Racial Differences in Minnesota Nursing Home Residents' Quality of Life: The Importance of Looking Beyond Individual Predictors

"I feel like a caged pig in here": Language, Race, and Ethnic Identity in a Case Study Hmong Nursing Home Resident Quality of Life

Racial disparities in nursing home (NH) quality of life (QOL) are well established, yet, little is understood about actual experiences shaping QOL for Black, indigenous, and people of color (BIPOC) residents in NHs. This gap extends to BIPOC residents with limited English proficiency (LEP). Drawing on Kane's (2001) and Zubristky's (2013) QOL frameworks, this case study examined QOL experiences for Hmong NH residents, an ethnic and refugee group from Southeast Asia, in a NH with a high proportion of BIPOC residents. Methods include four months of observation, interviews with eight Hmong residents and five NH staff, and one community focus group. Thematic analysis revealed significant challenges in QOL. Exacerbated by language barriers and racism, many residents reported neglect, limited relationships, lack of meaningful activities, and dissatisfaction with food. These experiences fostered a sense of resignation and diminished QOL among Hmong residents, highlighting the need for additional supports for this group.

Cause of Death by Race and Ethnicity in Minnesota Before and During the COVID-19 Pandemic, 2019-2020

OBJECTIVES

To measure changes in cause of death dynamics in 2019 and 2020 and the relationship between the concurrent occurrence of the COVID-19 pandemic and mortality outcome by race and ethnicity.

PATIENTS AND METHODS

We used resident mortality data from the Minnesota Department of Health (MDH) to conduct a retrospective statistical analysis of deaths in Minnesota in 2019 relative to 2020 to assess changes in mortality in a pre-pandemic and pandemic period.

RESULTS

COVID-19 strongly contributed to ethnicity-related mortality disparities in Minnesota. Not only was there a greater proportion of COVID-19 decedents within Black and Hispanic populations, but their average decedent age was markedly lower relative to the White population. The Black population experienced a disproportionate increase in decedents with a 34% increase during 2020 compared to 2019.

CONCLUSIONS

This retrospective analysis of death dynamics and mortality outcomes in Minnesota from 2019 to 2020 demonstrated an increase in adverse mortality outcomes relative to the pre-pandemic period that disproportionately impacted Black and Hispanic minority populations.

Racial Differences in Nursing Home Quality of Life Among Residents Living With Alzheimer's Disease and Related Dementias

ObjectivesAmong nursing home (NH) residents with Alzheimer's disease (AD) and AD-related dementias (AD/ADRD), racial/ethnic disparities in quality of care exist. However, little is known about quality of life (QoL). This study examines racial/ethnic differences in self-reported QoL among NH residents with AD/ADRD. Methods: Validated, in-person QoL surveys from 12,562 long-stay NH residents with AD/ADRD in Minnesota (2012-2015) were linked to Minimum Data Set assessments and facility characteristics. Hierarchical linear models assessed disparities in resident-reported mean QoL score (range, 0-100 points), adjusting for case-mix and facility factors. Results: Compared to White residents, racially/ethnically minoritized residents reported significantly lower total mean QoL scores (75.53 points vs. 80.34 points, p < .001). After adjustment for resident- and facility-level characteristics, significant racial/ethnic differences remained, with large disparities in food enjoyment, attention from staff, and engagement domains. Discussion: Policy changes and practice guidelines are needed to address racial/ethnic disparities in QoL of NH residents with AD/ADRD.

Building evidence to advance health equity: a systematic review on care-related outcomes for older, minoritised populations in long-term care homes

BACKGROUND

Advancing health equity requires more contextualised evidence.

OBJECTIVES

To synthesise published evidence using an existing framework on the origins of health disparities and determine care-related outcome disparities for residents of long-term care, comparing minoritised populations to the context-specific dominant population.

DESIGN

Systematic review.

SUBJECTS

Residents of 24-hour long-term care homes.

METHODS

The protocol was registered a priori with PROSPERO (CRD42021269489). Literature published between 1 January 2000 and 26 September 2021, was searched, including studies comparing baseline characteristics and outcomes in minoritised versus dominant populations. Dual screening, two-reviewer verification for extraction, and risk of bias assessments were conducted to ensure rigour. Studies were synthesized using a conceptual framework to contextualise evidence according to multi-level factors contributing to the development of care disparities.

