Disparities in Long - Term Healthc are Barbara Messinger-Rapport, MD, PhD, CMD, FACP KEYWORDS  Health disparity  Nursing home  Assisted living  Chronic disease  End of life The goals of Healthy People 2010 (Fig. 1) recognize health disparities as a barrier to providing quality of care to everyone regardless of gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation.1 Examples of health disparities affecting older adults include the much lower vaccination rate for influenza and pneumococcus in Hispanics and African Americans compared with that in whites;2 lower rates of prescriptions for pain control in cancer-related pain for Hispanic and African Americans;3 and lower rates of procedures for knee and hip replacements, carotid endarterectomies, and coronary-artery bypass grafting for African Americans.4 Many aspects of the health care system may contribute to these disparities, including lack of or inadequacies in health coverage; lack of access to qualified physicians; lack of health literacy; geographic factors such as rural versus urban or region of the country. Health disparities in the subset of approximately 1.6 million older adults residing in nursing homes is not well studied but deserves more attention, given that approximately 1 in 4 Americans spend their last days in a nursing home.5 Disparities in the nursing home reflect both the preexisting health care disparities in the general community as well as the influence of organizational and reimbursement factors imposed by the nursing home. This article provides a historical review of relevant demographic and financial aspects of minority usage of nursing homes and identifies health care disparities associated with long-term care. Because there is so few data on Hispanic and Asian minorities in the nursing home, most of the examples revolve around African Americans. The discussion and conclusion suggest future directions to consider to meet Healthy People 2010 goals for the frailest elders. BACKGROUND Before the 1960s, minorities were much less likely than their white counterparts to reside in a nursing facility. Nursing homes were typically racially segregated (by law Section of Geriatric Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Mail Code A91, 9500 Euclid Avenue, Cleveland, OH 44195, USA E-mail address: rapporb@ccf.org Nurs Clin N Am 44 (2009) 179–185 doi:10.1016/j.cnur.2009.02.005 nursing.theclinics.com 0029-6465/09/$ – see front matter ª 2009 Elsevier Inc. All rights reserved. 180 Messinger-Rapport Fig. 1. Goals of Healthy People 2010: To eliminate health disparities and to increase quality and years of healthy life. (From Centers for Disease Control. Data 2010. Available at: http:// wonder.cdc.gov/data2010/index.htm. Accessed February 15, 2009.) or by default), and the cost likely placed nursing homes out of reach of minorities. Minority entry into the nursing home in large numbers was likely facilitated by the introduction of Medicaid as a payer in 1966. The Medicaid program became the largest purchaser of nursing home services by the 1990s.6 By 2004, nursing home use by blacks became 32% higher than that of whites.7 Despite legal elimination of segregation in 1964, nursing homes today remain relatively segregated more than 40 years later, with two-thirds of all African American residents living in just 10% of all facilities in 2000.8 The degree of segregation varies by location, with the Midwest having the highest degree of segregation and the south having the least. African Americans are significantly more likely to be served by facilities in the bottom quartile of many structural and performance measures of quality, such as staffing, inspection deficiencies, and financial viability.8 Finances likely play a significant role in both the degree of segregation and the quality of care in the facility. African Americans are 30% more likely to have Medicaid as a payer source than whites.7 Thus, nursing facilities with higher proportions of older African American residents are associated with heavy reliance on Medicaid.8 Medicaid rates are generally less than private-pay rates and sometimes less than actual costs of care, potentially limiting resources available on-site.9 Most homes with large proportions of African Americans are also privately owned, for-profit institutions, so they have no other source of revenue, such as philanthropy. Homes unable to attract sufficient private-pay patients tend to have lower nurse staffing levels and more serious inspection deficiencies.10 Nursing homes that have preferential admission policies for a selective religion or continuing care community may in practice (although not on paper) be limiting first-day-elegible Medicaid admissions. This practice facilitates admissions to those with sufficient resources that they are less likely to become eligible for Medicaid during their remaining lifetime, creating mainly white, female residential population. MANAGEMENT OF CHRONIC DISEASE Consider an 80-year-old, long-term resident, Mrs. Carter. She is a retired African American teacher, with diabetes, atrial fibrillation, hypertension, compensated heart failure, and a history of a mild stroke 5 years ago. She exhausted her private funds 2 years ago, and Medicaid now covers the cost of her nursing home care. Despite her medical conditions, she is fairly spry and cheerful, enjoying church services, card games, news groups, and gossiping with visitors. She fell once last year, bruising her knee, but did not sustain any other injuries. As an African American nursing home resident, she is more likely than a white resident to be hospitalized with a potentially inappropriate medication (PIM).11 She is less likely to receive antidiabetic medications.12 She is less likely to be prescribed Warfarin for atrial fibrillation in the setting of a prior stroke.13 If she lives in a for-profit nursing facility, she may be more likely to be exposed to influenza, because employee