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 to the differences in non-minority older adults, suggesting a disparity.
Methods:
We identified respondents aged ≥65 years with a diagnosis of Alzheimer’s 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 six individual activities of daily living (ADL). 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 vs. the community. The functional-limitations score was higher in NHs than in the community for both groups. Functional needs for all six ADLs for the minority group were greater in NHs compared to 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.
Keywords: Access to care, long-term-care, healthcare disparities
Introduction
The US long-term services and supports (LTSS) landscape for older adults has undergone a major transformation marked by a shift from nursing home (NH) care toward home and community-based services (HCBS).1,2 The drivers of this transformation are two-fold: the decreasing financial viability of the NH model and the federal focus on delivering LTSS in the least-restrictive environment. In regard to financial viability, LTSS in NHs are increasingly reimbursed by Medicaid in which Medicaid fails to cover the full cost needed to care for the resident.3-5 In the past, private-paying older adults offset the gap in covered costs; however a greater number of private-paying older adults are seeking care in alternative-based LTSS settings (e.g., assisted living).3,6 Consequently, NHs are forced to either redirect funds from areas that are important to resident care delivery, thereby creating concerns regarding poor care delivery, or face closure altogether.7,8 Those most at risk for experiencing these consequences in the unavailability of resources and an undersupply of quality NHs brought on by the growing disparities in private-pay vs. Medicaid payment rates are racial/ethnic minorities.6
Beyond the threat of the financial viability of the NH model, many stays in NHs are medically unjustifiable. This notion further drives federal entities to focus on providing the same care to older adults in the least-restrictive environment possible (i.e., home and community), which is also less costly.1 Many older adults do not need 24-hour NH care and can receive important services such as Meals on Wheels, medications, treatment, and therapy in the home or the community.9 Furthermore, NHs have been found to increase the burden of disease, perpetuate disparities in care (e.g., restraint use, antipsychotic use, end of life planning, and vaccination delivery) among specific racial/ethnic groups, and foster feelings of depression, and loss of freedom and independence.8,10-15
Despite the growing emphasis on providing LTSS outside of NHs, the US has seen an unprecedented demographic shift in the use of NH services among older adults with racial/ethnic minority backgrounds.6,16 Across an 11-year span (1998-2008), researchers noted an 11% increase in Black older adults receiving care in NHs and a 55% increase in Hispanic older adults; these values surpassed the overall population growth of Black and Hispanic groups in the US.6 Meanwhile, a 10% decline in the number of White older adults using NHs was observed during the same time period. The potential source of the differences seen in the growth of NH use among older adults with racial or ethnic minority backgrounds has been shaped by two overarching factors: (1) persistence of patterns of racial/ethnic residential segregation and the consequence of increased limited access to alternative-based LTSS (e.g., disparities in access to assisted living), and (2) the persistence and regulatory tolerance of patterns of racial discrimination (e.g., discrimination by facilities in admission practices).6,16-19 While there has been considerable research on the disparities Black and Hispanic older adults experience while receiving NH care and existing work examining the growth in NH use among this population has focused on societal or population-level factors (e.g., Medicaid reimbursement and residential segregation), little is known on a patient-level about LTSS need between White and Black and Hispanic older adults across settings that may point to a disparity in unnecessary nursing home use. This is particularly important when the same NH care could be delivered in the home and community with appropriate access to resources, services, and supports which all communities should have.
Because support for functional needs (e.g., deficits in activities of daily living [ADL]) is a primary driver of the use of LTSS (NH vs. home and community),20,21 we sought to determine whether older adults with diverse racial or ethnic backgrounds in NHs had the same functional needs as those in the home and community (hereafter referred to as community). If the same functional needs are present in both settings, this suggests that care in the NH could have been addressed in the community setting. We hypothesized that older adults with racial/ethnic minority backgrounds receiving NH care would have the same functional needs as those receiving care in the community, while White older adults in NHs would have greater functional needs than those in the community. Because we wanted to best account for the multiplicity of care needs that typically drive the need for LTSS, we restricted our examination of differences in functional need to the complex population of older adults diagnosed with Alzheimer’s disease or dementia.22 This allowed us to enhance our comparability of the groups across the two settings because of their likelihood to face similar challenges and needs.23,24
Methods
Design
This was an observational cross-sectional study. We used the 2016 Health and Retirement Study (HRS) to identify older adults in two LTSS settings: NH and community. The HRS is a nationally representative longitudinal survey of over 20,000 people in America25 that details the health, work, aging, demographics, retirement, and economic characteristics of adults ≥51 years of age. Every two years, a selected individual and/or the individual’s proxy is interviewed. The survey is supported by the National Institute on Aging and maintained by the University of Michigan.
