Abstract
Long-term services and supports (LTSS), including care received at home and in residential
settings such as nursing homes, are highly racially segregated; Black, Indigenous,
and persons of color (BIPOC) users have less access to quality care and report poorer
quality of life compared to their White counterparts. Systemic racism lies at the
root of these disparities, manifesting via racially segregated care, low Medicaid
reimbursement, and lack of livable wages for staff, along with other policies and
processes that exacerbate disparities. We reviewed Medicaid reimbursement, pay-for-performance,
public reporting of quality of care, and culture change in nursing homes and integrated
home- and community-based service (HCBS) programs as possible mechanisms for addressing
racial and ethnic disparities. We developed a set of recommendations for LTSS based
on existing evidence, including (1) increase Medicaid and Medicare reimbursement rates,
especially for providers serving high proportions of Medicaid-eligible and BIPOC older
adults; (2) reconsider the design of pay-for-performance programs as they relate to
providers who serve underserved groups; (3) include culturally sensitive measures,
such as quality of life, in public reporting of quality of care, and develop and report
health equity measures in outcomes of care for BIPOC individuals; (4) implement culture
change so services are more person-centered and homelike, alongside improvements in
staff wages and benefits in high-proportion BIPOC nursing homes; (5) expand access
to Medicaid-waivered HCBS services; (6) adopt culturally appropriate HCBS practices,
with special attention to family caregivers; (7) and increase promotion of integrated
HCBS programs that can be targeted to BIPOC consumers, and implement models that value
community health workers. Multipronged solutions may help diminish the role of systemic
racism in existing racial disparities in LTSS, and these recommendations provide steps
for action that are needed to reimagine how long-term care is delivered, especially
for BIPOC populations.
Keywords
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Article info
Publication history
Published online: December 24, 2021
Footnotes
This work was supported by the National Institutes of Health-National Institute on Minority Health and Health Disparities (grant no. R05MD010729) and by the National Institute on Aging (grant no. 1RF1AG069771-01) to T.P.S.
The authors declare no conflicts of interest.
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