Racial/Ethnic Disparities in Nursing Home Quality of Life Deficiencies, 2001 to 2011

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

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

Resident racial and ethnic composition, neighborhood-level socioeconomic status, and COVID-19 infections in California SNFs

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.

Implementation of a CMS Nursing Facility Initiative: Differences by Racial Minority Resident Population

Objectives: The CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents: Payment Reform (NFI 2) provided billing opportunities to incentivize participating facilities to keep long-stay residents onsite for acute care, rather than hospitalizing them. We examined cross-facility differences in NFI 2 implementation by racial composition of facility resident populations. Methods: We analyzed Medicare claims in conjunction with in-person and telephone interviews among facility staff to assess NFI 2 engagement in relation to racial minority resident population. Results: Participating facilities with larger racial minority resident populations faced additional barriers to NFI 2 implementation. These facilities submitted fewer NFI 2 claims, reported more challenges engaging resident families, and experienced greater facility staff and leadership instability, compared to facilities with predominantly white resident populations. Discussion: Addressing structural differences within facilities with larger populations of racial minority residents may encourage future development of targeted programs to support diverse nursing facilities.

Dismantling Systemic Racism in Long-Term Services and Supports: A Call to Action for Social Workers

Given the rapidly changing Long-Term Services and Supports (LTSS) system in the United States, it is essential for social workers and other health professionals to critically examine how this evolving landscape continues to shape racial inequities in formal LTSS and subsequent health outcomes. This commentary seeks to inform social work education, research, and practice by describing how systemic racism impacts the use and quality of formal LTSS. We present a call to action for social workers to dismantle systemic racism in LTSS that perpetuates ongoing racial inequities.

The Intersections of Structural Racism and Ageism in the Time of COVID-19: A Call to Action for Gerontological Nursing Science

The health consequences of systemic racism and ageism have received growing attention as the coronavirus disease 2019 pandemic has illuminated long-standing inadequacies and injustices that are structurally engrained in our health systems. The current State of the Science Commentary addresses the intersecting influences of systemic racism and ageism, and other "-isms" that conspire to create disparate health outcomes for older adults from historically excluded and marginalized backgrounds. We focus specifically on the long-term care sector as a representative microcosm of structural inequities, while recognizing that these unjust barriers to health are widespread, endemic, and pervasive. We present a call to action for gerontological nursing science to engage deeply and robustly in these realities, and the ethical and scientific imperative they present to ensure that all older adults encounter just conditions for maximizing their health and well-being. [Research in Gerontological Nursing, 15(1), 6-13.].

Variations Between Adult Day Services Centers in the United States by the Racial and Ethnic Case-Mix of Center Participants

This is the first nationally representative study to identify differences between adult day services centers, a unique home- and community-based service, by racial/ethnic case-mix: Centers were classified as having a majority of participants who were Hispanic, non-Hispanic Black, or non-Hispanic other race/ethnicities and non-Hispanic White. The associations between racial/ethnic case-mix and geographic and operational characteristics of centers and health and functioning needs of participants were assessed using multivariate regression analyses, using the 2014 National Study of Long-term Care Providers' survey of 2,432 centers. Half of all adult day centers predominantly served racial/ethnic minorities, which were more likely to be for-profit, had lower percentages of self-pay revenue, more commonly provided transportation services, and had higher percentages of participants with diabetes, compared with predominantly non-Hispanic White centers. Findings show differences by racial/ethnic case-mix, which are important when considering the long-term care needs of a diverse population of older adults.

The Landscape of Perception: Racial Differences in How Disability Is Viewed Among Older-Adult Cancer Survivors

This paper compares disability perceptions of Black with white older cancer survivors' to document racial disparities in these perceptions and the factors that contribute to them. The data are from a randomly selected tumor registry sample of 321 older adult cancer survivors from an NCI funded study. OLS regression models of disability perceptions, nested by race, examined the effects cancer and non-cancer health factors along with important covariates. Black older adult cancer survivors perceived themselves to be more disabled than did white survivors. Multivariate analyses showed a strong relationship between functional difficulties and disability perceptions for both Black and white survivors. However cancer-related factors such as continuing symptoms of the illness or treatment were relatively more important for Blacks. The findings suggest that race and cancer are both important factors in our understanding of disability in later life. These findings can then inform clinical best practices among minority older adults.