Sample
Our sample was restricted to individuals ≥65 years of age with a diagnosis of Alzheimer’s disease or dementia to allow for comparisons among older adults with similar needs. A respondent was determined to have a diagnosis of Alzheimer’s disease or dementia if the respondent or their proxy reported yes to one of the following questions: “has a doctor ever told you that you have Alzheimer’s disease?” or “has a doctor ever told you that you have dementia, senility, or any other serious memory impairment?” Black and Hispanic older adults were the primary groups of interest.26 Hispanic older adults could have identified with the White, Black, or Other race. We combined the Black and Hispanic respondents into a single minority group because the NH sample contained few Hispanic older adults (n=14). This has been done in past research when looking to assess racial/ethnic differences among these populations and the Black and Hispanic group has shared similar experiences in disparities in NH use and quality.27 Non-Hispanic White older adults (hereafter referred to as White) were included as a comparison group. All older adults in our sample were required to be receiving LTSS in NHs or the community. We included surveys that were completed by the older adult themselves or a proxy.
Measures
NH cohort
The NH cohort was defined as those who indicated on the HRS survey that they were living in a NH or other healthcare facility at the time of the survey.
Community cohort
The community cohort was defined as those who indicated that they received help (paid caregiver or unpaid caregiver, e.g., family) with a basic ADL or an instrumental ADL. LTSS delivery has been defined as receiving services and supports for both ADLs and instrumental ADLs.28 This cohort was exclusive of the NH cohort.
Outcomes
Functional need
We extrapolated information from the HRS about mobility impairments and ADLs to assess functional need. The first indicator of functional need consisted of 12-items assessing difficulty in performing a series of mobility activities. Each item was measured dichotomously; 1 and 0 representing difficulty and no difficulty with an item, respectively. We combined these 12-items to create one continuous variable which we named the functional limitations score. Higher scores equated to greater functional limitations. These items have been combined in other studies to create a functional limitations score and allowed our team to assess a range of functional limitations simultaneously.29-31 To additionally measure functional need, we individually examined six dichotomous indicators that assessed need for help with ADL. A description of the measures can be found in the Appendix.
Demographic characteristics
We were interested in several demographic characteristics with the potential to influence LTSS in NHs and in the community. These demographics included age, gender (male vs. female), marital status (single, married, widowed, separated/divorced), highest degree of education (no degree, GED/high school diploma, college degree and higher), and household income.
Analyses
We first used descriptive statistics to characterize the demographics of our sample. We compared the characteristics between setting stratified by minority status. We then performed unadjusted analyses to compare functional need by setting (NH vs. community), using differences in means and t-tests for continuous outcomes (functional limitations score), and odds ratios and chi-square tests for the dichotomous outcomes (six ADL indicators). We considered a disparity to be indicated if minority older adults showed no statistically significant differences in a functional need indicator between the two settings while the White group showed statistically significant differences in the respective functional need indicator. Examination of confidence intervals allowed for us to compare the magnitude of the error bound between the two groups to account for differences in sample sizes. To provide additional evidence for the existence of a disparity, a difference-in-difference test was performed to identify a significant difference between the difference of functional need by settings among White older adults and among minority older adults. We used a two-way ANOVA with an interaction term of setting by minority group for the functional limitation scores and used logistic regression with an interaction term of setting by minority group for the need for help with ADL indicators. There were several missing values in our ADL variables, ranging from 4 to 15. Only complete cases were included in the analyses. Since HRS used a stratified multistage sampling design, sample weights and two design variables were used in all analyses to account for differential probability of selection. All analyses were performed using SAS 9.4 (Cary, NC). We report 95% confidence intervals (CI) and p-values. We set our level of significance at p<.05, two-sided.
