NH residents in the community. Furthermore, NHs in states with more generous Medicaid payment rates may have an incentive to have residents with low-care needs to decrease their expenditures on care while receiving a similar payment rate.     

Medicaid Bed‐Hold Policies and Hospitalization of Long‐Stay Nursing Home Residents

Objective

To evaluate the effect of Medicaid bed-hold policies on hospitalization of long-stay nursing home residents.

Data Sources

A nationwide random sample of long-stay nursing home residents with data elements from Medicare claims and enrollment files, the Minimum Data Set, the Online Survey Certification and Reporting System, and Area Resource File. The sample consisted of 22,200,089 person-quarters from 754,592 individuals who became long-stay residents in 17,149 nursing homes over the period beginning January 1, 2000 through December 31, 2005.

Study Design

Linear regression models using a pre/post design adjusted for resident, nursing home, market, and state characteristics. Nursing home and year-quarter fixed effects were included to control for time-invariant facility influences and temporal trends associated with hospitalization of long-stay residents.

Principal Findings

Adoption of a Medicaid bed-hold policy was associated with an absolute increase of 0.493 percentage points (95% CI: 0.039–0.946) in hospitalizations of long-stay nursing home residents, representing a 3.883 percent relative increase over the baseline mean.

Conclusions

Medicaid bed-hold policies may increase the likelihood of hospitalization of long-stay nursing home residents and increase costs for the federal Medicare program.     

State-by-State Variation in the Number of Children and Young Adults in Nursing Homes, 2005–2012

Objectives One goal of Healthy People 2020 is to reduce the number of children and young adults living in nursing homes. However, little is known about the prevalence of nursing home use among children and young adults on a state-by-state basis. The objective of this study was to determine the prevalence of nursing home use among children and young adults in each state from 2005 to 2012. The study also looked for prevalence trends between 2005 and 2012. Methods The Centers for Medicare and Medicaid Services Minimum Data Set and US Census data were used to calculate the prevalence of nursing home residents among children and young adults aged 0–30 in each US state in 2012 and assess trends in each state from 2005 to 2012. Results In 2012, the prevalence of nursing home residents among children and young adults aged 0–30 varied across states, ranging from 14 in 100,000 (New Jersey) to 0.8 in 100,000 (Alaska). Testing for trends from 2005 to 2012 also revealed significant trends (p?<?0.05), with Florida trending upward with borderline statistical significance (p?=?0.05) and six states trending downward. Conclusion There is wide variation in the prevalence of nursing home residents among children and young adults aged 0–30 across states. There is also variation in the nursing home prevalence trends across states. Observed variations may represent potential opportunities for some states to reduce their population of children and young adults in nursing homes.     

Targeting Residents for Transitions from Nursing Home to Community

Objective. To analyze nursing home utilization patterns in order to identify potential targeting criteria for transitioning residents back to the community. Data Sources. Secondary data from minimum data set (MDS) assessments for an annual cohort of first‐time admissions (N=24,648) to all Minnesota nursing homes (N=394) from July 2005 to June 2006. Study Design. We conducted a longitudinal analysis from admission to 365 days. Major MDS variables were discharge status; resident's preference and support for community discharge; gender, age, and marital status; pay source; major diagnoses; cognitive impairment or dementia; activities of daily living; and continence. Principal Findings. At 90 days the majority of residents showed a preference or support for community discharge (64 percent). Many had health and functional conditions predictive of community discharge (40 percent) or low‐care requirements (20 percent). A supportive facility context, for example, emphasis on postacute care and consumer choice, increased transition rates. Conclusions. A community discharge intervention could be targeted to residents at 90 days after nursing home admission when short‐stay residents are at risk of becoming long‐stay residents.     

