Research Findings

Holmgren, Adler-Milstein, & Chen. (2018). Participation in a Voluntary Bundled Payment Program by Organizations Providing Care After an Acute Hospitalization. JAMA, 320(4), 402-404. doi:10.1001/jama.2018.8666
Spending on post–acute care (PAC), or care provided after a stay in an acute care hospital, is the largest driver of variation in total per capita Medicare spending.1 To address this, Medicare has targeted PAC spending in payment reforms such as Model 3 of Medicare’s Bundled Payments for Care Improvement (BPCI) initiative, a voluntary bundled payment program. Model 3 participants receive a target price for 30-, 60-, or 90-day PAC episodes initiated in the 30 days after hospital discharge. Model 3 is risk-bearing: participating organizations spending less than the target price receive a portion of the savings; those spending more must pay Medicare some of the difference.2 Model 3 is unique because it targets PAC organizations as the lead organizations that bear the risk, rather than acute care hospitals. Eligible PAC organizations include skilled nursing facilities (SNFs), inpatient rehabilitation facilities, long-term care hospitals, physician group practices, and home health agencies. We describe risk-bearing participation in Medicare’s BPCI Model 3 and factors associated with persistent risk-bearing participation by the largest group of organizations, SNFs.

Saliba, Weimer, Shi, & Mukamel. (2018). Examination of the New Short-Stay Nursing Home Quality Measures: Rehospitalizations, Emergency Department Visits, and Successful Returns to the Community. Inquiry, epub ahead of print.
In 2016, the Centers for Medicare & Medicaid Services (CMS) introduced 3 new quality measures (QMs) to its report card, Nursing Home Compare (NHC). These measures—rehospitalizations, emergency department visits, and successful discharges to the community—focus on short-stay residents. We offer a first analysis of nursing homes’ performance in terms of these new measures. We examined their properties and distribution across nursing homes using descriptive statistics and regression models. We found that, similar to other QMs, performance varies across the country, and that there is very minimal correlation between these 3 new QMs as well as between these QMs and other NHC QMs. Regression models reveal that better performance on these QMs tends to be associated with fewer deficiencies, higher staffing and more skilled staffing, nonprofit ownership, and lower proportion of Medicaid residents. Other characteristics are associated with better performance for some but not all 3 QMs. We also found improvement in all 3 QMs in the second year of publication. This study contributes to the validity of these measures by demonstrating their relationship to these structural QMs. It also suggests that these QMs are important by demonstrating their large variation across the country, suggesting substantial room for improvement, and finding that nursing homes are already responding to the incentives created by publication of these QMs.

Solomon Needleman, Kim, Jung, & Unruh. (2018). Baseline Rehospitalization Rates of Nursing Homes in Bundled Payments for Care Improvement. JAMDA, epub ahead of print. DOI:
The Bundled Payments for Care Improvement (BPCI) initiative was developed by the Center for Medicare and Medicaid Innovation with the goals of lowering health care expenditures while improving quality through enhanced coordination of services across different settings of care. Participating organizations enter into contractual arrangements where a single reimbursement is made from Medicare that must be divided among all providers involved in an episode of care. However, participation in BPCI is voluntary, and it is possible that early participants were already high-performing providers.

Keohane, Trivedi, & Mor. (2017). Recent Health Care Use and Medicaid Entry of Medicare Beneficiaries. The Gerontologist, epub ahead of print. January 9, 2017. doi: 10.1093/geront/gnw189
Purpose of the Study:
To examine the relationship between Medicaid entry and recent health care use among Medicare beneficiaries.
Design and Methods:
We identified Medicare beneficiaries without full Medicaid or use of hospital or nursing home services in 2008 (N = 2,163,387). A discrete survival analysis estimated beneficiaries’ monthly likelihood of entry into the full Medicaid program between January 2009 and June 2010.
During the 18-month study period, Medicaid entry occurred for 1.1% and 3.7% of beneficiaries who aged into Medicare or originally qualified for Medicare due to disability, respectively. Among beneficiaries who aged into Medicare, 49% of new Medicaid participants had no use of inpatient, skilled nursing facility, or nursing home services during the study period. Individuals who recently used inpatient, skilled nursing facility or nursing home services had monthly rates of 1.9, 14.0, and 38.1 new Medicaid participants per 1,000 beneficiaries, respectively, compared with 0.4 new Medicaid participants per 1,000 beneficiaries with no recent use of these services.
Although recent health care use predicted greater likelihood of Medicaid entry, half of new Medicaid participants used no hospital or nursing home care during the study period. These patterns should be considered when designing and evaluating interventions to reform health care delivery for dual-eligible beneficiaries.

