40 percent of African-American nursing home residents living in low-tier facilities

Racial and socioeconomic disparities are widespread in U.S. nursing homes, new Brown University research shows, with 40 percent of African-American nursing home residents living in low-tier facilities. Comparatively, 9 percent of whites live in low-tier homes, which operate with limited budgets and serve high concentrations of residents whose care is subsidized by Medicaid, the government health program for the poor and disabled.

These low-tier facilities employ significantly fewer registered nurses, nurse practitioners, and other well-trained staff, researchers found. The facilities were more likely to change ownership Ð a sign of financial or managerial problems. These homes were much more likely to serve the mentally ill and mentally retarded.

And, researchers found, these homes were more often cited for health-related deficiencies, such as serious bed sores and unnecessary use of restraints.

The result: A two-tiered system of care for America's elderly that can be found in virtually every state.

Vincent Mor, chairman of the Department of Community Health at Brown Medical School and the lead study author, said that the disparity is caused by economic forces. Low-tier facilities rely mainly on Medicaid reimbursements, which are lower than those paid out by Medicare, the federal insurance program for the elderly. Low-tier nursing homes serve few, if any, residents who pay higher rates through their own insurance or savings.

"People in low-tier homes have always been poor or simply exhausted their resources and can't pay for better care," Mor said. "African-Americans are five times as likely to be poor at this age, so you can't separate poverty from race."

Mor spearheaded the research with Jacqueline Zinn, an associate professor of health care management at Temple University. Their work appears in the latest issue of Milbank Quarterly, a peer-reviewed health policy journal.

Although some studies have touched on race and nursing home care, the authors said their work is the first comprehensive investigation of race, income and nursing home quality in the United States. Three separate data sets were used for the study, which reviewed 14,000 non-hospital based nursing homes nationwide.

Despite glaring evidence of a racial and economic divide, the authors don't suggest that substandard homes be immediately shut down. Residents may have no other place to go.

Instead, Mor and Zinn recommend a proactive prescription from government: Offer more training for nursing home managers; boost Medicaid reimbursement rates so facilities can improve staffing levels and quality; and give state or county governments the power to take over failing homes.

The authors also suggest an increase in payments to nursing homes that accept transfers from low-tier facilities. "You don't want to send these folks to the next bad place down the line," Mor said. "You want to put them in a place that is better."

Brown University Community Health faculty Joan Teno and Susan Miller contributed to the study, as did Joseph Angelelli, assistant professor of health policy and administration at Pennsylvania State University.

Funding for the project came from The Robert Wood Johnson Foundation, as well as the Agency for Healthcare Research and Quality and the National Institute on Aging.