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Addressing Systemic Racism in Nursing Homes: A Time for Action

      Abstract

      Long-term services and supports for older persons in the United States are provided in a complex, racially segregated system, with striking racial disparities in access, process, and outcomes of care for residents, which have been magnified during the Coronavirus Disease 2019 pandemic. These disparities are in large measure the result of longstanding patterns of structural, interpersonal, and cultural racism in US society, which in aggregate represent an underpinning of systemic racism that permeates the long-term care system's organization, administration, regulations, and human services. Mechanisms underlying the role of systemic racism in producing the observed disparities are numerous. Long-term care is fundamentally tied to geography, thereby reflecting disparities associated with residential segregation. Additional foundational drivers include a fragmented payment system that advantages persons with financial resources, and reimbursement policies that systematically undervalue long-term care workers. Eliminating disparities in health outcomes in these settings will therefore require a comprehensive approach to eliminating the role of systemic racism in promoting racial disparities.

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      References

        • Cassie K.M.
        • Cassie W.
        Racial disparities in the use of physical restraints in U.S. nursing homes.
        Health Soc Work. 2013; 38: 207-213
        • Cai S.
        • Mukamel D.B.
        • Temkin-Greener H.
        Pressure ulcer prevalence among black and white nursing home residents in New York state: Evidence of racial disparity?.
        Med Care. 2010; 48: 233-239
        • Harms S.
        • Bliss D.Z.
        • Garrard J.
        • et al.
        Prevalence of pressure ulcers by race and ethnicity for older adults admitted to nursing homes.
        J Gerontol Nurs. 2014; 40: 20-26
        • Bliss D.Z.
        • Gurvich O.
        • Savik K.
        • et al.
        Are there racial-ethnic disparities in time to pressure ulcer development and pressure ulcer treatment in older adults after nursing home admission?.
        J Aging Health. 2015; 27: 571-593
        • Li Y.
        • Yin J.
        • Cai X.
        • et al.
        Association of race and sites of care with pressure ulcers in high-risk nursing home residents.
        JAMA. 2011; 306: 179-186
        • Bardenheier B.
        • Wortley P.
        • Shefer A.
        • et al.
        Racial inequities in receipt of influenza vaccination among nursing home residents in the United States, 2008–2009: A pattern of low overall coverage in facilities in which most residents are black.
        J Am Med Dir Assoc. 2012; 13: 470-476
        • Bernabei R.
        • Gambassi G.
        • Lapane K.
        • et al.
        Management of pain in elderly patients with cancer.
        J Am Med Assoc. 1998; 279: 1877-1882
        • Mack D.S.
        • Hunnicutt J.N.
        • Jesdale B.M.
        • Lapane K.L.
        Non-Hispanic Black-White disparities in pain and pain management among newly admitted nursing home residents with cancer.
        J Pain Res. 2018; 11: 753-761
        • Gruneir A.
        • Miller S.C.
        • Feng Z.
        • et al.
        Relationship between state Medicaid policies, nursing home racial composition, and the risk of hospitalization for black and white residents.
        Health Serv Res. 2008; 43: 869-881
        • Travers J.L.
        • Dick A.W.
        • Stone P.W.
        Racial/ethnic differences in receipt of influenza and pneumococcal vaccination among long-stay nursing home residents.
        Health Serv Res. 2018; 53: 2203-2226
        • Li Y.
        • Cai X.
        Racial and ethnic disparities in social engagement among US nursing home residents.
        Med Care. 2014; 52: 314-321
        • Shippee T.P.
        • Ng W.
        • Bowblis J.R.
        Does living in a higher proportion minority facility improve quality of life for racial/ethnic minority residents in nursing homes?.
        Innov Aging. 2020; 4: igaa014
        • Green A.R.
        Time for nursing homes to recognize and address disparities in care.
        Jt Comm J Qual Patient Saf. 2017; 43: 551-553
        • Temkin-Greener H.
        • Guo W.
        • Mao Y.
        • et al.
        COVID-19 pandemic in assisted living communities: Results from seven states.
        J Am Geriatr Soc. 2020; 68: 2727-2734
        • Sharma H.
        • Perraillon M.C.
        • Werner R.M.
        • et al.
        Medicaid and nursing home choice: Why do duals end up in low-quality facilities?.
        J Appl Gerontol. 2020; 39: 981-990
        • Konetzka R.
        Testimony at a hearing on caring for seniors amid the COVID-19 crisis before the United States Senate Special Committee on Aging, May 21, 2020.
        (Available at:)
        • Li Y.
        • Temkin-Greener H.
        • Shan G.
        • Cai X.
        COVID-19 infections and deaths among Connecticut nursing home residents: Facility correlates.
        J Am Geriatr Soc. 2020; 68: 1899-1906
        • Kaiser Family Foundation
        COVID-19: Long-term care facilities.
