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Thao MS, Davila H, Shippee T. "I feel like a caged pig in here": Language, Race, and Ethnic Identity in a Case Study Hmong Nursing Home Resident Quality of Life. J Appl Gerontol 2024:7334648241271896. [PMID: 39140747 DOI: 10.1177/07334648241271896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
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.
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Affiliation(s)
- Mai See Thao
- University of Wisconsin-Madison, Madison, WI, USA
| | - Heather Davila
- Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Moyo P, Choudry E, George M, Zullo AR, Ritter AZ, Rahman M. Disparities in Access to Highly Rated Skilled Nursing Facilities among Medicare Beneficiaries with Opioid Use Disorder. J Am Med Dir Assoc 2024; 25:105190. [PMID: 39117298 DOI: 10.1016/j.jamda.2024.105190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVES To investigate disparities in admissions to highly rated skilled nursing facilities (SNFs) between Medicare beneficiaries with and without opioid use disorder (OUD). DESIGN Nationwide, retrospective observational cohort. SETTING AND PARTICIPANTS Medicare Fee-for-Service beneficiaries aged ≥18 years admitted to SNFs following hospitalization during 2016-2020 (n = 30,922 with OUD and n = 137,454 without OUD). METHODS Data used were 100% Medicare inpatient claims, nursing home administrative databases, and Nursing Home Compare. We identified hospitalized patients with and without OUD and matched them on age, sex, Part D low-income subsidy (LIS), and residential county. We compared the overall and component (quality, staffing, and health inspections) star ratings of SNFs that beneficiaries entered. Beneficiary-level regression models were conducted adjusting for race and ethnicity, Medicare-Medicaid dual status, comorbidity score, hospital length of stay, and state and year fixed effects. RESULTS The overall study sample had a mean (SD) age of 71.4 (11.4) years, 63.9% were female, and 57.4% had LIS. Among beneficiaries with OUD, 50.3% entered SNFs with above-average (4 or 5) overall rating compared with 51.3% among those without OUD. Distributions of above-average ratings among beneficiaries with and without OUD were as follows: 63.9% vs 62.2% for quality, 32.8% vs 34.9% for health inspections, and 46.2% vs 45.0% for staffing, respectively. Adjusted regression models indicated that beneficiaries with OUD were less likely to be admitted to facilities with above-average overall (OR 0.90, 95% CI 0.87-0.92), health inspection (OR 0.90, 95% CI 0.88-0.93), and staffing (OR 0.91, 95% CI 0.89-0.94) ratings compared with beneficiaries without OUD, whereas quality (OR 0.98, 95% CI 0.95-1.01) ratings did not differ. CONCLUSIONS AND IMPLICATIONS Despite mixed results on component ratings, our findings suggest a concerning disparity in the overall quality of SNFs admitting Medicare beneficiaries with OUD. Enhancing equitable access to high-quality SNF care for individuals with OUD is imperative amid rising demand and legal protections under the American Disabilities Act.
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Affiliation(s)
- Patience Moyo
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Erum Choudry
- Brown University School of Public Health, Providence, RI, USA
| | - Miriam George
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Ashley Z Ritter
- NewCourtland, Philadelphia, PA, USA; NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Momotazur Rahman
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
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Bromley E, Rahmanian Koushkaki S, Davis LG, Moon S, Resnick J, McCoy M, Bennett K, Rab S, Draxler CD, Jackson LT, Lovelace A, Sherin J. Addressing Mental Health Disability in Unsheltered Homelessness: Outpatient Conservatorship in Los Angeles. Psychiatr Serv 2024; 75:689-698. [PMID: 38268464 DOI: 10.1176/appi.ps.20230235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
OBJECTIVE The authors sought to describe a pilot program for gravely disabled individuals experiencing unsheltered homelessness in Los Angeles County that illustrates a promising public health framework to address mental health-related disability in homeless populations. METHODS Homeless outreach teams implementing the outpatient conservatorship (OPC) pilot program adopted a population health approach, multisystem care coordination, and prioritization of the least restrictive environments. The program allowed initiation of a Lanterman-Petris-Short (LPS) conservatorship outside of a hospital, with the goal of serving highly vulnerable individuals in the least restrictive settings. Between August 2020 and July 2021, the OPC pilot program served 43 clients, corresponding to 2% of those served by the outreach teams during that period. Using observational program evaluation data, the authors examined the impact of the program on this sample of participants. RESULTS At 12 months, 81% of OPC clients were no longer experiencing unsheltered homelessness; 65% accessed an LPS conservatorship. Although most OPC clients utilized a psychiatric hospital, 54% left locked settings earlier than would have been possible without the program. One-third of clients referred for LPS conservatorship used unlocked licensed residential facilities in the first year. Negative events, such as remaining in unsheltered homelessness, were more common among clients not referred for LPS conservatorship. CONCLUSIONS Timely receipt of street-based services and coordination of care before, during, and after referral for LPS conservatorship reduced use of restrictive settings. The OPC program's components constitute a promising triadic framework for addressing mental health disability among unsheltered individuals that warrants further investigation.
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Affiliation(s)
- Elizabeth Bromley
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, and Los Angeles County Department of Mental Health and University of California Los Angeles Public Mental Health Partnership, University of California Los Angeles, Los Angeles (Bromley, Rahmanian Koushkaki, Davis, McCoy, Sherin); Mental Illness Research, Education and Clinical Center, Greater Los Angeles Healthcare System, U.S. Department of Veterans Affairs, Los Angeles (Bromley, McCoy); Los Angeles County Department of Health Services, Los Angeles (Moon); Center for Community Health, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla (Resnick); Los Angeles County Department of Mental Health, Los Angeles (Bennett, Rab, Draxler, Jackson, Lovelace)
| | - Sara Rahmanian Koushkaki
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, and Los Angeles County Department of Mental Health and University of California Los Angeles Public Mental Health Partnership, University of California Los Angeles, Los Angeles (Bromley, Rahmanian Koushkaki, Davis, McCoy, Sherin); Mental Illness Research, Education and Clinical Center, Greater Los Angeles Healthcare System, U.S. Department of Veterans Affairs, Los Angeles (Bromley, McCoy); Los Angeles County Department of Health Services, Los Angeles (Moon); Center for Community Health, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla (Resnick); Los Angeles County Department of Mental Health, Los Angeles (Bennett, Rab, Draxler, Jackson, Lovelace)
| | - Lisa G Davis
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, and Los Angeles County Department of Mental Health and University of California Los Angeles Public Mental Health Partnership, University of California Los Angeles, Los Angeles (Bromley, Rahmanian Koushkaki, Davis, McCoy, Sherin); Mental Illness Research, Education and Clinical Center, Greater Los Angeles Healthcare System, U.S. Department of Veterans Affairs, Los Angeles (Bromley, McCoy); Los Angeles County Department of Health Services, Los Angeles (Moon); Center for Community Health, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla (Resnick); Los Angeles County Department of Mental Health, Los Angeles (Bennett, Rab, Draxler, Jackson, Lovelace)
| | - Stephanie Moon
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, and Los Angeles County Department of Mental Health and University of California Los Angeles Public Mental Health Partnership, University of California Los Angeles, Los Angeles (Bromley, Rahmanian Koushkaki, Davis, McCoy, Sherin); Mental Illness Research, Education and Clinical Center, Greater Los Angeles Healthcare System, U.S. Department of Veterans Affairs, Los Angeles (Bromley, McCoy); Los Angeles County Department of Health Services, Los Angeles (Moon); Center for Community Health, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla (Resnick); Los Angeles County Department of Mental Health, Los Angeles (Bennett, Rab, Draxler, Jackson, Lovelace)
| | - Jaclyn Resnick
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, and Los Angeles County Department of Mental Health and University of California Los Angeles Public Mental Health Partnership, University of California Los Angeles, Los Angeles (Bromley, Rahmanian Koushkaki, Davis, McCoy, Sherin); Mental Illness Research, Education and Clinical Center, Greater Los Angeles Healthcare System, U.S. Department of Veterans Affairs, Los Angeles (Bromley, McCoy); Los Angeles County Department of Health Services, Los Angeles (Moon); Center for Community Health, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla (Resnick); Los Angeles County Department of Mental Health, Los Angeles (Bennett, Rab, Draxler, Jackson, Lovelace)
| | - Matthew McCoy
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, and Los Angeles County Department of Mental Health and University of California Los Angeles Public Mental Health Partnership, University of California Los Angeles, Los Angeles (Bromley, Rahmanian Koushkaki, Davis, McCoy, Sherin); Mental Illness Research, Education and Clinical Center, Greater Los Angeles Healthcare System, U.S. Department of Veterans Affairs, Los Angeles (Bromley, McCoy); Los Angeles County Department of Health Services, Los Angeles (Moon); Center for Community Health, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla (Resnick); Los Angeles County Department of Mental Health, Los Angeles (Bennett, Rab, Draxler, Jackson, Lovelace)
| | - Karla Bennett
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, and Los Angeles County Department of Mental Health and University of California Los Angeles Public Mental Health Partnership, University of California Los Angeles, Los Angeles (Bromley, Rahmanian Koushkaki, Davis, McCoy, Sherin); Mental Illness Research, Education and Clinical Center, Greater Los Angeles Healthcare System, U.S. Department of Veterans Affairs, Los Angeles (Bromley, McCoy); Los Angeles County Department of Health Services, Los Angeles (Moon); Center for Community Health, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla (Resnick); Los Angeles County Department of Mental Health, Los Angeles (Bennett, Rab, Draxler, Jackson, Lovelace)
| | - Shayan Rab
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, and Los Angeles County Department of Mental Health and University of California Los Angeles Public Mental Health Partnership, University of California Los Angeles, Los Angeles (Bromley, Rahmanian Koushkaki, Davis, McCoy, Sherin); Mental Illness Research, Education and Clinical Center, Greater Los Angeles Healthcare System, U.S. Department of Veterans Affairs, Los Angeles (Bromley, McCoy); Los Angeles County Department of Health Services, Los Angeles (Moon); Center for Community Health, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla (Resnick); Los Angeles County Department of Mental Health, Los Angeles (Bennett, Rab, Draxler, Jackson, Lovelace)
| | - Connie D Draxler
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, and Los Angeles County Department of Mental Health and University of California Los Angeles Public Mental Health Partnership, University of California Los Angeles, Los Angeles (Bromley, Rahmanian Koushkaki, Davis, McCoy, Sherin); Mental Illness Research, Education and Clinical Center, Greater Los Angeles Healthcare System, U.S. Department of Veterans Affairs, Los Angeles (Bromley, McCoy); Los Angeles County Department of Health Services, Los Angeles (Moon); Center for Community Health, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla (Resnick); Los Angeles County Department of Mental Health, Los Angeles (Bennett, Rab, Draxler, Jackson, Lovelace)
| | - La Tina Jackson
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, and Los Angeles County Department of Mental Health and University of California Los Angeles Public Mental Health Partnership, University of California Los Angeles, Los Angeles (Bromley, Rahmanian Koushkaki, Davis, McCoy, Sherin); Mental Illness Research, Education and Clinical Center, Greater Los Angeles Healthcare System, U.S. Department of Veterans Affairs, Los Angeles (Bromley, McCoy); Los Angeles County Department of Health Services, Los Angeles (Moon); Center for Community Health, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla (Resnick); Los Angeles County Department of Mental Health, Los Angeles (Bennett, Rab, Draxler, Jackson, Lovelace)
| | - Aubree Lovelace
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, and Los Angeles County Department of Mental Health and University of California Los Angeles Public Mental Health Partnership, University of California Los Angeles, Los Angeles (Bromley, Rahmanian Koushkaki, Davis, McCoy, Sherin); Mental Illness Research, Education and Clinical Center, Greater Los Angeles Healthcare System, U.S. Department of Veterans Affairs, Los Angeles (Bromley, McCoy); Los Angeles County Department of Health Services, Los Angeles (Moon); Center for Community Health, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla (Resnick); Los Angeles County Department of Mental Health, Los Angeles (Bennett, Rab, Draxler, Jackson, Lovelace)
| | - Jonathan Sherin
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, and Los Angeles County Department of Mental Health and University of California Los Angeles Public Mental Health Partnership, University of California Los Angeles, Los Angeles (Bromley, Rahmanian Koushkaki, Davis, McCoy, Sherin); Mental Illness Research, Education and Clinical Center, Greater Los Angeles Healthcare System, U.S. Department of Veterans Affairs, Los Angeles (Bromley, McCoy); Los Angeles County Department of Health Services, Los Angeles (Moon); Center for Community Health, Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla (Resnick); Los Angeles County Department of Mental Health, Los Angeles (Bennett, Rab, Draxler, Jackson, Lovelace)
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Shippee TP, Parikh RR, Baker ZG, Bucy TI, Ng W, Jarosek S, Qin X, Woodhouse M, Nkimbeng M, McCarthy T. Racial Differences in Nursing Home Quality of Life Among Residents Living With Alzheimer's Disease and Related Dementias. J Aging Health 2024; 36:379-389. [PMID: 37493607 DOI: 10.1177/08982643231191164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
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.
