Objectives To examine the extent to which the racial/ethnic composition of nursing homes (NHs) and their communities affects the likelihood of COVID-19 cases and death in NHs; and whether and how the relationship between NH characteristics and COVID-19 cases and death varies with the racial/ethnic composition of the community in which a NH is located. Design Centers for Medicare and Medicare Services (CMS) Nursing Home COVID-19 data were linked with other NH- or community-level data (e.g. Certification and Survey Provider Enhanced Reporting, Minimum Data Set, Nursing Home Compare, and the American Community Survey). Setting and Participants NHs with more than 30 occupied beds (N=13,123) with weekly reported NH COVID-19 records between the weeks of 06/07/2020 and 08/23/2020. Measurements/ Model Weekly indicators of any new COVID-19 cases and any new deaths (outcome variables) were regressed on the percent of Black/Hispanic residents in a NH, stratified by the percent of Blacks/Hispanics in the community in which the NH was located. A set of linear probability models with NH random-effects and robust standard errors were estimated, accounting for other covariates. Results The racial/ethnic composition of NHs and their communities were both associated with the likelihood of having COVID-19 cases and death in NHs. The racial/ethnic composition of the community played an independent role in the likelihood of COVID-19 cases/death in NHs, even after accounting for the COVID-19 infection rate in the community (i.e. daily cases per 1000 people in the county). Moreover, the racial/ethnic composition of a community modified the relationship between NH characteristics (e.g. staffing) and the likelihoods of COVID-19 cases/death. Conclusions and Implications To curb the COVID-19 outbreaks in NHs and protect vulnerable populations, efforts may be especially needed in communities with a higher concentration of racial/ethnic minorities. Efforts may also be needed to reduce structural racism and address social risk factors to improve quality of care and population health in communities of color.

With the aging population, the number of older Americans with dementia is expected to grow rapidly. 1,2 Patients with dementia are reported to have higher health care utilization compared to those without dementia, including higher hospitalization rate, 3-5 longer hospital stays, 6,7 more emergency department (ED) visits, 4 higher probability of nursing home admission, 8 and longer nursing home stays. 9 Consequently, the cost of caring for patients with dementia is higher than for patients without dementia, 3,6 including patients with heart disease and cancer. 1,10 Although dementia is a complex neuropsychiatric illness often accompanied by other medical comorbidities, most care for patients

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Objective Explore within and across nursing home (NH) racial disparities in end‐of‐life (EOL) hospitalizations for residents with Alzheimer's disease or related dementia (ADRD), and examine whether severe cognitive impairment influences these relationships. Design Observational study merging, at the individual level, C2014‐2017 national‐level Minimum Data Set (MDS), Medicare Beneficiary Summary Files (MBSF), and Medicare Provider Analysis and Review (MedPAR). Nursing Home Compare (NHC) was also used. Setting Long‐stay residents who died in a NH or a hospital within 8 days of discharge. Participants Analytical sample included 665,033 decedent residents with ADRD in 14,595 facilities. Main outcomes and measures The outcome was hospitalization within 30 days of death. Key independent variables were race, severe cognitive impairment, and NH‐level proportion of black residents. Other covariates included socio‐demographics, dual eligibility, hospice enrollment, and chronic conditions. Facility‐level characteristics were also included (e.g. profit status, staffing hours, etc.). We fit linear probability models with robust standard errors, fixed and random effects. Results Compared to whites, black decedents had a significantly (p < 0.01) higher risk of EOL hospitalizations (7.88%). Among those with severe cognitive impairment, whites showed a lower risk of hospitalizations (6.04%). But EOL hospitalization risk among blacks with severe cognitive impairment was still significantly elevated (β = 0.0494; p < 0.01). A comparison of the base model with the fixed and random‐effects models showed statistically significant hospitalization risk by decedent's race both within and across facilities. Conclusions and relevance We found disparities between black and white residents with ADRD both within and across facilities. The within‐facility disparities may be due to residents' preferences and/or NH practices that contribute to differential treatment. The across facility differences point to the overall quality of care disparities in homes with a higher prevalence of black residents. Persistence of such systemic disparities among the most vulnerable individuals is extremely troubling.