        (Available at:)
        • Abrams H.R.
        • Loomer L.
        • Gandhi A.
        • Grabowski D.C.
        Characteristics of U.S. nursing homes with COVID-19 cases.
        J Am Geriatr Soc. 2020; 68: 1653-1656
        • Gebeloff R.
        • Ivory D.
        • Richtel M.
        • et al.
        The Striking Racial Divide in How Covid-19 Has Hit Nursing Homes.
        (New York Times. May 21, 2020. Available at:)
        • Li Y.
        • Cen X.
        • Cai X.
        • Temkin-Greener H.
        Racial and ethnic disparities in COVID-19 infections and deaths across U.S. nursing homes.
        J Am Geriatr Soc. 2020; 68: 2454-2461
        • Gorges R.J.
        • Konetzka R.T.
        Factors associated with racial differences in deaths among nursing home residents with COVID-19 infection in the US.
        JAMA Netw Open. 2021; 4: e2037431
        • Harris-Kojetin L.
        • Sengupta M.
        • Lendon J.P.
        • et al.
        Long-term care providers and services users in the United States, 2015–2016. National Center for Health Statistics.
        Vital Health Stat. 2019; 3
        • Konetzka R.T.
        • Werner R.M.
        Disparities in long-term care: Building equity into market-based reforms.
        Med Care Res Rev. 2009; 66: 491-521
        • Yearby R.
        African Americans can't win, break even, or get out of the system: The persistence of 'unequal treatment' in nursing home care (June 8, 2010). Temple Law Review 2010.
        (82. Available at:)
        https://ssrn.com/abstract=2036620
        Date accessed: August 20, 2020
        • Li Y.
        • Harrington C.
        • Temkin-Greener H.
        • et al.
        Deficiencies in care at nursing homes and racial/ethnic disparities across homes fell, 2006–11.
        Health Aff (Millwood). 2015; 34: 1139-1146
        • Hefele J.G.
        • Wang X.J.
        • Lim E.
        Fewer bonuses, more penalties at skilled nursing facilities serving vulnerable populations.
        Health Aff (Millwood). 2019; 38: 1127-1131
        • Mor V.
        • Zinn J.
        • Angelelli J.
        • et al.
        Driven to tiers: socioeconomic and racial disparities in the quality of nursing home care.
        Milbank Q. 2004; 82: 227-256
        • Harris A.P.
        • Pamukcu A.
        The civil rights of health: A new approach to challenging structural inequality.
        (UCLA Law Review. Available at:)
        • Grabowski D.C.
        Strengthening nursing home policy for the postpandemic world: How can we improve residents’ health outcomes and experiences? Commonwealth Fund Issue Brief, August 2020.
        (Available at:)
        • Howard D.L.
        • Sloane P.D.
        • Zimmerman S.
        • et al.
        Distribution of African Americans in residential care/assisted living and nursing homes: More evidence of racial disparity?.
        Am J Public Health. 2002; 92: 1272-1277
        • Zimmerman S.
        • Gruber-Baldini A.L.
        • Sloane P.D.
        • et al.
        Assisted living and nursing homes: Apples and oranges?.
        Gerontologist. 2003; 43: 107-117
        • Peck L.
        CCRC care segment performance outshines non-CCRCs.
        (NIC: December 20, 2020. Available at:)
        • Peck L.
        Executive survey insights special report: Owner/operators of CCRCs. NIC: June 4, 2020.
        (Available at:)
        • Anderson S.C.
        • Michelman J.E.
        • Johnson R.M.
        • Quick K.
        Rate setting and disclosure in continuing care retirement communities (CCRCs).
        J Health Care Finance. 2008; 34: 55-65
        • Regan T.
        Life plan communities failing to attract diverse resident populations.
        (Senior Housing News. July 23, 2018. Available at:)
        • Campbell S.
        Racial disparities in the direct care workforce: Spotlight on Black/African American workers.
        (PHI: February 2018. Available at:)
        • PHI. Workforce Data Center
        Last modified September 14, 2020.
        (Available at)
        • PHI Workforce Data Center
        Direct Care Workers by Race and Ethnicity, 2018.
        (Available at:)
        • The Commonwealth Fund
        The invisible COVID workforce: Direct care workers for those with disabilities.
        2020 (Available at:)
        • Campbell S.
        Racial and gender disparities within the direct care workforce: Five key findings.
        (PHI: November, 2017. Available at:)
        • Bates T.
        • Amah G.
        • Coffman J.
        Racial/Ethnic Diversity in the Long-term Care Workforce.
        (San Francisco, CA: UCSF Health Workforce Research Center on Long-Term Care UCSF Health Workforce Research Center on Long-Term Care, 3333 California Street, Suite 265, San Francisco, CA 94118, 2018. Available at:)
        • Yearby R.