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Affiliation(s)
- Tetyana Pylypiv Shippee
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Romil R Parikh
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Zachary G Baker
- Edson College of Nursing and Health Innovation, Arizona State University, Tempe, AZ, USA
| | - Taylor I Bucy
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Weiwen Ng
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Stephanie Jarosek
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Xuanzi Qin
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD, USA
| | - Mark Woodhouse
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Manka Nkimbeng
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Teresa McCarthy
- Department of Family Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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Fashaw‐Walters SA, Rahman M, Jarrín OF, Gee G, Mor V, Nkimbeng M, Thomas KS. Getting to the root: Examining within and between home health agency inequities in functional improvement. Health Serv Res 2024; 59:e14194. [PMID: 37356822 PMCID: PMC10915486 DOI: 10.1111/1475-6773.14194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023] Open
Abstract
OBJECTIVE To quantify racial, ethnic, and income-based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs). DATA SOURCES 2016-2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data. DATA COLLECTION/EXTRACTION METHODS Not Applicable. STUDY DESIGN We use multinomial-logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five-category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins. PRINCIPAL FINDINGS Of the 3+ million Medicare beneficiaries with a HH start-of-care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual-level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low-income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% CI:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income-based disparities persisted within HHAs. Black-White, Hispanic-White, and AIAN-White disparities were largely driven by between-HHA differences, whereas income-based disparities were mostly due to within-HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities. CONCLUSIONS Both within- and between-HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes.
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Affiliation(s)
- Shekinah A. Fashaw‐Walters
- Division of Health Policy and Management, School of Public HealthUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Momotazur Rahman
- Center for Gerontology and Healthcare Research, School of Public HealthBrown UniversityProvidenceRhode IslandUSA
- Department of Health Services, Policy, and Practice, School of Public HealthBrown UniversityProvidenceRhode IslandUSA
| | - Olga F. Jarrín
- Division of Nursing Science, School of Nursing, RutgersThe State University of New JerseyNew BrunswickNew HampshireUSA
| | - Gilbert Gee
- Department of Community Health Sciences, Fielding School of Public HealthUniversity of California at Los AngelesLos AngelesCaliforniaUSA
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, School of Public HealthBrown UniversityProvidenceRhode IslandUSA
- Department of Health Services, Policy, and Practice, School of Public HealthBrown UniversityProvidenceRhode IslandUSA
- Center of Innovation in Long‐Term Services and SupportsU.S. Department of Veterans Affairs Medical CenterProvidenceRhode IslandUSA
| | - Manka Nkimbeng
- Division of Health Policy and Management, School of Public HealthUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Kali S. Thomas
- Center for Gerontology and Healthcare Research, School of Public HealthBrown UniversityProvidenceRhode IslandUSA
- Department of Health Services, Policy, and Practice, School of Public HealthBrown UniversityProvidenceRhode IslandUSA
- Center of Innovation in Long‐Term Services and SupportsU.S. Department of Veterans Affairs Medical CenterProvidenceRhode IslandUSA
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Bigger SE, Hemphill JC, Njoroge T, Doyon K, Glenn L. Black Americans, hospitalization, and advance care planning: Structural vulnerability in Home Health Value-Based Purchasing. Am J Hosp Palliat Care 2024; 41:140-149. [PMID: 37192103 DOI: 10.1177/10499091231176281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
Skilled home health (HH) is the largest long-term care setting and the fastest-growing site of healthcare in the United States (U.S.). Home Health Value-Based Purchasing (HHVBP) is a structure of Medicare that penalizes U.S. HH agencies for high hospitalization rates. Prior studies have shown inconsistent evidence about associations of race with hospitalization rates in HH. Evidence supports that Black or African Americans are less likely to participate in advance care planning (ACP), or to complete written advance directives, which could affect their potential for hospitalization when nearing end of life. In this quasi-experimental study, we used Medicare administrative datasets, the Weighted Acute Care Services Use Rates (WACSUR) score, and the Advance Care Planning Protocol (ACPP) score to determine whether the proportion of Black HH patients in the U.S. was correlated with acute care use rates and the robustness of agency protocols on ACP. We used primary and secondary data from the U.S. from 2016-2020. We included Medicare-certified HH agencies. Spearman's correlation coefficient was used. We found a statistical trend showing that the greater proportion of Black patients enrolled in a HH agency, the greater tendency to have a high hospitalization rate. Our findings suggest that HHVBP may encourage patient selection and exacerbate health disparities. Our findings support recommendations for alternative measures of quality in HH to include measures of goal-concordant care coordination when patients are denied admission to HH.
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Shireman TI, Fashaw-Walters S, Zhang T, Zullo AR, Gerlach LB, Coe AB, Daiello L, Lo D, Strominger J, Bynum JPW. Federal Nursing Home Policies on Antipsychotics had Similar Impacts by Race and Ethnicity for Residents With Dementia. J Am Med Dir Assoc 2023; 24:1283-1289.e4. [PMID: 37127131 PMCID: PMC10523862 DOI: 10.1016/j.jamda.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/15/2023] [Accepted: 03/20/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Federal initiatives have been successful in reducing antipsychotic exposure in nursing home residents with dementia. We assessed if these initiatives were implemented equally across racial and ethnic minority groups. DESIGN Retrospective, cross-sectional trends study. SETTING AND PARTICIPANTS National long-stay nursing home residents with dementia from 2011 to 2017. METHODS We examined trends in psychotropic drug class exposures from the Minimum Data Set assessments for non-Hispanic Black (NHB), Hispanic, and non-Hispanic White (NHW) residents using interrupted time-series analyses with age-sex standardized quarterly outcomes and time points to denote the National Partnership (2012) and Five Star Rating changes (2015). RESULTS Initially, antipsychotic (33.0%) and sedative (6.8%) exposure was highest for Hispanic residents; antidepressant (59.8%) and anxiolytic (23.4%) exposure was highest for NHW residents; NHB residents had the lowest use of each. Antipsychotic use dropped at the time of the Partnership (β = -0.8807, P = .0023) and the slope declined further after the Partnership (β = -0.6611, P < .0001) for NHW. In comparison to NHW, the level and slope changes for NHB and Hispanics were not significantly different. The Five Star Rating change did not impact the level of antipsychotic use (β = 0.027, P = .9467), but the slope changed to indicate a slowed rate of decline (β = 0.1317, P = .4075) for NHW. As to the other psychotropic drug classes, there were few significant differences between trends seen in the racial and ethnic subgroups. The following exceptions were noted: antidepressant use decreased at a faster rate for NHB residents post-Partnership (β = -0.1485, P = .0371), and after the Five Star Rating change, NHB residents (β = -0.0428, P = .0312) and Hispanic residents (β = -0.0834, P < .0001) saw antidepressant use decrease faster than NHW. Sedative use in slope post-Partnership period (β = -0.086, P = .0275) and post-Five Star Rating (β = -0.0775, P < .0001) declined faster among Hispanic residents. CONCLUSIONS AND IMPLICATIONS We found little evidence of clinically meaningful differences in changes to 4 classes of psychotropic medication use among racial and ethnic minority nursing home residents with dementia following 2 major federal initiatives.
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Affiliation(s)
- Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Shekinah Fashaw-Walters
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Lauren B Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Antoinette B Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Lori Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Neurology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Julie P W Bynum
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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FASHAW‐WALTERS SHEKINAHA, RAHMAN MOMOTAZUR, GEE GILBERT, MOR VINCENT, RIVERA‐HERNANDEZ MARICRUZ, FORD CERON, THOMAS KALIS. Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access. Milbank Q 2023; 101:527-559. [PMID: 36961089 PMCID: PMC10262386 DOI: 10.1111/1468-0009.12616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 11/14/2022] [Accepted: 01/03/2023] [Indexed: 03/25/2023] Open
Abstract
Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated. CONTEXT Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors. METHODS We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design. FINDINGS After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use. CONCLUSIONS Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.
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Affiliation(s)
| | - MOMOTAZUR RAHMAN
- Center for Gerontology and Healthcare ResearchSchool of Public HealthBrown University
- School of Public HealthBrown University
| | - GILBERT GEE
- Fielding School of Public HealthUniversity of California at Los Angeles
| | - VINCENT MOR
- Center for Gerontology and Healthcare ResearchSchool of Public HealthBrown University
- School of Public HealthBrown University
- US Department of Veterans Affairs Medical CenterCenter of Innovation in Long‐Term Services and Supports
| | - MARICRUZ RIVERA‐HERNANDEZ
- Center for Gerontology and Healthcare ResearchSchool of Public HealthBrown University
- School of Public HealthBrown University
| | - CERON FORD
- School of Public HealthUniversity of Minnesota
| | - KALI S. THOMAS
- Center for Gerontology and Healthcare ResearchSchool of Public HealthBrown University
- School of Public HealthBrown University
- US Department of Veterans Affairs Medical CenterCenter of Innovation in Long‐Term Services and Supports
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9
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Bowblis JR, Akosionu O, Ng W, Shippee TP. Identifying Nursing Homes With Diverse Racial and Ethnic Resident Compositions: The Importance of Group Heterogeneity and Geographic Context. Med Care Res Rev 2023; 80:175-186. [PMID: 36408838 DOI: 10.1177/10775587221134870] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
| | | | - Weiwen Ng
- University of Minnesota, Twin Cities, Minneapolis, USA
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10
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Engeda JC, Karmarkar EN, Mitsunaga TM, Raymond KL, Oh P, Epson E. Resident racial and ethnic composition, neighborhood-level socioeconomic status, and COVID-19 infections in California SNFs. J Am Geriatr Soc 2023; 71:157-166. [PMID: 36196970 PMCID: PMC9874461 DOI: 10.1111/jgs.18076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 07/18/2022] [Accepted: 08/30/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND In California, >29,000 residents in skilled nursing facility (SNFs) were diagnosed with novel coronavirus disease 2019 (COVID-19) between March 2020 and November 2020. Prior research suggests that SNFs serving racially and ethnically minoritized residents often have fewer resources and lower quality of care. We performed a cross-sectional analysis of COVID-19 incidence among residents in California SNFs, assessing the association of SNF-level racial and ethnic compositions and facility- and neighborhood-level (census tract- and county-level) indicators of socioeconomic status (SES). METHODS SNFs were grouped based on racial and ethnic composition using data from the Centers for Medicare and Medicaid Services; categories included SNFs with ≥88% White residents, SNFs with ≥32% Black or Latinx residents, SNFs with ≥32% Asian residents, or SNFs not serving a high proportion of any racial and ethnic composition (mixed). SNF resident-level COVID-19 infection data were obtained from the National Healthcare Safety Network from May 25, 2020 to August 16, 2020. Multilevel mixed-effects negative binomial regressions were used to estimate incidence rate ratios (IRR) for confirmed COVID-19 infections among residents. RESULTS Among 971 SNFs included in our sample, 119 (12.3%) had ≥88% White residents; 215 (22.1%) had ≥32% Black or Latinx residents; 78 (8.0%) had ≥32% Asian residents; and 559 (57.6%) were racially and ethnically mixed. After adjusting for confounders, SNFs with ≥32% Black or Latinx residents (IRR = 2.40 [95% CI = 1.56, 3.68]) and SNFs with mixed racial and ethnic composition (IRR = 2.12 [95% CI = 1.49, 3.03]) both had higher COVID-19 incidence rates than SNFs with ≥88% White residents. COVID-19 incidence rates were also found to be higher in SNFs with low SES neighborhoods compared to those in high SES neighborhoods. CONCLUSION Public health personnel should consider SNF- and neighborhood-level factors when identifying facilities to prioritize for COVID-19 outbreak prevention and control.
