Racial Disparities in Access to Long-Term Care:
The Illusive Pursuit of Equity
David Barton Smith, Zhanlian Feng, Mary L. Fennell, Jacqueline Zinn, Vincent Mor
While nursing homes were insulated from civil-rights enforcement at the time of the implementation of the Medicare program and lagged behind other parts of the health sector in providing comparable access to minorities, they are the only providers for which current reporting requirements make it possible to fully assess racial disparities in use and quality of care. We find that African Americans' use of nursing homes in 2000 in the United States was 14 percent higher than Caucasians' use. The largest relative African American use of nursing homes in 2000 took place in the South and West. Average nursing-home case-mix acuity for African Americans and Caucasians were essentially identical, suggesting that shifts in payment incentives have eliminated the selective admission of easy-care private-pay (predominantly Caucasian) patients and helped fuel the growth of private pay home care and assisted living for this segment of the population. While these shifts in incentives helped increase the use of nursing homes by African Americans, a high degree of segregation and disparity in the quality of the nursing homes used by African Americans persists. Parity in use is an illusive benchmark for measuring progress in assuring equity in treatment.
Click here for the article.
Separate And Unequal: Racial Segregation And Disparities In Quality Across U.S. Nursing Homes
David Barton Smith, Zhanlian Feng, Mary L. Fennell, Jacqueline S. Zinn, Vincent Mor
We describe the racial segregation in U.S. nursing homes and its relationship to racial disparities in the quality of care. Nursing homes remain relatively segregated, roughly mirroring the residential segregation within metropolitan areas. As a result, blacks are much more likely than whites to be located in nursing homes that have serious deficiencies, lower staffing ratios, and greater financial vulnerability. Changing health care providers’ behavior will not be sufficient to eliminate disparities in medical treatment in nursing homes. Persistent segregation among homes poses a substantial barrier to progress.
Click here for the article.
Mental Illness In Nursing Homes: Variations Across States
David C. Grabowski, Kelly A. Aschbrenner, Zhanlian Feng, Vincent Mor
Placing people with mental illnesses in nursing homes is an important policy concern. Using nursing home Minimum Data Set assessments from 2005, we found much variation across states in both the rates of mental illness among nursing home admissions and the estimated rates of admission among people with mental illnesses. We also found that newly admitted people with mental illnesses were younger and more likely to become long-stay residents than those admitted with other conditions. Taken together, these results suggest that state-level mental health and nursing home factors may influence the likelihood of long-term nursing home use for people with mental illnesses.
Click here for the article.
The Revolving Door Of Rehospitalization From Skilled Nursing Facilities
Vincent Mor, Orna Intrator, Zhanlian Feng and David C. Grabowski
Almost one-fourth of Medicare beneficiaries discharged from the hospital to a skilled nursing facility were readmitted to the hospital within thirty days; this cost Medicare $4.34 billion in 2006. Especially in an elderly population, cycling into and out of hospitals can be emotionally upsetting and can increase the likelihood of medical errors related to care coordination. Payment incentives in Medicare do not encourage providers to coordinate beneficiaries’ care. Revising these incentives could achieve major savings for providers and improved quality of life for beneficiaries.
Click here for the article.
Elderly Hispanics More Likely To Reside In Poor-Quality Nursing Homes
Mary L. Fennell, Zhanlian Feng, Melissa A. Clark and Vincent Mor
The proportion of Hispanics age sixty-five and older who are living in nursing homes rose from 5 percent in 2000 to 6.4 percent in 2005. Although segregation in nursing homes seems to have declined slightly, elderly Hispanics are more likely than their non-Hispanic white peers to reside in nursing homes that are characterized by severe deficiencies in performance, understaffing, and poor care.
Click here for the article.
Prevalence of Nursing Assistant Training and Certification Programs Within Nursing Homes, 1997–2007
Denise A. Tyler, Hye-Young Jung, Zhanlian Feng and Vincent Mor
We found that the prevalence of nursing home (NH)-based nurse aide training and certification programs dropped throughout the study period, 1997-2007, so it is likely that most certified nursing assistants (CNAs) are now receiving their pre-employment training outside the NH setting. In addition, we found that those CNAs trained outside the NH are paying a greater share of their training costs. The shifting of CNA training to venues other than NHs raises important questions about the quality of training and states’ ability to monitor training programs. In addition, increased costs for CNAs receiving training outside NHs may possibly create a disincentive to entering this field.
Click here for the article.
Hospital Characteristics Associated with Feeding Tube Placement in Nursing Home Residents With Advanced Cognitive Impairment
Joan M. Teno, Susan L. Mitchell, Pedro L. Gozalo, David Dosa, Amy Hsu, Orna Intrator, Vincent Mor
Dementia is a devastating illness that impacts not only one’s mind, but a person’s physical functioning. Dementia patients often develop eating problems, such as choking on food, and eating problems herald the final stages of this disease. The best available evidence suggests that feeding tubes do not improve survival or other patient outcomes. Our previous research found that nearly 70% of feeding tube insertions occur in an acute care hospital during a medical illness. As reported in the February 10, 2010 issue of the Journal of the American Medical Association, members of the Multiple Transitions team of the Shaping Long Term Care in America project examined the variation and characteristics of 2797 hospitals that were associated with feeding tube insertions among 163,022 hospitalized nursing home residents with advanced cognitive impairment.
Among hospitalized nursing home residents, we found average feeding tube insertion rates of 6.5 out of 100 admissions. This varied with for-profit, larger hospitals, and those hospitals with a more aggressive approach to end-of-life having the highest rate of feeding tube insertions. In some hospitals, one in three admissions result in feeding tube insertions while 12% of the hospitals studied did not insert any feeding tubes during the 8 years of the study. To help hospitals examine their rate of feeding tube insertions, we have published a table with the overall feeding tube insertion rate and feeding tube insertion rate for 2006-2007 for those hospitals that had at least 25 admissions of nursing home residents with advanced dementia. We hope that hospitals will examine these results with attention to how decisions are made for persons with advanced dementia to ensure their informed wishes are respected.
The table of results can be found here:
http://ltcfocus.org/Upload/intubation.pdf
A video clip about the study is available at:
http://pubs.ama-assn.org/homepage/media/pastreleases.dtl
For more information on this study, please see the following press release:
http://news.brown.edu/pressreleases/2010/02/teno