        • Mohapatra S.
        Law, structural racism, and the COVID-19 pandemic.
        J Law Biosci. 2000; 7: lsaa036
        • Williams D.R.
        • Lawrence J.A.
        • Davis B.A.
        Racism and health: Evidence and needed research.
        Annu Rev Public Health. 2019; 40: 105-125
        • Elias S.
        • Feagin J.
        Racial Theories in Social Science.
        Routledge, New York2016: 267
        • Evans M.
        Structural violence, socioeconomic rights, and transformative justice.
        J Human Rights. 2016; 15: 1-20
        • Bailey Z.D.
        • Krieger N.
        • Agénor M.
        • et al.
        Structural racism and health inequities in the USA: Evidence and interventions.
        Lancet. 2017; 389: 1453-1463
        • Cornell P.Y.
        • Zhang W.
        • Smith L.
        • et al.
        Developments in the market for assisted living: Residential care availability in 2017.
        J Am Med Dir Assoc. 2020; 21: 1718-1723
        • Cogburn C.D.
        Culture, race, and health: Implications for racial inequities and population health.
        Milbank Q. 2019; 97: 736-761
        • Loomer L.
        • Volandes A.E.
        • Mitchell S.L.
        • et al.
        Black nursing home residents more likely to watch advance care planning video.
        J Am Geriatr Soc. 2020; 68: 603-608
        • Center for Medicare and Medicaid Services
        Request for Information: Recommended measure set for Medicaid-funded home and community base services. September, 2020, page 29, QA 29.
        (Available at:)
        • Krieger N.
        Embodying inequality: A review of concepts, measures, and methods for studying health consequences of discrimination.
        Int J Health Ser. 1999; 29: 295-352
        • Chaturvedi R.
        • Gabriel R.A.
        Coronavirus disease health care delivery impact on African Americans.
        Disaster Med Public Health Prep. 2020; (May 29. [Epub ahead of print])
        • Stepanikova I.
        • Oates G.R.
        Perceived discrimination and privilege in health care: the role of socioeconomic status and race.
        Am J Prev Med. 2017; 52: S86-S94
        • McIntosh K.
        • Moss E.
        • Nunn R.
        • Shambaugh J.
        Examining the Black-white wealth gap.
        (The Brookings Institution, February 27, 2020. Available at:)
        • Bowen D.B.
        Structural inequality: The real COVID-19 threat to America’s health and how strengthening the Affordable Care Act can help.
        Geo L J. 2020; 108: 1679-1716
        • Gee G.C.
        • Ford C.L.
        Structural racism and health inequities: Old issues, new directions.
        Du Bois Rev. 2011; 8: 115-132
        • Brown T.
        The intersection and accumulation of racial and gender inequality: black women’s wealth trajectories.
        Rev Black Polit Econ. 2012; 39: 239-258
        • Chernof B.A.
        • Mann C.
        Building the long-term care system of the future: Will the COVID-19 nursing home tragedies lead to real reform?.
        Health Affairs Blog. 2020;
        • Zimmerman S.
        • Dumond-Stryker C.
        • Tandan M.
        • et al.
        Nontraditional small house nursing homes have fewer COVID-19 cases and deaths.
        J Am Med Dir Assoc. 2021; 22: 489-493
        • Zimmerman S.
        • Bowers B.J.
        • Cohen L.W.
        • et al.
        New evidence on the Green House Model of nursing home care: Synthesis of findings and implications for policy, practice, and research.
        Health Serv Res. 2016; 51: 475-496
        • Feagin J.
        • Bennefield Z.
        Systemic racism and U.S. health care.
        Soc Sci Med. 2014; 103: 7-14
        • Clark B.R.
        Disentangling fact from fiction: The realities of unequal health care treatment.
        DePaul J Health Care Law. 2005; 9: 1023-1100
        • Steil J.
        • Albright L.
        • Rugh J.
        • Massey D.
        The social structure of mortgage discrimination.
        Housing Studies. 2018; 5: 759-776
        • Tse-Chuan T.
        • Matthews S.A.
        Death by segregation: Does the dimension of racial segregation matter?.
        PLoS One. 2015; 10: 1-26
        • Nolen L.
        • Beckman A.L.
        • Sandoe E.
        How foundational moments in Medicaid’s history reinforced rather than eliminated racial health disparities.
        (Health Affairs Blog. September 1, 2020. Available at:)
        • Li Y.
        • Cen X.
        • Cai X.
        • Temkin-Greener H.
        Perceived patient safety culture in nursing homes associated with “Nursing Home Compare” performance indicators.
        Med Care. 2019; 57: 641-647
        • Castle N.G.
        An examination of special focus facility nursing homes.