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Affiliation(s)
- Joseph C. Engeda
- California Department of Public HealthHealthcare‐Associated Infections ProgramRichmondCaliforniaUSA,Public Health and Scientific ResearchSocial & Scientific SystemsDurhamNorth CarolinaUSA
| | - Ellora N. Karmarkar
- California Department of Public HealthHealthcare‐Associated Infections ProgramRichmondCaliforniaUSA
| | - Tisha M. Mitsunaga
- California Department of Public HealthHealthcare‐Associated Infections ProgramRichmondCaliforniaUSA
| | - Kristal L. Raymond
- California Department of Public HealthOffice of Health EquitySacramentoCaliforniaUSA
| | - Peter Oh
- California Department of Public HealthOffice of Health EquitySacramentoCaliforniaUSA
| | - Erin Epson
- California Department of Public HealthHealthcare‐Associated Infections ProgramRichmondCaliforniaUSA
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11
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Shippee TP, Davila H, Ng W, Bowblis JR, Akosionu O, Skarphol T, See Thao M, Woodhouse M, Thorpe RJ. Evidence to inform policy and practice: Mechanisms to address racial/ethnic disparities in nursing home quality of life. Innov Aging 2022; 6:igac037. [PMID: 35832200 PMCID: PMC9273400 DOI: 10.1093/geroni/igac037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and Objectives
Abundant evidence documents racial/ethnic disparities in access, quality of care, and quality of life (QoL) among nursing home (NH) residents who are Black, Indigenous and people of color (BIPOC) compared to White residents. BIPOC residents are more likely to be admitted to lower quality NHs and to experience worse outcomes. Yet, little is known about processes for differences in QoL among residents receiving care in high proportion BIPOC NHs. This study presents an examination of the processes for racial/ethnic disparities in QoL in high-proportion BIPOC facilities while highlighting variability in QoL between these facilities.
Research Design and Methods
Guided by the Minority Health and Health Disparities Research Framework and the Zubritsky framework for QoL in NHs, we employ a concurrent mixed-methods approach involving in-depth case studies of six high-proportion BIPOC NHs in Minnesota (96 resident interviews; 61 staff interviews; 614 hours of observation), coupled with state-wide survey data on residents’ QoL linked to resident clinical Minimum Data Set assessments.
Results
Quantitative findings show that BIPOC residents experience lower QoL than White residents across various domains. Qualitative findings reveal variability in BIPOC residents’ QoL between high proportion BIPOC facilities. In some facilities, BIPOC residents experienced worse QoL based on their race/ethnicity, while in others BIPOC residents QoL was not directly affected by their race/ethnicity or they had mixed experiences.
Discussion and Implications
The findings highlight variability in racial/ethnic disparities in QoL across NHs with a high proportion of BIPOC residents. We identify health equity initiatives, including engaging with community BIPOC organizations and volunteers, and providing more resources to high-proportion BIPOC facilities to support staff training, additional staffing, and culturally-specific programming. Given the increasing racial/ethnic diversity of NHs, ensuring equity in QoL for BIPOC residents is an urgent priority for NHs to remain relevant in the future.
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Affiliation(s)
- Tetyana P Shippee
- Address correspondence to: Tetyana P. Shippee, PhD, Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455, USA. E-mail:
| | - Heather Davila
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Division of General Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Weiwen Ng
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - John R Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, Ohio, USA
| | - Odichinma Akosionu
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tricia Skarphol
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mai See Thao
- Department of Religious Studies and Anthropology, University of Wisconsin–Oshkosh, Oskhosh, Wisconsin, USA
| | - Mark Woodhouse
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Roland J Thorpe
- Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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12
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Travers JL, Dick AW, Wu B, Grabowski D, Robison J, Agarwal M, Perera GU, Stone PW. A Profile of Black and Latino Older Adults Receiving Care in Nursing Homes: 2011-2017. J Am Med Dir Assoc 2022; 23:1833-1837.e2. [PMID: 35594945 DOI: 10.1016/j.jamda.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 04/10/2022] [Accepted: 04/14/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify if disparate trends in the access and use of nursing home (NH) services among Black and Latino older adults compared with White older adults persist. Access was operationalized as the NHs that served Black, Latino, and White residents. Use was operationalized as the utilization of NH services by Black, Latino, and White residents. DESIGN This was an observational study analyzing facility-level data from LTCfocus for 2011 to 2017. SETTING AND PARTICIPANTS All NH residents present in US NHs participating in the Centers for Medicare and Medicaid Services program on the first Thursday in April in the years 2011 to 2017. NHs with fewer than 4500 bed-days per year are excluded in the LCTfocus dataset. Black, Latino, and White were the racial/ethnic groups of interest. METHODS We calculated the mean percentage of each racial/ethnic group in NHs (Black, Latino, White) annually along with the number of NHs that provided care for these groups. We conducted a simple trend analysis using ordinary least squares to estimate the change in NH access and use by racial/ethnic group over time. RESULTS Our NH sample ranged from 15,564 in 2011 to 14,956 in 2017. Latino older residents' use of NHs increased by 20.47% and Black residents increased by 11.42%, whereas there was a 1.36% decrease in White residents' use of NHs. In this 7-year span, there was a 4.44% and 6.41% decline in the number of NHs that serve any Black and Latino older adults, respectively, compared with a 2.26% decline in NHs that serve only White older adults (access). CONCLUSIONS AND IMPLICATIONS Our findings reveal a continued disproportionate rise in Black and Latino older adults' use of NHs while the number of NHs that serve this population have declined. This work can inform federal and state policies to ensure access to long-term care services and supports in the community for all older adults and prevent inappropriate NH closures.
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Affiliation(s)
- Jasmine L Travers
- Rory Meyers College of Nursing, New York University, New York, NY, USA.
| | | | - Bei Wu
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | | | | | - Mansi Agarwal
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
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13
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Vogelsmeier A, Popejoy L, Fritz E, Canada K, Ge B, Brandt L, Rantz M. Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity. BMC Health Serv Res 2022; 22:626. [PMID: 35538575 PMCID: PMC9087933 DOI: 10.1186/s12913-022-08036-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers. Methods This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long-stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described. Results Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable. Conclusions Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.
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Affiliation(s)
- Amy Vogelsmeier
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.
| | - Lori Popejoy
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Elizabeth Fritz
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Kelli Canada
- School of Social Work, University of Missouri, Columbia, MO, USA
| | - Bin Ge
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Lea Brandt
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Marilyn Rantz
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
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14
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Abstract
As the late Robert Kane observed, the term nursing home is often a misnomer. Most U.S. nursing homes lack adequate nursing staff, and they are typically not very homelike in either their physical structure or culture. These problems were magnified during the pandemic. The underlying reasons for these longstanding issues are that most state Medicaid payment systems reimburse nursing homes at a relatively low level and the government does not hold nursing homes accountable for spending dollars on direct resident care. To encourage increased staffing and more homelike models of care, policymakers need to reform how nursing homes are paid and hold facilities accountable for how they spend government dollars. With these reforms, the term nursing home will become more appropriate in the United States.
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Affiliation(s)
- David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
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15
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Oney M, White L, Coe NB. Out‐of‐pocket costs attributable to dementia: A longitudinal analysis. J Am Geriatr Soc 2022; 70:1538-1545. [PMID: 35278213 PMCID: PMC9106861 DOI: 10.1111/jgs.17746] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/25/2022] [Accepted: 02/17/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Alzheimer's disease and related dementias (ADRD) affect 5.7 million Americans, and are expensive despite the lack of a cure or even treatments effective in managing the disease. The literature thus far has tended to focus on the costs to Medicare, even though one of the main characteristics of ADRD (the loss of independence and ability to care for oneself) incurs costs not covered by Medicare. METHODS In this paper, we use survey data for 2002-2016 from the Health and Retirement Study to estimate the out-of-pocket costs of ADRD for the patient and their family through the first 8 years after the onset of symptoms, as defined by a standardized 27-point scale of cognitive ability. A two-part model developed by Basu and Manning (2010) allows us to separate the costs attributable to ADRD into two components, one driven by differences in longevity and one driven by differences in utilization. RESULTS We identified a cohort of 3619 incident dementia cases, 38.9% were male, and 66.9% were non-Hispanic White. Dementia onset was 77.7 years of age, on average. OOP costs attributable to dementia are $8751 over the first 8 years after the onset. These incremental costs are driven by nursing home expenditures, which are largely uninsured in the US. OOP spending is highest for whites and women. CONCLUSION The financial burden of ADRD is significant, and largely attributable to the lack of wide-spread long-term care insurance.
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Affiliation(s)
- Melissa Oney
- Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Lindsay White
- Center for Health Care Quality and Outcomes RTI International Seattle Washington USA
| | - Norma B. Coe
- Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
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16
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Werner RM, Konetzka RT. Reimagining Financing and Payment of Long-Term Care. J Am Med Dir Assoc 2022; 23:220-224. [PMID: 34942158 PMCID: PMC8695540 DOI: 10.1016/j.jamda.2021.11.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/19/2021] [Accepted: 11/24/2021] [Indexed: 11/17/2022]
Abstract
The COVID-19 pandemic revealed fundamental problems with the structure of long-term care financing and payment in the United States. The piecemeal system that exists suffers from several key problems, including underfunding, fragmentation across types and sites of care, and substantial variation in payment across states and populations. These problems result in inefficient allocation of resources, limited access to care, substandard quality, and inequities in both access and quality. We propose a new federal benefit for long-term care, most likely as part of the Medicare program. Essential features of this benefit include taxpayer subsidies, along the lines of other Medicare benefits, and coverage across the range of long-term care services, including both residential and home- and community-based care. A new federal benefit has the most potential to break down administrative barriers and improve resource allocation, to ensure adequate payment rates across all states, to expand access to care by spreading risk across the entire Medicare population, and to improve equity by extending coverage to all Medicare beneficiaries who want it. A new federal benefit is politically challenging, requiring bold action by Congress, and entails the risks of administrative challenges and unintended consequences. However, in this case, retaining the status quo remains the far greater risk.
