NASHP’s State Nursing Home Learning Collaborative convenes seven states (Kentucky, Maine, Minnesota, Nebraska, New Jersey, Ohio, and Pennsylvania) focused on improving the quality of life in nursing homes. In partnership with West Health, NASHP supports these states as they work to address nursing home quality of care, payment and cost, administrative oversight, and more.
This work is aligned with and inspired by the National Academies of Sciences, Engineering, and Medicine’s 2022 report, The National Imperative to Improve Nursing Home Quality. The report calls for urgent action to improve care quality, staffing, and accountability and recommends systemic changes in financing, regulation, and delivery.
The Learning Collaborative states are addressing a wide range of issues in nursing home reform through innovations such as bolstering staff, actively listening to residents, leveraging data for effective oversight, enhancing ownership transparency, providing technical support to nursing facilities, and using Rural Health Transformation Program (RHTP) funds. The promising practices highlighted in this policy brief can serve as examples for states seeking to advance similar reforms.
State Innovations
Bolstering Staff
Having a well-trained, person-centered, and adequately staffed workforce is a primary concern for states, nursing home administrators, and residents alike. Research has shown that increased staffing often correlates with higher quality of care. The One Big Beautiful Bill Act (OBBBA) delayed the implementation of a federal minimum long-term care staffing standards rule until 2034. The Centers for Medicare and Medicaid Services (CMS) launched a nursing home staffing campaign in 2025 to increase nurse staffing levels in nursing facilities. Its targeted efforts include financial incentives, such as tuition reimbursement, and streamlined access to state-approved nurse aide training programs.
Through a Health Resources and Services Administration Geriatric Workforce Enhancement Program grant, Kentucky’s Cabinet for Health and Family Services partnered with the University of Louisville to develop a certified nursing assistant staffing career ladder. Career ladders promote career mobility by providing clear, supported pathways for training and advancement toward higher-paid, higher-skill roles that can strengthen retention and improve workforce quality.
Maine’s Department of Health and Human Services launched a Medicaid nursing facility rate reform initiative in 2025 to address longstanding direct care workforce challenges. The rate model limits reliance on temporary agency staff and encourages stable, long-term employment through increased wages — building on a law guaranteeing direct care workers at least 125 percent of minimum wage — and expanded training and workforce development efforts.
Pennsylvania’s Long-Term Care Transformation Office has advanced workforce resiliency across long-term care settings through its LTC Rise 2.0 Program, the Quality Investment Program, and the Transformation Team. These initiatives support professional growth through continuing education, leadership training, and strategies that promote workforce well-being, strengthening the capacity of providers to deliver high-quality, resident-centered care.
Recognizing the importance of retaining qualified care staff in nursing facilities, New Jersey enacted P.L. 2020 c.89, setting the minimum wage for long-term care facility direct-care staff members $3 higher than the state minimum wage and mandating that all long-term care facilities in the state spend at least 90 percent of their revenue on direct care. The New Jersey Department of Human Services collects patient care ratio reports from nursing facilities to ensure compliance with this law, allowing for greater transparency and accountability in nursing facility spending. Continuing efforts to improve staffing in nursing facilities, the Department of Human Services also updated its Nursing Home Quality Incentive Payment Program to include new measures that reward facilities for improving nurse staffing levels and reducing staffing turnover.
Actively Listening to Residents
States are placing nursing home residents at the center of their nursing home reform efforts. Residents are directly affected by the quality and operation of the nursing homes in which they live; their experience and feedback are essential to making improvements. Integrating resident voices into nursing home initiatives can lead states to focus on change that residents desire.
The Kentucky Cabinet for Health and Family Services issued a directive to the Kentucky State Long-Term Care Ombudsman Programs to host Nursing Home Residents’ Rights Forums, 20 of which were held in October 2024. Residents highlighted the need for more staff, prompt call light responses, appreciation for relationships built at their nursing homes, desire for additional activities within nursing homes, and gratitude for the opportunity to use their voice. Feedback from the residents who attended is guiding Kentucky’s priorities in nursing home reform.