Results
Descriptive Statistics
Among 186 minority older adults, 145 (74.9%, 95% CI 67.6-82.2%) received care in the community, and 41 (25.1%, 95% CI 17.8-32.4%) received care in a NH. In comparison, 357 White older adults were equally distributed between the two settings (NH, n=177 [49.5%, 95% CI 44.2-54.9%] and community, n=180 [50.5%, 95 % CI 45.1-55.8%]). Reported percentages reflect adjustment for sample weights. Between the two settings, minority older adults were not different in marital status and education, but in the NH were younger in age, less likely to be female, and had greater income when compared to the community setting (p<0.05). For example, minority older adults in NHs had an average age of 78 years, whereas minority older adults in the community had an average age of 82 years. In contrast, White older adults differed in all demographic characteristics between the two settings (p<0.05) except for education. White older adults who were older age, female, unmarried, and lower income tended to receive care in NHs than in the community. For example, White older adults in NHs had an average age of 87 whereas white older adults in the community had an average age of 82. A complete description of these characteristics can be found in Table 1.
Table 1.
Demographic characteristics of older adults by minority status and setting of care
| Characteristic | Minority Mean (95% CI) or n (%, 95% CI) |
P-value | White Mean (95% CI) or n (%, 95% CI) |
P-value | ||
|---|---|---|---|---|---|---|
| Community N=145 |
Nursing Home N=41 |
Community N=180 |
Nursing Home N=177 |
|||
| Age, years | 82.4 (80.7-84.1) | 78.1 (74.7-81.5) | 0.024 | 81.9 (80.2-83.5) | 86.8 (85.2-88.3) | <0.001 |
| Gender (Female) | 104 (76.7, 70.2-83.2) | 21 (42.3, 27.0-57.5) | <0.001 | 107 (55.6, 47.0-64.1) | 128 (72.1, 64.6-79.6) | 0.003 |
| Education | 0.440 | 0.270 | ||||
| No degree | 80 (59.3, 48.5-70.1) | 23 (46.9, 29.8-64.1) | 33 (15.9, 10.0-21.7) | 38 (19.3, 13.2-25.2) | ||
| GED or High school diploma | 51 (32.7, 23.8-41.6) | 15 (42.6, 25.5-59.6) | 103 (57.5, 49.9-65.0) | 108 (60.6, 52.2-69.1) | ||
| College degree and higher | 14 (8.0, 3.4-12.6) | 3 (10.5, 0.0-24.5) | 44 (26.6, 19.2-34.1) | 31 (20.1, 13.8-26.3) | ||
| Marital status | 0.86 | <0.001 | ||||
| Married | 47 (26.5, 17.0-35.9) | 9 (27.9, 14.9-40.8) | 81 (48.4, 38.0-58.7) | 35 (14.9, 9.3-20.6) | ||
| Not married | 98 (73.5, 64.1-83.0) | 32 (72.1, 59.2-85.1) | 99 (51.6, 41.3-62.0) | 142 (85.1, 79.4-90.7) | ||
| Income, $k | 13.7 (11.9-15.5) | 25.0 (23.2-26.8) | <0.001 | 35.3 (25.0-45.6) | 21.12 (18.6-23.6) | 0.002 |
Source: Authors’ analysis of data from the Health and Retirement Study, 2016. CI = confidence interval. Means and percentages are weighted. Minority = Black and Hispanic.
Differences in Functional Needs
Table 2 shows unadjusted analyses for the functional need variables. The mean functional limitation score of minority older adults was significantly higher in NHs than in the community (8.0, 95% CI 7.2-8.7 vs. 6.7, 95% CI 6.2-7.1, respectively). This finding was also true for the White older adult group (7.3, 95% CI 7.1-7.6 vs. 5.6, 95% CI 5.3-6.0, respectively). Even though the mean difference in functional limitation scores were significantly different in each racial/ethnic group (p=0.02 for the minority group and p<0.001 for the White group), there was no significant difference in the two mean differences (difference-in-difference test: p=0.58). Odds ratios (using NH as a reference level) for all six need for help with ADL indicators were significantly <1 for the minority group, which indicated the need for help with ADLs was lesser in the community than in NHs for the minority group. All need for help with ADL indicators except for “help with eating” were lesser in the community than in NHs for the White group. These differences in the White group did not differ from those in the minority group (difference-in-difference test: all p-values>0.05). Details about mean differences of functional limitations score, odds ratios of ADLs, and difference-in-difference test are reported in Table 3.