Ryskina, Polsky, & Werner. (2017). Physicians and Advanced Practitioners Specializing in Nursing Home Care, 2012-2015. JAMA, 318(20), 2040-2042. doi:10.1001/jama.2017.13378
Nursing home care is common, costly, and variable in quality. For instance, between September 2009 and August 2010, 23% of the 1.5 million hospital discharges to post–acute care in nursing homes resulted in rehospitalization or death within 30 days, with variation across facilities. One approach adopted by hospitals to improve care over the past decade was to concentrate it among physicians who specialize in treating hospitalized patients (hospitalists). Our goal was to determine whether nursing homes are adopting this strategy by measuring the prevalence of “nursing home specialists” between 2012 and 2015.

Berridge, Miller, S., Tyler. (2016). Staff Empowerment Practices and CNA Retention: Findings from a Nationally Representative Nursing Home Culture Change Survey. J Appl Gerontol. 2016 Aug 25. pii: 0733464816665204. [Epub ahead of print] PubMed PMID: 27566304.
This article examines whether staff empowerment practices common to nursing home culture change are associated with certified nursing assistant (CNA) retention. Data from 2,034 nursing home administrators from a 2009/2010 national nursing home survey and ordered logistic regression were used. After adjustment for covariates, a greater staff empowerment practice score was positively associated with greater retention. Compared with the low empowerment category, nursing homes with scores in the medium category had a 44% greater likelihood of having higher CNA retention (odds ratio [OR] = 1.44; 95% confidence interval [CI] = [1.15, 1.81], p = .001) and those with high empowerment scores had a 64% greater likelihood of having higher CNA retention (OR = 1.64; 95% CI = [1.34, 2.00], p < 001). Greater opportunities for CNA empowerment are associated with longer CNA retention. This research suggests that staffing empowerment practices on the whole are worthwhile from the CNA staffing stability perspective.

Berry SD, Lee Y, Zullo AR, Kiel DP, Dosa D, Mor V. (2016). Incidence of Hip Fracture in U.S. Nursing Homes. J Gerontol A Biol Sci Med Sci, 71(9):1230-4. doi: 10.1093/gerona/glw034. PubMed PMID: 26980299; PubMed Central PMCID: PMC4978364.
Hip fractures are associated with significant morbidity and mortality in the nursing home. Our objective was to describe the incidence rate (IR) of hip fracture according to age, sex, and race in a nationwide sample of long-stay nursing home residents.
Using 2007-2010 Medicare claims data linked with the Minimum Data Set, we identified 892,837 long-stay residents (≥100 days in the same nursing facility) between May 1, 2007 and April 30, 2008. Hip fractures were defined using Part A diagnostic codes (ICD-9). Residents were followed from the date they became a long-stay resident until the first event of death, discharge, hip fracture, or 2 years of follow-up.
Mean age was 84 years (range 65-113 years), and 74.5% were women. 83.9% were white and 12.0% were black. The overall IR of hip fracture was 2.3/100 person years. The IR was similar in men and women across age groups. The IR of hip fracture was highest in Native Americans aged 85 years or older (3.7/100 person years), in whites (2.6/100 person years), and during the first 100 days of institutionalization (2.7/100 person years). IRs of hip fracture were lowest in blacks (1.3/100 person years).
In nursing home residents surviving 100 days or more in a facility, the incidence of hip fracture is high, particularly among older white, Native American, and newly admitted residents. This is the first nationwide study to provide sex- and age-specific estimates among U.S. nursing home residents, and it underscores the magnitude of the problem.

