Nursing home care is currently a two-tiered system. The lower tier consists of facilities housing mainly Medicaid residents and, as a result, has very limited resources. The nearly 15 percent of U.S. nonhospital-based nursing homes that serve predominantly Medicaid residents have fewer nurses, lower occupancy rates, and more health-related deficiencies. They are more likely to be terminated from the Medicaid/Medicare program, are disproportionately located in the poorest counties, and are more likely to serve African-American residents than are other facilities. The public reporting of quality indicators, intended to improve quality through market mechanisms, may result in driving poor homes out of business and will disproportionately affect nonwhite residents living in poor communities. This article recommends a proactive policy stance to mitigate these consequences of quality competition.T hose writing on the quality of nursing home care have, for the most part, framed the discussion in terms of its uniformly poor quality and have largely ignored the prospects and implications of a two-tiered system differentiated by quality. In contrast, our article provides evidence of a two-tiered system of nursing home care. The lower tier consists of facilities with high proportions of Medicaid residents and, as a result, very limited resources. Thus, stratification affects the number, type, and quality of services provided to residents of lower-tier facilities, who are disproportionately poor and from minority

ABSTRACT: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. [Health Affairs 26, no. 5 (2007): 1448-1458 10.1377/hlthaff.26.5.1448 T h e e f f e c t o f r ac i a l s e g r e gat i o n on disparities in medical treatment has only recently received attention from researchers. This research has shown that blacks are more likely than whites to seek care from hospitals that have fewer resources in terms of up-to-date technology.1 They are also more likely to receive care at hospitals with higher surgical mortality rates, undergo cardiovascular procedures at lower-volume hospitals, and receive maternity services at hospitals that have higher risk-adjusted neonatal mortality rates for both black and white infants.2 Blacks are also more likely to receive their primary care from physicians who tend to be less well trained than from physicians who primarily treat whites; have less access than whites to important clinical resources such as high-quality subspecialists, diagnostic imaging, and nonemergency admissions to hospitals; and report less control over their work, more time pressure, and higher rates of burnout than their white peers.3 These differences in primary care are reflected in missed opportunities among blacks for higher rates of early intervention with breast and prostate cancer treatment. 4 A tiered system of nursing home care that concentrates blacks in marginal-quality nursing homes also appears to exist. 5 n Historical background. Historically, segregation and discrimination in access to higher-quality nursing homes in the United States have never been systematically addressed. Before Medicare and Medicaid were implemented in 1966, nursing homes in the South were totally segregated by Jim Crow laws and in the North almost as much by patterns of use and admission practices. Racial segregation also took place within homes through separate floors and wings; it has persisted in some homes through similar segregation by payer status. In the past, blacks have had far more limited access to nursing home care than whites have had. In 1963, nursing home use by nonwhites over age sixty-five was 39 percent that of whites.6 A decade later, well after the implementation of Medicare and Medicaid, use of nursing homes by elderly blacks was still only 47 percent that of elderly whites. n Early noncompliance with the law. Title VI of the 1964 Civil Rights Act prohibits segregation and other forms of discrimination in any organization receiving federal funds. In s...

Employment of NP/PAs in NHs, the provision of intravenous therapy, and the operation of certified nurse assistant training programs appear to reduce ACS hospitalizations, and may be feasible cost-saving policy interventions.

Objective. Hospitalizations of nursing home residents are costly and expose residents to iatrogenic disease and social and psychological harm. Economic constraints imposed by payers of care, predominantly Medicaid policies, are hypothesized to impact hospitalizations. Data Sources/Study Setting. Federally mandated resident assessments were merged with Medicare claims and eligibility files to determine hospitalizations and death within 150 days of baseline assessment. Nursing home and market characteristics were obtained from the Online Survey Certification and Reporting, and the Area Resource File, respectively. States' average daily Medicaid nursing home payments and bed-hold policies were obtained independently. Study Design. Prospective cohort study of 570,614 older ( ! 65-year-old), non-MCO (Medicare Managed Care), long-stay ( ! 90 days) residents in 8,997 urban, freestanding nursing homes assessed between April and June 2000, using multilevel models to test the impact of state policies on hospitalizations controlling for resident, nursing home, and market characteristics. Principal Findings. Overall, 99,379 (17.4 percent) residents were hospitalized with rates varying from 8.4 percent in Utah to 24.9 percent in Louisiana. Higher Medicaid per diem was associated with lower odds of hospitalizations (5 percent lower for each $10 above average $103.5, confidence intervals [CI] 0.91-0.99). Hospitalization odds were higher by 36 percent in states with bed-hold policies (CI: 1.12-1.63). Conclusions. State Medicaid bed-hold policy and per-diem payment have important implications for nursing home hospitalizations, which are predominantly financed by Medicare. This study emphasizes the importance of properly aligning state Medicaid and federal Medicare policies in regards to the subsidy of acute, maintenance, and preventive care in the nursing home setting.

Objective To determine whether the rate of rehospitalization is lower among patients discharged to skilled nursing facilities (SNFs) with which a hospital has a strong linkage. Data Sources/Collection We used national Medicare enrollment, claims and the Minimum Data Set to examine 2.8 million newly discharged patients to 15,063 SNFs from 2,477 general hospitals between 2004 and 2006. Study Design We examined the relationship between the proportion of discharges from a hospital to alternative SNFs on the rehospitalization of patients treated by that hospital-SNF pair using an instrumental variable approach. We used distances to alternative SNFs from residence of the patients of the originating hospital as the instrument. Principal Findings Our estimates suggest that if the proportion of a hospital’s discharges to a SNF were to increase by 10 percentage points, the likelihood of patients treated by that hospital-SNF pair to be re-hospitalized within 30 days would decline by 1.2 percentage points, largely driven by fewer rehospitalizations within a week of hospital discharge. Conclusions Stronger hospital-SNF linkages, independent of hospital ownership, were found to reduce rehospitalization rates. As hospitals are held accountable for patients’ outcomes post-discharge under the Affordable Care Act, hospitals may steer their patients preferentially to fewer SNFs.

Future studies of facility turnover should avoid modeling turnover as a linear function of a single set of predictors in order to provide clearer recommendations for practice.

Objective To examine associations between nursing homes’ quality and publication of the Nursing Home Compare quality report card. Data Sources/Study Settings Primary and secondary data for 2001–2003:701 survey responses of a random sample of nursing homes; the Minimum Data Set (MDS) with information about all residents in these facilities, and the Nursing Home Compare published QM scores. Study Design Survey responses provided information on twenty specific actions taken by nursing homes in response to publication of the report card. MDS data were used to calculate five quality measures (QMs) for each quarter, covering a period before and following publication of the report. Statistical regression techniques were used to determine if trends in these QMs have changed following publication of the report card in relation to actions undertaken by nursing homes. Principal findings Two of the five QMs show improvement following publication. Several specific actions were associated with these improvements. Conclusions Publication of the Nursing Home Compare report card was associated with improvement in some but not all reported dimensions of quality. This suggests that report cards may motivate providers to improve quality, but it also raises questions as to why it was not effective across the board.

The purpose of this study was to examine behavioral differences between for-profit (FP) and not-for-profit (NFP) nursing homes. Previous studies have failed to establish consistent behavioral differences. This study uses a simultaneous equation model to control for potential endogeneity among system variables, with model parameters estimated using 3SLS. The study provides evidence that NFPs provide significantly higher quality of care to Medicaid beneficiaries and to self-pay residents than do FPs, as evidenced by better staffing and better outcomes among nursing homes with residents at higher risk for adverse outcomes.