Contributions of Race and Payer Source to Nursing Home Quality of Care. Do Individual Level Effects Remain after Controlling for Facility Level Effects?

Objective: We examined the contributions of individual race and Medicaid coverage to disparities in nursing home (NH) quality of care, after accounting for the facility level effects of racial and Medicaid segregation in NHs that have been observed in the US.

Methodology: We studied current residents (White n=11,249, Black n=1,258) aged 50 and older from the 2004 National Nursing Home Survey (NNHS). A Non-Linear Mixed (multilevel) Model was used to examine the influence of individual and facility characteristics on three measures of NH quality available in the NNHS.

Findings: Black residents were no more likely than their White counterparts to experience the use of restraints or a hospital admission. Residents in facilities with higher share of Blacks were more likely to experience restraints (OR 1.980, 95% CI [1.449, 2.704]). Medicaid payment was not significant to predict NH quality at the individual level, while residents in facilities with a higher share of individuals covered by Medicaid (>60%) had greater odds of experiencing daily use of restraints (OR 2.184, 95% CI [1.201, 3.970]) and hospitalizations (OR 1.742, 95% CI [1.091, 2.783]). Additionally, at the individual level, increasing age, being male, increasing functional limitations, Medicare as the payer at admission and being diagnosed with dementia were important factors to predict poorer NH quality.

Implications: To address disparities, federal legislation will need to focus on factors that contribute to poor quality in NHs with significant shares of Black residents and those covered by Medicaid; factors which remain after accounting for facility staffing.