David Barton Smith

Geographic Concentration and Correlates of Nursing Home Closures: 1999–2008

BACKGROUND While demographic shifts project an increased need for long-term care for an aging population, hundreds of nursing homes close each year. We examine whether nursing home closures are geographically concentrated and related to local community characteristics such as the racial and ethnic population mix and poverty. METHODS National Online Survey Certification and Reporting data were used to document cumulative nursing facility closures over a decade, 1999 through 2008. Census 2000 zip code level demographics and poverty rates were matched to study facilities. The weighted Gini coefficient was used to measure geographic concentration of closures, and geographic information system maps to illustrate spatial clustering patterns of closures. Changes in bed supply due to closures were examined at various geographic levels. RESULTS Between 1999 and 2008, a national total of 1776 freestanding nursing homes closed (11%), compared with 1126 closures of hospital-based facilities (nearly 50%). Combined, there was a net loss of over 5% of beds. The relative risk of closure was significantly higher in zip code areas with a higher proportion of blacks or Hispanics or a higher poverty rate. The weighted Gini coefficient for closures was 0.55 across all metropolitan statistical areas and 0.71 across zip codes. Closures tended to be spatially clustered in minority-concentrated zip codes around the urban core, often in pockets of concentrated poverty. CONCLUSIONS Nursing home closures are geographically concentrated in minority and poor communities. Since nursing home use among the minority elderly population is growing while it is declining among whites, these findings suggest that disparities in access will increase.

Population Ecology and the Racial Integration of Hospitals and Nursing Homes in the United States

Although the passage of major civil-rights legislation in the 1960s compelled American hospitals to take concerted steps to achieve racial integration, nursing homes did not come under the same organizational and financial pressures to do so. As a result, nursing homes remained significantly segregated; to this day, there is a greater discrepancy between black and white peoples access to long-term-care facilities than to acute-care hospitals. The perspective of population ecology may be used to help account for these disparate historical outcomes; economics, demographics, and more subtle patterns of discrimination continue to reinforce forms of segregation in health-care facilities.

The racial integration of health facilities.

No published measures of racial integration in health facilities in the United States exist. This article reviews the problems with possible sources of data. It then derives estimates of the degree of integration in nursing homes and hospitals from the 1985 National Nursing Home and National Hospital Discharge surveys. Nursing homes were less racially integrated than hospitals. Health facilities in the South were more integrated than in any other region of the country. There was little difference in the degree of racial segregation of publicly financed patients and those whose care was financed from private sources. Data on nursing homes in Pennsylvania illustrate in more detail some of the consequences of such patterns of segregation. The article discusses some of the reasons for the lack of easy access to such information and makes recommendations for addressing it.

The accumulated challenges of long-term care.

During the past century, long-term care in the United States has evolved through five cycles of development, each lasting approximately twenty years. Each, focusing on distinct concerns, produced unintended consequences. Each also added a layer to an accumulation of contradictory approaches--a patchwork system now pushed to the breaking point by increasing needs and financial pressures. Future policies must achieve a better synthesis of approaches inherited from the past, while addressing their unintended consequences. Foremost must be assuring access to essential care, delivery of high-quality services in an increasingly deinstitutionalized system, and a reduction in social and economic disparities.

Separate and Unequal Access and Quality of Care in Nursing Homes: Transformation of the Long Term Care Industry and Implications of the Research Program for Aging Hispanics

This chapter will review several important themes concerning long term care availability, quality of care, and market changes, with special reference to frail aging Hispanics. This review will be based on work performed by Brown University researchers under the aegis of an NIA Program Project, “Shaping Long Term Care in America” (1PO1 AG027296-01A1). Our review will include a brief historical overview of patterns in nursing home use, more recent analyses on racial/ethnic disparities in care access, and current trends in the composition of nursing home residents. We will also examine differences in nursing home performance for homes with different proportions of Hispanic and black residents. Finally, we will review results from a recent study of nursing home closure, which clearly shows differences in closure rates correlated with larger proportions of Hispanic and black residents. Implications of these trends will be discussed for the future of long term care availability and the needs of frail Hispanic elderly.

The Hospital Support Game Revisited

This paper updates a well-known case study in which Ray Elling examined the failure of community health planning in a medium-sized American city. During the period described by Elling, the citys hospitals had managed to resist efforts to rationalize the system by marshalling the support of their respective constituents. This political gamesmanship gave way in the late sixties and early seventies to greater cooperation and a significant consolidation of the hospitals. The authors hypothesize that an important factor influencing this development was the change in medical technology. The effects on the communitys health care delivery are also discussed.