How various disparities impact nursing home residents' health across Ohio

Introduction

The older adult population is increasing in the United States. Statistics show that there were 52.4 million older adults, ages 65 and older in 2018.[[1]](https://acl.gov/sites/default/files/Aging and Disability in America/2019ProfileOlderAmericans508.pdf) In 2060, it is expected that this population will grow to 97.5 million.[1] This trend is also reflected in Ohio. According to Miami University’s Scripps Gerontology Center, more than 1 in 4 adults will be 60 years old or older by 2025.[2] As the older adult population increases, it will most likely depend on long-term services and supports (LTSS). LTSS can provide care for older adults in their homes, through home and community-based services (HCBS) or in assisted-living programs. Another type of LTSS is the assistance offered through nursing homes, which provide medical care, meals and rehabilitation services.[3] Even though nursing homes are a resource for older adults, these centers can have problems that impact residents’ health and quality of life. A variety of different disparities play a role in residents’ health experiences across the United States, however little research is available on Ohio’s nursing homes. Hence, the purpose of this paper is to explore disparities and their health implications on Ohio’s older adult population in nursing homes. Specifically, the following research questions will be addressed:

• How do disparities in Ohio nursing facilities affect older adults’ health and what public policy solutions can address these issues?
• Are racial disparities the only type of disparities present in Ohio nursing homes?This paper includes key informant interviews that were conducted to understand the nursing home environment throughout Ohio, followed by a literature review about race as the major disparity in nursing facilities across the United States and the health implications for residents. An analysis section is also incorporated to understand why nursing homes in Ohio are experiencing challenges concerning disparities and negative health outcomes. Finally, policy recommendations will be included to address any emergent issues.  

KEY TAKEAWAYS

• Key informants expressed that there are racial disparities in nursing homes throughout Ohio, but there are other disparities such as socioeconomic status (SES), gender and geography.
• Researchers who studied nursing home disparities across the United States identified an association between race and negative health outcomes.
• Since the relationships between various disparities and residents’ health is an emerging issue in Ohio’s nursing homes, it is important to develop more disparity-focused analysis to understand Ohio’s landscape and take specific policy steps to improve conditions and training for staff serving the residential population.

Methodology

The Center for Community Solutions conducted 10 key-informant interviews with experts in the long-term care field across Ohio. They were located in northeast, central and southern Ohio. The interviewer, who is the author of this paper, informed the interviewees that they will remain anonymous throughout the paper. After the interviews were completed, the interviewer compared responses and created themes based on similar responses.

 The quality of life in nursing homes is also often determined by the availability of specialized care and culturally appropriate activities for each nursing home resident.

Results from key-informant interviews

Before addressing the research questions and themes regarding outcomes, one must recognize the types of quality improvement indicators in nursing homes across Ohio. According to key informants, some of the quality improvement indicators include infection control; staff retention; injury and health; and quality of life for nursing home residents. One participant believed that infection control was the number one indicator of quality due to COVID-19’s prevalence in facilities with poor control that serve a population of residents that are already suffering from comorbidities. In regards to health and injury, other key informants listed problems residents experienced such as falls, wounds, weight loss, pressure ulcers and misuse of psychotropic medicine. The quality of life in nursing homes is also often determined by the availability of specialized care and culturally appropriate activities for each nursing home resident. For example, one key informant expressed that some nursing homes should include activities and food that are enjoyable to the Black community. Understanding quality improvement indicators can provide insights into the issues that are present in nursing homes surrounding disparities and health.  

Theme 1: There are a variety of disparities present in nursing homes across Ohio.  

According to the majority of key informants, racial disparities exist in nursing homes throughout Ohio. One individual stated that Black residents who already experience racial disparities associated with COVID-19 will suffer from worse health outcomes generally. Another key informant mentioned that racial disparities are present in nursing homes because there is a lack of Black providers who serve older adults. Even though there are racial disparities, it is not the only type of disparity present. SES, or having a low income, determines whether older adults can access nursing homes. If older adults do not have enough resources, then they will not be able to access higher-quality nursing homes. In addition, the locations of the nursing homes correlate with the amount of resources made available to residents. For example, one key informant discussed nursing homes in rural areas with fewer resources such as beds, and specialty staff. A key informant explained that gender is a disparity because women live longer than men, which make women more susceptible to chronic health issues, long term. Also, residents having less access to specialized medical staff is a disparity according to some key informants. For instance, one key informant explained that registered nurses (RNs) work in hospitals whereas licensed practical nurses (LPNs), who typically have less training than RNs, work in nursing homes. Finally, another health care disparity some nursing home residents dealt with is the mistrust of the medical system. As a result of mistrust, when residents seek medical help, it usually only occurs when their health conditions get worse, and thus many do not access preventative services in a timely manner.

 Residents having less access to specialized medical staff is a disparity according to some key informants.