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

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

Predicting Coronavirus Disease 2019 Infection Risk and Related Risk Drivers in Nursing Homes: A Machine Learning Approach

OBJECTIVE

Inform coronavirus disease 2019 (COVID-19) infection prevention measures by identifying and assessing risk and possible vectors of infection in nursing homes (NHs) using a machine-learning approach.

DESIGN

This retrospective cohort study used a gradient boosting algorithm to evaluate risk of COVID-19 infection (ie, presence of at least 1 confirmed COVID-19 resident) in NHs.

SETTING AND PARTICIPANTS

The model was trained on outcomes from 1146 NHs in Massachusetts, Georgia, and New Jersey, reporting COVID-19 case data on April 20, 2020. Risk indices generated from the model using data from May 4 were prospectively validated against outcomes reported on May 11 from 1021 NHs in California.

METHODS

Model features, pertaining to facility and community characteristics, were obtained from a self-constructed dataset based on multiple public and private sources. The model was assessed via out-of-sample area under the receiver operating characteristic curve (AUC), sensitivity, and specificity in the training (via 10-fold cross-validation) and validation datasets.

RESULTS

The mean AUC, sensitivity, and specificity of the model over 10-fold cross-validation were 0.729 [95% confidence interval (CI) 0.690‒0.767], 0.670 (95% CI 0.477‒0.862), and 0.611 (95% CI 0.412‒0.809), respectively. Prospective out-of-sample validation yielded similar performance measures (AUC 0.721; sensitivity 0.622; specificity 0.713). The strongest predictors of COVID-19 infection were identified as the NH's county's infection rate and the number of separate units in the NH; other predictors included the county's population density, historical Centers of Medicare and Medicaid Services cited health deficiencies, and the NH's resident density (in persons per 1000 square feet). In addition, the NH's historical percentage of non-Hispanic white residents was identified as a protective factor.

CONCLUSIONS AND IMPLICATIONS

A machine-learning model can help quantify and predict NH infection risk. The identified risk factors support the early identification and management of presymptomatic and asymptomatic individuals (eg, staff) entering the NH from the surrounding community and the development of financially sustainable staff testing initiatives in preventing COVID-19 infection.

Addressing Racial Biases in Medicine: A Review of the Literature, Critique, and Recommendations

This article reviews the literature on racism in medicine in the United States and reflects on the persistent barriers to diminishing racial biases in the U.S. health care system. Espoused strategies for decreasing racial disparities and reducing racial biases among physicians are critiqued, and recommendations are offered. Those recommendations include increasing the number of minority students in medical school, using Xavier University in New Orleans, Louisiana, as the model for medical school preparation; revamping the teaching of cultural competence; ensuring the quality of non-clinical staff; and reducing the risk of burnout among medical providers.

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

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

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

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

Health-Related Quality of Life of Economically Disadvantaged African American Older Adults: Age and Gender Differences

Background: The association between age and health-related quality of life (HRQoL) is still under debate. While some research shows older age is associated with better HRQoL, other studies show no or negative association between age and HRQoL. In addition, while the association between age and HRQoL may depend on race, ethnicity, gender, and their intersections, most previous research on this link has been performed in predominantly White Middle Class. Objective: To explore gender differences in the association between age and mental and physical HRQoL in a sample of economically disadvantaged African American (AA) older adults. Methods: This cross-sectional survey was conducted in South Los Angeles between 2015 to 2018. A total number of 740 economically disadvantaged AA older adults (age ≥ 55 years) were enrolled in this study, using non-random sampling. This includes 266 AA men and 474 AA women. The independent variable of interest was age. Dependent variables of interest were physical component scores (PCS) and mental component scores (MCS), two main summary scores of the HRQoL, measured using Short Form-12 (SF-12). Gender was the moderator. Socioeconomic status (educational attainment and financial difficulty) were covariates. Linear regression models were used to analyze the data. Results: AA women reported worse PCS; however, gender did not impact MCS. In the pooled sample, high age was associated with better PCS and MCS. In the pooled sample, a significant interaction was found between gender and age on PCS, suggesting a stronger effect of age on PCS for AA men than AA women. In gender-stratified models, older age was associated with better PCS for AA men but not AA women. Older age was similarly and positively associated with better MCS for AA men and women. Conclusions: There may be some gender differences in the implications of ageing for the physical HRQoL of AA older adults. It is unclear how old age may have a boosting effect on physical HRQoL for AA men but not AA women. Future research should test gender differences in the effect of age on physical health indicators such as chronic disease as well as cognitive processes involved in the evaluation of own's health in AA men and women.

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

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