Trends in Serious Mental Illness in US Assisted Living Compared to Nursing Homes and the Community: 2007-2017

Published:September 18, 2020DOI:


      • What is the primary question addressed by this study?
        Has the prevalence of serious mental illness (SMI) in assisted living (AL) increased in recent years?
      • What is the main finding of this study?
        Rates of SMI in AL increased between 2007 and 2017 at a rate faster than the community but slower than in nursing homes. We found substantial between- and within- state variability in the percentage of residents with a diagnosis of SMI.
      • What is the meaning of the finding?
        Given the increased prevalence of SMI in AL, research is needed into the care needs of this population.



      Little is known about the prevalence of serious mental illness (SMI) in assisted living (AL) communities in the United States. Trends in the prevalence of SMI in AL communities were examined over time and in relationship to characteristics such as dual eligibility and health conditions. Within- and between-state variability of SMI in AL was also examined.


      Samples of Medicare beneficiaries who lived in the 48 contiguous states were created: individuals who resided in the community, in a nursing home (NH), and in an AL community on December 31st of each year (2007–2017). We conducted univariate analysis to display the trends in SMI over time in AL compared with NHs and the community. To demonstrate intrastate variability, we examined the prevalence of SMI for each state. We described within-nation and within-state variability using a Lorenz curve and GINI coefficients, respectively.


      The prevalence of SMI in AL increased by 54%, rising from 7.4% in 2007 to 11.4% in 2017. Residents with SMI were more likely to be dually eligible for Medicare and Medicaid than residents without SMI. The prevalence of SMI in AL ranged from to 3.2% in Wyoming to 33.1% in New York. Approximately 10% of AL communities had over half of the sample's AL residents with SMI.


      Given the increased proportion of residents with SMI in AL, research is needed into the mental health and social care needs of this population. Analysis is needed to uncover reasons for variations among states.

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        • Harris-Kojetin L
        • Sengupta M
        • Penn Lendon J
        • et al.
        Long-term care providers and services users in the United States: 2015–2016. National Center for Health Statistics.
        Vital Health Stat. 2019; 3: 1-25
        • Walters J.
        Uncertainty, isomorphism, and the birth of a new industry: regulatory policy development in a new health services sector, 1994-2004.
        Admin Soc. 2012; 44: 458-486
        • Zimmerman S
        • Sloane PD
        • Reed D
        Dementia prevalence and care in assisted living.
        Health Aff (Millwood). 2014; 33: 658-666
        • Khatutsky G
        • Ormond C
        • Wiener JM
        Residential Care Communities and Their Residents in 2010: A National Portrait. DHHS Publication No. 2016-1041.
        National Center for Health Statistics, Hyattsville, MD2016
        • Dawson WD
        • Nash M.
        Aging with serious mental illness: one state's response.
        Generations. 2018; 42: 63-70
        • Lepore M
        • Knowles M
        • Porter KA
        • et al.
        Medicaid beneficiaries' access to residential care settings.
        J Hous Elderly. 2017; 31: 351-366
        • Ng T
        • Stone J
        • Harrington C
        Medicaid home and community-based services: how consumer access is restricted by state policies.
        J Aging Soc Policy. 2015; 27: 21-46
      1. US Government Accountability Office. Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed. (Publication No. GAO-180-179) Available at: (2018) Accessed April 7, 2020

        • Morgan LA
        • Perez R
        • Frankowski AC
        • et al.
        Mental illness in assisted living: challenges for quality of life and care.
        J Hous Elderly. 2016; 30: 185-198
        • Muralidharan A
        • Mills WL
        • Evans DR
        • et al.
        Preparing long-term care staff to meet the needs of aging persons with serious mental illness.
        J Am Med Dir Assoc. 2019; 20: 683-688
        • Molinari VA
        • Merritt SS
        • Mills WL
        • et al.
        Serious mental illness in Florida nursing homes: need for training.
        Gerontol Geriatr Educ 29. 2008; : 66-83
        • Dobbs D
        • Hayes J
        • Chapin R
        • et al.
        The relationship between psychiatric disorders and the ability to age in place in assisted living.
        Am J Geriatr Psychiatry. 2006; 14: 613-620
        • Li Y
        • Cai X
        • Cram P
        Are patients with serious mental illness more likely to be admitted to nursing homes with more deficiencies in care?.
        Med Care. 2011; 49: 397-405
        • Temkin-Greener H.
        • Campbell L.
        • Cai X.
        • et al.
        Are post-acute patients with behavioral health disorders admitted to lower quality nursing homes?.
        Am J Geriatr Psychiatry. 2018; 26: 643-654
        • Rahman M
        • Grabowski DC
        • Intrator O
        • et al.
        Serious mental illness and nursing home quality of care.
        Health Serv Res. 2013; 48: 1279-1298
        • McGarry BE
        • Joyce NR
        • McGuire
        • et al.
        Association between high proportions of seriously mentally ill nursing home residents and the quality of resident care.
        J Am Geriatr Soc. 2009; 67: 2346-2352
        • Mor V
        • Zinn J
        • Teno JM
        • et al.
        Driven to tiers: socioeconomic and racial disparities in the quality of nursing home care.
        Milbank Q. 2004; 82: 227-256
      2. Jester DJ, Hyer K, Bowblis JR. Quality concerns in nursing homes that serve large proportions of residents with serious mental illness [published online ahead of print, 2020 May 31]. Gerontologist. 2020;gnaa044. doi:10.1093/geront/gnaa044