Theme 2: Medicaid is not the only reason why disparities exist in Ohio’s nursing homes.  

There were mixed reviews from key informants as to whether Medicaid coverage was the cause of disparities in Ohio’s nursing homes. One key informant thought Medicaid impacted disparities in nursing homes because the program reimburses nursing homes at lower rates than other forms of insurance, which may correlate to high turnover of nursing home staff. Another expert stated that Medicaid reimbursement correlates with what older adults endure in nursing homes. Specifically, if there is a decrease in reimbursement, then residents’ quality of care and staff working experiences are negatively impacted. Thus, based on some of the key informants’ responses, Medicaid plays a role as to why disparities are present in Ohio’s nursing homes because it can impact staffing.  

Most of the key informants did not believe Medicaid reimbursement, is the only reason for nursing home disparities. The majority of participants reported that staffing challenges are the reason for disparities in Ohio’s nursing homes. In fact, most of the experts cited high turnover rates among staff. Medicaid is tied to this issue as well though, as lower wages are due to Medicaid reimbursement, and those lower wages in the field do not encourage people to work in nursing homes with one key informant highlighting wages average $11 an hour. Other experts expressed that racial and implicit biases from staff towards residents can be a driver behind disparities. Finally, other key informants pointed out that social determinants of health influence disparities. For instance, some nursing homes cannot provide transportation to specialty care services due to the cost associated.

 Medicaid plays a role as to why disparities are present in Ohio’s nursing homes because it can impact staffing.

Theme 3: Health outcomes appear due to the lower quality of care and racial disparities within nursing homes.  

Unfortunately, nursing home disparities in Ohio negatively impact the health of residents. Two patterns emerged from key informants’ comments concerning the health outcomes of residents. One of the patterns was that residents, regardless of race, experience a lower quality of health care. One key informant stated that due to limited staffing, residents will not be able to receive the appropriate treatment plans for their health issue/s. For example, in regards to nutrition, an expert described if a nursing home has poor-quality food, then the residents may lose weight which leads to other health issues and complications. They also explained that not enough staff will cause residents to have pressure ulcers, also called bedsores, due to a lack of movement for individuals with mobility challenges. Another participant reported that low-skilled nursing staff are unable to provide robust therapy and recreational programs necessary to maintain overall wellness.  

Lastly, one troubling pattern that emerged in interviews comes from racial disparities within a single facility which can lead to specific health problems for Black residents and other minorities. One key informant explained that if the nursing home is subpar overall, then there will be more bed sores among Black residents than their white counterparts. Another participant described minorities who are in majority white nursing homes, especially in Southern Ohio, and how they can suffer from isolation because they may not be able to connect to residents and/or staff culturally. Isolation can lead to mental health conditions such as depression, so it is important for residents to avoid it as to not increase their comorbidities.

Literature review

Although key informants qualitatively indicate there are various disparities that occur in nursing homes across Ohio, other researchers pointed out a quantitative pattern of racial disparities present in these facilities across the United States. One of the ways in which disparities, including race, are present in nursing homes can be seen through a metric known as quality of life (QOL). According to some researchers, QOL “measures non-clinical aspects of residents’ lives in nursing homes and includes satisfaction with activities offered, meals, and relationships with staff and other residents.”[4] Residents living in nursing homes endure different QOL challenges due to racial disparities. Various studies reported that minorities who live in high-proportion minority nursing homes reported lower QOL scores than white residents living in low-proportion minority nursing homes. [4],[5],[6] Furthermore, minority residents experienced lower QOL than white residents regardless of whether they lived in a low-minority or a high-minority nursing home.[6]

 Minority residents experienced lower QOL than white residents regardless of whether they lived in a low-minority or a high-minority nursing home.

Besides QOL, there are other indications of racial disparities within nursing homes that impact the health of residents. For instance, researchers examined the magnitude and the association between racial segregation and health care disparities in nursing homes in Missouri.[7] The health care outcomes they examined were physical restraint, influenza vaccination, high-risk pressure ulcers, and pneumococcal vaccination. They found that in nursing homes with higher proportions of Black residents, residents were more likely to have suffered from pressure ulcers, also called bedsores, and are less likely to have received influenza and pneumococcal vaccines. In addition, across Missouri, Black residents received poorer health care compared to the overall population in nursing facilities. Researchers from the University of Minnesota observed the racial and ethnic disparities in the healing of stages two to four pressure ulcers (the severity of bedsores based on how far they invade the tissues) in nursing homes.[8] They discovered that for Black older adults who were admitted into nursing homes with pressure ulcers, those ulcers were less likely to be healed by the time they had reached the 90-day admission mark compared to their white counterparts.  

Currently, disparities are more prevalent in nursing homes since the start of the COVID-19 pandemic. During the early stages of the pandemic, nursing home residents had a higher chance of being diagnosed with COVID-19 due to the lack of testing, because first responders were the primary group to receive this service.[4] Other studies later pointed out the differences in COVID-19 cases and deaths based on race in nursing homes. For example, a news writer from the Center for Infectious Disease Research and Policy (CIDRAP) stated that nursing facilities with a large percentage of minority residents had an average 3.3 times more deaths due to COVID-19 than majority white facilities.[9] Scholars from Rochester and Oakland described in their study of 76,735 residents in 921 nursing homes that the amount of weekly new COVID-19 cases in nursing homes was 0.4 cases per facility with low proportions of racial/ethnic minorities and increased to 1.5 cases per facility for nursing homes with a high proportion of racial/ethnic minorities.[10] Before the pandemic, nursing homes already exhibited racial disparities due to segregation, fewer staff members, lower QOL and infection control.[11] The pandemic magnified those disparities that negatively affect older adult minorities in nursing homes.

 Black residents in four states, including Ohio, received lower rates of pharmacologic diabetic treatments than white residents.

Unfortunately, little data exists about how disparities impact the health of minorities in Ohio nursing homes. Research about minorities in Ohio nursing homes not related to COVID-19 is outdated. With that said, there are some legacy indicators of disparities worth highlighting. In one study, researchers examined the prevalence of ethnic and racial disparities in diabetic treatment among older adults living in long-term care facilities in five states, including Ohio.[12] The other states were South Dakota, New York, Kansas, Maine and Mississippi. They discovered that Black residents in four states, including Ohio, received lower rates of pharmacologic diabetic treatments than white residents. There is also other research concerning disparities and health within nursing homes in Ohio regarding depression.[13] In this study, researchers found out that Blacks in nursing homes were less likely to receive depression treatment and they were “half as likely as whites to be diagnosed with depression.”[13]  

Despite the limited information about disparities, generally, in Ohio nursing homes, COVID-19 often revealed the ways in which disparities are present as a measure of medical vulnerability. And while the Centers for Medicare and Medicaid Services recently posted cases and deaths of COVID-19 in specific nursing homes across Ohio, the data is not broken down by demographics such as race, gender and income. [14] Thus, Community Solutions has had to rely on key informant interviews to understand disparities in Ohio nursing homes and how they impact the health of residents.  

Analysis

Based on the key informants’ responses, various factors go into the Ohio nursing homes that are underperforming, especially relating to racial and ethnic disparities. Nursing home staff issues seem to be major contributing factors due to issues like low pay and high turnover. According to the Paraprofessional Healthcare Institute, in 2016 nursing assistants working in nursing homes throughout Ohio made $11.04 per hour and 53 percent made below 200 percent of the federal poverty level.[15] Two hundred percent of the poverty level means a family of three earned up to $40,180 in 2016.[16] Another factor that contributes to the problems within Ohio’s nursing homes is the association between Medicaid reimbursement and the quality of nursing homes. A group of researchers reported that “ensuring a living wage for direct care workers is not sustainable if the primary source of LTSS funding continues to be the Medicaid program.”[17] If Medicaid reimbursement is low, then nursing homes cannot afford to pay their staff enough or provide adequate resources. In fact, one of the key informants described how Medicaid rates only increase every 10 years, which is problematic when considering that many nursing home staff members are underpaid. With that said, increases allocated to Ohio’s industry have not focused on staff retention nor seem to concentrate on issues of quality or training.  

The final factor that makes Ohio nursing homes problematic for residents is implicit bias from nursing home staff. Besides the key informants’ beliefs about how implicit employee bias affects residents, there is research that pointed this out as well. Experts from Duke University and the University of North Carolina at Chapel Hill studied whether North Carolina nursing home staff displayed implicit bias when selecting fall prevention interventions for nursing home residents.[18] Based on 1,615 vignette surveys (hypothetical situations in which the participants pick certain actions), there was a small trace of implicit bias from nursing home staff. Specifically, Black residents in the vignettes were less likely to receive environmental modifications to prevent falls. Thus, implicit bias from staff can possibly prevent some older adults from receiving the proper care in nursing homes.

Policy recommendations

There are various ways to address nursing home disparities across Ohio. First, professionals should invest in research about how nursing home disparities affect the health of older adults in Ohio. Due to the lack of disparity research in nursing homes across Ohio, more older adults will continue to experience health issues. Research can influence public policy by helping legislators understand why there is a need to implement policies to reduce disparities for residents. Also, research can influence professionals to find interventions that work best to lessen the disparities. Overall, research like this is the foundation to solve public health issues.

 Implicit bias training should be required for nursing home staff.

Second, implicit bias training should be required for nursing home staff. Many of the key informants stated that professionals should first identify if disparities exist within these settings, and if they do, then discuss how to address them. When working on this activity, implicit bias training can be one of the ways to resolve disparities and poor health outcomes in nursing homes. Although there is not a specific implicit bias training for nursing home staff, some states are aiming to implement mandatory training for health care professionals. For example, Governor Gretchen Whitmer of Michigan signed Executive Directive 2020-7 in 2020, which allows the Department of Licensing and Regulatory Affairs (LARA) to develop rules surrounding implicit bias training as a requirement for licensure and registration (including renewals) for health care professionals.[19] Starting implicit bias training in Ohio’s nursing homes can possibly help staff improve residents’ quality of life and quality of care.

 If direct care workers’ pay increased by 15 percent, then it would provide benefits like a lower turnover staff rate.

The final recommendation to resolve disparities and the health of residents in Ohio’s nursing homes is to have targeted reimbursement policies that increase pay for nursing home staff and incentivize meaningful quality improvement beyond simple rate increases. Researchers described that LeadingAge and LeadingAge LTSS Center at the University of Massachusetts (UMASS) Boston conducted research and concluded that if direct care workers’ pay increased by 15 percent ($9.4 billion in 2022), then it would provide benefits like a lower turnover staff rate, residents receiving reliable care and workers depending less on public assistance.[17] Also, some states work with managed care organizations to improve pay and benefits for direct care workers. Specifically, in Wisconsin, an appropriations bill passed in 2017 increased a “portion of funds in managed care contracts that go toward aide wages, bonuses, time off and benefits.”[18] By understanding the research and learning from other state governments, legislators in Ohio can possibly increase pay for nursing home staff.

 Older adults who live in nursing homes across Ohio face various disparities that impact their health.

Conclusion

Older adults who live in nursing homes across Ohio face various disparities that impact their health. Some disparities include race, SES, mistrust of the medical system and the locations of nursing homes (ZIP codes, rural and urban areas). These disparities negatively impact the health of residents such as not receiving the proper treatment plans, isolation and weight loss. Furthermore, some of the main reasons why disparities exist within Ohio’s nursing homes are due to staffing issues and implicit bias toward residents. In order to reduce disparities and improve health of nursing home residents, professionals should conduct more research on how disparities impact nursing homes in Ohio since the data is limited. From the research, policymakers can consider implementing reimbursement mechanisms to encourage implicit bias training for nursing home staff and increased wages. Likewise, they can learn from other state governments and the actions they have taken to resolve these issues, especially as it relates to clinical quality. Taking the following solutions into consideration will allow nursing home residents across to receive the best health care and living experience(s).  

[1] Administration on Aging. (2020, May). 2019 profile of older Americans. https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2019ProfileOlderAmericans508.pdf  

[2] Miami University Scripps Gerontology Center. (n.d.). Ohio’s changing population.  

[3] NIH National Institute on Aging. (2017, May 1). Residential facilities, assisted living, and nursing homes. https://www.nia.nih.gov/health/residential-facilities-assisted-living-and-nursing-homes  

[4] Shippee, T. P., Akosionu, O., Ng, W., Woodhouse, M., Duan, Y., Thao, M. S., & Bowblis, J. R. (2020, May 31). COVID-19 pandemic: Exacerbating racial/ethnic disparities in long-term services and supports. Journal of Aging & Social Policy, 32, 323-333. https://doi.org/10.1080/08959420.2020.1772004  

[5] Shippee, T. T., Ng, W., Duan, Y., Woodhouse, M., Akosionu, O., Chu, H., Ahluwalia, J. S., Gaugler, J. E., Virnig, B. A., Bowblis, J. R. (2020, December). Changes over time in racial/ethnic differences in quality of life for nursing home residents: Patterns within and between Facilities. Journal of Aging Health, 32(10), 1498-1509. https://doi.org/10.1177/0898264320939006  

[6] Shippee, T. P., Ng, W., & Bowblis, J. R. (2020). Does living in a higher proportion minority facility improve quality of life for racial/ethnic minority residents in nursing homes? Innovation in Aging, 4(3), 1-9. https://doi.org/10.1093/geroni/igaa014  

[7] Chang, Y. J., Siegel, B., & Wilkerson, G. (2011, March 1). Measuring healthcare disparities and racial segregation in Missouri nursing homes. Journal for Healthcare Quality, 34(1), 16-25. https://doi.org/10.1111/j.1945-1474.2011.00135.x  

[8] Bliss, D. Z., Gurvich, O., Savik, K., Eberly, L. E., Harms, S., Mueller, C., Garrard, J., Cunanan, K., & Wiltzen, K. (2017, September). Racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission. Archives of Gerontology and Geriatrics, 72, 187–194. https://doi.org/10.1016/j.archger.2017.06.009  

[9] Van Beusekom, M. (2021, February 10). COVID deaths 3 times higher in nursing homes with more non-white residents. University of Minnesota.