Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

JANUARY 2001 

OEI-05-99-00701 

YOUNGER NURSING FACILITY 

RESIDENTS WITH MENTAL ILLNESS: 

An Unidentified Population 
OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General (OIG), mandated by Public Law 95-452, as 

amended by Public Law 100-504, is to protect the integrity of the Department of Health and 

Human Services programs as well as the health and welfare of beneficiaries served by them. This 

statutory mission is carried out through a nationwide program of audits, investigations, 

inspections, sanctions, and fraud alerts. The Inspector General informs the Secretary of program 

and management problems and recommends legislative, regulatory, and operational approaches to 

correct them. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 

Inspector General. It conducts short-term management and program evaluations (called 

inspections) that focus on issues of concern to the Department, the Congress, and the public. The 

inspection reports provide findings and recommendations on the efficiency, vulnerability, and 

effectiveness of departmental programs. 

OEI's Chicago Regional Office prepared this report under the direction of William C. Moran, 

Regional Inspector General and Natalie Coen, Deputy Regional Inspector General. Principal OEI 

staff included: 

REGION 

Emily Melnick, Project Leader

Ianna Kachoris, Program Analyst

Stacy Thompson, Intern

Kristine Zeabart, Intern

HEADQUARTERS 

Susan Burbach, Program Specialist 

Bambi Straw, Program Specialist 

Linda Moscoe, Program Analyst 

Brian Ritchie, Program Analyst 

To obtain copies of this report, please call the Chicago Regional Office at 312-353-4124. 

Reports are also available on the World Wide Web at our home page address: 

http://www.dhhs.gov/progorg/oei 
EXECUTIVE SUMMARY 

PURPOSE 

To determine the extent to which younger individuals with mental illness reside in nursing 

facilities. 

BACKGROUND 

This inspection is one in a series of Office of Inspector General reports on individuals with 

mental illness in nursing facilities. A companion to this report, “Younger Nursing Home 

Residents with Mental Illness: Pre-Admission Screening and Resident Review 

Implementation and Oversight” (OEI 05-99-00700) examines the admission and mental 

health screenings of Medicaid beneficiaries, ages 22-64, who have a serious mental illness 

and reside in nursing facilities. In that study we found that State implementation of PreAdmission Screening and Resident Review (PASRR) systems, the primary mechanism by 

which individuals with mental illness in nursing facilities are monitored, is inadequate to 

identify whether younger individuals with mental illness are appropriately screened, 

evaluated and placed in nursing facilities. 

This report attempts to ascertain the extent to which younger individuals with mental 

illness reside in nursing facilities. In addition, we wanted to identify the amount of 

Medicaid funds spent to care for this population. The national average for percentage of 

individuals in nursing facilities being treated for mental illness is unknown. A recent 

review of the National Nursing Home Surveys estimates that in 1995, there were 

approximately 12,000 nursing facility residents under age 65 with a primary mental illness 

diagnosis. We believe this figure may not accurately reflect the number of younger 

nursing facility residents with serious mental illness. 

The 1999 Olmstead v. L.C. Supreme Court decision asserted that States are obliged to 

administer their services, programs, and activities to individuals with disabilities in the 

“most integrated setting” appropriate to their needs. Olmstead challenges States to 

prevent and correct inappropriate institutionalization and to review intake and admissions 

procedures to assure that individuals are served in the most integrated setting appropriate. 

Federal Data Sources 

The Health Care Financing Administration’s (HCFA) Medicaid Statistical Information 

System (MSIS) collects claims and eligibility data for medical services reimbursed with 

Title XIX funds. Its purpose is to “collect, manage, analyze and disseminate information 

Younger Nursing Facility Residents with Mental Illness i OEI-05-99-00701 
on eligibles, recipients, utilization and payment for services covered by State Medicaid 

programs.” 

The HCFA Minimum Data Set (MDS) collects resident assessment information “to aid in 

the survey and certification of Medicare/Medicaid long-term care facilities and to study the 

effectiveness and quality of care given in those facilities.” The MDS is also intended to 

“support regulatory, reimbursement, policy, and research functions.” 

To identify the number of nursing facility residents between the ages of 22 and 64 with a 

severe mental illness, we examined MSIS and MDS data and conducted a 51 State survey. 

FINDINGS 

We cannot conclusively determine the number of younger individuals with mental 

illness that reside in nursing facilities 

After collecting data from MSIS, MDS and our 51 State survey, we cannot conclusively 

determine the number of younger individuals with mental illness that reside in nursing 

facilities. In attempting to identify this population, we encountered data inconsistencies 

including: the dates for which the most recent data was available; the ability to capture 

primary and/or secondary diagnosis; the scope of the data collected; and differing provider 

identification numbers for individual nursing facilities. 

The HCFA data sources do not provide comparable information. Federal MSIS data for 

39 States indicates that 5,745 Medicaid beneficiaries with a primary diagnosis of mental 

illness between the ages of 22 and 64 reside in nursing facilities. Federal MDS data 

indicates that 17,919 younger Medicaid beneficiaries with any diagnosis of mental illness 

reside in nursing facilities in these same States. 

Further, HCFA data and our 51 State survey yield inconsistent results. For example, the 

MDS data indicates that the number of younger nursing facility residents with mental 

illness represents, on average, 1.6 percent of States’ nursing facility populations. Our 

State survey indicates that for 20 States reporting this information, these residents 

represent, on average, 20 percent of their nursing facility populations. 

The MSIS claims data cannot be validated. Only 10 of the 19 nursing facilities we visited 

were identified as having submitted at least one claim for younger nursing facility residents 

with mental illness. None of the 187 individuals whose case files we reviewed were 

identified in MSIS as having a Medicaid claim for nursing facility services, despite listing 

Medicaid as their payer source. 

Younger Nursing Facility Residents with Mental Illness ii OEI-05-99-00701 
MSIS cannot be matched with MDS to yield reliable results for research and analysis and 

thus we could not discern pertinent facility level information. We were able to identify 

and match in MDS only 39 percent of nursing facilities that MSIS identified as having at 

least one younger individual with mental illness. For 10 States, none of the nursing 

facilities matched between MSIS and MDS. 

Medicaid expenditures cannot be validated 

In order to calculate States’ Medicaid expenditures for younger nursing facility residents 

with mental illness, we had to rely on MSIS and State data. However, we believe that 

MSIS is an inaccurate representation and underestimation of Medicaid expenditures for 

this population. Medicaid expenditure data from MSIS is not validated either by our 51 

State survey or our case file review. Eight States reported that they spent $30.9 million 

total in Federal Fiscal Year 1998 while MSIS indicated that for these eight States, total 

Medicaid expenditures was $15.8 million. Our survey data indicates that, on average, 

States spend $12.3 million per year on younger nursing facility residents with mental 

illness, while MSIS indicates that States, on average, spend $4.9 million per year. 