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Affiliation(s)
- Rachel M Werner
- Department of Medicine, Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - R Tamara Konetzka
- Department of Public Health Sciences, Department of Medicine, The University of Chicago Biological Sciences, Chicago, IL, USA.
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17
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Shippee TP, Fabius CD, Fashaw-Walters S, Bowblis JR, Nkimbeng M, Bucy TI, Duan Y, Ng W, Akosionu O, Travers JL. Evidence for Action: Addressing Systemic Racism Across Long-Term Services and Supports. J Am Med Dir Assoc 2022; 23:214-219. [PMID: 34958742 PMCID: PMC8821413 DOI: 10.1016/j.jamda.2021.12.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 02/03/2023]
Abstract
Long-term services and supports (LTSS), including care received at home and in residential settings such as nursing homes, are highly racially segregated; Black, Indigenous, and persons of color (BIPOC) users have less access to quality care and report poorer quality of life compared to their White counterparts. Systemic racism lies at the root of these disparities, manifesting via racially segregated care, low Medicaid reimbursement, and lack of livable wages for staff, along with other policies and processes that exacerbate disparities. We reviewed Medicaid reimbursement, pay-for-performance, public reporting of quality of care, and culture change in nursing homes and integrated home- and community-based service (HCBS) programs as possible mechanisms for addressing racial and ethnic disparities. We developed a set of recommendations for LTSS based on existing evidence, including (1) increase Medicaid and Medicare reimbursement rates, especially for providers serving high proportions of Medicaid-eligible and BIPOC older adults; (2) reconsider the design of pay-for-performance programs as they relate to providers who serve underserved groups; (3) include culturally sensitive measures, such as quality of life, in public reporting of quality of care, and develop and report health equity measures in outcomes of care for BIPOC individuals; (4) implement culture change so services are more person-centered and homelike, alongside improvements in staff wages and benefits in high-proportion BIPOC nursing homes; (5) expand access to Medicaid-waivered HCBS services; (6) adopt culturally appropriate HCBS practices, with special attention to family caregivers; (7) and increase promotion of integrated HCBS programs that can be targeted to BIPOC consumers, and implement models that value community health workers. Multipronged solutions may help diminish the role of systemic racism in existing racial disparities in LTSS, and these recommendations provide steps for action that are needed to reimagine how long-term care is delivered, especially for BIPOC populations.
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Affiliation(s)
| | - Chanee D. Fabius
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - John R. Bowblis
- Miami University, Farmer School of Business and Scripps Gerontology Center, Oxford, Ohio, USA
| | - Manka Nkimbeng
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Taylor I. Bucy
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Yinfei Duan
- University of Alberta Faculty of Nursing, Edmonton, Alberta, Canada
| | - Weiwen Ng
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Odichinma Akosionu
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Jasmine L. Travers
- New York University Rory Meyers College of Nursing, New York, New York, USA
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18
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Abstract
IMPORTANCE The new Medicare Skilled Nursing Facility Value-Based Purchasing program (SNF VBP) seeks to improve patient outcomes by awarding financial incentives or penalties based on 30-day hospital readmission rates. Skilled nursing facilities (SNFs) can avoid a penalty through low baseline readmission rates or improvement over time. OBJECTIVE To assess the baseline performance and improvement over time of SNFs in the SNF VBP program. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study examined readmission rates, financial penalties and incentives, and facility and patient characteristics associated with these outcomes at 14 959 US SNFs that received Medicare payments between January 1, 2015, and December 31, 2019. MAIN OUTCOMES AND MEASURES Outcomes were readmission rates and financial penalties by facility. The SNFs were classified as improvers in the analysis if they had better improvement scores than baseline scores under the program and achievers if they had higher baseline scores than improvement scores. RESULTS Of 14 959 SNFs studied, 1849 (12.3%) were assigned their improvement score as their performance score in the first year of the program. Of these, 1167 (63.1%) received a financial penalty, whereas 374 (20.2%) received a bonus. Only 52 facilities that performed poorly at baseline (0.3% of all SNFs and 0.7% of below-median performers) were able to improve enough to avoid a financial penalty, despite large improvements in readmission rates. Improver SNFs treated larger racial minority populations (mean [SD], 74.57% [23.42%] White in the improver group vs 79.15% [22.18%] in the achiever group) and were located in counties with larger minority populations (mean [SD], 15.48% [14.05%] Black in the improver group vs 11.57% [12.72%] Black in the achiever group). The most important predictors of improvement were related to SNF finances, such as operating margin (mean [SD], -0.74 [13.87]) and occupancy rates (mean [SD], 79.93 [14.81]). CONCLUSIONS AND RELEVANCE This cross-sectional study suggests that the SNF VBP program did not offer a viable path for nearly all low-performing SNFs to avoid financial penalties through improved readmission rates.
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Affiliation(s)
- Robert E. Burke
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Yao Xu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Liam Rose
- Health Economics Resource Center, Department of Veterans Affairs, Palo Alto, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, California
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Fashaw-Walters SA, Rahman M, Gee G, Mor V, White M, Thomas KS. Out Of Reach: Inequities In The Use Of High-Quality Home Health Agencies. Health Aff (Millwood) 2022; 41:247-255. [PMID: 35130066 PMCID: PMC8883595 DOI: 10.1377/hlthaff.2021.01408] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Patients receiving home health services from high-quality home health agencies often experience fewer adverse outcomes (for example, hospitalizations) than patients receiving services from low-quality agencies. Using administrative data from 2016 and regression analysis, we examined individual- and neighborhood-level racial, ethnic, and socioeconomic factors associated with the use of high-quality home health agencies. We found that Black and Hispanic home health patients had a 2.2-percentage-point and a 2.5-percentage-point lower adjusted probability of high-quality agency use, respectively, compared with their White counterparts within the same neighborhoods. Low-income patients had a 1.2-percentage-point lower adjusted probability of high-quality agency use compared with their higher-income counterparts, whereas home health patients residing in neighborhoods with higher proportions of marginalized residents had a lower adjusted probability of high-quality agency use. Some 40-77 percent of the disparities in high-quality agency use were attributable to neighborhood-level factors. Ameliorating these inequities will require policies that dismantle structural and institutional barriers related to residential segregation.
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Affiliation(s)
| | | | - Gilbert Gee
- Gilbert Gee, University of California Los Angeles, Los Angeles, California
| | - Vincent Mor
- Vincent Mor, Brown University and Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | | | - Kali S Thomas
- Kali S. Thomas, Brown University and Providence Veterans Affairs Medical Center
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Grabowski DC. Response to the Commentary: The Intersections of Structural Racism and Ageism in the Time of COVID-19: Racism and Ageism Help Explain Underinvestment in Long-Term Care: An Important Call to Action. Res Gerontol Nurs 2022; 15:14-15. [PMID: 35044862 DOI: 10.3928/19404921-20211209-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Fabius CD, Parker LJ, Thorpe RJ. The Influence of Race and Gender on Receiving Assistance with Daily Activities among Older Americans. Innov Aging 2021; 6:igab060. [PMID: 35233471 PMCID: PMC8874838 DOI: 10.1093/geroni/igab060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Indexed: 11/29/2022] Open
Abstract
Background and Objectives Nearly 8.2 million community-dwelling, older Medicare beneficiaries receive support from long-term services and supports (LTSS) with routine daily activities. Prior work demonstrates disability-related disparities; however, it is unclear whether these patterns persist among LTSS recipients and across specific sets of activities. We examine race and gender differences in receiving help with self-care (e.g., eating), mobility (e.g., getting around the house), and household (e.g., shopping) activities in a nationally representative sample of community-dwelling Medicare beneficiaries receiving LTSS. Research Design and Methods Cross-sectional analysis of 1,808 White and Black older adults receiving assistance with routine daily activities in the 2015 National Health and Aging Trends Study. Bivariate statistics were used to describe the sample and provide comparisons of characteristics by race and gender. Logistic regression models examined race and gender differences in receiving assistance with self-care, mobility, and household activities after adjusting for sociodemographic and health characteristics. Results Race and gender differences were observed across all sociodemographic and health characteristics, as well as for all forms of assistance. Relative to White men, Black men had lower odds of receiving help with self-care activities. White and black women had higher odds and Black men had lower odds of getting help with mobility activities than White men. Black men and White and Black women all had higher odds of receiving assistance with household tasks compared to White men. Discussion and Implications Our findings indicate that, despite prior evidence of disability-related disparities, the receipt of help with self-care, mobility, and household activities varies by race and gender. Findings reveal several target areas for future research. Future work should examine the role of cultural and social preferences for care, as well as the appropriateness of help, as evidenced by health service use and changes in quality of life.
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Affiliation(s)
- Chanee D Fabius
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lauren J Parker
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Roland J Thorpe
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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22
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Temkin-Greener H, Mao Y, McGarry B, Zimmerman S, Li Y. Health Care Use and Outcomes in Assisted Living Communities: Race, Ethnicity, and Dual Eligibility. Med Care Res Rev 2021; 79:500-510. [PMID: 34623210 DOI: 10.1177/10775587211050189] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Assisted Living (AL) has become an important residential long-term care option in the United States, yet very little is known about the nature and quality of care received in this setting by racial/ethnic minorities or residents dually eligible for Medicare and Medicaid. Using calendar year 2018 Medicare data, we identified 255,564 fee-for-service Medicare beneficiaries age 55+ who resided in 24,108 ALs across the United States. We fit several logistic regression models with individual-level covariates and AL-level fixed effects, to examine the association between race/ethnicity and dual status with inpatient hospital admission, 30-day readmission, emergency room use, and nursing home placement. Significant variations in these measures were found both within and across ALs for racial/ethnic minority and dual residents. Our results suggest that disparities in outcomes are most significant by dual eligibility status rather than by race/ethnicity alone. These findings provide important implications for providers, policy makers, and researchers.
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Affiliation(s)
| | | | | | | | - Yue Li
- University of Rochester, NY, USA
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23
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Fashaw-Walters SA, McCreedy E, Bynum JPW, Thomas KS, Shireman TI. Disproportionate increases in schizophrenia diagnoses among Black nursing home residents with ADRD. J Am Geriatr Soc 2021; 69:3623-3630. [PMID: 34590709 DOI: 10.1111/jgs.17464] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 06/04/2021] [Accepted: 06/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous research demonstrated an increase in the reporting of schizophrenia diagnoses among nursing home (NH) residents after the Centers for Medicare & Medicaid Services National Partnership to Improve Dementia Care. Given known health and healthcare disparities among Black NH residents, we examined how race and Alzheimer's and related dementia (ADRD) status influenced the rate of schizophrenia diagnoses among NH residents following the partnership. METHODS We used a quasi-experimental difference-in-differences design to study the quarterly prevalence of schizophrenia among US long-stay NH residents aged 65 years and older, by Black race and ADRD status. Using 2011-2015 Minimum Data Set 3.0 assessments, our analysis controlled for age, sex, measures of function and frailty (activities of daily living [ADL] and Changes in Health, End-stage disease and Symptoms and Signs scores) and behavioral expressions. RESULTS There were over 1.2 million older long-stay NH residents, annually. Schizophrenia diagnoses were highest among residents with ADRD. Among residents without ADRD, Black residents had higher rates of schizophrenia diagnoses compared to their nonblack counterparts prior to the partnership. Following the partnership, Black residents with ADRD had a significant increase of 1.7% in schizophrenia as compared to nonblack residents with ADRD who had a decrease of 1.7% (p = 0.007). CONCLUSIONS Following the partnership, Black NH residents with ADRD were more likely to have a schizophrenia diagnosis documented on their MDS assessments, and schizophrenia rates increased for Black NH residents with ADRD only. Further work is needed to examine the impact of "colorblind" policies such as the partnership and to determine if schizophrenia diagnoses are appropriately applied in NH practice, particularly for black Americans with ADRD.
