Study Documents NH Changes Since OBRA ’87: Greater Diversity, Higher Acuity, Fewer Bedbound Residents

February 11, 2020

Today’s nursing homes (NHs) look much different than they did when the Omnibus Budget Reconciliation Act of 1987 (OBRA’87) was passed, according to a study in the February issue of JAMDA. There is greater diversity and higher acuity now, and care has evolved to meet the changing needs of residents.

In Thirty-Year Trends in Nursing Home Composition and Quality Since the Passage of the Omnibus Reconciliation Act, the authors analyzed data from the National Nursing Home Survey, Online Survey Certification and Reporting Data/Certification and Survey Provider Enhanced Reporting, and data from They found that in the past 30 years, the NH industry has decreased in size by nearly 400 facilities, with an increase in the number of non-profit, dually-certified, and chain facilities, as well as those with an Alzheimer’s special care unit.

The NH population has changed as well. There are more racial and ethnic minorities in this setting. While the number of long-stay residents has remained stable, the percentage of residents admitted from the hospital has increased by over 15%, with more people coming into NHs for rehabilitative/post-acute care. The number of residents with Medicaid as a primary payer has decreased, while the percentage of those mostly supported by Medicare has risen. Acuity has increased, and more residents have physical and/or cognitive issues and need help with various activities of daily living such as bathing. The number of residents with dementia, as well as those with psychiatric diagnoses, has risen considerably. At the same time, fewer residents are bedbound.

Overall, quality process measures have improved. Staffing hours are up, and the proportion of residents being physically restrained is way down (to 1%). The number of residents receiving antipsychotics also has dropped.

OBRA’87 called for a dramatic overhaul of the NH quality assurance system. It included a minimum set of standards and rights for people residing in Medicare- and Medicaid-certified NHs. The OBRA law focused on residents’ quality of life and care; expectations for improved or maintained resident health; as well as residents’ rights to banking, organized family councils, and freedom from unnecessary physical and chemical restraints. It also standardized certification standards and enforcement strategies.

The authors observed, “While it can be argued that NHs still have room to improve in their quality indicators, it is important to note that despite an increasingly vulnerable and higher need population, we still observe quality gains among NHs during this time period.” They concluded, “While NHs continue to focus more on short-stay post-acute care residents and long-stay residents with dementia, more work will need to be done in community-based settings to ensure the highest quality care and life.”

This study was conducted by researchers at the Center for Gerontology and Healthcare Research and Department of Health Services, Policy, and Practice at the School of Public Health, Brown University, Providence, RI; and the Center of Innovation in Long-Term Services and Supports, U.S. Department of Veteran Affairs Medical Center, Providence, RI.

Click here for more information on the findings above and more details about the study. To contact the researchers or JAMDA editor for an interview, please email


JAMDA is the official journal of AMDA – The Society for Post-Acute and Long-Term Care Medicine. JAMDA publishes peer-reviewed articles including original studies, reviews, clinical experience articles, case reports, and more, on all topics more important to post-acute and long-term care medicine. Visit for more information.

About AMDA – The Society for Post-Acute and Long-Term Care Medicine
AMDA – The Society for Post-Acute and Long-Term Care Medicine is the only medical specialty society representing the community of over 50,000 medical directors, physicians, nurse practitioners, physician assistants, and other practitioners working in the various post-acute and long-term care (PALTC) settings. Dedicated to defining and improving quality, we advance our mission through timely professional development, evidence-based clinical guidance, and tireless advocacy on behalf of members, patients, families, and staff. Visit for more information.