States do not know where younger individuals with mental illness are receiving 

long-term care 

Many State mental health authorities (SMHA) responding to our survey reported difficulty 

submitting information regarding the number of individuals with mental illness between the 

ages of 22 and 64 in various types of long-term care facilities. In addition, SMHAs had 

difficulty providing us with expenditure information. Of the 43 SMHAs that responded to 

our survey, only 13 were able to provide us with the complete expenditure information we 

requested. 

State Medicaid agencies also had difficulty reporting expenditure information for all types 

of long-term care facilities and specifically for nursing facilities. Only 15 of 36 State 

Medicaid agencies were able to report Medicaid expenditures for younger nursing facility 

residents with a primary or secondary diagnosis of mental illness. Only nine States were 

able to provide us with complete expenditure figures for younger individuals with a 

primary diagnosis of mental illness. 

OTHER CONSIDERATIONS 

Our inspection focuses on younger nursing facility residents with mental illness. However, 

the issues we encountered regarding the validity and reliability of the data raise significant 

concerns about the broader use of both MDS and MSIS data in making and evaluating 

health care policy. Our unsuccessful attempt to identify this population is indicative of a 

larger problem with these Federal data sources. This examination 

Younger Nursing Facility Residents with Mental Illness iii OEI-05-99-00701 
C

questions the use of Federal data sources to accurately yield important demographic, 

utilization, and expenditure information upon which to base policy. Without reliable 

information that enables us to identify populations of individuals requiring particular types 

of services, we cannot assess appropriateness, access and quality of care, nor determine 

the effectiveness of Federal Medicaid and nursing facility policy. 

RECOMMENDATIONS 

Recent attention on individuals with mental illness, particularly those in institutional 

settings, increases the need for the Health Care Financing Administration to ensure that 

Federal data systems can respond to both the Administration’s and the public’s inquiry 

into the status of younger nursing facility residents with serious mental illness. The HCFA 

should be able to use both the MSIS, MDS and other related Federal data systems to 

monitor the extent to which nursing facility residents have mental illness and, in turn, 

receive needed mental health treatment. 

In order to improve the ability of HCFA and States to produce accurate nursing 

facility information and to increase the ability to monitor care and treatment of 

Medicaid nursing facility residents with mental illness, we recommend that HCFA: 

C assign unique provider numbers for long-term care facilities that submit 

information to Federal data sources; 

C provide training and clearer coding instructions to improve the ability of nursing 

home staff and of the MDS instrument to capture mental illness diagnoses; 

C make MDS and MSIS data available in a timely manner; 

C require States to report information by age; and 

C require States to report information by diagnosis. 

In response to the Olmstead Supreme Court Decision that requires individuals to 

be placed in the “most integrated and least restrictive setting appropriate,” we 

recommend that HCFA: 

C facilitate the availability of improved MSIS and MDS data to assist States in 

complying with HCFA’s directive to identify residents and periodically review the 

services of all residents in Medicaid-funded institutional settings; and 

C encourage States to use MSIS and MDS data systems to help demonstrate that the 

State has “a comprehensive, effectively working plan for placing qualified persons 

with disabilities in the most integrated setting appropriate.” 

Younger Nursing Facility Residents with Mental Illness iv OEI-05-99-00701 
AGENCY COMMENTS 

We received comments from the Health Care Financing Administration (HCFA) and the 

Assistant Secretary for Planning and Evaluation (ASPE). The HCFA concurs with six of 

our seven recommendations. The ASPE provided general comments. Where appropriate 

we changed the report to reflect their comments. The full HCFA and ASPE comments are 

contained in Appendix A. We would like to thank HCFA and ASPE for their assistance in 

conducting this study and for providing us with comments. 

The HCFA believes that “mental health is central to the overall well being of all our 

beneficiaries, including younger nursing facility residents” and that “monitoring these 

residents’ care and treatment and maintaining accurate nursing facility information is 

essential to their well-being.” 

The one recommendation that HCFA does not concur with is amending the MDS to 

distinguish between primary, secondary and tertiary diagnoses. The HCFA proposes an 

alternative to our recommendation that would “provide training and clearer coding 

instructions to improve the ability of nursing home staff and of the MDS instrument to 

capture Mental Illness diagnoses.” We agree with HCFA that providing training and 

improved coding instructions is in accordance with the intent of our recommendation and 

have changed our recommendation accordingly. 

The HCFA expressed concern that the difficulty we experience in finding mental health 

information may be due to the timing of the study. We want to clarify that our 

methodology did not rely on information captured exclusively by an initial MDS 

assessment. Instead, both our reviews of MDS initial and quarterly assessments of 

individual medical files and of the MDS database universe for a six month period would 

have enabled us to capture mental health diagnoses. 

The HCFA reports that they have concerns that our inspection does not accurately depict 

their role in determining State compliance with the Olmstead Decision. What we wanted 

to emphasize was that improved MSIS and MDS data systems can help facilitate States’ 

compliance with the Olmstead Decision as part of a multi-faceted approach. We agree 

that the improvements HCFA has committed to making should prove to be beneficial. 

The ASPE expressed concern that the focus of our report, younger individuals with 

serious mental illness, comprise less than 3% of nursing home residents according to the 

1996 Medical Expenditure Panel Survey (MEPS). We believe that there is not a reliable 

source of information to determine this population. More importantly, we continue to 

believe that regardless of the overall size of the national population of younger nursing 

facility residents with serious mental illness, their presence and care in nursing facilities 

warrants HCFA’s specialized attention. 

Younger Nursing Facility Residents with Mental Illness v OEI-05-99-00701 
T ABLE OF CONTENTS 

PAGE 

EXECUTIVE SUMMARY

INTRODUCTION ..................................................... 1

FINDINGS ................................................................ 9

Information inadequate to identify younger nursing facility residents with mental illness .... 9

Medicaid expenditure data cannot be validated ................................. 13

States do not know where younger individuals with mental illness receive long-term care . 14

OTHER CONSIDERATIONS ........................................... 17

RECOMMENDATIONS ............................................... 18

AGENCY COMMENTS ................................................ 20

APPENDIX

A. Agency Comments .................................................... 22

Younger Nursing Facility Residents with Mental Illness vi OEI-05-99-00701 
INTRODUCTION 

PURPOSE 

To determine the extent to which younger individuals with mental illness reside in nursing 

facilities. 

BACKGROUND 

This inspection is one in a series of Office of Inspector General reports on individuals with 

mental illness in nursing facilities. A companion to this report, “Younger Nursing Home 

Residents with Mental Illness: Pre-Admission Screening and Resident Review 

Implementation and Oversight” (OEI 05-99-00700) examines the admission and mental 

health screenings of Medicaid beneficiaries, ages 22-64, who have a serious mental illness 

and reside in nursing facilities. In that study we found that State implementation of PreAdmission Screening and Resident Review (PASRR) systems, the primary mechanism by 

which individuals with mental illness in nursing facilities are monitored, is inadequate to 

identify whether individuals are appropriately placed and their mental health needs are 

addressed. 

De-Institutionalization 

Between 1955 and 1985, many large State mental institutions closed, reducing by 80 

percent States’ institutionalized population of individuals with mental illness. Deinstitutionalization changed the health care delivery system for individuals with mental 

illness and challenged States and communities to identify alternative treatment options for 

individuals with mental illness. The national focus shifted to rehabilitating individuals with 

mental illness in community-based programs, tailored to a wide variety of needs. 

However, in many communities, de-institutionalization accelerated without the creation of 

local programs commensurate with the population requiring placement. According to the 

1999 “Mental Health: A Report of the Surgeon General,” community care and deinstitutionalization programs were implemented without evidence of effectiveness and 

needed services are not always available. 

Individuals with Mental Illness in Nursing Facilities 

The Pre-Admission Screening and Resident Review (PASRR) mandated by the Omnibus 

Budget Reconciliation Act of 1987 targets nursing facility applicants and residents with a 

Younger Nursing Facility Residents with Mental Illness 1 OEI-05-99-00701 
probable mental illness diagnosis for mandatory psychiatric evaluation. This process was 

designed to divert psychiatric patients from nursing facilities and prevent the inappropriate 

admission and retention of people with mental disabilities, thereby eliminating the use of 

nursing homes for individuals with chronic mental illness. In addition, PASRR was 

intended to identify residents in need of more appropriate acute treatment in hospitals or 

long-term treatment in community based settings,1 and to improve the accountability of 

nursing facilities for the appropriate management of psychiatric disorders in their 

residents.2 We examined the PASRR and the safeguards that monitor the admission and 

mental health treatment of younger Medicaid beneficiaries who have a serious mental 

illness and reside in nursing facilities in a companion report.3 

Nursing facilities have traditionally been “the last refuge” for individuals with mental 

illness. Individuals with mental illness may find themselves in a nursing facility because of 

physical and behavioral problems, the lack of caretakers, or insufficient community 

services, including long-term care.”4 The availability of necessary mental health treatment 

for nursing home residents with mental illness has long been a concern. A 1986 Institute 

of Medicine report suggests that patients with severe mental illness de-institutionalized 

from State mental hospitals were being discharged to nursing homes that could not 

provide the specialized services they needed.”5 

In addition, experts believe that the placement of non-elderly residents with mental illness 

in nursing facilities with elderly residents raises questions regarding the ability of nursing 

facilities to provide appropriate care to both populations. There are significant differences 

between the needs of the geriatric population and younger adults with mental illness who 

reside in nursing facilities. There is also concern regarding the lack of mental health 

training and experience of typical nursing facility staff. 

Nursing facility residents with serious and persistent mental illness 

The national average for percentage of individuals in nursing facilities being treated for 

mental illness is unknown. A recent review of the National Nursing Home Survey 

(NNHS) indicates that nationally, in 1995, there were 70,000 residents in nursing 

1 Surgeon General Report 1999 

2 Journal American Geriatric Society 45:1173-1181, 1997. 

3 “Younger Nursing Home Residents with Mental Illness: Pre-Admission Screening and Resident 

Review” (OEI-05-99-00700) 

4 Psychiatric Services 51:354-358, March 2000. American Psychiatric Association 

5 Psychiatric Services, February 1998, Vol 49, No. 3, p. 229-233. 

Younger Nursing Facility Residents with Mental Illness 2 OEI-05-99-00701 
facilities with a primary mental illness diagnosis.6 The review estimates that there are 

between 8,000 to more than one million residents of nursing facilities with a mental illness, 

including individuals with dementias, depression and schizophrenia -- with and without 

comorbidities. The report emphasizes that further subclassification is needed to produce a 

better estimate since the clinical and social policies to deal with mental illness, with and 

without physical comorbidity, are quite different. The NNHS review estimates that there 

are approximately 12,000 nursing facility residents with severe mental illness under age 

65. 7 We believe this figure may underestimate the number of younger nursing facility 

residents with serious mental illness. 

The Olmstead Decision 

The 1999 Olmstead v. L. C. Supreme Court decision asserted that continued 

institutionalization may violate the rights of an individual with mental illness or mental 

retardation under Title II of the Americans with Disabilities Act. The Supreme Court 

interpreted Title II to oblige States to administer their services, programs, and activities 

“in the most integrated setting appropriate to the needs of qualified individuals with 

disabilities.”8 

Title II gives an individual the right to live in the most appropriate community integrated 

setting. States are required to provide community-based services for persons with 

disabilities when the State’s treatment professionals determine that such placement is 

appropriate. States must take into consideration their resources and the needs of other 

people with mental disabilities in making such determinations. 

The Olmstead Decision challenges States to “prevent and correct inappropriate 

institutionalization and to review intake and admissions processes to assure that persons 

with disabilities are served in the most integrated setting appropriate.” In response to the 

Olmstead Decision, the Department issued a letter to all governors in January 2000, 

stating that “no person should have to live in a nursing home or other institution if he or 

she can live in his or her community.” Moreover, the Department said that “unnecessary 

institutionalization of individuals with disabilities is discrimination under the Americans 

with Disabilities Act.”9 

Recently, the Health Care Financing Administration (HCFA) sent a letter to State 

Medicaid Directors because “Medicaid programs play a critical role in making 

6 Psychiatric Services 51:354-358, March 2000. American Psychiatric Association.

7 Psychiatric Services 51:354-358, March 2000. American Psychiatric Association.

8 28 CFR 35.130(d)

9 New York Times, February 13, 2000

Younger Nursing Facility Residents with Mental Illness 3 OEI-05-99-00701 
community services available.” The HCFA informed the States that under the Court’s 

decision, States are required to provide community-based services for persons with 

disabilities when the placement can be reasonably accommodated, taking into account the 

resources available to the State and the needs of others who are receiving State-supported 

disability services.10 The HCFA has interpreted the ruling to mean that a State waiting list 

for services that moves reasonably well can be considered in compliance with the decision. 

State Medicaid directors are encouraged to periodically review the services of all residents 

in Medicaid-funded institutional settings. 

Surgeon General’s Report 

Additional recent attention to the care of individuals with mental illness in nursing facilities 

was brought about by the “Mental Health: A Report of the Surgeon General” which states 

that there are “major barriers that prevent the delivery of appropriate care to residents of 

nursing facilities who have mental illness.”11 Researchers have found that, despite a high 

prevalence of individuals with mental illness residing in nursing facilities, these facilities are 

ill-equipped to meet their needs.12 The report also states that “Medicaid policies 

discouraged nursing facilities from providing specialized mental health services, and 

Medicaid reimbursements for residents have been too low to provide a strong incentive for 

participation by highly trained mental health providers.”13 

Funding and State Responsibility for Treating Individuals with Mental Illness 

Historically, States have primary responsibility for funding the treatment of persons with 

mental illness. However, during the past two decades, the role of direct State funding of 

mental health care has been reduced, whereas Medicaid funding of mental health care has 

grown in importance. Despite the Federal Government’s current larger financial 

investment in mental health services, Medicaid and Medicare impose limitations on 

coverage for the long-term care of individuals with mental illness. These coverage 

limitations are intended to reinforce States’ primary responsibility for this population. 

10 State Medicaid Director Letter January 14, 2000 

11 Mental Health: A Report of the Surgeon General, p. 374 

12 Lombardo, N.E. Barriers to mental health services for nursing home residents. Washington, DC: 

American Association of Retired Persons, 1994. 

13 Surgeon General Report 199, p. 374. 

Younger Nursing Facility Residents with Mental Illness 4 OEI-05-99-00701 
In particular, Medicaid will not pay for services provided in an institution for mental 

disease (IMD) for individuals ages 22 to 64.14 The Social Security Act defines an IMD as 

“a hospital, nursing facility, or other institution of more than 16 beds, that is primarily 

engaged in providing diagnosis, treatment, or care of persons with mental diseases, 

including medical attention, nursing care and related services.”15 Medicaid will pay for the 

care of individuals with mental illness in nursing facilities where 50 percent or less of the 

facility’s beds were filled by residents with mental illness.16 

According to the Surgeon General’s report, the estimated number of psychiatric residents 

of all ages treated in nursing facilities has significantly increased, based on the record level 

of Medicaid and Medicare bills for treatment of mental illnesses. In 1996, treatment costs 

of individuals with mental illness was $66.7 billion.17 Medicaid comprised 19 percent of 

total expenditures on mental health treatment ($13 billion).18 Care for persons with mental 

illness residing in nursing facilities accounted for $4.7 billion (7.1%) of total mental health 

expenditures ($69 billion). 

14 Social Security Act Section §1905 (h)(I)(C) provides that the 21st birthday is the cut off point for 

benefits unless the beneficiary is under psychiatric care prior to and following their 21st birthday 

in which case they may continue to receive covered care until recovery or their 22nd birthday, 

whichever comes first. For purpose of this report, in order to avoid confusion,, we reviewed 

individuals ages 22 to 54. 

15 Social Security Act Section §1905 (h)(2)(I) 

16 1981 Medicaid ruling 

17 Health Care Financing Administration (HCFA) 1996 estimates of national health expenditures 

18 “Mental Health: A Report of the Surgeon General” 1999 

Younger Nursing Facility Residents with Mental Illness 5 OEI-05-99-00701 
Mental Health Expenditures by Payer 1996 

Percent of total 

MH Expenditures 

MH Expenditures 

(in billions) 

Percent of all health 

care expenditures for 

this category 

PRIVATE PAY 47% $32.43 6% 

Private insurance 27% $18.63 6% 

Out of pocket 17% $11.73 6% 

Other private pay 3% $2.07 5% 

PUBLIC PAY 53% $37.00 8% 

Medicaid 19% $13.00 9% 

State/Local 18% $12.42 18% 

Medicare 14% $10.00 5% 

Other Federal (VA, DoD, 

SAMHSA Block Grants) 

2% $1.38 3% 

Source: Mental Health: A Report of the Surgeon General 

Federal Budget: 

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

National Institute of Mental Health

Medicaid mental health

Medicare mental health

Federal Data Sources 

MSIS 

$2.5 billion (FY1999) 

$0.5 billion (FY1999) [34% 

discretionary, 66% block grants] 

$0.9 million (FY1999) 

$13.11 billion (1996) 

$9.66 billion (1996) 

The purpose of the Medicaid Statistical Information System (MSIS) is to “collect, 

manage, analyze and disseminate information on eligibles, recipients, utilization and 

payment for services covered by State Medicaid programs.” States provide HCFA with 

quarterly computer files containing specified data elements for: (1) persons covered by 

Medicaid (Eligible files); and, (2) adjudicated claims (Paid Claims files) for medical 

services reimbursed with Title XIX funds. These data files are furnished quarterly 

according to the Federal Fiscal Year (FY) schedule. The MSIS is used by HCFA to 

produce Medicaid program characteristics and utilization information for the States. The 

MSIS data files also provide HCFA with a large-scale database of State eligibles and 

services for other analyses. Prior to FY 1999, MSIS was a voluntary program. However, 

in accordance with the Balanced Budget Act of 1997, all claims processed on or after 

January 1, 1999 must be submitted electronically in the MSIS format. 

Younger Nursing Facility Residents with Mental Illness 6 OEI-05-99-00701 
MDS 

The Federal Minimum Data Set (MDS) was established to “aid in the administration of the 

survey and certification of Medicare/Medicaid long-term care facilities and to study the 

effectiveness and quality of care given in those facilities.” The MDS was also designed to 

“support regulatory, reimbursement, policy, and research functions, and enable regulators 

to provide long-term care facility staff with outcome data for providers’ internal quality 

improvement activities.” Federal MDS information is collected daily from all nursing 

facilities for all residents, regardless of payer source. The MDS assessment cycle, which 

captures information on admission, discharge and when a change in health status occurs, is 

collected quarterly. 

SCOPE 

This report evaluates Federal and State data used to identify the mental illness diagnosis of 

nursing facility residents, the numbers of nursing facility residents with a mental illness 

diagnosis, as well as expenditures for this population. We focused our study on Medicaid 

residents of nursing facilities between the ages of 22 and 64 with a “severe and persistent 

mental illness” as their primary or secondary diagnosis. We did not evaluate residents 

with Alzheimers’s disease, dementia or organic brain disorders. We focused on this 

population because we believe there are fundamental features of care and protection 

unique to younger persons with severe and persistent mental illness residing in the nursing 

facilities. 

We produced a companion report, “Younger Nursing Home Residents with Mental 

Illness: Pre-Admission Screening and Resident Review Implementation and Oversight” 

(OEI 05-99-00700) which evaluates the safeguards that monitor the admission and mental 

health treatment of Medicaid beneficiaries, ages 22-64 who have a serious mental illness 

and reside in nursing facilities. 

METHODOLOGY 

For the 39 States that submitted Medicaid claims and eligibility information to HCFA’s 

Medicaid Statistical Information System during the 4th quarter of 1998, we attempted to 

identify the number of nursing facility residents between the ages of 22 and 64 with a 

primary diagnosis of severe mental illness that had a Medicaid claim. 

We analyzed the Minimum Data Set from January through June 1999, to discover how 

many Medicaid resident assessments for residents ages 22 to 64 indicated a mental illness 

diagnosis. 

Younger Nursing Facility Residents with Mental Illness 7 OEI-05-99-00701 
We conducted a national survey of 50 State Mental Health, Medicaid and Medicare/ 

Medicaid Survey agencies and State Long-Term Care (LTC) Ombudsmen and the District 

of Columbia, henceforth referred to as the “51 State Survey,” to understand the extent to 

which nursing facilities in each State provide care for persons ages 22 to 64 with a major 

mental illness diagnosis from the International Classification of Diseases, 9th Revision 

(ICD-9) codes 293-301, 311, 312. We also received State and Medicaid mental health 

treatment expenditures for this population. In addition, we surveyed States to determine 

in what other types of long-term care settings younger individuals with mental illness 

reside and State expenditures in those settings. 

We received 131 surveys from 50 States: 

C 43 from State mental health authorities,

C 36 from Medicaid agencies,

C 29 from State Medicare/Medicaid Survey agencies, and 

C 23 from the State LTC Ombudsmen. 

We made onsite visits to five States — California, Florida, Kansas, Minnesota and 

Pennsylvania to conduct State agency interviews, visit nursing facilities and conduct case 

file review. We selected these States based on: 

C the high percentage of residents with a mental illness as their primary or 

secondary diagnosis in individual nursing facilities as identified by the 

Federal Online Survey and Certification Reporting System (OSCAR) data; 

C their submission of data to MSIS in FY 199819; and 

C geographic location. 

In each of the five case study States, we selected four nursing facilities based on the high 

percentage of residents ages 22-64 with a primary or secondary diagnosis of mental illness 

being cared for in that facility, as well as geographic proximity. In the 5 case study States, 

we visited 19 nursing facilities and reviewed 187 resident case files of current nursing 

facility Medicaid residents between the ages of 22 and 64 with a major mental illness 

diagnosis from the International Classification of Diseases, 9th Revision (ICD-9) codes 

293-301, 311, 312. We selected the files to review either through a random sample of a 

specific nursing facility’s population of younger individuals with serious mental illness or 

where time permitted, a review of all residents whose age and diagnosis qualified them to 

be part of our study population. 

We conducted our review in accordance with the Quality Standards for Inspections issued 

by the President’s Council on Integrity and Efficiency. 

19 All 5 States we visited submitted data to the Federal MSIS as of 1998. 

Younger Nursing Facility Residents with Mental Illness 8 OEI-05-99-00701
F I N D I N G S 

We cannot conclusively determine the number of younger 

nursing facility residents with mental illness 

Federal Intent for Data Sources 

According to HCFA, the individual paid claims and eligibility information that is captured 

by the Medicaid Statistical Information System (MSIS) are used for program analysis and 

national research on Medicaid populations and expenditures. The HCFA indicates that 

current uses of MSIS data include health care research and evaluation activities; program 

utilization and expenditures forecasting; analyses of policy alternatives; responses to 

congressional inquiries; and matches to other health related databases.20 

The Minimum Data Set (MDS), HCFA's database on nursing facility resident assessments 

was established, in part, to study the effectiveness and quality of care given in that setting. 

The MDS was designed to “support regulatory, reimbursement, policy, and research 

functions” and “provide outcome data for providers.”21 

Using both the MSIS and MDS, we attempted to ascertain the extent to which younger 

individuals with mental illness reside in nursing facilities. In addition, we wanted to 

identify the amount of Medicaid funds spent to care for this population. In order to fill 

any gaps and to validate the data provided by MSIS and MDS, we conducted a 51 State, 4 

agency survey and collected data from our site visit case file review. Specifically, we 

wanted to identify the following characteristics of States’ nursing facility populations: 

C the total number of younger individuals with mental illness residing in nursing 

facilities; 

C the percent of States’ nursing facility populations that are younger individuals with 

mental illness; 

C the total number of States’ nursing facilities that care for younger individuals with 

mental illness; 

C the percent of States’ nursing facilities that care for younger individuals with 

mental illness; and 

20 HCFA Website 

21 HCFA Website 

Younger Nursing Facility Residents with Mental Illness 9 OEI-05-99-00701 
C in nursing facilities that have at least one younger resident with mental illness, how 

many and what percent (on average) of the nursing facility population are younger 

individuals with mental illness. 

Data inconsistencies 

In using different Federal data sources, we encountered inconsistencies including: 

C the dates for which the most recent data was available;

C the manner in which a younger individual with mental illness could be

identified, i.e. matching diagnosis to claims or to resident assessments; 

C the capability to capture primary and/or secondary diagnosis; 

C the scope of the data collected, i.e. for how many States data was available; 

and 

C different provider identification numbers, i.e. the lack of unique provider 

identifiers for a specific facility. 

The table below highlights the differences between the two data sets and the data captured 

in our survey and case file review. 

Data sources & Data captured 

Data 

Source 

Time Period States 

Included 

Manner 

data 

collected 

Capability of capturing 

mental illness 

diagnosis 

MSIS Fourth Quarter 

1998 

39 Voluntary Primary Only 

MDS January - June 

1999 

All 50 States 

& Territories 

NF 

Reported 

ALL diagnoses 

State 

Survey 

Federal FY 

1998 

33 State 

reported 

Primary AND/OR 

Secondary 

Case file 

review 

February/March 

2000 

5 OEI 

collected 

ALL diagnoses 

Data is inconclusive 

After collecting data from the above identified sources, we cannot conclusively determine 

the extent to which younger individuals with mental illness reside in nursing facilities. 

Federal MSIS data for 39 States indicates that in fourth quarter FY 1998, 5,745 Medicaid 

beneficiaries residing in nursing facilities are between the ages of 22 and 64 and have a 

primary diagnosis of mental illness. This number represents only 32 percent of the 

population of younger individuals with mental illness that are identified in MDS, for the 

same 39 States. The MDS data for January through June of 1999 yields an unduplicated 

Younger Nursing Facility Residents with Mental Illness 10 OEI-05-99-00701 
--

-- --

--

-- --

count of 17,919 younger nursing facility residents with any diagnosis of mental illness in 

the 39 States. In all States and Territories, an unduplicated count in MDS indicates that 

there were 45,710 younger, Medicaid nursing facility residents with mental illness. 

According to MDS, on average, younger individuals with mental illness represent 1.6 

percent of States’ nursing facility populations. This information is inconsistent with our 

survey data. Twenty State mental health authorities (SMHAs) reported a total of 40,277 

younger nursing facility residents with mental illness. These 20 States report that, on 

average, 10 percent of a State’s nursing facility population is comprised of younger 

individuals with a primary diagnosis of mental illness, and 20 percent is comprised of 

younger individuals with a primary or secondary diagnosis of mental illness. Our case file 

review of 19 nursing facilities indicated that approximately 14 percent of these nursing 

facility residents were younger individuals with a primary or secondary diagnosis of mental 

illness. 

The table below demonstrates that data inconsistencies prevent us from making a 

definitive assessment of the total number of younger nursing facility residents with mental 

illness. 

Total Number and Percent of Younger Individuals with Mental Illness in Nursing 

Facilities 

MSIS22 

(34 States) 

MDS 

(39 States) 

23 State 

Reported 

Data 

(20 States)24 

Case File 

Review 

(19 

Facilities) 

Total Number of NF Residents NR 1,101,599 2,712 

Number of Younger Individuals with MI 

Residing in NFs 

5,745 17,919 40,277 385 

Percent of NF Residents that are Younger 

Individuals with MI 

1.6% 14.2% 

Average Number of Younger Individuals w/ 

Mental Illness Residing in NFs in a State 

169 459 2,014 

Average % States’ NF Population of 

Younger Individuals with Mental Illness 

1.6% 10%25 

NR = Not Requested 

22 MSIS data for 34 of the 39 MSIS States. 5 States did not submit this information to HCFA.

23 MDS data for the 39 States that submitted information to MSIS.

24 20 State mental health authorities reporting

25 Unweighted average of percentages reported by 18 State Medicaid agencies

Younger Nursing Facility Residents with Mental Illness 11 OEI-05-99-00701 
Claims data cannot be validated 

We attempted to validate the MSIS expenditures by identifying in the MSIS claims and 

eligibility files the 19 nursing facilities we visited and the 187 younger Medicaid 

beneficiaries with mental illness whose files we reviewed. Only 10 of the 19 nursing 

facilities were identified as having submitted at least one claim for younger individuals 

with mental illness. To identify individual claims for nursing facility residents, we 

attempted to identify the 187 individuals whose case files we reviewed. None of these 

residents were found in MSIS, even though 111 were admitted to the nursing facility in 

1998 or prior and had indicated Medicaid as their payer source. 

Matching data sources yields unreliable results 

Contrary to HCFA’s assertion, MSIS cannot be matched with MDS to yield reliable 

results for research and analysis. As a result, we could not discern valuable facility level 

information. We attempted to identify the average percent of a nursing facility’s total 

population with a mental illness between the ages of 22 and 64. To do so, we planned to 

use MDS to provide the total population of the nursing facility, while MSIS would 

provide us with the number of individuals with mental illness between the ages of 22 and 

64. Then, we planned to cross the provider numbers of MSIS and MDS to identify the 

average percent of a nursing facility’s total population with a mental illness between the 

ages of 22 and 64 for each of the 34 States that submitted information to MSIS. 

However, we were only able to identify and match with MDS 39 percent of nursing 

facilities that MSIS identified as having at least one younger individual with mental illness. 

The percent of nursing facility matches between MSIS and MDS ranges from 0 to 92 

percent in the 39 reporting States. For 10 States, none of their nursing facilities matched 

with the MDS nursing facility identifiers. Therefore, we cannot say with any certainty 

what percent of nursing facility residents, on average, are younger individuals with mental 

illness. 

Our inability to match the providers in these two HCFA data sources can be partially 

attributed to the lack of a unique provider number for each nursing facility. The inability 

to match nursing facility data from MSIS and MDS has ramifications for obtaining reliable 

information regarding nursing homes overall. States frequently assign facilities different 

numbers when submitting information to different Federal data sources. The MSIS 

provider numbers are often different than the MDS provider number assigned to a facility 

for the Minimum Data Set. A given provider may have one number for MSIS, another for 

MDS, another for OSCAR, and yet another for Social Security and Internal Revenue 

Service tax purposes. In addition, States may assign a new provider number when there is 

a change in nursing facility ownership. 

Younger Nursing Facility Residents with Mental Illness 12 OEI-05-99-00701 
State survey difficulties 

State survey respondents indicated that they had difficulty providing the information we 

requested regarding younger individuals with mental illness in nursing facilities. Many 

States were unable to respond to our information request because they do not collect or 

sort data by age. In addition, Medicaid and Survey Agencies in 20 States reported that 

they could not distinguish data by primary and secondary diagnosis. Two States also 

indicated that secondary diagnosis is not incorporated into their central database. 

A few States expressed frustration with the MDS system, reporting that it is incomplete 

and that it does not break out diagnosis by primary or secondary diagnosis so that they 

could not use these data to respond to our survey. Three State agencies stated that 

information was unavailable because the MDS is incomplete. One State indicated that 

they would like to use MDS for identifying this population but they know that MDS lacks 

the necessary data. 

Medicaid expenditures cannot be validated 

To calculate States’ Medicaid expenditures for younger nursing facility residents with 

mental illness, we had to rely on MSIS and State data -- MDS does not collect 

expenditure information other than resident’s payer source. We believe however, that 

MSIS is an inaccurate representation and underestimation of Medicaid expenditures for 

this population. 

As discussed above, MSIS does not accurately account for the number of younger 

individuals with mental illness who submit a Medicaid claim for nursing facility services. 

In addition, MSIS captures claims and eligibility information matched to a specific 

diagnosis code. A nursing facility claim for per diem might not identify an individual with 

a serious mental illness if it is not his/her primary diagnosis. Therefore, this data 

underestimates State and Federal expenditures for this population. 

Medicaid expenditure data from MSIS is not validated by our survey and case file review. 

There is a discrepancy in the Medicaid expenditures identified through MSIS and in our 

State survey. Eight States that responded to our survey provided Medicaid expenditures 

for younger nursing facility residents with a primary diagnosis of mental illness also 

submitted claims to MSIS. These eight States reported that they spent, in total, $30.8 

million in Medicaid dollars in Federal FY 1998. 

However, this figure is twice the amount indicated by MSIS data for this population in 

these same eight States. The MSIS data indicates that the total Medicaid expenditure for 

the eight States was approximately $15.7 million for Federal FY 1998 ($3.9 million for 

Younger Nursing Facility Residents with Mental Illness 13 OEI-05-99-00701 
4th Quarter 1998). 26 Further, our survey data indicates that on average States spent $3.1 

million for one quarter, or $12.3 million for one year, on younger nursing facility residents 

with mental illness.27 However, MSIS data indicates that, on average, States spend $1.2 

million per quarter on this population, approximately $4.9 million per year. 

States do not know where younger individuals with mental 

illness are receiving long-term care 

State mental health authorities 

State mental health authorities (SMHA) responding to our national survey report that 

individuals with mental illness, ages 22-64, reside in a variety of long-term care facility 

settings. However many of the SMHAs that responded to our survey reported that they 

had difficulty reporting the number of individuals in this specific age group residing in the 

types of facilities outlined in the chart below. Many States could not provide us with this 

information as they do not report by age. Twelve States report that facility level 

information was unavailable. Four States were only able to provide long-term care facility 

health information for all ages. 

Long-Term Care Options for Younger Individuals with Mental Illness 

Type of Long-term 

Care Facility 

States 

Reporting 

Residents 

(Total) 

Residents 

(Average) 

IMD’s 14 141,825 10,130 

State Psychiatric Hospitals 27 75,971 2,814 

Community-Based Facilities 17 44,069 2,592 

Hospital Psychiatric Wards 11 89,707 8,155 

Nursing Facilities 20 40,277 2,014 

Other28 8 34,505 4,313 

Source: 51 State Mental Health Authority Survey 

26 For all 39 States MSIS data indicates that for 4th Quarter 1998 $41.6 million (or $166.4 million 

for the year) Medicaid dollars were spent on mental health claims for younger individuals with 

mental illness in nursing facilities. 

27 Thirteen States reporting. 

28 “Other” includes assisted living, board and care or personal care homes. 

Younger Nursing Facility Residents with Mental Illness 14 OEI-05-99-00701 
Many States that responded to our survey were not able to provide all of the expenditure 

information we requested. Of the 43 State mental health authorities that responded to our 

survey, only 13 were able to provide us with expenditures from all of the funding sources 

we requested.29 For these 13 States, the total mental health expenditure is $2.4 billion. 

On average, State funds accounted for 69.2 percent of total mental health expenditures for 

these States. 

State Mental Health Expenditures Reported by 13 States 

Funding Source Total Dollars Average % of Total MH 

State Funds $1.4 billion 69.2% 

SAMHSA Block 

Grants 

$143.9 million 4.8% 

Specialized Services $57.8 million 1.5% 

Other $886 million 37.1% 

Total $2.4 billion 

Source: 51 State Mental Health Agency Survey 

Medicaid Agencies 

State Medicaid agencies also had difficulty reporting expenditure information for all types

of long-term care facilities and specifically nursing facilities. Most State Medicaid

agencies did not report expenditure information for the types of long-term care facilities

where younger individuals with serious mental illness may reside. Only 15 of 36 State

Medicaid agencies were able to report Medicaid expenditure for younger nursing facility

residents with a primary or secondary diagnosis of mental illness. These 15 States report

spending a total of $466.3 million in Medicaid funds for this population.

Only nine States were able to provide complete expenditure information for younger

individuals with a primary diagnosis of mental illness. In total, these nine States spent

$426.8 million in Medicaid funds on individuals of all ages with a primary diagnosis of

mental illness in all types of facilities. The same nine States reported that, in total, they

spent $29.8 million in Medicaid funds on younger nursing facility

residents with a primary diagnosis of mental illness and $125.7 million for this population

in all types of long-term care facilities. 

29 Of the 43 State mental health authorities that responded to our survey 35 were able to report 

dollars from State funds, 33 were able to report SAMHSA block grant dollars, and only 22 States 

were able to report specialized service dollars. 

Younger Nursing Facility Residents with Mental Illness 15 OEI-05-99-00701 
Medicaid Expenditures for Individuals with a Primary Mental Illness Diagnosis 

Ages 22-64 in 

nursing facility 

Ages 22-64 in all 

long-term care facilities 

All ages in all 

long-term care facilities 

9 States $29.8 million $125.7 million $426.8 million 

Source: 51 State Survey, 2000, Fiscal Year 1998 

Younger Nursing Facility Residents with Mental Illness 16 OEI-05-99-00701 
OTHER CONSIDERATIONS 

Our inspection focuses on younger nursing facility residents with mental illness. However, 

the issues we encountered regarding the validity and reliability of the data raise significant 

concerns about the broader use of both MDS and MSIS data in making and evaluating 

health care policy. Our unsuccessful attempt to identify this population is indicative of a 

larger problem with these Federal data sources. This examination questions the use of 

Federal data sources to accurately yield important demographic, utilization, and 

expenditure information upon which to base policy. Without reliable information that 

enables us to identify populations of individuals requiring particular types of services, we 

cannot assess appropriateness, access and quality of care, nor determine the effectiveness 

of Federal Medicaid and nursing facility policy. 

Younger Nursing Facility Residents with Mental Illness 17 OEI-05-99-00701 
R E C O M M E N D A T I O N S 

Recent attention on individuals with mental illness, particularly those in institutional 

settings, increases the need for HCFA to ensure that Federal data systems can respond to 

both the Administration’s and the public’s inquiry of the status of younger nursing facility 

residents with serious mental illness. In response to both the “Mental Health: A Report of 

the Surgeon General” and the Olmstead Supreme Court Decision, the Administration has 

focused attention on ensuring the appropriate care of individuals with mental illness in 

nursing facilities and the fact that “no person should have to live in a nursing home or 

other institution if he or she can live in his or her community.” 

The HCFA and others should be able to use both MSIS, MDS and other related Federal 

data systems to monitor the extent to which nursing facility residents have mental illness 

and, in turn, receive needed mental health treatment. Instead, the use of Federal MSIS 

and MDS data to identify younger individuals with mental illness is limited by the lack of a 

unique provider identifier to cross and match providers in more than one data source, the 

lack of available data that is timely, the time differential in available data from these two 

sources, and the type of data collected. The MSIS is primarily used by HCFA for 

beneficiary enrollment information, while States use MDS to provide information to State 

survey agencies and individual facilities. 

Effective MSIS and MDS data systems can better ensure that barriers which prevent the 

necessary care provided to all residents of nursing facilities are being systematically 

evaluated and, in turn, eliminated. The HCFA must ensure that MSIS and MDS data 

systems produce comprehensive, consistent, valid, reliable and accurate information in 

order to facilitate the identification of nursing facility residents both within and across 

individual databases in order to provide a comprehensive picture of how nursing facility 

residents are affected by current policies. 

In order to improve the ability of HCFA to produce accurate nursing facility 

information and to monitor the care and treatment of Medicaid nursing facility 

residents, we recommend that HCFA: 

C assign unique provider numbers to long-term care facilities that submit information 

to Federal data sources; 

C provide training and clearer coding instructions to improve the ability of nursing 

home staff and of the MDS instrument to capture mental illness diagnoses 

C make MDS and MSIS data available in a timely manner; 

C require States to report information by age; and 

C require States to report information by diagnosis. 

Younger Nursing Facility Residents with Mental Illness 18 OEI-05-99-00701 
In response to the Olmstead Supreme Court Decision that requires individuals to 

be placed in the “most integrated and least restrictive setting appropriate,” we 

recommend that HCFA: 

C facilitate the availability of [improved] MSIS and MDS data to be used to assist 

States in complying with HCFA’s directive to identify residents and periodically 

review the services of all residents in Medicaid-funded institutional settings; and 

C encourage States to use MSIS and MDS data systems to demonstrate that the 

State has “a comprehensive, effective working plan for placing qualified persons 

with disabilities in the most integrated setting appropriate.” 

Younger Nursing Facility Residents with Mental Illness 19 OEI-05-99-00701 
AGENCY COMMENTS 

We received comments from the Health Care Financing Administration (HCFA) and the 

Assistant Secretary for Planning and Evaluation (ASPE). The HCFA concurs with six of 

our seven recommendations. The ASPE provided general comments. Where appropriate 

we changed the report to reflect their comments. The full HCFA and ASPE comments are 

contained in Appendix A. 

The HCFA believes that “mental health is central to the overall well being of all our 

beneficiaries, including younger nursing facility residents” and that “monitoring these 

residents’ care and treatment and maintaining accurate nursing facility information is 

essential to their well-being.” We would like to thank HCFA for their assistance in 

conducting this study and for providing us with substantive and insightful comments. 

The one recommendation that HCFA does not concur with is amending the MDS to 

distinguish between primary, secondary and tertiary diagnoses. The HCFA proposes an 

alternative to our recommendation that would “provide training and clearer coding 

instructions to improve the ability of nursing home staff and of the MDS instrument to 

capture Mental Illness diagnoses.” Specifically, HCFA proposes including a clarification 

of the coding requirements surrounding completion of the Diagnoses section of the MDS 

and in particular, capturing mental illness diagnoses. The Manual revision is planned for 

Spring 2001. Our intent to making changes in the MDS is to enhance nursing facilities’ 

ability to capture serious mental illness regardless of the ranking of diagnosis and increase 

nursing facilities’ ability to identify and accurately care plan for younger residents with any 

serious mental illness. We agree with HCFA that providing training and improved coding 

instructions is in accordance with the intent of our recommendation and have changed our 

recommendation accordingly. 

The HCFA expressed concern that the difficulty we experience in finding mental health 

information may be due to the timing of the study. In particular, concern was expressed 

that we were looking for diagnostic information not required to be included in the MDS 

database at the time of our study. We want to clarify that our methodology did not rely 

on information captured exclusively by an initial MDS assessment which before its latest 

iteration may not have included relevant mental health information. Instead, we reviewed 

medical files of individuals with serious mental illness that included both their initial MDS 

assessment and at least two quarterly MDS assessments which would have captured their 

mental illness diagnosis had it been accurately recorded by the nursing facility. In 

addition, our review of the MDS database universe for a six month period allowed us to 

capture both the initial and at least one quarterly MDS assessment which, again would 

have enabled us to capture mental health diagnoses. 

Younger Nursing Facility Residents with Mental Illness 20 OEI-05-99-00701 
The HCFA reports that they have concerns that our inspection does not accurately depict 

their role in determining State compliance with the Olmstead Decision. What we wanted 

to emphasize was that improved MSIS and MDS data systems can help facilitate States’ 

compliance with the Olmstead Decision as part of a multi-faceted approach. We agree 

that the improvements HCFA has committed to making should prove to be beneficial. 

The ASPE expressed concern that the focus of our report, younger individuals with 

serious mental illness, comprise less than 3% of nursing home residents according to the 

1996 Medical Expenditure Panel Survey (MEPS). The MEPS bases this particular figure 

on information gathered from the MDS. Again, as we point out in our report, the MDS is 

not a reliable data source for a variety of reasons. Further, in 1996, when the MEPS was 

released, the ability to capture mental illness diagnosis through the MDS was even more 

limited than the time period we reviewed. 

In addition, ASPE states that the MDS and MSIS are difficult to compare because they 

capture different diagnostic information. We agree with ASPE that MDS and MSIS are 

difficult to compare which contributed to our inability to accurately quantify this 

population. More importantly, we continue to believe that regardless of the overall size of 

the national population of younger nursing facility residents with serious mental illness, 

their presence and care in nursing facilities warrants HCFA’s specialized attention. 

We would like to thank ASPE for providing us with comments. 

Younger Nursing Facility Residents with Mental Illness 21 OEI-05-99-00701 
APPENDIX A 

Agency Comments

Younger Nursing Facility Residents with Mental Illness 22 OEI-05-99-00701 
APPENDIX A 

Agency Comments

Younger Nursing Facility Residents with Mental Illness 23 OEI-05-99-00701 
APPENDIX A 

Agency Comments

Younger Nursing Facility Residents with Mental Illness 24 OEI-05-99-00701 
APPENDIX A 

Agency Comments

Younger Nursing Facility Residents with Mental Illness 25 OEI-05-99-00701 
APPENDIX A 

Agency Comments

Younger Nursing Facility Residents with Mental Illness 26 OEI-05-99-00701 
APPENDIX A 

Agency Comments

Younger Nursing Facility Residents with Mental Illness 27 OEI-05-99-00701 
APPENDIX A 

Agency Comments

Younger Nursing Facility Residents with Mental Illness 28 OEI-05-99-00701 
APPENDIX A 

Agency Comments

Younger Nursing Facility Residents with Mental Illness 29 OEI-05-99-00701 
APPENDIX A 

Agency Comments

Younger Nursing Facility Residents with Mental Illness 30 OEI-05-99-00701 
APPENDIX A 

Agency Comments

Younger Nursing Facility Residents with Mental Illness 31 OEI-05-99-00701 
APPENDIX A 

Agency Comments

Younger Nursing Facility Residents with Mental Illness 32 OEI-05-99-00701