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Affiliation(s)
- Shekinah A Fashaw-Walters
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kali S Thomas
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
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24
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Innes HM, Walsh K, Österberg T. The inverse care law and the significance of income for utilization of longterm care services in a Nordic welfare state. Soc Sci Med 2021; 282:114125. [PMID: 34216942 DOI: 10.1016/j.socscimed.2021.114125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 03/18/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022]
Abstract
The Inverse Care Law states that the availability of good medical care tends to vary inversely with the need of the population served, with previous research indicating that migrant populations might be particularly at risk of this phenomenon. However, the degree to which the law applies to long-term care services (LTCS) in diverse ageing societies, where sizable older migrant populations need to be accounted for, has not been well investigated. To ensure equitable service provision, and to achieve European goals promoting a social right to care, it is critical to assess the extent to which such diverse populations are being neglected. This paper investigates the relationship between income and utilization of LTCS in Sweden amongst older native-born residents and older migrants born in low-, middle-, and high-income countries. The universality of its welfare system and the documented income differentials between foreign- and Swedish-born persons makes Sweden a particularly interesting case for assessing whether the most disadvantaged are the most underserved. The analysis uses register data on a total population of all older residents in Sweden, encompassing approximately two million persons. The results indicate that the Inverse Care Law does not apply to the utilization of LTCS by Swedish-born older people, nor by the majority of older migrants. However, the Inverse Care Law does appear to operate for older persons born in low-income countries who do not have a partner.
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Affiliation(s)
- Hanna Mac Innes
- University of Gothenburg, Department of Social Work, Sprängkullsgatan 23-25. PO Box 720, SE, 405 30, Gothenburg, Sweden; University of Gothenburg Centre for Ageing and Health (Age Cap), Sweden Institute of Neuroscience and Physiology, Wallinsgatan 6, SE, 431 41, Mölndal, Sweden.
| | - Kieran Walsh
- Professor of Ageing and Public Policy, Director - Irish Centre for Social Gerontology Institute for Lifecourse and Society, NUI, Galway, Ireland
| | - Torun Österberg
- University of Gothenburg, Department of Social Work, Sprängkullsgatan 23-25. PO Box 720, SE, 405 30, Gothenburg, Sweden
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25
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Travers JL, Naylor MD, Coe NB, Meng C, Li F, Cohen AB. Demographic Characteristics Driving Disparities in Receipt of Long-term Services and Supports in the Community Setting. Med Care 2021; 59:537-542. [PMID: 33827107 PMCID: PMC8119333 DOI: 10.1097/mlr.0000000000001544] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Research suggests that growth in Black and Hispanic (minority) older adults' nursing home (NH) use may be the result of disparities in access to community-based and alternative long-term services and supports (LTSS). OBJECTIVE We aimed to determine whether minority groups receiving care in NHs versus the community had fewer differences in their functional needs compared with the differences in nonminority older adults, suggesting a disparity. METHODS We identified respondents aged 65 years or above with a diagnosis of Alzheimer disease or dementia in the 2016 Health and Retirement Study who reported requiring LTSS help. We performed unadjusted analyses to assess the difference in functional need between community and NH care. Functional need was operationalized using a functional limitations score and 6 individual activities of daily living. We compared the LTSS setting for minority older adults to White older adults using difference-in-differences. RESULTS There were 186 minority older adults (community=75%, NH=25%) and 357 White older adults (community=50%, NH=50%). Between settings, minority older adults did not differ in education or marital status, but were younger and had greater income in the NH versus the community. The functional limitations score was higher in NHs than in the community for both groups. Functional needs for all 6 activities of daily living for the minority group were greater in NHs compared with the community. CONCLUSION Functional need for minority older adults differed by setting while demographics varied in unexpected ways. Factors such as familial and financial support are important to consider when implementing programs to keep older adults out of NHs.
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Affiliation(s)
| | - Mary D. Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing
| | - Norma B. Coe
- University of Pennsylvania Perelman School of Medicine
| | - Can Meng
- Yale Center for Analytical Sciences, Department of Biostatistics, Yale School of Public Health
| | - Fangyong Li
- Yale Center for Analytical Sciences, Department of Biostatistics, Yale School of Public Health
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26
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Beiting KJ, Huisingh‐Scheetz M, Walker J, Graupner J, Martinchek M, Thompson K, Levine S, Gleason LJ. Management and outcomes of a COVID-19 outbreak in a nursing home with predominantly Black residents. J Am Geriatr Soc 2021; 69:1155-1165. [PMID: 33739444 PMCID: PMC8218575 DOI: 10.1111/jgs.17126] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND/OBJECTIVES Few studies present clinical management approaches and outcomes of coronavirus disease 2019 (COVID-19) outbreaks in skilled nursing facilities (SNFs). We describe outcomes of a clinical management pathway for a large COVID-19 outbreak in an urban SNF with predominantly racial minority (>90% black), medically complex, older residents. DESIGN Single-center, retrospective, and observational cohort study (March 1, 2020-May 31, 2020). SETTING AND PARTICIPANTS All subacute and long-term care residents at an urban SNF between March 1, 2020 and May 31, 2020 (Chicago, IL). INTERVENTION A multicomponent management pathway was developed to manage a large COVID-19 outbreak in an SNF. MEASUREMENTS Chart review was used to extract demographics, comorbidities, symptoms, lab results, and clinical outcomes over 12 weeks, which were summarized and compared between residents with and without COVID-19. RESULTS A multicomponent clinical management pathway was used to care for residents with COVID-19, which included frequent scheduled clinical and laboratory evaluation, use of intravenous fluids, supplemental oxygen, antibiotics when indicated, and goals-of-care discussions. Of the 204 residents, 172 (84.3%) tested positive for SARS-CoV-2 during the 3-month period, with 50.5% symptomatic, 9.3% presymptomatic, and 24.5% asymptomatic, with a 30-day mortality rate of 15.7%. Predominant symptoms were low-grade fever >99 °F, anorexia, delirium, and fatigue. While in the facility, approximately one-quarter of residents experienced hypernatremia [Na > 145 mEq/L] (24.5%), acute kidney injury [Cr > 0.03 mg/dL or 1.5× baseline] (29.7%), or leukopenia [WBC < 4.8 1000/mm3 ] (39.4%). CONCLUSION We present the first available clinical strategy guiding the medical management of a COVID-19 syndrome in an urban SNF, caring for largely black residents, which may lead to improved mortality.
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Affiliation(s)
- Kimberly J. Beiting
- Department of Medicine, Section of Geriatrics and Palliative MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Megan Huisingh‐Scheetz
- Department of Medicine, Section of Geriatrics and Palliative MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Jacob Walker
- Department of Medicine, Section of Geriatrics and Palliative MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Jeffrey Graupner
- Department of Medicine, Section of Geriatrics and Palliative MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Michelle Martinchek
- Department of Medicine, Section of Geriatrics and Palliative MedicineUniversity of ChicagoChicagoIllinoisUSA
- Department of Physician Assistant StudiesSchool of Health and Rehabilitation Sciences, MGH Institute of Health ProfessionsBostonMassachusettsUSA
| | - Katherine Thompson
- Department of Medicine, Section of Geriatrics and Palliative MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Stacie Levine
- Department of Medicine, Section of Geriatrics and Palliative MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Lauren J. Gleason
- Department of Medicine, Section of Geriatrics and Palliative MedicineUniversity of ChicagoChicagoIllinoisUSA
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27
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Travers JL, Agarwal M, Estrada LV, Dick AW, Gracner T, Wu B, Stone PW. Assessment of Coronavirus Disease 2019 Infection and Mortality Rates Among Nursing Homes With Different Proportions of Black Residents. J Am Med Dir Assoc 2021; 22:893-898.e2. [PMID: 33762185 PMCID: PMC7898962 DOI: 10.1016/j.jamda.2021.02.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Coronavirus disease 2019 (COVID-19) has disproportionately impacted nursing homes (NHs) with large shares of Black residents. We examined the associations between the proportion of Black residents in NHs and COVID-19 infections and deaths, accounting for structural bias (operationalized as county-level factors) and stratifying by urbanicity/rurality. DESIGN This was a cross-sectional observational cohort study using publicly available data from the LTCfocus, Centers for Disease Control and Prevention Long-Term Care Facility COVID-19 Module, and the NYTimes county-level COVID-19 database. Four multivariable linear regression models omitting and including facility characteristics, COVID-19 burden, and county-level fixed effects were estimated. SETTING AND PARTICIPANTS In total, 11,587 US NHs that reported data on COVID-19 to the Centers for Disease Control and Prevention and had data in LTCfocus and NYTimes from January 20, 2020 through July 19, 2020. MEASURES Proportion of Black residents in NHs (exposure); COVID-19 infections and deaths (main outcomes). RESULTS The proportion of Black residents in NHs were as follows: none= 3639 (31.4%), <20% = 1020 (8.8%), 20%-49.9% = 1586 (13.7%), ≥50% = 681 (5.9%), not reported = 4661 (40.2%). NHs with any Black residents showed significantly more COVID-19 infections and deaths than NHs with no Black residents. There were 13.6 percentage points more infections and 3.5 percentage points more deaths in NHs with ≥50% Black residents than in NHs with no Black residents (P < .001). Although facility characteristics explained some of the differences found in multivariable analyses, county-level factors and rurality explained more of the differences. CONCLUSIONS AND IMPLICATIONS It is likely that attributes of place, such as resources, services, and providers, important to equitable care and health outcomes are not readily available to counties where NHs have greater proportions of Black residents. Structural bias may underlie these inequities. It is imperative that support be provided to NHs that serve greater proportions of Black residents while considering the rurality of the NH setting.
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Affiliation(s)
- Jasmine L Travers
- Rory Meyers College of Nursing, New York University, New York, NY, USA.
| | - Mansi Agarwal
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Leah V Estrada
- Center for Health Policy, Columbia University School of Nursing, New York, NY, USA
| | - Andrew W Dick
- Health Unit and Economics, Sociology and Statistics Group, Rand Corporation, Boston, MA, USA
| | | | - Bei Wu
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Patricia W Stone
- Center for Health Policy, Columbia University School of Nursing, New York, NY, USA
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28
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Addressing Systemic Racism in Nursing Homes: A Time for Action. J Am Med Dir Assoc 2021; 22:886-892. [PMID: 33775548 DOI: 10.1016/j.jamda.2021.02.023] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 02/24/2021] [Accepted: 02/24/2021] [Indexed: 11/22/2022]
Abstract
Long-term services and supports for older persons in the United States are provided in a complex, racially segregated system, with striking racial disparities in access, process, and outcomes of care for residents, which have been magnified during the Coronavirus Disease 2019 pandemic. These disparities are in large measure the result of longstanding patterns of structural, interpersonal, and cultural racism in US society, which in aggregate represent an underpinning of systemic racism that permeates the long-term care system's organization, administration, regulations, and human services. Mechanisms underlying the role of systemic racism in producing the observed disparities are numerous. Long-term care is fundamentally tied to geography, thereby reflecting disparities associated with residential segregation. Additional foundational drivers include a fragmented payment system that advantages persons with financial resources, and reimbursement policies that systematically undervalue long-term care workers. Eliminating disparities in health outcomes in these settings will therefore require a comprehensive approach to eliminating the role of systemic racism in promoting racial disparities.