vaccination rates are lower than those in nonprofit facilities.14 However, if she happens to be living in a facility with few African American residents, she will be less likely to be hospitalized than she would be in a facility with more African Disparities in Long-Term Healthcare American residents.15 Facilities with fewer black residents typically rely less on Medicaid as a payer; they may be able to afford more staff and services and, potentially, be better able to manage chronic disease, promote an active lifestyle both physically and cognitively, and reduce hospitalization. For example, facilities that have more than 35% private-pay residents employ mid-level practitioners (nurse practitioners [NPs] or physician assistant [PA]), use intravenous (IV) therapy, or have a certified nurse aide program are less likely to hospitalize residents for acute coronary syndrome.16 ADDRESSING END-OF-LIFE ISSUES End-of-life care in the nursing home is considered unsatisfactory by many residents and families. Unmet needs include addressing pain and dyspnea, physician communication, emotional support, and being treated with respect.17 Consider the case of Mrs. Jones, an 85-year-old African American woman with moderate to severe dementia. She was admitted to the nursing home following several hospitalizations and had recently been diagnosed with systolic heart failure, with an ejection fraction of 12%. She was prescribed 12 medications requiring more than 20 pills daily, not unusual in a person with multiple medical conditions. Despite her dementia, she can express her needs and recognize her family. She was tearful, disoriented, in pain from severe shoulder arthritis, and occasionally agitated—once taking off her clothes in the hallway and another time threatening the housekeeping staff with a table knife. She has a poor appetite and lost 20 lb in the past 6 months. Her family states that she has no advance directives, and she has always been a ‘‘full code’’ during hospitalizations, because they are concerned that the hospital will not offer appropriate treatment to those with a ‘‘do not resuscitate’’ (DNR) status. If Mrs. Jones lives in a for-profit, primarily Medicaid facility, she is less likely to be the beneficiary of special programs, such as dementia, palliative care, or hospice.18 Should her heart failure require IV therapy, she would need to be hospitalized, since for-profit facilities are less likely to offer specialized clinical services, such as peripherally inserted central lines, to manage heart failure.18 It is not unusual that Mrs. Jones has no advance directive of any type. African Americans are less likely than whites to have DNR orders19 or living wills;20 Hispanics are about one-third as likely as whites to have DNR orders although just as likely as whites to have living wills.20 Since advance directives are felt to enhance autonomy and improve the quality of care at the end of life, this disparity suggests that minority residents are relatively disadvantaged. Should Mrs. Jones continue to lose weight, she will likely be offered a feeding tube. Residents of large, for-profit, urban nursing homes with a higher percentage of nonwhite residents are more likely to have feeding tubes in the setting of severe cognitive impairment.21 Experiences with the health care system and problems with trust in physician and nursing staff affect decisions regarding feeding tubes in dementia.22 DISCUSSION Health disparities in the community likely result from the interplay of insurance; access to qualified physicians and services; health literacy and cultural disparities; and geographic distribution. Health disparities in the nursing home may be more complex because of the impact of the nature of the facility on care and care outcomes. The example of hospitalization risks provides insight into the complexity of health disparities and the interaction of underlying predictive factors. In the 2 examples of hospitalization, one by Gruneir and colleagues15 on hospitalization and one by Intrator and 181 182 Messinger-Rapport colleagues16 on hospitalization for acute coronary syndrome, simply residing in a facility with a high concentration of African Americans or Medicaid residents increases the risk of hospitalization for all residents, regardless of race or ethnicity.15,16 The entrance of mid-level practitioners into long-term care may improve adherence to chronic care guidelines, reduce hospital admission rates, and decrease the total number of medications.23 For example, if there were an NP or a PA involved with Mrs. Carter’s care and partnering with the physician, the burdens and benefits of anticoagulation might have been addressed more thoroughly. The mid-level practitioner may query staff about her postural instability and the effect of potential loss of function should she have a stroke and may spend time with her and her family discussing the burden and benefit of oral anticoagulation. The result would be a more carefully crafted decision and likely closer monitoring. Additionally, there is evidence that physicians who specialize in nursing home care are on-site at nursing homes more frequently and have quicker response times to emergencies.24,25 The American Medical Directors Association developed a Certified Medical Director program in 1991, which includes a week-long course of didactic sessions with past training and experience. Recertification requires Continuing Medical Education in nursing home care and management. There are now nearly 2,400 Certified Medical Directors. States may begin to demand a level of geriatric education in the nursing home practitioner. The state of Maryland, in 2000, began to phase in proscriptive requirements for the education of physicians in geriatric principles to improve nursing home care in their state.26,27 Improving reimbursement rates of facilities from Medicaid may be helpful as well, since Medicaid often does not cover the