Profiles of nursing home residents with HIV

Nursing homes are part of the long-term care continuum available to people with advanced HIV disease. The objective of this paper is to profile nursing home residents with HIV at the time of admission, using the Minimum Data Set (MDS). These resident profiles contain sociodemographic characteristics, health status measures, and special treatments and procedures. There are 5,115 admission assessments in the MDS for residents with HIV between June 22, 1998, and January 17, 2000, analyzed for this study. Newly admitted nursing residents with HIV are predominantly male (69.4 percent) and minority (75.4 percent black and Hispanic), relatively young (44.45 years), and heavily Medicaid dependent (70.5 percent). These residents are typically clinically complex and receive a range of special treatments, procedures, and programs. Nursing home residents with HIV are a distinct subset of nursing home residents, largely dependent on the state Medicaid programs to pay for their care.     

Racial inequities in receipt of influenza vaccination among nursing home residents in the United States, 2008-2009: a pattern of low overall coverage in facilities in which most residents are black

ObjectivesNationwide among nursing home residents, receipt of the influenza vaccine is 8 to 9 percentage points lower among blacks than among whites. The objective of this study was to determine if the national inequity in vaccination is because of the characteristics of facilities and/or residents.DesignCross-sectional study with multilevel modeling.Setting and ParticipantsStates in which 1% or more of nursing home residents were black and the difference in influenza vaccination coverage between white and black nursing home residents was 1 percentage point or higher (n = 39 states and the District of Columbia). Data on residents (n = 2,359,321) were obtained from the Centers for Medicare &; Medicaid Service’s Minimum Data Set for October 1, 2008, through March 31, 2009.MeasurementsResidents’ influenza vaccination status (vaccinated, refused vaccine, or not offered vaccination).ResultsStates with higher overall influenza vaccination coverage among nursing home residents had smaller racial inequities. In nursing homes with higher proportions of black residents, vaccination coverage was lower for both blacks and whites. The most dramatic inequities existed between whites in nursing homes with 0% blacks (L1) and blacks in nursing homes with 50% or more blacks (L5) in states with overall racial inequities of 10 percentage points or more. In these states, more black nursing home residents lived in nursing homes with 50% or more blacks (L5); in general, the same homes with low overall coverage.ConclusionInequities in influenza vaccination coverage among nursing home residents are largely because of low vaccination coverage in nursing homes with a high proportion of black residents. Findings indicate that implementation of culturally appropriate interventions to increase vaccination in facilities with larger proportions of black residents may reduce the racial gap in influenza vaccination as well as increase overall state-level vaccination.     

Activities of daily living and costs in nursing homes

Functionality, as measured by activities of daily living (ADL), is the most important predictor of the cost of nursing home care. Data from a field-test version of the federally mandated Minimum Data Set (MDS) were examined using analysis of variance (ANOVA) and recursive partitioning methods to determine the relationships between ADL limitations and nursing cost (wage-weighted nursing time) among nursing home residents (n = 6,663). From this analysis, an index based on limitations in four ADLs was created. The developed ADL index is a readily determined measure of functional status useful in allocating nursing staff within nursing homes and in comparing the functional status of groups of residents, explaining 30 percent of variance in nursing costs among nursing home residents.     

Hospitalization of nursing home residents: the effects of states' Medicaid payment and bed-hold policies