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Gorges RJ, Konetzka RT. Factors Associated With Racial Differences in Deaths Among Nursing Home Residents With COVID-19 Infection in the US. JAMA Netw Open 2021; 4:e2037431. [PMID: 33566110 PMCID: PMC7876590 DOI: 10.1001/jamanetworkopen.2020.37431] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
IMPORTANCE It is important to understand differences in coronavirus disease 2019 (COVID-19) deaths by nursing home racial composition and the potential reasons for these differences so that limited resources can be distributed equitably. OBJECTIVE To describe differences in the number of COVID-19 deaths by nursing home racial composition and examine the factors associated with these differences. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of 13 312 nursing homes in the US used the Nursing Home COVID-19 Public File from the Centers for Medicare and Medicaid Services, which contains COVID-19 cases and deaths among nursing home residents as self-reported by nursing homes beginning between January 1, 2020, and May 24, 2020, and ending on September 13, 2020. Data were analyzed from July 28 to December 18, 2020. EXPOSURES Confirmed or suspected COVID-19 infection. Confirmed cases were defined as COVID-19 infection confirmed by a diagnostic laboratory test. Suspected cases were defined as signs and/or symptoms of COVID-19 infection or patient-specific transmission-based precautions for COVID-19 infection. MAIN OUTCOMES AND MEASURES Deaths associated with COVID-19 among nursing home residents. Death counts were compared by nursing home racial composition, which was measured as the proportion of White residents. RESULTS Among 13 312 nursing homes included in the study, the overall mean (SD) age of residents was 79.5 (6.7) years. A total of 51 606 COVID-19-associated deaths among residents were reported, with a mean (SD) of 3.9 (8.0) deaths per facility. The mean (SD) number of deaths in nursing homes with the lowest proportion of White residents (quintile 1) vs nursing homes with the highest proportions of White residents (quintile 5) were 5.6 (9.2) and 1.7 (4.8), respectively. Facilities in quintile 1 experienced a mean (SE) of 3.9 (0.2) more deaths than those in quintile 5, representing a 3.3-fold higher number of deaths in quintile 1 compared with quintile 5. Adjustment for the number of certified beds reduced the mean (SE) difference between these 2 nursing home groups to 2.2 (0.2) deaths. Controlling for case mix measures and other nursing home characteristics did not modify this association. Adjustment for county-level COVID-19 prevalence further reduced the mean (SE) difference to 1.0 (0.2) death. CONCLUSIONS AND RELEVANCE In this study, nursing homes with the highest proportions of non-White residents experienced COVID-19 death counts that were 3.3-fold higher than those of facilities with the highest proportions of White residents. These differences were associated with factors such as larger nursing home size and higher infection burden in counties in which nursing homes with high proportions of non-White residents were located. Focusing limited available resources on facilities with high proportions of non-White residents is needed to support nursing homes during potential future outbreaks.
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Affiliation(s)
- Rebecca J. Gorges
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
- Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, Illinois
| | - R. Tamara Konetzka
- Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, Illinois
- Department of Medicine, Biological Sciences Division, University of Chicago, Chicago, Illinois
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30
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Snowden LR, Graaf G. COVID-19, Social Determinants Past, Present, and Future, and African Americans' Health. J Racial Ethn Health Disparities 2021; 8:12-20. [PMID: 33230737 PMCID: PMC7682952 DOI: 10.1007/s40615-020-00923-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/09/2020] [Accepted: 11/03/2020] [Indexed: 11/28/2022]
Abstract
As the COVID-19 pandemic progresses, more African Americans than whites are falling ill and dying from the virus and more are losing livelihoods from the accompanying recession. The virus thereby exploits structural disadvantages, rooted partly in historical and contemporary anti-Black sentiments, working against African Americans. These include higher rates of comorbid illness and more limited health care access, higher rates of disadvantageous labor market positioning and community and housing conditions, greater exposure to long-term care residence, and higher incarceration rates. COVID-19 also exposes African Americans' greater vulnerability to recession, and possibly greater susceptibility to accompanying behavioral health problems. If they are left unaddressed, the very vulnerabilities COVID-19 exploits may perpetuate themselves. However, continuing and supplementing health and economic COVID mitigation policies can disproportionately benefit African Americans and reduce short- and long-term adverse effects. The greater impact of COVID-19 on African Americans demonstrates the consequences of pervasive social and economic inequality and marks this as a critical time to prevent further compounding of adverse effects.
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Affiliation(s)
- Lonnie R. Snowden
- School of Public Health, University of California, Berkeley, University Hall #235, Berkeley, CA 94720 USA
| | - Genevieve Graaf
- School of Social Work, University of Texas, Arlington, Arlington, TX USA
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31
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Shippee TT, Ng W, Duan Y, Woodhouse M, Akosionu O, Chu H, Ahluwalia JS, Gaugler JE, Virnig BA, Bowblis JR. Changes over Time in Racial/Ethnic Differences in Quality of Life for Nursing Home Residents: Patterns within and between Facilities. J Aging Health 2020; 32:1498-1509. [PMID: 32648793 PMCID: PMC9121738 DOI: 10.1177/0898264320939006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | - Weiwen Ng
- University of Minnesota, Twin Cities, USA
| | | | | | | | - Haitao Chu
- University of Minnesota, Twin Cities, USA
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32
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Konetzka RT, Jung DH, Gorges RJ, Sanghavi P. Outcomes of Medicaid home- and community-based long-term services relative to nursing home care among dual eligibles. Health Serv Res 2020; 55:973-982. [PMID: 33258129 PMCID: PMC7704475 DOI: 10.1111/1475-6773.13573] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To provide the first plausibly causal national estimates of health outcomes for older dual-eligible recipients of Medicaid HCBS relative to nursing home care and to explore possible mechanisms for the effect. DATA SOURCES We use 2005 and 2012 Medicaid Analytic eXtract (MAX), a national compilation of Medicaid claims, merged with Medicare claims to identify hospital admissions, our main outcome variable. STUDY DESIGN We model the effects of HCBS using a longitudinal instrumental variables framework. To address the endogeneity of HCBS receipt, we instrument for it using the county percentage of nonelderly long-term care users who receive HCBS. The percentage of nonelderly users is highly predictive of HCBS use for an elderly beneficiary, but because the instrument was derived from a separate population, the exclusion restriction is unlikely to be violated. POPULATION STUDIED 1,312,498 older adults (65+) dually enrolled in Medicaid and Medicare and are using long-term care. We also examine heterogeneity of effects by race/ethnicity and the presence of dementia. PRINCIPAL FINDINGS HCBS users have 10 percentage points higher (P < .01) annual rates of hospitalization than their nursing home counterparts when selection bias is addressed; rates of potentially avoidable hospitalizations are 3 percentage points higher (P < .01). These differences persist across races, dementia status, and intensity of HCBS spending. CONCLUSIONS Shifting Medicaid long-term care funding for older adults from nursing homes to HCBS, while well-motivated, results in the unintended consequence of substantially higher hospitalization rates for older dual eligibles. The quality and/or quantity of services may be inadequate for some HCBS recipients. Hospitalizations are costly to Medicare but also to the HCBS recipient in terms of stress and risks. Although consumer preferences to remain at home may outweigh poor outcomes of HCBS, the full costs and benefits need to be considered. HCBS outcomes-not just expansion-need more attention.
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Affiliation(s)
- R. Tamara Konetzka
- Department of Public Health SciencesThe University of Chicago Biological SciencesChicagoIllinoisUSA
| | - Daniel H. Jung
- Department of Public Health SciencesThe University of Chicago Biological SciencesChicagoIllinoisUSA
| | - Rebecca J. Gorges
- Department of Public Health SciencesThe University of Chicago Biological SciencesChicagoIllinoisUSA
| | - Prachi Sanghavi
- Department of Public Health SciencesThe University of Chicago Biological SciencesChicagoIllinoisUSA
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Jenkins Morales M, Robert SA. Black-White Disparities in Moves to Assisted Living and Nursing Homes Among Older Medicare Beneficiaries. J Gerontol B Psychol Sci Soc Sci 2020; 75:1972-1982. [PMID: 31665513 PMCID: PMC7566960 DOI: 10.1093/geronb/gbz141] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Investigate black-white disparities in older adults' moves to assisted living and nursing homes and draw from the Andersen Healthcare Utilization Model to test explanations for any disparities. METHODS Data are from a nationally representative sample of older community-dwelling Medicare beneficiaries from the 2015 (N = 5,212) National Health and Aging Trends Study (NHATS). We use stepwise multinomial logistic regression to examine black-white disparities in moves out of community housing to assisted living or a nursing home over 2 years, before and after adjusting for predisposing (age, gender), enabling (income, housing tenure, Medicaid, living arrangement) and need (activities of daily living [ADL] limitation, physical capacity, self-rated health, and dementia) factors. RESULTS Black older adults are less likely to move to assisted living and are more likely to move to a nursing home compared to white older adults. Black-white disparities in moves to nursing homes are explained by black-white differences in enabling and need factors, whereas black-white disparities in moves to assisted living remain even after adjusting for enabling and need factors. DISCUSSION Unmeasured factors related to systemic racism (e.g., residential racial segregation, racial discrimination) and/or black-white differences in care preferences might further explain black-white disparities in moves to assisted living and warrant further investigation.
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Gorges RJ, Sanghavi P, Konetzka RT. A National Examination Of Long-Term Care Setting, Outcomes, And Disparities Among Elderly Dual Eligibles. Health Aff (Millwood) 2020; 38:1110-1118. [PMID: 31260370 DOI: 10.1377/hlthaff.2018.05409] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The benefits of expanding funding for Medicaid long-term care home and community-based services (HCBS) relative to institutional care are often taken as self-evident. However, little is known about the outcomes of these services, especially for racial and ethnic minority groups, whose members tend to use the services more than whites do, and for people with dementia who may need high-intensity care. Using national Medicaid claims data on older adults enrolled in both Medicare and Medicaid, we found that overall hospitalization rates were similar for HCBS and nursing facility users, although nursing facility users were generally sicker as reflected in their claims history. Among HCBS users, blacks were more likely to be hospitalized than non-Hispanic whites were, and the gap widened among blacks and whites with dementia. Also, conditional on receiving HCBS, Medicaid HCBS spending was higher for whites than for nonwhites, and higher Medicare and Medicaid hospital spending for blacks and Hispanics did not offset this difference. Our findings suggest that home and community-based services need to be carefully targeted to avoid adverse outcomes and that the racial/ethnic disparities in access to high-quality institutional long-term care are also present in HCBS. Policy makers should consider the full costs and benefits of shifting care from nursing facilities to home and community settings and the potential implications for equity.
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Affiliation(s)
- Rebecca J Gorges
- Rebecca J. Gorges is a PhD candidate in the Harris School of Public Policy, University of Chicago, in Illinois
| | - Prachi Sanghavi
- Prachi Sanghavi is an assistant professor in the Department of Public Health Sciences, University of Chicago
| | - R Tamara Konetzka
- R. Tamara Konetzka ( ) is a professor in the Department of Public Health Sciences and the Department of Medicine, University of Chicago
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Sabatello M, Burke TB, McDonald KE, Appelbaum PS. Disability, Ethics, and Health Care in the COVID-19 Pandemic. Am J Public Health 2020; 110:1523-1527. [PMID: 32816541 DOI: 10.2105/ajph.2020.305837] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This article considers key ethical, legal, and medical dilemmas arising for people with disabilities in the COVID-19 pandemic. We highlight the limited application of existing frameworks of emergency planning with and for people with disabilities in the COVID-19 pandemic, explore key concerns and issues affecting the health care of people with disabilities (i.e., access to information and clinician-patient communication, nondiscrimination and reasonable accommodations, and rationing of medical goods), and indicate possible solutions. Finally, we suggest clinical and public health policy measures to ensure that people with disabilities are included in the planning of future pandemic-related efforts.The devastation evoked by the COVID-19 pandemic raises challenging dilemmas in bioethics. It also speaks to social justice issues that have plagued historically marginalized communities in the United States.Responses to the pandemic must be bound by legal standards, principles of distributive justice, and societal norms of protecting vulnerable populations-core commitments of public health-to ensure that inequities are not exacerbated, and should provide a pathway for improvements to ensure equitable access and treatment in the future.