Goldberg EM, Trivedi AN, Mor V, Jung HY, Rahman M. (2016). Favorable Risk Selection in Medicare Advantage: Trends in Mortality and Plan Exits Among Nursing Home Beneficiaries. Med Care Res Rev. 2016 Aug 11. [Epub ahead of print] PMID: 27516452
The 2003 Medicare Modernization Act (MMA) increased payments to Medicare Advantage plans and instituted a new risk-adjustment payment model to reduce plans’ incentives to enroll healthier Medicare beneficiaries and avoid those with higher costs. Whether the MMA reduced risk selection remains debatable. This study uses mortality differences, nursing home utilization, and switch rates to assess whether the MMA successfully decreased risk selection from 2000 to 2012. We found no decrease in the mortality difference or adjusted difference in nursing home use between plan beneficiaries pre- and post the MMA. Among beneficiaries with nursing home use, disenrollment from Medicare Advantage plans declined from 20% to 12%, but it remained 6 times higher than the switch rate from traditional Medicare to Medicare Advantage. These findings suggest that the MMA was not associated with reductions in favorable risk selection, as measured by mortality, nursing home use, and switch rates.

Jung HY, Trivedi AN, Grabowski DC, Mor V. (2016). Does More Therapy in Skilled Nursing Facilities Lead to Better Outcomes in Patients With Hip Fracture? Phys Ther, 96(1):81-9. doi: 10.2522/ptj.20150090. PubMed PMID: 26586858; PubMed Central PMCID: PMC4706596
Skilled nursing facilities (SNFs) have increasingly been providing more therapy hours to beneficiaries of Medicare. It is not known whether these increases have improved patient outcomes.
The study objectives were: (1) to examine temporal trends in therapy hour volumes and (2) to evaluate whether more therapy hours are associated with improved patient outcomes.
This was a retrospective cohort study.
Data sources included the Minimum Data Set, Medicare inpatient claims, and the Online Survey, Certification, and Reporting System. The study population consisted of 481,908 beneficiaries of Medicare fee-for-service who were admitted to 15,496 SNFs after hip fracture from 2000 to 2009. Linear regression models with facility and time fixed effects were used to estimate the association between the quantity of therapy provided in SNFs and the likelihood of discharge to home.
The average number of therapy hours increased by 52% during the study period, with relatively little change in case mix at SNF admission. An additional hour of therapy per week was associated with a 3.1-percentage-point (95% confidence interval=3.0, 3.1) increase in the likelihood of discharge to home. The effect of additional therapy decreased as the Resource Utilization Group category increased, and additional therapy did not benefit patients in the highest Resource Utilization Group category.
Minimum Data Set assessments did not cover details of therapeutic interventions throughout the entire SNF stay and captured only a 7-day retrospective period for measures of the quantity of therapy provided.
Increases in the quantity of therapy during the study period cannot be explained by changes in case mix at SNF admission. More therapy hours in SNFs appear to improve outcomes, except for patients with the greatest need.

Keohane LM, Rahman M, Mor V. (2016). Reforming Access: Trends in Medicaid Enrollment for New Medicare Beneficiaries, 2008-2011. Health Serv Res. 2016 Apr;51(2):550-69. doi: 10.1111/1475-6773.12349. PubMed PMID: 26251174; PubMed Central PMCID: PMC4799898.
To evaluate whether aligning the Part D low-income subsidy and Medicaid program enrollment pathways in 2010 increased Medicaid participation among new Medicare beneficiaries.
Medicare enrollment records for years 2007-2011.
We used a multinomial logistic model with state fixed effects to examine the annual change in limited and full Medicaid enrollment among new Medicare beneficiaries for 2 years before and after the reforms (2008-2011).
We identified new Medicare beneficiaries in the years 2008-2011 and their participation in Medicaid based on Medicare enrollment records.
The percentage of beneficiaries enrolling in limited Medicaid at the start of Medicare coverage increased in 2010 by 0.3 percentage points for individuals aging into Medicare and by 1.3 percentage points for those qualifying due to disability (p < .001). There was no significant difference in the size of enrollment increases between states with and without concurrent limited Medicaid eligibility expansions.
Our findings suggest that streamlining financial assistance programs may improve Medicare beneficiaries' access to benefits.