OBJECTIVE: Hospitalizations of nursing home residents are costly and expose residents to iatrogenic disease and social and psychological harm. Economic constraints imposed by payers of care, predominantly Medicaid policies, are hypothesized to impact hospitalizations. DATA SOURCES/STUDY SETTING: Federally mandated resident assessments were merged with Medicare claims and eligibility files to determine hospitalizations and death within 150 days of baseline assessment. Nursing home and market characteristics were obtained from the Online Survey Certification and Reporting, and the Area Resource File, respectively. States' average daily Medicaid nursing home payments and bed-hold policies were obtained independently. STUDY DESIGN: Prospective cohort study of 570,614 older (> or =65-year-old), non-MCO (Medicare Managed Care), long-stay (> or =90 days) residents in 8,997 urban, freestanding nursing homes assessed between April and June 2000, using multilevel models to test the impact of state policies on hospitalizations controlling for resident, nursing home, and market characteristics. PRINCIPAL FINDINGS: Overall, 99,379 (17.4 percent) residents were hospitalized with rates varying from 8.4 percent in Utah to 24.9 percent in Louisiana. Higher Medicaid per diem was associated with lower odds of hospitalizations (5 percent lower for each $10 above average $103.5, confidence intervals [CI] 0.91-0.99). Hospitalization odds were higher by 36 percent in states with bed-hold policies (CI: 1.12-1.63). CONCLUSIONS: State Medicaid bed-hold policy and per-diem payment have important implications for nursing home hospitalizations, which are predominantly financed by Medicare. This study emphasizes the importance of properly aligning state Medicaid and federal Medicare policies in regards to the subsidy of acute, maintenance, and preventive care in the nursing home setting.     

Hospice Family Members' Perceptions of and Experiences With End-of-Life Care in the Nursing Home

Objective

Even though more than 25% of Americans die in nursing homes, end-of-life care has consistently been found to be less than adequate in this setting. Even for those residents on hospice, end-of-life care has been found to be problematic. This study had 2 research questions; (1) How do family members of hospice nursing home residents differ in their anxiety, depression, quality of life, social networks, perceptions of pain medication, and health compared with family members of community dwelling hospice patients? (2) What are family members’ perceptions of and experiences with end-of-life care in the nursing home setting?

Methods

This study is a secondary mixed methods analysis of interviews with family members of hospice nursing home residents and a comparative statistical analysis of standard outcome measures between family members of hospice patients in the nursing home and family members of hospice patients residing in the community.

Results

Outcome measures for family members of nursing home residents were compared (n = 176) with family members of community-dwelling hospice patients (n = 267). The family members of nursing home residents reported higher quality of life; however, levels of anxiety, depression, perceptions of pain medicine, and health were similar for hospice family members in the nursing home and in the community. Lending an understanding to the stress for hospice family members of nursing home residents, concerns were found with collaboration between the nursing home and the hospice, nursing home care that did not meet family expectations, communication problems, and resident care concerns including pain management. Some family members reported positive end-of-life care experiences in the nursing home setting.

Conclusion

These interviews identify a multitude of barriers to quality end-of-life care in the nursing home setting, and demonstrate that support for family members is an essential part of quality end-of-life care for residents. This study suggests that nursing homes should embrace the opportunity to demonstrate the value of family participation in the care-planning process.     

Explaining differences in remuneration rates of nursing homes in Germany

Remuneration rates of German nursing homes are prospectively negotiated between long-term care insurance (LTCI) and social assistance on the one side and nursing homes on the other. They differ considerably across regions while there is no evidence for substantial differences in care provision. This article explains the differences in the remuneration rates by observable characteristics of the nursing home, its residents and its region with a special focus on the largest federal state of North Rhine Westphalia, in which the most expensive nursing homes are located. We use data from the German Federal Statistical Office for 2005 on all nursing homes that offer full-time residential care for the elderly. We find that differences in remuneration rates can partly be explained by exogenous factors. Controls for residents, nursing homes and district characteristics explain roughly 30 % of the price difference; 40 % can be ascribed to a regionally different kind of negotiation between nursing homes and LTCI. Thirty percent of the raw price difference remains unexplained by observable characteristics.     

An overview of nursing home facilities: data from the 1997 National Nursing Home Survey

OBJECTIVE: This report presents estimates on the number and distribution of nursing home facilities, their services, current residents, and discharges in the United States during 1997. METHODS: Data presented in this report are estimates based on a sample of nursing home facilities, residents, and discharges from the 1997 National Nursing Home Survey (NHHS). The survey collects information about providers and recipients of care from nursing home facilities. NHHS has been periodically conducted by the National Center for Health Statistics since 1973. RESULTS: In 1997 there were an estimated 1.6 million current residents and 2.4 million discharges from 17,000 nursing homes nationwide. These facilities were predominantly proprietary and certified by both Medicare and Medicaid. There was an average of 107 beds per nursing home with an occupancy rate of 88 percent and a discharge rate of 130 patients per 100 beds. The majority of nursing home residents and discharges were elderly, white, and female.     