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Affiliation(s)
- Maya Sabatello
- Maya Sabatello and Paul S. Appelbaum are with the Center for Law, Ethics, and Psychiatry, Department of Psychiatry, Columbia University, New York, NY. Teresa Blankmeyer Burke is with the Department of History, Philosophy, Religion, and Sociology, Gallaudet University, Washington, DC. Katherine E. McDonald is with the Department of Public Health, Falk College, Syracuse University, Syracuse, NY
| | - Teresa Blankmeyer Burke
- Maya Sabatello and Paul S. Appelbaum are with the Center for Law, Ethics, and Psychiatry, Department of Psychiatry, Columbia University, New York, NY. Teresa Blankmeyer Burke is with the Department of History, Philosophy, Religion, and Sociology, Gallaudet University, Washington, DC. Katherine E. McDonald is with the Department of Public Health, Falk College, Syracuse University, Syracuse, NY
| | - Katherine E McDonald
- Maya Sabatello and Paul S. Appelbaum are with the Center for Law, Ethics, and Psychiatry, Department of Psychiatry, Columbia University, New York, NY. Teresa Blankmeyer Burke is with the Department of History, Philosophy, Religion, and Sociology, Gallaudet University, Washington, DC. Katherine E. McDonald is with the Department of Public Health, Falk College, Syracuse University, Syracuse, NY
| | - Paul S Appelbaum
- Maya Sabatello and Paul S. Appelbaum are with the Center for Law, Ethics, and Psychiatry, Department of Psychiatry, Columbia University, New York, NY. Teresa Blankmeyer Burke is with the Department of History, Philosophy, Religion, and Sociology, Gallaudet University, Washington, DC. Katherine E. McDonald is with the Department of Public Health, Falk College, Syracuse University, Syracuse, NY
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Shippee TP, Akosionu O, Ng W, Woodhouse M, Duan Y, Thao MS, Bowblis JR. COVID-19 Pandemic: Exacerbating Racial/Ethnic Disparities in Long-Term Services and Supports. J Aging Soc Policy 2020; 32:323-333. [PMID: 32476614 PMCID: PMC9152947 DOI: 10.1080/08959420.2020.1772004] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Tetyana P. Shippee
- Associate Professor, Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware St SMC 729, Minneapolis, MN, 55116
| | - Odichinma Akosionu
- Research Assistant, Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware St MMC 729, Minneapolis, MN, 55455
| | - Weiwen Ng
- Research Assistant, Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware St, Minneapolis, MN, 55116
| | - Mark Woodhouse
- Database Manager, School of Public Health, University of Minnesota, 420 Delaware St, Minneapolis, MN, 55116
| | - Yinfei Duan
- Research Assistant, School of Public Health, University of Minnesota, 5-140 Weaver-Densford Hall, 308 Harvard Street SE, Minneapolis, MN 55455
| | - Mai See Thao
- Postdoctoral Fellow in Primary Care Research, Department of Family and Community Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Post Office Box 26509, Milwaukee, WI 53226
| | - John R. Bowblis
- Professor of Economics, Farmer School of Business, Miami University, 800 E. High Street, Oxford, OH 45056
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Shippee TP, Ng W, Bowblis JR. Does Living in a Higher Proportion Minority Facility Improve Quality of Life for Racial/Ethnic Minority Residents in Nursing Homes? Innov Aging 2020; 4:igaa014. [PMID: 32529052 PMCID: PMC7272785 DOI: 10.1093/geroni/igaa014] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Tetyana P Shippee
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Weiwen Ng
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - John R Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, Ohio
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Mauldin RL, Lee K, Tang W, Herrera S, Williams A. Supports and gaps in federal policy for addressing racial and ethnic disparities among long-term care facility residents. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2020; 63:354-370. [PMID: 32338585 DOI: 10.1080/01634372.2020.1758270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Rebecca L Mauldin
- School of Social Work, University of Texas at Arlington , Arlington, Texas, USA
| | - Kathy Lee
- School of Social Work, University of Texas at Arlington , Arlington, Texas, USA
| | - Weizhou Tang
- Leonard Davis School of Gerontology, University of Southern California , Los Angeles, California, USA
| | - Sarah Herrera
- School of Social Work, University of Texas at Arlington , Arlington, Texas, USA
| | - Antwan Williams
- School of Social Work, University of Texas at Arlington , Arlington, Texas, USA
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Fashaw S, Chisholm L, Mor V, Meyers DJ, Liu X, Gammonley D, Thomas K. Inappropriate Antipsychotic Use: The Impact of Nursing Home Socioeconomic and Racial Composition. J Am Geriatr Soc 2020; 68:630-636. [PMID: 31967325 PMCID: PMC7110922 DOI: 10.1111/jgs.16316] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 12/01/2019] [Accepted: 12/12/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Previous research suggests black nursing home (NH) residents are more likely to receive inappropriate antipsychotics. Our aim was to examine how NH characteristics, particularly the racial and socioeconomic composition of residents, are associated with the inappropriate use of antipsychotics. DESIGN This study used a longitudinal approach to examine national data from Long-Term Care: Facts on Care in the US (LTCFocUS.org) between 2000 and 2015. We used a multivariate linear regression model with year and state fixed effects to estimate the prevalence of inappropriate antipsychotic use at the NH level. SETTING Free-standing NHs in the United States. PARTICIPANTS The sample consisted of 12 964 NHs. MEASUREMENTS The outcome variable was inappropriate antipsychotic use at the facility level. The primary indicator variables were whether a facility had high proportions of black residents and the percentage of residents with Medicaid as their primary payer. RESULTS NHs with high and low proportions of blacks had similar rates of antipsychotic use in the unadjusted analyses. NHs with high proportions of black residents had significantly lower rates of inappropriate antipsychotic use (β = -2; P < .001) in the adjusted analyses. Facilities with high proportions of Medicaid-reliant residents had higher proportions of inappropriate use (β = .04; P < .001). CONCLUSION Findings from this study indicate a decline in the use of antipsychotics. Although findings from this study indicated facilities with higher proportions of blacks had lower inappropriate antipsychotic use, facility-level socioeconomic disparities continued to persist among NHs. Policy interventions that focus on reimbursement need to be considered to promote reductions in antipsychotic use, specifically among Medicaid-reliant NHs. J Am Geriatr Soc 68:630-636, 2020.
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Affiliation(s)
- Shekinah Fashaw
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Latarsha Chisholm
- Department of Health Management & Informatics, College of Community Innovation and Education, University of Central Florida, Orlando, Florida
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
- Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - David J Meyers
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Xinliang Liu
- Department of Health Management & Informatics, College of Community Innovation and Education, University of Central Florida, Orlando, Florida
| | - Denise Gammonley
- School of Social Work, College of Health Professions and Sciences, University of Central Florida, Orlando, Florida
| | - Kali Thomas
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
- Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island
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Sanghavi P, Pan S, Caudry D. Assessment of nursing home reporting of major injury falls for quality measurement on nursing home compare. Health Serv Res 2019; 55:201-210. [PMID: 31884706 PMCID: PMC7080404 DOI: 10.1111/1475-6773.13247] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess the accuracy of nursing home self-report of major injury falls on the Minimum Data Set (MDS). DATA SOURCES MDS assessments and Medicare claims, 2011-2015. STUDY DESIGN/METHODS We linked inpatient claims for major injury falls with MDS assessments. The proportion of claims-identified falls reported for each fall-related MDS item was calculated. Using multilevel modeling, we assessed patient and nursing home characteristics that may be predictive of poor reporting. We created a claims-based major injury fall rate for each nursing home and estimated its correlation with Nursing Home Compare (NHC) measures. PRINCIPAL FINDINGS We identified 150,828 major injury falls in claims that occurred during nursing home residency. For the MDS item used by NHC, only 57.5 percent were reported. Reporting was higher for long-stay (62.9 percent) than short-stay (47.2 percent), and for white (59.0 percent) than nonwhite residents (46.4 percent). Adjusting for facility-level race differences, reporting was lower for nonwhite people than white people; holding constant patient race, having larger proportions of nonwhite people in a nursing home was associated with lower reporting. The correlation between fall rates based on claims vs the MDS was 0.22. CONCLUSIONS The nursing home-reported data used for the NHC falls measure may be highly inaccurate.
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Affiliation(s)
- Prachi Sanghavi
- Department of Public Health Sciences, The University of Chicago Biological Sciences, Chicago, Illinois
| | - Shengyuan Pan
- Department of Public Health Sciences, The University of Chicago Biological Sciences, Chicago, Illinois
| | - Daryl Caudry
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Ko M, Newcomer RJ, Bindman AB, Kang T, Hulett D, Spetz J. Changing home care aides: Differences between family and non-family care in California Medicaid home and community-based services. Home Health Care Serv Q 2019; 39:1-16. [PMID: 31826707 DOI: 10.1080/01621424.2019.1701601] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In California Medicaid home-and-community-based services (HCBS), recipients' family members receive payment as home care aides (HCAs). We analyzed data on first-time HCBS recipients to examine factors associated with the likelihood of switching HCAs within the first year of services. Those with family HCAs were less than half as likely to change than those with non-family HCAs and racial/ethnic minorities with non-family HCAs had the highest switching rates. Lower wages and local unemployment were associated with switching of non-family HCAs but not family HCAs. Policymakers can foster continuity of home care by paying family members for home care and raising worker wages.
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Affiliation(s)
- Michelle Ko
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, USA
| | - Robert J Newcomer
- Department of Public Health Sciences, University of California, San Francisco, USA
| | - Andrew B Bindman
- Department of Public Health Sciences, University of California, San Francisco, USA
| | - Taewoon Kang
- Department of Public Health Sciences, University of California, San Francisco, USA
| | - Denis Hulett
- California Medicaid Research Institute, University of California, San Francisco, USA
| | - Joanne Spetz
- Department of Public Health Sciences, University of California, San Francisco, USA
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Sharma H, Konetzka RT, Smieliauskas F. The Relationship Between Reported Staffing and Expenditures in Nursing Homes. Med Care Res Rev 2019; 76:758-783. [PMID: 29094651 PMCID: PMC7478324 DOI: 10.1177/1077558717739214] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Dramatic improvements in reported nursing home quality, including staffing ratios, have come under increased scrutiny in recent years because they are based on data self-reported by nursing homes. In contrast to other domains, the key mechanism for real improvement in the staffing ratios domain is clearer: to improve scores, nursing homes should increase staffing expenditures. We analyze the relationship between changes in expenditures and reported staffing quality pre- versus post the 5-star rating system. Our results show that the relationship between expenditures and licensed practical nurse staffing is weaker in the post-5-star period, overall, and across subgroups; furthermore, there is a weaker relationship between expenditures and registered nurse staffing among for-profit facilities with a high share of Medicaid residents in the post-5-star period. The weaker relationship between staffing expenditures and staffing scores in the post-5-star era underscores the potential for gaming of the self-reported staffing scores and the need for more reliable sources.