RESULTS

Twenty-one of 34 included studies demonstrated disparities in care outcomes for minoritised groups compared to majority groups. Thirty-one studies observed differences in individual-level characteristics (e.g. age, education, underlying conditions) upon entry to homes, with several outcome disparities (e.g. restraint use, number of medications) present at baseline and remaining or worsening over time. Significant gaps in evidence were identified, particularly an absence of literature on provider information and evidence on the experience of intersecting minority identities that contribute to care-related outcome disparities in long-term care.

CONCLUSION

This review found differences in minoritised populations' care-related outcomes. The findings provide guidance for future health equity policy and research-supporting diverse and intersectional capacity building in long-term care.

Counting what counts: assessing quality of life and its social determinants among nursing home residents with dementia

BACKGROUND

Maximizing quality of life (QoL) is a major goal of care for people with dementia in nursing homes (NHs). Social determinants are critical for residents' QoL. However, similar to the United States and other countries, most Canadian NHs routinely monitor and publicly report quality of care, but not resident QoL and its social determinants. Therefore, we lack robust, quantitative studies evaluating the association of multiple intersecting social determinants with NH residents' QoL. The goal of this study is to address this critical knowledge gap.

METHODS

We will recruit a random sample of 80 NHs from 5 Canadian provinces (Alberta, British Columbia, Manitoba, Nova Scotia, Ontario). We will stratify facilities by urban/rural location, for-profit/not-for-profit ownership, and size (above/below median number of beds among urban versus rural facilities in each province). In video-based structured interviews with care staff, we will complete QoL assessments for each of ~ 4,320 residents, using the DEMQOL-CH, a validated, feasible tool for this purpose. We will also assess resident's social determinants of QoL, using items from validated Canadian population surveys. Health and quality of care data will come from routinely collected Resident Assessment Instrument - Minimum Data Set 2.0 records. Knowledge users (health system decision makers, Alzheimer Societies, NH managers, care staff, people with dementia and their family/friend caregivers) have been involved in the design of this study, and we will partner with them throughout the study. We will share and discuss study findings with knowledge users in web-based summits with embedded focus groups. This will provide much needed data on knowledge users' interpretations, usefulness and intended use of data on NH residents' QoL and its health and social determinants.

DISCUSSION

This large-scale, robust, quantitative study will address a major knowledge gap by assessing QoL and multiple intersecting social determinants of QoL among NH residents with dementia. We will also generate evidence on clusters of intersecting social determinants of QoL. This study will be a prerequisite for future studies to investigate in depth the mechanisms leading to QoL inequities in LTC, longitudinal studies to identify trajectories in QoL, and robust intervention studies aiming to reduce these inequities.

The (un)caring experienced by racialized and/or ethnoculturally diverse residents in supportive living: a qualitative study

BACKGROUND

Racialized and/or ethnocultural minority older adults in supportive living settings may not have access to appropriate services and activities. Most supportive living facilities are mainstream (not specific to one group); however, culturally specific facilities are purpose-built to accommodate older adults from a particular group. Our objective was to describe the perspectives of diverse participants about access to culturally appropriate care, accessible services, and social and recreation activities in culturally specific and mainstream (non-specific) supportive living facilities.

METHODS

We conducted semi-structured interviews with 21 people (11 staff, 8 family members, 2 residents) from 7 supportive living homes (2 culturally specific and 5 mainstream) in Alberta, Canada. We used a rapid qualitative inquiry approach to structure the data collection and analysis.

RESULTS

Staff and family members described challenges in accessing culturally appropriate care in mainstream facilities. Family members expressed guilt and shame when their relative moved to supportive living, and they specifically described long waitlists for beds in culturally specific homes. Once in the facility, language barriers contributed to quality of care issues (e.g., delayed assessments) and challenges accessing recreation and social activities in both mainstream and culturally specific homes. Mainstream facilities often did not have appropriate food options and had limited supports for religious practices. Residents who had better English language proficiency had an easier transition to supportive living.

CONCLUSIONS

Racialized and/or ethnoculturally diverse residents in mainstream supportive living facilities did not receive culturally appropriate care. Creating standalone facilities for every cultural group is not feasible; therefore, we must improve the care in mainstream facilities, including recruiting more diverse staff and integrating a wider range of recreation and religious services and food options.