Low serum folic acid levels in a nursing home population: a clinical experience.

Four hundred fifty-five residents of the Wisconsin Veterans Home had fasting serum specimens obtained for folic acid as part of standard practice. Twenty-nine percent were taking folic acid supplements. Six percent (n = 28) were taking phenytoin, a folate antagonist. No resident receiving a folate supplement (400 mcg/day) had a low serum folic acid level. This finding may be important for practitioners selecting a dose of folic acid for nursing home patients. Of the 325 residents not receiving a folate supplement, nine (3%) had low folic acid levels (< 2.5 ng/mL). Two of the nine were receiving phenytoin. Five were characterized by staff as eating well. As low serum levels are preventable with a multivitamin, we believe that supplementation with a multivitamin containing 400 mcg folic acid/day should be considered in nursing home residents.     

Knowledge of and Perceived Need for Evidence-Based Education About Antipsychotic Medications Among Nursing Home Leadership and Staff

Background/Objectives

Antipsychotic use is common in US nursing homes, despite evidence of increased risk of morbidity and mortality, and limited efficacy in older adults with dementia. Knowledge, attitudes, and beliefs regarding antipsychotic use among nursing home staff are unclear. The study aim was to describe nursing home leadership and direct care staff members’ knowledge of antipsychotic risks, beliefs and attitudes about the effectiveness of antipsychotics and nonpharmacologic management of dementia-related behaviors, and perceived need for evidence-based training about antipsychotic medication safety.

Design, Setting, Participants, and Measurements

Survey of leadership and direct care staff of nursing homes in Connecticut was conducted in June 2011. Questionnaire domains included knowledge of antipsychotic risks, attitudes about caring for residents with dementia, satisfaction with current behavior management training, beliefs about antipsychotic effectiveness, and need for staff training about antipsychotics and behavior management.

Results

A total of 138 nursing home leaders and 779 direct care staff provided useable questionnaires. Only 24% of nursing home leaders identified at least 1 severe adverse effect of antipsychotics; 13% of LPNs and 12% of RNs listed at least 1 severe adverse effect. Fifty-six percent of direct care staff believed that medications worked well to manage resident behavior. Leaders were satisfied with the training that staff received to manage residents with challenging behaviors (62%). Fifty-five percent of direct care staff felt that they had enough training on how to handle difficult residents; only 37% felt they could do so without using medications.

Conclusions

Findings suggest that a comprehensive multifaceted intervention designed for nursing homes should aim to improve knowledge of antipsychotic medication risks, change beliefs about appropriateness and effectiveness of antipsychotics for behavior management, and impart strategies and approaches for nonpharmacologic behavior management.     

The Care Span: Growth of racial and ethnic minorities in US nursing homes driven by demographics and possible disparities in options

Between 1999 and 2008, the number of elderly Hispanics and Asians living in US nursing homes grew by 54.9?percent and 54.1?percent, respectively, while the number of elderly black residents increased 10.8?percent. During the same period, the number of white nursing home residents declined 10.2?percent. These shifts have been driven in part by changing demographics, especially the fast growth of older minority populations. However, the numbers of minority residents in nursing homes increased more rapidly than the minority population overall, even in areas with high concentrations of minority populations. Thus, these results may indicate unequal minority access to home and community-based alternatives, which are generally preferred for long-term care. When designing initiatives to balance institutional and noninstitutional long-term care, policy makers should take steps to reduce racial and ethnic disparities.     