        • Carder PC.
        State regulatory approaches for dementia care in residential care and assisted living.
        Gerontologist. 2017; 57: 776-786
        • Street D
        • Burge S
        • Quadagno J
        The effect of licensure type on the policies, practices, and resident composition of Florida assisted living facilities.
        Gerontologist. 2009; 49: 211-223
        • CCW
        Chronic Condition Data Warehouse User Manual, Version 3.6 [accessed on September 8, 2020]. CMS Research Data Assistant Center (ResDAC).
        Iowa Foundation for Medical Care, Des Moines, IA2016 (Available at:)
        • Intrator O
        • Hiris J
        • Berg
        • et al.
        The residential history file: studying nursing home residents' long‐term care histories.
        Health Serv Res. 2011; 46: 120-137
        • Thomas KS
        • Dosa DM
        • Gozalo PL
        • et al.
        A methodology to identify a cohort of Medicare beneficiaries residing in large assisted living facilities using administrative data.
        Med Care. 2018; 56: e10-e15
        • Thomas KS
        • Zhang W
        • Cornell PY
        • et al.
        State variability in the prevalence and healthcare utilization of assisted living residents with dementia.
        J Am Geriatr Soc. 2020; 68: 1504-1511
        • Cornell PY
        • Zhang W
        • Thomas KS
        Changes in long-term care markets: assisted living supply and the prevalence of low-care residents in nursing homes.
        J Am Med Dir Assoc. 2020; 21 (e4): 1161-1165
        • Thomas KS
        • Belanger E
        • Zhang W
        • et al.
        State variability in assisted living residents' end-of-life care trajectories.
        J Am Med Dir Assoc. 2020; 21: 415-419
        • Grabowski DC
        • Stevenson DG
        • Cornell PY
        Assisted living expansion and the market for nursing home care.
        Health Serv Res. 2012; 47: 2296
        • Lin WC
        • Zhang J
        • Leung GY
        • et al.
        Chronic physical conditions in older adults with mental illness and/or substance use disorders.
        J Am Geriatr Soc. 2011; 59: 1913-1921
        • Bahorik AL
        • Satre DD
        • Kline-Simon AH
        Serious mental illness and medical comorbidities: findings from an integrated health care system.
        J Psychosom Res. 2017; 100: 35-45
        • Groves-Kirkby CJ
        • Denman AR
        • Phillips PS
        Lorenz Curve and Gini coefficient: novel tools for analysing seasonal variation of environmental radon gas.
        J Environ Manage. 2009; 90: 2480-2487
      3. Carder PC, O'Keeffe J, O'Keeffe C. Compendium of Residential Care and Assisted Living Regulations and Policy: 2015 Edition Executive Summary. Available from: Accessed May 6, 2020.

        • Carlson E
        • Coffey G
        • Fecondo J
        • et al.
        Medicaid funding for assisted living care: a five-state examination.
        J Hous Elderly. 2010; 24: 5-27
      4. Transitional Adult Homes. New York State. Accessed July 16, 2020.

        • Bowersox NW
        • Szymanski BJ
        • McCarthy JF
        Associations between psychiatric inpatient Bed supply and the prevalence of serious mental illness in veterans affairs nursing homes.
        Am J Public Health. 2013; 103: 1325-1331
        • Cotton P
        • Newhouse JP
        • Volpp KG
        • et al.
        Medicare advantage: issues, insights, and implications for the future.
        Popul Health Manag. 2016; 19: S1-S8
        • Landon BE
        • Zaslavsky AM
        • Saunders RC
        • et al.
        Analysis of Medicare advantage HMOs compared with traditional Medicare shows lower use of many services during 2003-09.
        Health Aff (Millwood). 2012; 31: 2609-2617
        • Davis KA
        • Sudlow CL
        • Hotopf M
        Can mental health diagnoses in administrative data be used for research? A systematic review of the accuracy of routinely collected diagnoses.
        BMC Psychiatry. 2016; 16: 263