Identifying Nursing Homes With Diverse Racial and Ethnic Resident Compositions: The Importance of Group Heterogeneity and Geographic Context

Racial/ethnic composition of nursing home (NH) plays a particularly important role in NH quality. A key methodological issue is defining when an NH serves a low versus high proportion of racially/ethnically diverse residents. Using the Minimum Data Set from 2015 merged with Certification and Survey Provider Enhanced Reports, we calculated the racial/ethnic composition of U.S.-based NHs for Black or Hispanic residents specifically, and a general Black, Indigenous, and People of Color (BIPOC) grouping for long-stay residents. We examined different definitions of having a high racial/ethnic composition by varying percentile thresholds of composition, state-specific and national thresholds, and restricting composition to BIPOC residents as well as only Black and Hispanic residents. NHs with a high racial/ethnic composition have different facility characteristics than the average NH. Based on this, we make suggestions for how to identify NHs with diverse racial/ethnic resident compositions.

Cause of Death by Race and Ethnicity in Minnesota Before and During the COVID-19 Pandemic, 2019-2020

Objectives

To measure changes in cause of death dynamics in 2019 and 2020 and the relationship between concurrent occurrence of the COVID-19 pandemic and mortality outcome by race and ethnicity.

Patients and Methods

We used resident mortality data from the Minnesota Department of Health (MDH) to conduct retrospective statistical analysis of deaths in Minnesota in 2019 relative to 2020 to assess changes in mortality in a pre-pandemic and pandemic period.

Results

COVID-19 strongly contributed to ethnicity-related mortality disparities in Minnesota. Not only was there a greater proportion of COVID-19 decedents within the Black and Hispanic populations, but their average decedent age was markedly lower relative to the White population. The Black population experienced a disproportionate increase in decedents with a 34% increase during 2020 compared to 2019.

Conclusions

This retrospective analysis of death dynamics and mortality outcomes in Minnesota from 2019 to 2020 demonstrated an increase in adverse mortality outcomes relative to the pre-pandemic period that disproportionately impacted Black and Hispanic minority populations. Access to non-pharmaceutical interventions combating COVID-19 infection in Black and Hispanic communities should be expanded in Minnesota.

Quality of Life Scores for Nursing Home Residents are Stable Over Time: Evidence from Minnesota

Quality of life (QoL) is important to nursing home (NH) residents, yet QoL is only publicly reported in a few states, in part because of concerns regarding measure stability. This study used QoL data from Minnesota, one of the few states that collects the measures, to test the stability of QoL over time. To do so, we assessed responses from two resident cohorts who were surveyed in subsequent years (2012-2013 and 2014-2015). Stability was measured using intra-class correlation (ICC) obtained from hierarchical linear models. Overall QoL had ICCs of 0.604 and 0.614, respectively. Our findings show that person-reported QoL has adequate stability over a period of one year. Findings have implications for higher adoption of person-reported QoL measure in long-term care.

Racial Disparities in COVID-19 and Excess Mortality in Minnesota

The coronavirus disease 2019 (COVID-19) pandemic has produced vastly disproportionate deaths for communities of color in the United States. Minnesota seemingly stands out as an exception to this national pattern, with white Minnesotans accounting for 80 percent of the population and 82 percent of COVID-19 deaths. The authors examine confirmed COVID-19 mortality alongside deaths indirectly attributable to the pandemic-"excess mortality"-in Minnesota. This analysis reveals profound racial disparities: age-adjusted excess mortality rates for whites are exceeded by a factor of 2.8 to 5.3 for all other racial groups, with the highest rates among Black, Latino, and Native Minnesotans. The seemingly small disparities in COVID-19 deaths in Minnesota reflect the interaction of three factors: the natural history of the disease, whose early toll was heavily concentrated in nursing homes; an exceptionally divergent age distribution in the state; and a greatly different proportion of excess mortality captured in confirmed COVID-19 rates for white Minnesotans compared with most other groups.

Changes over Time in Racial/Ethnic Differences in Quality of Life for Nursing Home Residents: Patterns within and between Facilities

Objectives: To investigate trends in racial/ethnic differences in nursing home (NH) residents' quality of life (QoL) and assess these patterns within and between facilities. Method: Data include resident-reported QoL surveys (n = 60,093), the Minimum Data Set, and facility-level characteristics (n = 376 facilities) for Minnesota. Hierarchical linear models were estimated to identify differences in QoL by resident race/ethnicity and facility racial/ethnic minority composition for 2011-2015. Results: White residents in low-proportion racial/ethnic minority facilities reported higher QoL than both minority and white residents in high-proportion minority facilities. While the year-to-year differences were not statistically significant, the point estimates for white-minority disparity widened over time. Discussion: Racial/ethnic differences in QoL are persistent and may be widening over time. The QoL disparity reported by minority residents and all residents in high-proportion minority facilities underscores the importance of examining NH structural characteristics and practices to ultimately achieve the goal of optimal, person-centered care in NHs.

Decomposing Racial and Ethnic Disparities in Nursing Home Quality of Life

This study examines the racial/ethnic disparity among nursing home (NH) residents using a self-reported, validated measure of quality of life (QoL) among long-stay residents in Minnesota. Blinder-Oaxaca decomposition techniques determine which resident and facility factors are the potential sources of the racial/ethnic disparities in QoL. Black, Indigenous, and other People of Color (BIPOC) report lower QoL than White residents. Facility structural characteristics and being a NH with a high proportion of residents who are BIPOC are the factors that have the largest explanatory share of the disparity. Modifiable characteristics like staffing levels explain a small share of the disparity. To improve the QoL of BIPOC NH residents, efforts need to focus on addressing systemic disparities for NHs with a high proportion of residents who are BIPOC.

COVID-19 Pandemic: Exacerbating Racial/Ethnic Disparities in Long-Term Services and Supports

What services are available and where racial and ethnic minorities receive long-term services and supports (LTSS) have resulted in a lower quality of care and life for racial/ethnic minority users. These disparities are only likely to worsen during the COVID-19 pandemic, as the pandemic has disproportionately affected racial and ethnic minority communities both in the rate of infection and virus-related mortality. By examining these disparities in the context of the pandemic, we bring to light the challenges and issues faced in LTSS by minority communities with regard to this virus as well as the disparities in LTSS that have always existed.

Does Living in a Higher Proportion Minority Facility Improve Quality of Life for Racial/Ethnic Minority Residents in Nursing Homes?

Background and Objectives

The proportion of racial/ethnic minority older adults in nursing homes (NHs) has increased dramatically and will surpass the proportion of white adults by 2030.Yet, little is known about minority groups’ experiences related to the quality of life (QOL). QOL is a person-centered measure, capturing multiple aspects of well-being. NH quality has been commonly measured using clinical care indicators, but there is growing recognition for the need to include QOL. This study examines the role of individual race/ethnicity, facility racial/ethnic composition, and the interaction of both for NH resident QOL.

Research Design and Methods

We used a unique state-level data set that includes self-reported QOL surveys with a random sample of long-stay Minnesota NH residents, using a multidimensional measure of QOL. These surveys were linked to resident clinical data from the Minimum Dataset 3.0 and facility-level characteristics. Minnesota is one of the two states in the nation that collects validated QOL measures, linked to data on resident and detailed facility characteristics. We used mixed-effects models, with random intercepts to model summary QOL score and individual domains.

Results

We identified significant racial disparities in NH resident QOL. Minority residents report significantly lower QOL scores than white residents, and NHs with higher proportion minority residents have significantly lower QOL scores. Minority residents have significantly lower adjusted QOL than white residents, whether they are in low- or high-minority facilities, indicating a remaining gap in individual care needs.

Discussion and Implications

The findings highlight system-level racial disparities in NH residents QOL, with residents who live in high-proportion minority NHs facing the greatest threats to their QOL. Efforts need to focus on reducing racial/ethnic disparities in QOL, including potential public reporting (similar to quality of care) and resources and attention to provision of culturally sensitive care in NHs to address residents’ unique needs.

Supports and gaps in federal policy for addressing racial and ethnic disparities among long-term care facility residents

Older adults from racial and ethnic minority groups are likely to face disparities in their health as well as care experiences in long-term care facilities such as nursing homes and assisted living facilities just as they do in the United States as a whole. Policymakers in the United States face concerns around long-term services and supports to address the growing demands of a rapidly aging population through public and private sector initiatives. It is important to create inclusive and culturally responsive environments to meet the needs of diverse groups of older adults. In spite of federal policy that supports minority health and protects the well-being of long-term care facility residents, racial and ethnic disparities persist in long-term care facilities. This manuscript describes supports and gaps in the current United States' federal policy to reduce racial and ethnic disparities in long-term care facilities. Implications for social workers are discussed and recommendations include efforts to revise portions of the Patient Protection and Affordable Care Act of 2010, amending regulations regarding long-term care facilities' training and oversight, and tailoring the Long-Term Care Ombudsman Program's data collection, analysis, and reporting requirements to include racial and ethnic demographic data.

Disparities in Nursing Home Use and Quality Among African American, Hispanic, and White Medicare Residents With Alzheimer's Disease and Related Dementias

Objective: This article examines differences in nursing home use and quality among Medicare beneficiaries, in both Medicare Advantage and fee-for-service, newly admitted to nursing homes with Alzheimer's disease and related dementias (ADRD). Method: Retrospective, national, population-based study of Medicare residents newly admitted to nursing homes with ADRD by race and ethnic group. Our analytic sample included 1,302,099 nursing home residents-268,181 with a diagnosis of ADRD-in 13,532 nursing homes from 2014. Results: We found that a larger share of Hispanic Medicare residents that are admitted to nursing homes have ADRD compared with African American and White beneficiaries. Both Hispanics and African Americans with ADRD received care in segregated nursing homes with fewer resources and lower quality of care compared with White residents. Discussion: These results have implications for targeted efforts to achieve health care equity and quality improvement efforts among nursing homes that serve minority patients.

A value-critical policy analysis of the nursing home reform act: a focus on care of African American and Latino residents

Improving nursing home care has been a central legislative focus since the 1980s; The major response effort to address these reports of poor-quality care was first met with a federal rule in 1987, the Nursing Home Reform Act (NHRA). Since enactment of the NHRA in 1987, and despite an increasing utilization of nursing home care by aging minorities, the standardization of care practice, or quality indicators (e.g., structural, process, and outcome measures), within long-term nursing home care have remained relatively unchanged. This paper reports a value-critical policy analysis of the most recent final action rule, effective on November 28 of 2016 by the Centers for Medicare and Medicaid Services (CMS) with a particular focus on its impact on African-American and Latino older adults. This paper presents results of two policy analyses. Taken together, this merged analysis focuses on an overview of the problem, the groups most affected by the problem, current program goals and objectives, forms of benefits and services, and a current state of the social problem. Following the analysis, we present changes and improvements to be made, as well as proposals for reform and recommendations for policy changes.

A National-Level Analysis of the Relationship Between Nursing Home Satisfaction and Quality

Little research has explored the relationship between consumer satisfaction and quality in nursing homes (NHs) beyond the few states mandating satisfaction surveys. We examine this relationship through data from 1,765 NHs in the 50 states and District of Columbia using My InnerView resident or family satisfaction instruments in 2013 and 2014, merged with Certification and Survey Provider Enhanced Reporting, LTCfocus, and NH Compare (NHC) data. Family and resident satisfaction correlated modestly; both correlated weakly and negatively with any quality-of-care (QoC) and any quality-of-life deficiencies and positively with NHC five-star ratings; this latter positive association persisted after covariate adjustment; the negative relationship between QoC deficiencies and family satisfaction also remained. Overall, models explained relatively small proportions of satisfaction variance; correlates of satisfaction varied between residents and families. Findings suggest that satisfaction is a unique dimension of quality and that resident and family satisfaction represent different constructs.

Factors Associated With Changes in Perceived Quality of Life Among Elderly Recipients of Long-Term Services and Supports

OBJECTIVES

Advance knowledge about changes in multiple dimensions of health related quality of life (HRQoL) among older adults receiving long-term services and supports (LTSS) over time and across settings.

DESIGN

A prospective, observational, longitudinal cohort design.

SETTING

Nursing homes (NHs), assisted living facilities (ALFs), community.

PARTICIPANTS

A total of 470 older adults who were first-time recipients of LTSS.

MEASUREMENT

Single-item quality-of-life measure assessed every 3 months over 2 years. HRQoL domains of emotional status, functional status, and social support were measured using standardized instruments.

RESULTS

Multivariable mixed effects model with time varying covariates revealed that quality-of-life ratings decreased over time (P < .001). Quality-of-life ratings were higher among enrollees with fewer depressive symptoms (P < .001), higher general physical function (P < .001), enhanced emotional well-being (P < .001), and greater social support (P = .004). Ratings also were higher among those with increased deficits in activities of daily living (P = .02). Ratings were highest among enrollees who received LTSS from ALFs, followed by NHs, then home and community-based services (H&CBS), but only findings between ALFs and H&CBS were statistically significant (P < .001). Finally, ratings tended to decrease over time among enrollees with greater cognitive impairment and increase over time among enrollees with less cognitive impairment (P < .001).

CONCLUSIONS

Findings advance knowledge regarding what is arguably the most important outcome of elderly LTSS recipients: quality of life. Understanding associations between multiple HRQoL domains and quality of life over time and directly from LTSS recipients represents a critical step in enhancing care processes and outcomes of this vulnerable population.