A multivariate fall risk assessment model for VHA nursing homes using the minimum data set

OBJECTIVES: The purpose of this study was to develop a multivariate fall risk assessment model beyond the current fall Resident Assessment Protocol (RAP) triggers for nursing home residents using the Minimum Data Set (MDS). DESIGN: Retrospective, clustered secondary data analysis. Setting: National Veterans Health Administration (VHA) long-term care nursing homes (N = 136). PARTICIPANTS: The study population consisted of 6577 national VHA nursing home residents who had an annual assessment during FY 2005, identified from the MDS, as well as an earlier annual or admission assessment within a 1-year look-back period. MEASUREMENT: A dichotomous multivariate model of nursing home residents coded with a fall on selected fall risk characteristics from the MDS, estimated with general estimation equations (GEE). RESULTS: There were 17 170 assessments corresponding to 6577 long-term care nursing home residents. The increased odds ratio (OR) of being classified as a faller relative to the omitted "dependent" category of activities of daily living (ADL) ranged from OR = 1.35 for "limited" ADL category up to OR = 1.57 for "extensive-2" ADL (P < .0001). Unsteady gait more than doubles the odds of being a faller (OR = 2.63, P < .0001). The use of assistive devices such as canes, walkers, or crutches, or the use of wheelchairs increases the odds of being a faller (OR = 1.17, P < .0005) or (OR = 1.19, P < .0002), respectively. Foot problems may also increase the odds of being a faller (OR = 1.26, P < .0016). Alzheimer's or other dementias also increase the odds of being classified as a faller (OR = 1.18, P < .0219) or (OR=1.22, P < .0001), respectively. In addition, anger (OR = 1.19, P < .0065); wandering (OR = 1.53, P < .0001); or use of antipsychotic medications (OR = 1.15, P < .0039), antianxiety medications (OR = 1.13, P < .0323), or antidepressant medications (OR = 1.39, P < .0001) was also associated with the odds of being a faller. CONCLUSIONS: This national study in one of the largest managed healthcare systems in the United States has empirically confirmed the relative importance of certain risk factors for falls in long-term care settings. The model incorporated an ADL index and adjusted for case mix by including only long-term care nursing home residents. The study offers clinicians practical estimates by combining multiple univariate MDS elements in an empirically based, multivariate fall risk assessment model.     

The Effect of State Medicaid Case-Mix Payment on Nursing Home Resident Acuity

Objective. To examine the relationship between Medicaid case-mix payment and nursing home resident acuity.
Data Sources. Longitudinal Minimum Data Set (MDS) resident assessments from 1999 to 2002 and Online Survey Certification and Reporting (OSCAR) data from 1996 to 2002, for all freestanding nursing homes in the 48 contiguous U.S. states.
Study Design. We used a facility fixed-effects model to examine the effect of introducing state case-mix payment on changes in nursing home case-mix acuity. Facility acuity was measured by aggregating the nursing case-mix index (NCMI) from the MDS using the Resource Utilization Group (Version III) resident classification system, separately for new admits and long-stay residents, and by an OSCAR-derived index combining a range of activity of daily living dependencies and special treatment measures.
Data Collection/Extraction Methods. We followed facilities over the study period to create a longitudinal data file based on the MDS and OSCAR, respectively, and linked facilities with longitudinal data on state case-mix payment policies for the same period.
Principal Findings. Across three acuity measures and two data sources, we found that states shifting to case-mix payment increased nursing home acuity levels over the study period. Specifically, we observed a 2.5 percent increase in the average acuity of new admits and a 1.3 to 1.4 percent increase in the acuity of long-stay residents, following the introduction of case-mix payment.
Conclusions. The adoption of case-mix payment increased access to care for higher acuity Medicaid residents.     

Serious Mental Illness and Nursing Home Quality of Care

Objective

To estimate the effect of a nursing home''s share of residents with a serious mental illness (SMI) on the quality of care.

Data Sources

Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims.

Study Design

We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects.

Principal Findings

An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non-SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents.

Conclusions

Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight.