These descriptive results on nursing home use during 2000–05 by elderly Hispanics, and on the relative likelihood of residing in poorly performing nursing homes, reveal three clear findings.
First, the numbers of elderly Hispanics residing in nursing homes has been growing and will continue to grow. Although nursing home use rates overall have declined recently among non-Hispanic whites, there is considerable geographic variability in use rates among Hispanics. In Metropolitan Statistical Areas in the Southwest with large proportions of Hispanic residents, nursing home use rates by elderly Hispanics are often higher than those of whites (). Nationally, the percentage of nursing homes with no Hispanic residents has declined significantly.
Second, elderly Hispanics are more likely than their non-Hispanic white peers to reside in nursing homes of poor quality. This result is consistent across three different constructs of nursing home quality: inspection deficiencies, staffing, and financial viability.
The findings are consistent at the level of both the nursing home and the Metropolitan Statistical Area. There are differences in nursing home performance levels by the percentage of nursing home residents who are Hispanic. As the percentage of Hispanic residents increases, nursing homes are more likely to be characterized by more severe deficiencies in performance, less likely to be deficiency or restraint-free, more likely to be understaffed, and more likely to be heavily dependent upon Medicaid funding. At the Metropolitan Statistical Area level, we can see that Hispanics are more likely to experience poor care, precisely because they are served by poor-quality facilities. These differences were consistent across the 2000–05 time period.
Third, these descriptive results suggest that perhaps the “buffering” effect of Hispanic family culture and values is weakening. Although the desire to keep Hispanic elders out of formal long-term care settings maybe very strong, the reality of the economic situation facing many Hispanic families may be overwhelming, particularly given rising rates of adult Hispanic women in the labor market and the rising cost of nursing home alternatives.
Unexplored Questions Our exploratory analyses did not allow us to address a number of important questions. For example, there may be differences in patterns of unequal access to high-quality nursing homes across different Hispanic groups, such as Mexican Americans compared to Cuban Americans or Puerto Rican Americans. Because these different subgroups are often geographically distinct, it is difficult to determine what is influencing observed patterns: ethnicity or geography.
The initial choice of nursing home placement following an acute care event or hospitalization is constrained by both hospital and nursing home bed availability. However, the “decision” at ninety days post acute (that is, to transform into a long-stay) could be constrained by a completely different set of family choices and long-term care market issues. In addition, the date at which Hispanic elders migrated to the United States may affect eligibility for both Medicare and Medicaid funding, complicating the choice set for Hispanic families even more.
Finally, migration patterns vary across different Hispanic groups, in terms of both historical timing of migration waves and age at time of migration. For example, elderly Cuban immigrants are more likely to be longer-term U.S. residents, compared to elderly Mexican immigrants; this might provide an advantage to elderly Cuban Americans' access to higher-quality nursing home care.24
Another set of factors not addressed in this analysis concerns the confounding of nursing home care quality with access to resources, either patient-related or nursing home-related. Our measures of the percentage of private-pay patients and the percentage of Medicaid patients are an indirect assessment of levels of nursing home resources that have been consistently tied to differences in nursing home care quality.3,4
The more dependent a nursing home is on Medicaid as a source of revenue, the less likely it is to have access to other resources that can help improve care quality.3
Thus, the pattern of “lower-tier” facilities emerges where underresourced facilities care for disproportionate numbers of patients who are both poor and from minority groups. Elderly Hispanics are less likely to be insured and more likely to be frail, disabled, or in poor health, compared to all other elderly subpopulations. As larger numbers of elderly Hispanics move into lower-tier facilities (for lack of personal resources needed for nursing home alternatives), the clustering of high-need acuity levels, inadequate staffing, and higher rates of inspection deficiencies combine into a relentless downward spiral. Lower-tier facilities are more likely to be terminated from the Medicaid and Medicare programs and are at greater risk of closure.
Possible Policy Interventions
Others have discussed possible policy interventions that range from allowing poor-quality nursing homes to fail, increasing Medicaid reimbursement rates, and various efforts to build quality improvement efforts within troubled homes.25,26
There is no straightforward resolution to this issue, and any single proposal could run the risk of putting poor minority elders at even greater risk of inadequate care or displacement, or might encounter enormous political backlash.
The pattern of “lowertier” facilities emerges where under resourced faxcilities care for disproportionate numbers of patients who are both poor and from minority groups.
More resources must be part of the “fix,” but not the only part, and those additional resources must be focused on the homes that are most at risk. Policy proposals are needed that target at-risk nursing homes with multiple innovative solutions, including perhaps changes in management or “receivership” strategies, and the use of local volunteers and community oversight.
For elderly Hispanics, the prospect of a stay of any length in a nursing home is traumatic and isolating, given cultural and linguistic gaps. For them to be relegated to the bottom tier of care alternatives is a disparity that must be addressed.