Ohio Governor Mike DeWine signed an Executive Order in 2023 to create the Ohio Governor’s Nursing Home Quality and Accountability Task Force. To understand the experience of nursing home residents, the task force hosted public listening sessions in seven areas of Ohio. These listening sessions informed the Nursing Home Quality & Accountability Task Force Recommendations Report and subsequent reforms in the state. Resident rights are a guiding pillar for the state’s nursing home care system, and empowering residents is a key dimension of the task force recommendations.
Leveraging Data for Effective Oversight
States are increasingly looking toward leveraging data for effective oversight. Early warning systems — as seen in Minnesota and New Jersey — can assist states to proactively monitor quality of care and a facility’s financial health to identify trends and circumvent issues. Ohio’s public facing dashboard uses data for older adults and their caregivers to make informed decisions on their care.
Minnesota’s Department of Health, Department of Human Services, and Office of Ombudsman for Long-Term Care are working to develop an “early warning signs” dashboard to identify at-risk nursing homes. The dashboard may include the selection and integration of data sources into a unified system that includes metrics that flag potential risks, such as four or more on-site complaint visits per quarter, CMS G harm level or Immediate Jeopardy citations issued in the past year, and indicators from the State Nursing Home Report Card. The effort includes an inter-agency partnership to discuss risk factors for receivership and closure.
Ohio’s Long-Term Care Quality Navigator — developed collaboratively by the Ohio Department of Aging and InnovateOhio Platform — centralizes key data on nursing facilities in the state to help consumers make informed choices for their care. Originating from Governor DeWine’s Nursing Home Quality and Accountability Task Force, the award-winning platform allows user-friendly searches and filters by a range of criteria, including side-by-side facility comparisons. The dashboard integrates continuously refreshed data from CMS, state long-term care resources, resident and family satisfaction surveys, and facility-specific attributes (such as pet policies, religious affiliation, and special care services), while offering direct links to inspections and full survey results. The second and most recent version of the tool expands to include assisted living facilities, a guided search “care quiz,” and cost-of-care information. Ohio’s approach emphasizes extensive user testing, alignment with quality initiatives, and use of an “internal command center” with deeper data analytics to support regulatory oversight.
New Jersey’s Office of Long-Term Care Resiliency evaluates long-term care facilities and determines the level of support needed based on triggered risk factors. Up to 25 facilities, including those on the CMS Special Focus Facility candidate list and other 1–2 star facilities identified by state partners, are monitored and assisted according to their risk scores. Facilities receive frequent and varying levels of support in the form of on-site or off-site Mission Critical Team interventions such as training, operational guidance, and resources.
Enhancing Ownership Transparency
With increasingly complex ownership structures, states are gathering data to understand the parties involved in their state’s nursing homes and using this data to ensure nursing homes are not owned or run by so-called “bad actors.” The state role in ownership oversight is a combination of information collection and intervention.
Ohio revised its state code in 2024 to increase oversight of nursing home operation and ownership. The revised code requires additional information to be submitted in change of operator license applications, including disclosure of all direct and indirect owners of 5 percent or more, disclosure of ownership or interest in a different nursing home in or out of Ohio, and evidence of a bond or other financial security to demonstrate sufficient resources. The operator applying must have at least five years of experience, plans for quality assurance and risk management, liability insurance, and attestation to adequate staffing levels.
Pennsylvania requires facilities to notify the Department of Health when a change in 5 percent or more of stock or equity, a change of ownership, or a change of management occurs. The transaction cannot close without approval from the state. The state code was revised in 2023 to enhance oversight through increased reporting requirements, such as an annual financial report, identification of individual ties or familial ties to other facilities, and disclosure of history of financial distress and criminal actions. The state releases monthly nursing home facility license and ownership information for the public.
Emerging Innovation: In 2026, Weill Cornell Medicine will launch the Health Economics Financing and Transparency Initiative (HEFTI), a new resource hub designed to improve ownership transparency and support informed decision-making in nursing home care. HEFTI will provide accessible financial, ownership, and quality data of U.S. long-term care and physician practice organizations, including those with private equity or public ownership. States will be able to use HEFTI’s visualizations and generate customizable reports to strengthen oversight and policy development.
Providing Technical Support to Nursing Homes
States are providing direct technical assistance to nursing homes to keep nursing homes open and safe for residents. This includes staff trainings, quality improvement programs, and other individualized efforts to address needs and issues in nursing facilities. State technical assistance is separate and often in addition to more punitive and/or value-based programs.
Maine delivers technical assistance on quality improvement strategies through its Quality, Excellence, Staffing, and Teamwork (QuEST) initiative, an instrumental part of the state’s newly implemented value-based payment program. In 2025, QuEST provided monthly learning sessions led by national experts on topics such as reducing the use of antipsychotic medications, implementing resident and family satisfaction surveys, using culture change practices to reduce staff turnover and dependency on temporary agency staff, and taking a deeper dive into technical subject matter such as payroll based journal and the CMS 5-Star rating system. Nursing homes that participated in seven or more hours of designated technical assistance activities in 2025 were eligible for a share of the $8.1 million Quality Bonus Pool. These efforts represent a burgeoning partnership among Maine’s Department of Health and Human Services, the Maine Long-Term Care Ombudsman Program, Maine Health Care Association, and nursing homes across the state, aligning efforts to improve quality care for long-term care residents.
New Jersey has a designated Office of Long-Term Care Resiliency in its Department of Health to support long-term care facilities. The office oversees Mission Critical Long-Term Care Teams, established by legislation to identify facilities in need of increased oversight and direct intervention to prevent the decline of health and safety or the disruption of necessary health care services at the facility. Each Mission Critical Long-Term Care Team works collaboratively with long-term care facilities to improve the financial and operating outcomes of the facility and provide technical assistance quality training, with a focus on resident health and safety.
Ohio has created a cross-agency technical assistance program supporting long-term care facilities. The Department of Aging’s Excellence in Clinical & Educational Learning (EXCEL) Academy is the latest in a series of new initiatives launched as a result of the work of the Ohio Governor’s Nursing Home Quality & Accountability Task Force. EXCEL Academy is designed to empower nursing homes and their staff to shine through continuing education and support from clinical experts. EXCEL Academy is offered at no cost to nursing home facilities, and the curricula are approved for continuing education hours. Additionally, the Department of Health created Ohio’s Provider Resources and Education Program. The program supports nursing homes and other long-term care providers with education, training, and other resources designed to improve and protect the safety, health, and quality of life for residents and others in their care.
Using the Rural Health Transformation Program Funds
Funded through OBBBA, the CMS RHTP will provide states with $50 billion over five years to strengthen and modernize health care in rural communities. Each state will develop unique plans to expand health care access, strengthen workforces, build infrastructure and technology, and support care delivery innovation within rural communities.
Rural nursing homes are essential to address the long-term care needs of rural populations and often serve as key employers in rural communities. Check out NASHP’s rural health resources to learn more about the RHTP overall.
Minnesota’s RHTP application includes a proposed activity to provide local physical and oral health care delivery with mobile units. Mobile health care vans will visit various community locations, including nursing homes. Because rural residents may live far from health care facilities, the mobile medical services can reach more members with in-person physical examinations or specialty medical services.
Nebraska’s RHTP application proposes to implement a Behavioral Health Nursing Homes Pilot. This program will build post-acute care capacity for individuals with serious mental illness and complex behavioral needs, particularly for those that are dual-eligible for Medicare and Medicaid. This targeted investment will provide the support necessary to integrate behavioral health clinicians into existing nursing facilities and support minimal infrastructure modifications to meet the specialized needs of behavioral health patients.
More Information on State Nursing Home Reform
NASHP’s new nursing homes webpage is a good resource for additional nursing home policy innovations, including “State Medicaid Value-Based Payment Incentivizes Staffing in Nursing Homes” and “State Strategies to Enhance Behavioral Health Care in Nursing Facilities.”
As states explore reimagining nursing homes, Stuart Butler’s “The Need to Reframe Nursing Homes as Community Hubs” is another helpful resource.
Our partners in the Learning Collaborative, The National Consumer Voice for Quality Long-Term Care and the Moving Forward Nursing Home Quality Coalition, also provide a plethora of resources to advance nursing home reform.
NASHP looks forward to continuing to support and learn from the Nursing Home Learning Collaborative through 2026.
Acknowledgments
NASHP would like to express our gratitude to West Health for its support of and partnership with NASHP’s Nursing Home Learning Collaborative. The authors would also like to thank the state officials from the Nursing Home Learning Collaborative for their review of this paper.