Miller, Livingstone, & Ronneberg. (2016). Media Portrayal of the Nursing Home Sector: A Longitudinal Analysis of 51 U.S. Newspapers. The Gerontologist. Published online February 16, 2016. doi: 10.1093/geront/gnv684
Most Americans' low opinion of the nursing home (NH) sector could derive, in part, from the way in which it is portrayed in the media. This study furthers understanding of media portrayal of the NH sector by identifying how NHs were depicted in 51U.S. newspapers from 1999 to 2008.
Keyword searches of the LexisNexis database were performed to identify 16,280 NH-related articles. Article content was analyzed, and tone, themes, prominence, and central actor were assessed. Basic frequencies and descriptive statistics were used to examine article content across regions, market type, and over time.
Findings reveal considerably less NH coverage in the Western United States and a steady decline in NH coverage nationally over time. Most articles were news stories; more than one third were located on the front page of the newspaper or section. Most articles focused on NH industry and government interests, very few on residents/family and community concerns. Most articles were neutral or negative in tone; very few were positive or mixed. Common themes included quality, financing, and legal concerns. Tone, themes, and other article attributes varied across region, market type, and over time.
Overall, findings reveal changes in how newspapers framed NH coverage, not only with respect to tone but also with respect to what dimensions of this complex issue have been emphasized during the time period analyzed. Variation in media coverage may contribute to differences in government and public views toward the NH sector across regions and over time.

Mitchell SL, Mor V, Gozalo PL, Servadio JL, Teno JM. (2016). Tube Feeding in US Nursing Home Residents With Advanced Dementia, 2000-2014. JAMA. 2016 Aug 16;316(7):769-70. PMID: 27533163 PMCID: PMC4991625.
Research letter.

Mor V, Rahman M, McHugh J. (2016). Accountability of Hospitals for Medicare Beneficiaries' Postacute Care Discharge Disposition. JAMA Intern Med, 176(1):119-21. doi: 10.1001/jamainternmed.2015.6508. PubMed PMID: 26595256; PubMed Central PMCID: PMC4718077.
Invited commentary.

Rahman M, Galarraga O, Zinn JS, Grabowski DC, Mor V. (2016). The Impact of Certificate-of-Need Laws on Nursing Home and Home Health Care Expenditures. Med Care Res Rev. 2016 Feb;73(1):85-105. doi: 10.1177/1077558715597161. PubMed PMID:  26223431; PubMed Central PMCID: PMC4916841
Over the past two decades, nursing homes and home health care agencies have been influenced by several Medicare and Medicaid policy changes including the adoption of prospective payment for Medicare-paid postacute care and Medicaid-paid long-term home and community-based care reforms. This article examines how spending growth in these sectors was affected by state certificate-of-need (CON) laws, which were designed to limit the growth of providers and have remained unchanged for several decades. Compared with states without CON laws, Medicare and Medicaid spending in states with CON laws grew faster for nursing home care and more slowly for home health care. In particular, we observed the slowest growth in community-based care in states with CON for both the nursing home and home health industries. Thus, controlling for other factors, public postacute and long-term care expenditures in CON states have become dominated by nursing homes.

Rahman M, McHugh J, Gozalo PL, Ackerly DC, Mor V. (2016). The Contribution of Skilled Nursing Facilities to Hospitals' Readmission Rate. Health Serv Res. 2016 May 18. doi: 10.1111/1475-6773.12507. [Epub ahead of print] PubMed PMID: 27193697.
To examine the relative influence of hospital and skilled nursing facilities (SNFs) on 30-day rehospitalization.
Data Sources/Settings
Elderly Medicare beneficiaries newly admitted to a SNF following hospitalization.
Study Design
We ranked hospitals and SNFs into quartiles based on previous years’ adjusted rehospitalization rates (ARRs) and examined how rehospitalizations from a given hospital vary depending upon the admitting SNF ARR quartile. We examined whether the availability of SNFs with low rehospitalization rates influenced hospitals’ SNF readmission rates and whether changes in a hospital's ARR over 3 years is associated with changes in the SNFs to which they discharge.
Principal Findings
Hospital readmission rates from SNFs varied 5 percentage points between patients discharged to SNFs in the lowest and the highest rehospitalization quartiles. Low rehospitalization rate hospitals sent a larger fraction of their patients to the lowest rehospitalization SNFs available in the area. A 10 percent increase in hospital's share of discharges to the lowest rehospitalization quartile SNFs is associated with a 1 percentage point reduction in hospital's ARR.
The SNF rehospitalization rate has greater influence on patients’ risk of rehospitalization than the discharging hospital. Identifying high-performing SNFs may be a powerful strategy for hospitals to reduce rehospitalizations.

Rivera-Hernandez M, Leyva B, Keohane LM, Trivedi AN. (2016). Quality of Care for White and Hispanic Medicare Advantage Enrollees in the United States and Puerto Rico. JAMA Intern Med. 2016 Jun 1;176(6):787-94. doi: 10.1001/jamainternmed.2016.0267. PubMed PMID: 27111865; PubMed Central PMCID: PMC4934661.
Geographic, racial, and ethnic variations in quality of care and outcomes have been well documented among the Medicare population. Few data exist on beneficiaries living in Puerto Rico, three-quarters of whom enroll in Medicare Advantage (MA).
To determine the quality of care provided to white and Hispanic MA enrollees in the United States and Puerto Rico.
A cross-sectional study of MA enrollees in 2011 was conducted, including white enrollees in the United States (n = 6?289?374), Hispanic enrollees in the United States (n = 795?039), and Hispanic enrollees in Puerto Rico (n = 267?016). The study was conducted from January 1, 2011, to December 31, 2011; data analysis took place from January 19, 2015, to January 2, 2016.
Seventeen performance measures related to diabetes mellitus (including hemoglobin A1c control, retinal eye examination, low-density lipoprotein cholesterol control, nephropathy screening, and blood pressure control), cardiovascular disease (including low-density lipoprotein cholesterol control, blood pressure control, and use of a β-blocker after myocardial infarction), cancer screening (colorectal and breast), and appropriate medications (including systemic corticosteroids and bronchodilators for chronic obstructive pulmonary disease [COPD] and disease-modifying antirheumatic drugs).
Of the 7.35 million MA enrollees in the United States and Puerto Rico in our study, 1.06 million (14.4%) were Hispanic. Approximately 25.1% of all Hispanic MA enrollees resided in Puerto Rico, which was more than those residing in any state. For 15 of the 17 measures assessed, Hispanic MA enrollees in Puerto Rico received worse care compared with Hispanics in the United States, with absolute differences in performance rates ranging from 2.2 percentage points for blood pressure control in diabetes mellitus (P = .03) to 31.3 percentage points for use of disease-modifying antirheumatic drug therapy (P < .01). Adjusted performance differences between Hispanic MA enrollees in Puerto Rico and Hispanic MA enrollees in the United States exceeded 20 percentage points for 3 measures: use of disease-modifying antirheumatic drug therapy (-23.8 percentage points [95% CI, -30.9 to -16.8]), use of systemic corticosteroid in COPD exacerbation (-21.3 percentage points [95% CI, -27.5 to -15.1]), and use of bronchodilator therapy in COPD exacerbation (-22.7 percentage points [95% CI, -27.7 to -17.6]).
We found modest differences in care between white and Hispanic MA enrollees in the United States but substantially worse care for enrollees in Puerto Rico compared with their US counterparts. Major efforts are needed to improve care delivery on the island to a level equivalent to the United States.

Rozanova, Miller, E., & Wetle. (2016). Depictions of Nursing Home Residents in US Newspapers: Successful Aging vs Frailty.  International Journal of Ageing and Society, FirstView Article, 1-25. DOI: 10.1017/S0144686X14000907. 
The media shape both what people consider significant and how people think about key issues. This paper explored the cultural beliefs and stereotypes that underlie media portrayals of nursing homes. The analysis of texts of 157 articles about nursing homes published from 1999 to 2008 on the front pages of four major-market American newspapers (The New York Times, Chicago Tribune, Los Angeles Times and The Washington Post) was conducted using a qualitative approach inspired by comparative narrative and critical discourse analysis. Results suggest two major themes, each with several narrative components: (a) managing disposable lives (bodies outliving bank accounts; making frailty affordable; and the economics of triage); and (b) retaining purchasing power as successful ageing (consumption as a sign of market participation, spending money as an indicator of autonomy; and financial planning as preparation for future decline). Thus, the results indicate that nursing home residency in-and-of-itself is not a marker of unsuccessful ageing. This, instead, depends, in part, on the extent of choice available as a result of the level of financial solvency. This study shines light on the betwixt and between zone that distinguishes the Third and Fourth Ages; that is, independence versus dependence in old age. If individuals in a nursing home retain control over the management of their lives through the maintenance of financial independence, even if physically frail, association of nursing home residence with the Fourth Age may be ameliorated.