        Gerontologist. 2010; 50: 400-407
      1. CARES Act provider Relief Fund: Allocation for Skilled Nursing Facilities and Nursing Homes.
        (Available at:)
        • Gebeloff R.
        • Ivory D.
        • Richtel M.
        • et al.
        The striking racial divide in how COVID-19 has hit nursing homes.
        (New York Times, September 10, 2020. Available at:)
        • Azar K.M.J.
        • Shen Z.
        • Romanelli R.J.
        • et al.
        Disparities in outcomes among COVID-19 patients in a large health care system In California.
        Health Aff (Millwood). 2020; 39: 1253-1262
        • Wadhera R.K.
        • Wadhera P.
        • Gaba P.
        • et al.
        Variation in COVID-19 hospitalizations and deaths across New York city boroughs.
        JAMA. 2020; 323: 2192-2195
        • Hooper M.W.
        • Nápoles A.M.
        • Pérez-Stable E.J.
        COVID-19 and racial/ethnic disparities.
        JAMA. 2020; 323: 2466-2467
        • Thakur N.
        • Lovinsky-Desir S.
        • Bime C.
        • et al.
        The structural and social determinants of the racial/ethnic disparities in the U.S. COVID-19 pandemic. What's our role?.
        Am J Respir Crit Care Med. 2020; 202: 943-949
        • Braveman P.
        • Egerter S.
        • Williams D.R.
        The social determinants of health: coming of age.
        Annu Rev Public Health. 2011; 32: 381-398
        • Shippee T.P.
        • Akosionu O.
        • Ng W.
        • et al.
        COVID-19 pandemic: exacerbating racial/ethnic disparities in long-term services and supports.
        J Aging Soc Policy. 2020; 32: 323-333
        • Evans M.K.
        • Rosenbaum L.
        • Malina D.
        • et al.
        Diagnosing and treating systemic racism.
        N Engl J Med. 2020; 383: 274-276
        • Yearby R.
        Structural racism and health disparities: Reconfiguring the social determinants of health framework to include the root case.
        J Law Med Ethics. 2020; 48: 518-526
        • Alexander M.
        The New Jim Crow: Mass Incarceration in the Age of Colorblindness.
        New Press, New York2012
        • Braithwaite R.
        • Warren R.
        The African American petri dish.
        J Health Care Poor Underserved. 2020; 31: 491-502
        • Dowling M.K.
        • Kelly R.L.
        Policy solutions for reversing the color-blind public health response to COVID-19 in the US.
        JAMA. 2020; 324: 229-230
        • Yearby R.
        The Cycle of ‘Unequal Treatment’ with Health Care Reform: Acknowledging and Addressing the Continuation of Racial bias (January 16, 2012). 44 Conn. L. Rev. 1281 (2012), Case Legal Studies Research Paper No. 2012–19.
        (Available at)
        https://ssrn.com/abstract=2035928
        Date accessed: March 23, 2021
        • Smith D.B.
        • Feng Z.
        • Fennell M.L.
        • et al.
        Separate and unequal: Racial segregation and disparities in quality across U.S. nursing homes [published correction appears in Health Aff (Millwood). 2007 Nov-Dec;26(6):1794].
        Health Aff (Millwood). 2007; 26: 1448-1458
        • Yaya S.
        • Yeboah H.
        • Charles C.H.
        • et al.
        Ethnic and racial disparities in COVID-19-related deaths: counting the trees, hiding the forest.
        BMJ Glob Health. 2020; 5: e002913
        • Ford C.L.
        • Airhihenbuwa C.O.
        The public health critical race methodology: Praxis for antiracism research.
        Soc Sci Med. 2010; 71: 1390-1398
      2. Vighte B.W. Bradley A.L. Cohen M. Hartmann H. Designing universal family care: state-based social insurance programs for early child care and education, paid family and medical leave, and long-term services and supports. National Academy of Social Insurance. 2019 (Available at:)
        • Dodson L.
        • Zincavage R.M.
        “It’s like a family”: caring labor, exploitation, and race in nursing homes.
        Gend Soc. 2007; 21: 905-928
        • Baughman R.
        • Smith K.
        The effect of Medicaid Wage Pass-Through Programs on the wages of direct care workers.
        Med Care. 2010; 48: 426-432
        • Feng Z.
        • Lee Y.S.
        • Kuo S.
        • et al.
        Do Medicaid Wage pass-through payments increase nursing home staffing?.
        Heath Serv Research. 2010; 45: 728-747
        • Foster A.D.
        • Lee Y.S.
        Staffing subsidies and the quality of care in nursing homes.
        (June 12, 2013. Available at:)
        • Travers J.L.
        • Teitelman A.M.
        • Jenkins K.A.
        • Castle N.G.
        Exploring social-based discrimination among nursing home certified nursing assistants.
        Nurs Inq. 2020; 27: e12315