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Loomer L, Volandes AE, Mitchell SL, Belanger E, McCreedy E, Palmer JA, Mor V. Black Nursing Home Residents More Likely to Watch Advance Care Planning Video. J Am Geriatr Soc 2019; 68:603-608. [PMID: 31660609 DOI: 10.1111/jgs.16237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/01/2019] [Accepted: 10/01/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES This study aims to identify resident characteristics associated with being offered and subsequently shown an advance care planning (ACP) video in the Pragmatic Trial of Video Education in Nursing Homes (PROVEN) and if differences are driven by within- and/or between-facility differences. DESIGN Cross-sectional study, from March 1, 2016, to May 31, 2018. SETTING A total of 119 PROVEN intervention nursing homes (NHs). PARTICIPANTS A total of 43 303 new NH admissions. MEASUREMENTS Data came from the Minimum Data Set and an electronic record documenting whether a video was offered and shown to residents. We conduct both naïve logistic regression models and hierarchical logistic models, controlling for NH fixed effects, to examine the overall differences in offer and show rate by resident characteristics. RESULTS In naïve regression models, compared to white residents, black residents are 7.8 percentage point (pp) (95% confidence interval [CI] = -9.1 to -6.5 pp) less likely to be offered the video. These differences decrease to 1.3 pp (95% CI = -2.61 to -0.02 pp) when accounting for NH fixed effects. In fully adjusted models, black residents compared to white residents were 2.1 pp more likely to watch the video contingent on being offered (95% CI = 0.4-3.7 pp). Residents with cognitive impairment were less likely to be offered and shown the video. CONCLUSIONS After controlling for NH fixed effects, there were smaller racial differences in being offered the video, but once offered, black residents were more likely to watch the video. This suggests that black residents are receptive to this type of ACP intervention but need to be given an opportunity to be exposed. J Am Geriatr Soc 68:603-608, 2020.
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Affiliation(s)
- Lacey Loomer
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Angelo E Volandes
- Section of General Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Susan L Mitchell
- Hebrew Senior Life, Institute for Aging Research, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Emmanuelle Belanger
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island
| | - Jennifer A Palmer
- Hebrew Senior Life, Institute for Aging Research, Boston, Massachusetts
| | - Vincent Mor
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island.,Providence Veterans Administration Medical Center, Center of Innovation in Health Services Research & Development Service (HSR&D), Providence, Rhode Island
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Racial Disparities in Medicaid Home and Community-Based Service Utilization among White, Black, and Hispanic Adults with Multiple Sclerosis: Implications of State Policy. J Racial Ethn Health Disparities 2019; 6:1200-1207. [PMID: 31359384 DOI: 10.1007/s40615-019-00621-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/14/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
Abstract
Home- and community-based services (HCBS) provide support to individuals needing assistance with daily activities, like people with multiple sclerosis (MS) who often experience functional impairment. Research notes racial differences in HCBS utilization among people with MS, which may be attributed to state's relative amount of long-term service and support (LTSS) expenditures dedicated to HCBS (HCBS priority). As a first step in untangling this mechanism, we explored how HCBS priority may contribute to racial differences in service utilization. Using Medicaid claims data for a national cohort of dual eligibles with MS, we find state HCBS priority is associated with disparities in utilization-blacks and Hispanics receiving HCBS more often do so in low-priority states compared with whites. Findings indicate a need for additional research focusing on health equity to further examine effects on quality of life and health outcomes of individuals who would benefit from more generous HCBS policies, specifically determining whether minorities in low-HCBS states fare worse than those in high-priority states. Findings from the present study can help policymakers more effectively design HCBS programs for diverse individuals.
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Huang SS, Banaszak-Holl J, Yuan S, Hirth RA. The Determinants and Variation of Nursing Home Private-Pay Prices: Organizational and Market Structure. Med Care Res Rev 2019; 78:173-180. [PMID: 31218922 DOI: 10.1177/1077558719857335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nursing home (NH) care is arguably the most significant financial risk faced by the elderly without long-term care insurance or Medicaid coverage. Annual out-of-pocket expenditures for NH care can easily exceed $70,000. However, our understanding of private-pay prices is limited by data availability. Utilizing a unique data set on NH prices from 2005 through 2010 across eight states, we find that NH price growth has consistently outpaced growth in consumer and medical care prices. After adjusting for geographical and facility differences, for-profit chains charge the lowest prices, independently operated for-profit and nonprofit NHs have similar prices, and nonprofit chains charge the highest prices. Adjusted prices are also likely to be higher when NHs have higher occupancy rates and markets are more concentrated. The significant differences in price across organizational and market structures suggest private-pay prices can be an important factor when evaluating and comparing the value of NH care.
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46
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Felix HC, Ali M, Bird TM, Cottoms N, Stewart MK. Are community health workers more effective in identifying persons in need of home and community-based long-term services than standard-passive approaches. Home Health Care Serv Q 2019; 38:194-208. [PMID: 31060448 DOI: 10.1080/01621424.2019.1604461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Consumers prefer home and community-based long-term care (LTC) services (HCBS) but lack information on those services. We examined the use of community health workers (CHWs) to find and help Medicaid beneficiaries with unmet LTC needs access HCBS compared to standard HCBS outreach approaches. We found that CHWs were very effective at finding persons with greater needs and were better able to help them access a greater range of HCBS services. We also found that five times fewer HCBS beneficiaries helped by CHWs had to use nursing home care services than those not helped by the CHWs despite the fact that their health status was poorer than those not helped by the CHWs. Our study provides evidence of the effectiveness of CHWs for HCBS service awareness and navigation.
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Affiliation(s)
- Holly C Felix
- a Fay W. Boozman College of Public Health , University of Arkansas for Medical Sciences , Little Rock , AR , USA
| | - Mir Ali
- a Fay W. Boozman College of Public Health , University of Arkansas for Medical Sciences , Little Rock , AR , USA
| | - T Mac Bird
- a Fay W. Boozman College of Public Health , University of Arkansas for Medical Sciences , Little Rock , AR , USA
| | - Naomi Cottoms
- b Tri County Rural Health Network , Helena-West Helena , AR , USA
| | - M Kate Stewart
- a Fay W. Boozman College of Public Health , University of Arkansas for Medical Sciences , Little Rock , AR , USA
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Sharma H, Perraillon MC, Werner RM, Grabowski DC, Konetzka RT. Medicaid and Nursing Home Choice: Why Do Duals End Up in Low-Quality Facilities? J Appl Gerontol 2019; 39:981-990. [PMID: 30957619 DOI: 10.1177/0733464819838447] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We provide empirical evidence on the relative importance of specific observable factors that can explain why individuals enrolled in both Medicare and Medicaid (duals) are concentrated in lower quality nursing homes, relative to those not on Medicaid. Descriptive results show that duals are 9.7 percentage points more likely than nonduals to be admitted to a low-quality (1-2 stars) nursing home. Using the Blinder-Oaxaca decomposition approach in a multivariate framework, we find that 35.4% of the difference in admission to low-quality nursing homes can be explained by differences in the distribution of observable characteristics. Differences in education and distance to high-quality nursing homes are important drivers, as are health status and race. Our findings highlight the need for creative policy solutions targeting the modifiable factors to reduce the disparity.
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Nee R, Thurlow JS, Norris KC, Yuan C, Watson MA, Agodoa LY, Abbott KC. Association of Race and Poverty With Mortality Among Nursing Home Residents on Maintenance Dialysis. J Am Med Dir Assoc 2019; 20:904-910. [PMID: 30929962 DOI: 10.1016/j.jamda.2019.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 01/19/2019] [Accepted: 02/11/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The association of race, ethnicity, and socioeconomic factors with survival rates of nursing home (NH) residents with treated end-stage renal disease (ESRD) is unclear. We examined whether race/ethnicity, ZIP code-level, and individual-level indicators of poverty relate to mortality of NH residents on dialysis. DESIGN Retrospective cohort study. PARTICIPANTS/SETTING Using the United States Renal Data System database, we identified 56,194 nursing home residents initiated on maintenance dialysis from January 1, 2007 through December 31, 2013, followed until May 31, 2014. MEASUREMENTS We evaluated baseline characteristics of the NH cohort on dialysis, including race and ethnicity. We assessed the Medicare-Medicaid dual eligibility status as an indicator of individual-level poverty and ZIP code-level median household income (MHI) data. We conducted Cox regression analyses with all-cause mortality as the outcome variable, adjusted for clinical and sociodemographic factors including end-of-life preferences. RESULTS Adjusted Cox analysis showed a significantly lower risk of death among black vs nonblack NH residents [adjusted hazard ratio (AHR) 0.91, 95% confidence interval (CI) 0.89, 0.94]. Dual-eligibility status was significantly associated with lower risk of death compared to those with Medicare alone (AHR 0.80, 95% CI 0.78, 0.82). Compared to those in higher MHI quintile levels, NH ESRD patients in the lowest quintile were significantly associated with higher risk of death (AHR 1.09, 95% CI 1.06, 1.13). CONCLUSIONS/IMPLICATIONS Black and Hispanic NH residents on dialysis had an apparent survival advantage. This "survival paradox" occurs despite well-documented racial/ethnic disparities in ESRD and NH care and warrants further exploration that could generate new insights into means of improving survival of all NH residents on dialysis. Area-level indicator of poverty was independently associated with mortality, whereas dual-eligibility status for Medicare and Medicaid was associated with lower risk of death, which could be partly explained by improved access to care.
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Affiliation(s)
- Robert Nee
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, MD; Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - John S Thurlow
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, MD; Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Keith C Norris
- Department of Medicine, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA
| | - Christina Yuan
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, MD; Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Maura A Watson
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, MD; Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Lawrence Y Agodoa
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Kevin C Abbott
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
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Chisholm L, Zhang NJ, Hyer K, Pradhan R, Unruh L, Lin FC. Culture Change in Nursing Homes: What Is the Role of Nursing Home Resources? INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2018; 55:46958018787043. [PMID: 30015532 PMCID: PMC6050816 DOI: 10.1177/0046958018787043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Quality of care has been a long-standing issue in US nursing homes. The culture
change movement attempts to transition nursing homes from health care
institutions to person-centered homes. While the adoption of culture change has
been spreading across nursing homes, barriers to adoption persist. Nursing homes
that disproportionately serve minority residents may have additional challenges
implementing culture change compared with other facilities due to limited
financial and staffing resources. The objective of this study was to examine how
nursing home characteristics are associated with culture change adoption in
Central Florida nursing homes. This cross-sectional study included 81 directors
of nursing (DONs) who completed the Artifacts of Culture Change survey. In
addition, nursing home organizational data were obtained from the Certification
and Survey Provider Enhanced Reports (CASPER). A logistic regression was
conducted to examine the relationship between high culture change adoption and
nursing home characteristics. The overall adoption of culture change scores in
Central Florida nursing homes was low. Nevertheless, there was variability
across nursing homes in the adoption of culture change. High culture change
adoption was associated with nursing homes having lower proportions of Medicaid
residents.
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Affiliation(s)
| | | | | | - Rohit Pradhan
- 4 University of Arkansas for Medical Sciences, Little Rock, USA
| | - Lynn Unruh
- 1 University of Central Florida, Orlando, USA
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Yuan Y, Louis C, Cabral H, Schneider JC, Ryan CM, Kazis LE. Socioeconomic and Geographic Disparities in Accessing Nursing Homes With High Star Ratings. J Am Med Dir Assoc 2018; 19:852-859.e2. [DOI: 10.1016/j.jamda.2018.05.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/26/2018] [Accepted: 05/21/2018] [Indexed: 10/28/2022]
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