Teno JM, Gozalo P, Khandelwal N, Curtis JR, Meltzer D, Engelberg R, Mor V. (2016). Association of Increasing Use of Mechanical Ventilation Among Nursing Home Residents With Advanced Dementia and Intensive Care Unit Beds. JAMA Intern Med. 2016 Oct 10. [Epub ahead of print] PMID: 27723891
Mechanical ventilation may be lifesaving, but in certain persons, such as those with advanced dementia, it may prolong patient suffering without a clear survival benefit.
To describe the use and outcomes of mechanical ventilation and its association with the increasing numbers of intensive care unit (ICU) beds in the United States for patients with advanced dementia residing in a nursing home 120 days before that hospital admission.
This retrospective cohort study evaluated Medicare beneficiaries with advanced dementia hospitalized from January 1, 2000, to December 31, 2013, using the Minimum Data Set assessments linked with Medicare part A claims. A hospital fixed-effect, multivariable logistic regression model examined the effect of changes in ICU beds within individual hospitals and the likelihood of receiving mechanical ventilation, controlling for patients' demographic characteristics, function, and comorbidities.
Mechanical ventilation.
From 2000 to 2013, a total of 635?008 hospitalizations of 380?060 eligible patients occurred (30.5% male and 69.5% female; mean [SD] age, 84.4 [7.4] years). Use of mechanical ventilation increased from 39 per 1000 hospitalizations in 2000 to 78 per 1000 hospitalizations in 2013 (P < .001, test of linear trend). As the number of ICU beds in a hospital increased over time, patients with advanced dementia were more likely to receive mechanical ventilation (ie, adjusted odds ratio per 10 ICU bed increase, 1.06; 95% CI, 1.05-1.07). In 2013, hospitals in the top decile in the number of ICU beds were reimbursed $9611.89 per hospitalization compared with $8050.24 per hospitalization in the lower decile (P < .001) without an improvement in 1-year mortality (65.2% vs 64.6%; P = 54).
Among hospitalized nursing home residents with advanced dementia, we found an increase in the use of mechanical ventilation over time without substantial improvement in survival. This increase in the use of mechanical ventilation was associated with an increase in the number of ICU beds within a hospital.

Winblad, Mor, McHugh, Rahman. (2016). ACO-Affiliated Hospitals Reduced Rehospitalizations from Skilled Nursing Facilities Faster Than Other Hospitals. Health Affairs, 36(1), 67-73. doi: 10.1377/hlthaff.2016.0759
Medicare’s more than 420 accountable care organizations (ACOs) provide care for a considerable percentage of the elderly in the United States. One goal of ACOs is to improve care coordination and thereby decrease rates of rehospitalization. We examined whether ACO-affiliated hospitals were more effective than other hospitals in reducing rehospitalizations from skilled nursing facilities. We found a general reduction in rehospitalizations from 2007 to 2013, which suggests that all hospitals made efforts to reduce rehospitalizations. The ACO-affiliated hospitals, however, were able to reduce rehospitalizations more quickly than other hospitals. The reductions suggest that ACO-affiliated hospitals are either discharging to the nursing facilities more effectively compared to other hospitals or targeting at-risk patients better, or enhancing information sharing and communication between hospitals and skilled nursing facilities. Policy makers expect that reducing readmissions to hospitals will generate major savings and improve the quality of life for the frail elderly. However, further work is needed to investigate the precise mechanisms that underlie the reduction of readmissions among ACO-affiliated hospitals.
Lepore, M., & Leland, N.E. (2015). Nursing homes that increased the proportion of Medicare days saw gains in quality outcomes for long-stay residents. Health Affairs, 34(12), 2121-2128. doi: 10.1377/hlthaff.2015.0303. [PMID: 26643633]
Nursing homes are increasingly providing rehabilitative care to short-stay residents under Medicare's skilled nursing facility coverage, which is much more generous than Medicaid's coverage for long-stay residents. This shift creates the potential for both beneficial and detrimental effects on outcomes for such residents. Examining nationwide facility-level nursing home data for the period 2007-10, we found that increasing the proportion of Medicare-covered patient days in a nursing home was significantly associated with improvements in the quality of the three outcomes we considered for long-stay residents. We saw significant decreases in the percentages of long-stay residents with daily pain (from 5.1 percent to 3.4 percent), with worsening pressure ulcers (from 2.5 percent to 2.0 percent), and with a decline in performing activities of daily living (from 15.9 percent to 14.9 percent). These findings reinforce previous research indicating that quality outcomes tend to be superior in nursing homes with greater financial resources. They also bolster arguments for financial investments in nursing homes, including increases in Medicaid payment rates, to support better care for long-stay residents.