Table 2.
Functional need of older adults by minority status and setting of care
| Outcomes | Minority Mean (95% CI) or n (%, 95% CI) |
White Mean (95% CI) or n (%, 95% CI) |
||
|---|---|---|---|---|
| Community N=145 |
Nursing Home N=41 |
Community N=180 |
Nursing Home N=177 |
|
| Functional limitations score | 6.7 (6.2-7.1) | 8.0 (7.2-8.7) | 5.6 (5.3-6.0) | 7.3 (7.1-7.6) |
| Need for Help with ADL | ||||
| Help w/ dressing | 80 (89.9, 82.2-97.6) | 33 (100.0, --) | 83 (90.3, 84.1-96.4) | 133 (98.5, 96.8-100) |
| Help w/ walking | 53 (75.2, 64.2-86.2) | 28 (98.4, 95.1-100) | 57 (74.7, 67.1-82.4) | 106 (90.6, 85.9-95.2) |
| Help w/ bathing | 77 (84.0, 74.2-93.7) | 37 (100.0, --) | 97 (89.9, 82.4-97.5) | 154 (98.4, 96.2-100) |
| Help w/ eating | 36 (59.8, 48.6-71.1) | 23 (91.0, 79.5-100) | 50 (65.7, 56.9-74.5) | 76 (78.6, 70.0-87.2) |
| Help w/ getting in/out of bed | 49 (82.6, 69.6-95.6) | 31 (100.0, --) | 51 (73.5, 62.9-84.1) | 105 (93.0, 89.6-96.3) |
| Help w/ toileting | 41 (61.2, 47.7-74.6) | 26 (91.4, 82.5-100) | 45 (64.4, 53.5-75.3) | 101 (86.9, 80.7-93.1) |
Source: Authors’ analysis of data from the Health and Retirement Study, 2016. CI = confidence interval; ADL = activities of daily living. Means and percentages are weighted. Minority = Black and Hispanic.
Table 3.
Difference in difference test for functional need of older adults by minority status and setting of care (Community vs Nursing Home)
| Outcomes | Minority | P-value | White | P-value | Diff in Diff | P-value |
|---|---|---|---|---|---|---|
| Community vs NH Mean Diff (95% CI) or OR (95% CI) |
Community vs NH Mean Diff (95% CI) or OR (95% CI) |
Diff in Mean Diff (95% CI) or OR (95% CI) |
||||
| Functional limitations score | −1.33 (−2.43, −0.23) | 0.020 | −1.69 (−2.25, −1.13) | <0.001 | 0.36 (−0.95, 1.67) | 0.580 |
| Need for Help with ADL | ||||||
| Help w/ dressing | 0.09 (0.02, 0.51) | <0.001 | 0.14 (0.03, 0.58) | 0.001 | 0.66 (0.06, 6.79) | 0.730 |
| Help w/ walking | 0.05 (0.01, 0.33) | <0.001 | 0.31 (0.14. 0.69) | 0.001 | 0.16 (0.02, 1.31) | 0.095 |
| Help w/ bathing | 0.05 (0.01, 0.47) | 0.001 | 0.14 (0.03, 0.77) | 0.009 | 0.36 (0.03, 4.27) | 0.420 |
| Help w/ eating | 0.15 (0.04, 0.61) | 0.001 | 0.52 (0.25, 1.10) | 0.054 | 0.28 (0.07, 1.15) | 0.087 |
| Help w/ getting in/out of bed | 0.05 (0.01, 0.33) | <0.001 | 0.21 (0.09, 0.47) | <0.001 | 0.25 (0.04, 1.59) | 0.150 |
| Help w/ toileting | 0.15 (0.05, 0.47) | <0.001 | 0.27 (0.13, 0.55) | <0.001 | 0.54 (0.18, 1.66) | 0.290 |
Source: Authors’ analysis of data from the Health and Retirement Study, 2016. OR = odds ratio; CI = confidence interval; NH = nursing home; Diff = difference; ADL = activities of daily living. For functional score, the mean difference is calculated as the community mean score minus the nursing home mean score. For calculating OR, nursing home is the reference level. Means and percentages are weighted. Minority = Black and Hispanic.
Discussion
In this national observational cohort study, we assessed disparities in access to community care by determining if there were fewer differences in functional need between settings in which LTSS were received—NH vs. community—among older adults from racial/ethnic minority groups compared to White older adults. All measures of functional need (functional limitation and need for help with ADL) for minority older adults did differ significantly between the two settings (i.e., functional needs were greater in NHs than in the community in all areas assessed), and all but one measure differed for White older adults between the two settings. Analyses comparing the differences in functional need between the minority and White group across these settings were not statistically significant. Although not a direct aim of our study, we found several unexpected variations in important demographic characteristics among Black and Hispanic older adults between the NH setting and the community setting, as compared to White older adults. Our findings highlight the variation in unexpected differences in demographics among older adults with racial/ethnic minority backgrounds between the two settings, in the context of potential disparities in receiving LTSS in the community.
A comparison between the demographic characteristics of older adults with racial/ethnic minority backgrounds receiving care in NHs and the same group receiving care in the community revealed no statistically significant differences between the two groups in marital status and education. Additionally, minority older adults in the NHs were younger, had higher income, and were more likely to be male when compared to minority older adults in the community. Conversely, White older adults receiving care in the NH had lower income and were less likely to be married, male, and younger than the White older adults receiving care in the community. These findings associated with the racial/ethnic minority older adult group were unforeseen. For example, we expected to see those with higher income in the home and community, because the higher income would allow older adults to pay for everyday necessities, such as food, transportation, and housing. Findings specific to female gender from AARP indicate that Black and Hispanic women age 75 or older were more likely than White women in that age group to have incomes below the poverty level.32 This would make them eligible for both Medicaid and subsequent care to meet their everyday needs provided in NHs, thus potentially explaining why we did not find the Black and Hispanic group to have higher income in the community setting. We also expected to see those who were married to remain in their homes because they had access to spousal support as a likely means of providing needed care.33 Similarly, other researchers have found that men with functional impairment tend to live in the community setting rather than in NHs, because they are more likely to be married and have support from spouses or children and view NH use as a sign of loss of independence.32,34,35 Finally, age typically drives the intensity of LTSS use as care needs increase with aging, therefore we would expect to see those who were in the NH to be older than those in the community. These findings suggest that Black and Hispanic older adults may not have access to necessary resources and support systems (e.g., income and familial support) that would enable them to remain in the community setting to receive their LTSS, despite recent shifts in national priorities aimed at keeping older adults in the community and outside of NHs. Moreover, similar disparities have been reported previously.36-38 Research conducted by the Office of the Assistant Secretary for Planning and Evaluation found that paid care (i.e., NH) is common among people of color because of their likelihood to qualify for Medicaid financed care.36-38 Important to note, there were no differences in functional need between the minority and White group therefore it is unlikely that the minority group was more disabled.
Our findings are critical because healthcare reform efforts focused on the delivery of HCBS are underway. These include publicly supported Medicaid state programs under the Balancing LTSS initiative.1,39 These programs vary by state and provide eligible older adults with a range of LTSS to help them manage their care needs outside of NHs. For example, Money Follows the Person is a demonstration project that allows older adults to choose where they will live and receive services, with the aim of increasing the use of HCBS while reducing the use of institutionally based services.40 For people already living in institutionalized settings, supports can follow them to the community. The overall goal of these efforts is to create a system that is person-driven, inclusive, effective and accountable, sustainable and efficient, coordinated and transparent, and culturally competent.
State programs such as these could potentially fill gaps in unmet needs experienced by Black and Hispanic older adults who are receiving care in NHs but could be receiving their care in the community. However, identifying whether Black and Hispanic older adults are aware of and are accessing these resources is important. Moreover, it is possible that rather than providing an enhancement of the quality and consumer responsiveness of services by shifting to a HCBS-model, this shift may have helped to further re-segregate care and increase disparities. Existing research has found that not all communities have the same level of resources available, especially in poorer communities.41,42 Further research is needed to identify unmet needs that may be inhibiting the access of Black and Hispanic older adults to community-based LTSS. Whether these programs are providing resources that Black and Hispanic older adults value and need remains unknown. Finally, because most of these programs are available only to those who are eligible for Medicaid, their reach is inherently limited. Federal policies would be instrumental in filling noted gaps in access to community care.
Limitations
There are limitations. Patients with Alzheimer’s disease and other dementias have a diverse array of medical problems that contribute to their need for LTSS, and this study did not endeavor to disentangle this full complexity. Next, because the sample size of the minority group receiving care in NHs was small, we might have been unable to detect a small difference when one indeed existed. Moreover, we had to combine the Black and Hispanic group together due to a very small sample of Hispanic older adults. Importantly, however, we did find statistically significant differences for a majority of our analyses related to minority older adults. In addition, we reported confidence intervals so that we could assess the magnitude of the error bound between the minority and White group given the differences in sample sizes. It would be additionally beneficial to have evidence of disparities in NH use vs. community use for LTSS broken out by Black and Hispanic groups as there are likely differences between these groups. Additionally, the data contained several missing responses to the ADL needs variable, and this may have prevented us from fully understanding disparities in functional need. Next, due to limitations in the publicly-available data used for this analysis, we were unable to control for community-level characteristics (e.g. level of competition in the market, community per capita income, residential segregation, and other factors) that may have explained some of the disparities in the provision of LTSS. Lastly, most of the data were self-reported, and a small proportion of the responses were completed by a proxy. Because people who self-reported had varying levels of cognitive impairment, they might possibly have understated or overstated their functional needs. Nonetheless, our sample was restricted to a sample of older adults experiencing Alzheimer’s disease or dementia, which is a group that has been largely underrepresented in the literature.
Conclusion
Overall functional needs for older adults from racial/ethnic minority backgrounds were higher if they were living in NHs compared with the community, but the difference in functional needs between the two settings was not greater than for White older adults. Interestingly, several demographic characteristics did not differ or varied unexpectedly among older adults with racial/ethnic minority backgrounds between the two settings. Familial and income support along with other supports may be important factors to consider when developing and implementing programs to shift older adults from NHs to the community or, for those in the community, to allow them to remain there for as long as possible.
Finally, it is important to acknowledge the complex and difficult history of access to appropriate LTSS for racial/ethnic minorities now playing out in disparities in COVID-19 mortality rates.43 More research is needed to understand additional variations in care need patterns and unmet needs among racial/ethnic minorities and their caregivers across LTSS settings and how best to dismantle the structural practices that are driving inequitable access to appropriate LTSS. Without such evidence needed to drive LTSS policy, it is likely that Black and Hispanic older adults will continue to lack access to the necessary resources that will enable them to remain in the community setting for their LTSS and instead be at risk for disproportionate care in NHs.
Supplementary Material
Acknowledgments
Funding: This work was supported by an award from the National Institute on Aging under Grant (P30AG059302, PI: Werner, RM; Willis, A)). This publication was made possible by the VA Office of Academic Affiliations through the VA/National Clinician Scholars Program and Yale University and by CTSA Grant Number TL1 TR001864 from the National Center for Advancing Translational Science (NCATS), a component of the National Institutes of Health. JLT is supported by a Harold Amos career development award funded by the Robert Wood Johnson Foundation (RWJF; 77872 to JLT). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the U.S. Department of Veterans Affairs or the United States Government, or the Robert Wood Johnson Foundation.
Footnotes
Conflicts of Interest: The authors have no conflicts of interest to disclose
References
- 1.AARP Public Policy Institute. Health care reform improves access to Medicaid home and community-based services (PPI Fact Sheet, No. 192). In. Washington, DC: AARP Public Policy Institute; 2010. [Google Scholar]
- 2.Degenholtz HB, Park M, Kang Y, Nadash P. Variations among medicare beneficiaries living in different settings: Demographics, health status, and service use. Research on Aging. 2016;38(5):602–616. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.American Council on Aging. Medicaid coverage of nursing home care ∣ When, where and how much they pay. https://www.medicaidplanningassistance.org/medicaid-and-nursing-homes/. Published 2020. Accessed February 9, 2020.
- 4.Pruitt N Jr Quality of care in skilled nursing care centers. American Health Care Association. 2013. [Google Scholar]
- 5.Lepore MJ, Shield RR, Looze J, Tyler D, Mor V, Miller SC. Medicare and Medicaid reimbursement rates for nursing homes motivate select culture change practices but not comprehensive culture change. Journal of aging & social policy. 2015;27(3):215–231. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Feng Z, Fennell ML, Tyler DA, Clark M, Mor V. Growth of racial and ethnic minorities in US nursing homes driven by demographics and possible disparities in options. Health Affairs. 2011;30(7):1358–1365. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Lepore M, Leland NE. Nursing homes that increased the proportion of Medicare days saw gains in quality outcomes for long-stay residents. Health Affairs. 2015;34(12):2121–2128. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Mor V, Zinn J, Angelelli J, Teno JM, Miller SC. Driven to tiers: Socioeconomic and racial disparities in the quality of nursing home care. The Milbank Quarterly. 2004;82(2):227–256. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Centers for Medicare and Medicaid Services. PACE. n.d. [PubMed] [Google Scholar]
- 10.Travers JL, Schroeder KL, Blaylock TE, Stone PW. Racial/ethnic disparities in influenza and pneumococcal vaccinations among nursing home residents: A systematic review. The Gerontologist. 2018;58(4):e205–e217. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Fennell ML, Feng Z, Clark MA, Mor V. Elderly Hispanics more likely to reside in poor-quality nursing homes. Health Affairs. 2010;29(1):65–73. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Frahm KA, Brown LM, Hyer K. Racial disparities in end-of-life planning and services for deceased nursing home residents. Journal of the American Medical Directors Association. 2012;13(9):819. e817–819. e811. [DOI] [PubMed] [Google Scholar]
- 13.Cassie KM, Cassie W. Racial disparities in the use of physical restraints in US nursing homes. Health & Social Work. 2013;38(4):207–213. [DOI] [PubMed] [Google Scholar]
- 14.Grabowski DC, McGuire TG. Black-white disparities in care in nursing homes. Atlantic Economic Journal. 2009;37(3):299–314. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Hudson TJ, Cody M, Armitage TL, Curtis MA, Sullivan G. Disparities in use of antipsychotic medications among nursing home residents in Arkansas. Psychiatric Services. 2005;56(6):749–751. [DOI] [PubMed] [Google Scholar]
- 16.Smith DB, Feng Z, Fennell ML, Zinn JS, Mor V. Separate and unequal: Racial segregation and disparities in quality across US nursing homes. Health Affairs. 2007;26(5):1448–1458. [DOI] [PubMed] [Google Scholar]
- 17.Smith DB, Feng Z, Fennell ML, Zinn J, Mor V. Racial disparities in access to long-term care: The illusive pursuit of equity. Journal of Health Politics, Policy and Law. 2008;33(5):861–881. [DOI] [PubMed] [Google Scholar]
- 18.Allen PD, Cherry K. Race relations in the nursing home setting. Race, Gender & Class. 2006:36–45. [Google Scholar]
- 19.Gonzalez L Predicting racial disparities in nursing home admission: The role of discrimination, stressors, and neighborhood context. The Sociological Quarterly. 2019:1–21. [Google Scholar]
- 20.Travers JL, Hirschman KB, Naylor MD. Adapting Andersen’s expanded behavioral model of health services use to include older adults receiving long-term services and supports. BMC Geriatrics. 2020;20(1):1–16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Wysocki A, Butler M, Kane RL, Kane RA, Shippee T, Sainfort F. Long-term care for older adults: A review of home and community-based services versus institutional care. 2012. [PubMed] [Google Scholar]
- 22.Harris-Kojetin LD, Sengupta M, Lendon JP, Rome V, Valverde R, Caffrey C. Long-term care providers and services users in the United States, 2015–2016. 2019. [PubMed] [Google Scholar]
- 23.Afram B, Verbeek H, Bleijlevens MH, et al. Predicting institutional long-term care admission in dementia: A mixed-methods study of informal caregivers’ reports. Journal of Advanced Nursing. 2015;71(6):1351–1362. [DOI] [PubMed] [Google Scholar]
- 24.Andel R, Hyer K, Slack A. Risk factors for nursing home placement in older adults with and without dementia. Journal of Aging and Health. 2007;19(2):213–228. [DOI] [PubMed] [Google Scholar]
- 25.Juster FT, Suzman R. An overview of the Health and Retirement Study. Journal of Human Resources. 1995:S7–S56. [Google Scholar]
- 26.Konetzka RT, Werner RM. Disparities in long-term care: Building equity into market-based reforms. Medical Care Research and Review. 2009;66(5):491–521. [DOI] [PubMed] [Google Scholar]
- 27.Rivera-Hernandez M, Kumar A, Epstein-Lubow G, Thomas KS. Disparities in nursing home use and quality among African American, Hispanic, and White Medicare residents with Alzheimer’s disease and related dementias. Journal of Aging and Health. 2018:0898264318767778. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.U.S. Department of Health and Human Services. What is long-term care? https://longtermcare.acl.gov/the-basics/what-is-long-term-care.html. Published 2017. Updated October 10, 2017. Accessed February 29, 2020.
- 29.Wahrendorf M, Reinhardt JD, Siegrist J. Relationships of disability with age among adults aged 50 to 85: Evidence from the United States, England and continental Europe. PloS One. 2013;8(8). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Avendano M, Glymour MM, Banks J, Mackenbach JP. Health disadvantage in US adults aged 50 to 74 years: A comparison of the health of rich and poor Americans with that of Europeans. American Journal of Public Health. 2009;99(3):540–548. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Fonda S, Herzog AR. Documentation of physical functioning measured in the Health and Retirement Study and the Asset and Health Dynamics among the Oldest Old Study. Ann Arbor: University of Michigan Survey Research Center. 2004. [Google Scholar]
- 32.AARP. Women & long-term care. Facts Sheet Web site. https://assets.aarp.org/rgcenter/il/fs77r_ltc.pdf. Published n.d. Accessed February 29,, 2020. [Google Scholar]
- 33.Mudrazija S, Thomeer MB, Angel JL. Gender differences in institutional long-term care transitions. Women's Health Issues. 2015;25(5):441–449. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Span P Fewer beds for men entering nursing homes. The New York Times; 2012. [Google Scholar]
- 35.AALTCI. Long-Term Care - Important information For women. American Association for Long-Term Care Insurance. Published n.d. Accessed February 29, 2020. [Google Scholar]
- 36.Johnson RW. What Is the lifetime risk of needing and receiving long-term services and supports? Washington, DC: The Urban Institute. 2019. [Google Scholar]
- 37.Mottram P, Pitkala KK, Lees CC. Institutional versus at-home long term care for functionally dependent older people. Cochrane Database of Systematic Reviews. 2002(1). [DOI] [PubMed] [Google Scholar]
- 38.Young C, Hall AM, Gonçalves-Bradley DC, et al. Home or foster home care versus institutional long-term care for functionally dependent older people. Cochrane Database of Systematic Reviews. 2017(4). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Barth S, Klebonis J, Archibald N. Long-term services and supports opportunities in the Affordable Care Act. Retrieved on May. 2011;18:2018. [Google Scholar]
- 40.Medicaid.gov. Money Follows the Person. Centers for Medicare and Medicaid Services. https://www.medicaid.gov/medicaid/long-term-services-supports/money-follows-person/index.html. Published n.d. Accessed February 29, 2020. [Google Scholar]
- 41.Sugg MM, Spaulding TJ, Lane SJ, et al. Mapping community-level determinants of COVID-19 transmission in nursing homes: A multi-scale approach. Science of the Total Environment. 2020;752:141946. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Berridge C, Mor V. Disparities in the prevalence of unmet needs and their consequences among black and white older adults. Journal of Aging and Health. 2018;30(9):1427–1449. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Shippee TP, Akosionu O, Ng W, et al. COVID-19 pandemic: Exacerbating racial/ethnic disparities in long-term services and supports. Journal of Aging & Social Policy. 2020:1–11. [DOI] [PMC free article] [PubMed] [Google Scholar]
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