actual cost of care in the facility. In the study by Gruneir, each $10 increment in Medicaid reimbursement reduced the odds of hospitalization by 4% for white residents and 22% for African Americans.15 Facilities with primarily urban and minority residents are the most likely to benefit, and care could be improved by using the incremental income for staffing and additional special programs to provide higher-quality care. Interventions in end-of-life care in the nursing home are being addressed by multiple organizations. The American Medical Directors Association has a toolkit entitled Palliative Care in the Long-Term Care Setting, to be used by medical directors and interdisciplinary teams in the nursing home. Palliative care consultations by specialists (typically a Hospice medical director or advance NP) are now reimbursable at a facility irrespective of whether the resident is receiving skilled or custodial care. For a resident active in hospice, the hospice nurses will attend an interdisciplinary care conference and help keep family members apprised of the resident’s condition. The resident will receive extra attention in terms of an aide and may receive services that the facility does not have (music therapy, massage therapy, etc). The family will be monitored for complicated grieving for a year after the resident’s death. Unfortunately, interdisciplinary palliative care programs are not reimbursable by Medicare. The typical person enrolled in a palliative care program has a limited life expectancy (usually 6–12 months) or would qualify for hospice (less than a 6-month life expectancy) but refuses. Palliative care is appropriate for any stage of illness when there is a transition from treatment according to disease guidelines to meeting comfort needs, both physical and spiritual. Mrs. Jones (details of the case have been changed to maintain privacy) was actually enrolled into a new palliative care program offered by our facility. She and her family completed a survey of their concerns and values. The family stated they did not want hospitalization because of the delirium incurred by each hospitalization, but they did not want to forgo hospitalization for worsening symptoms. Medications that did not Disparities in Long-Term Healthcare clearly provide comfort (such as a statin) were eliminated, but medications that promoted better respiration were continued and adjusted (angiotensin-converting enzyme inhibitor, nitroglycerin). She received 3 doses of IV Lasix (Furosemide) in the facility, and then Aldactone (Spironolactone) was added to her regimen. She was given low doses of narcotics and a course of therapy for her shoulder pain, with remarkable improvement. During the course of 4 weeks, her confusion, edema, and dyspnea regressed, and her mobility improved. During the course of 6 months, her appetite returned, and she gained about 8 lb (not in edema). The activities and spiritual director worked with her to help identify therapeutic and distracting activities for her. The family was pleased with the outcome, and she is stable 2 years later with no hospitalizations. The development of this program was sponsored by a local charitable institution and was a joint project of the nursing home, a local hospice agency, and the Cleveland Clinic. Once running, the program typically had 3 active residents at any time (out of a facility of 100 beds) and required 1 hour-long interdisciplinary meeting twice each month. Finally, the impact of the rising use of assisted living facilities (ALFs) on health disparities is unclear but concerning. There are now nearly a million elders in ALFs.28 They are approximately the same age as those who reside in nursing homes, have a high prevalence of cognitive impairment, and are impaired in 2 basic activities of daily living. In the ALF, residents or their families retain responsibility for tending to their health care needs, and as a result, there is much less governmental oversight or data collection. Additionally, the overwhelming majority of ALFs accept private pay only. ALF cost is unaffordable for low- or moderate-income elders, unless they use assets as well as income to pay. The overall impact of the ALFs may be to siphon elders with the highest financial resources (usually whites) away from the nursing homes, leaving a higher proportion of residents (usually nonwhites) who rely on Medicaid facilities for care. If health care in nursing homes that rely heavily on Medicaid reimbursement continues to be bottom tier in terms of structural and performance measures of quality, then health care disparities for minorities will persist or even worsen with the growth of private-pay ALFs. SUMMARY Addressing the Healthy People 2010 goal of eliminating health disparities in the nursing home requires addressing facility and payer issues in addition to all the factors that contribute to health disparities in the community. The continued segregation of minority residents in facilities that rely heavily on Medicaid suggests a target for government intervention. Increasing Medicaid reimbursement may help reduce disparities, since there is evidence that Medicaid does not currently cover the basic cost of care. Increasing the coverage of Medicaid in ALFs and community care may stem the growing proportion and further segregation of minority Medicaid recipients in nursing home facilities. Requiring more education in geriatric principles and increased use of geriatric specialists in the nursing home (both physician and mid-level extender) may improve chronic disease care, reduce polypharmacy, and reduce hospital admissions. More disincentives to use PIMs, which may preferentially and adversely affect African Americans and those with Medicaid, may improve care in all facilities. Eliminating nonfinancial promoters of segregation, such as religious restrictions, may help desegregate facilities. 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