A study co-authored by Professor of Community Health Vincent Mor found evidence of widespread racial segregation among U.S. nursing homes and a correlation between segregation and disparities in quality of care, particularly for blacks.
Published in the latest issue of Health Affairs, the study found segregation was most acute in Midwest nursing home facilities and generally reflected patterns of residential segregation. Mor, chair of the community health department, served as the study's principal investigator.
"This study is one of the first to draw from inter-facility databases of resident information to address questions of disparity of care between nursing homes in a given metropolitan area," Mor said. "Before 1999, when these data were computerized, it was difficult to study questions relating to quality of care beyond an intra-facility level."
The study, "Separate and Unequal: Racial Segregation and Disparities in Quality Across U.S. Nursing Homes," is based on data from nursing home populations in 147 metropolitan regions in 2000. Researchers surveyed both nursing home population data and measures of quality of care in nursing homes and found that blacks were more likely to reside in nursing homes of poorer quality.
Using a Dissimilarity Index that represented the proportion of nursing home residents who would have to be moved to equalize the number of white and black residents, the study found that more than two-thirds of black nursing home residents were concentrated in fewer than 20 percent of the total number of nursing homes nationwide. Among the studied metropolitan regions, nursing homes in Cleveland showed the highest degree of nursing home segregation, and those in Columbus, Ga., were the least segregated. Boston's nursing homes ranked among the least segregated in the country.
Investigators evaluated nursing home quality based on nine indicators, such as registered nurse/nursing staff ratios, nursing homes' financial viability and deficiencies in care - such as the prevalence of bedsores or failure to provide residents with correct medicines or diet. Homes with concentrated black resident populations tended to have higher instances of care deficiencies, staffing shortages and financial insolvencies.
Mor cited racial segregation and community structure as key factors in blacks' unequal access to quality nursing home care. "Blacks become concentrated in some homes and not others because they go to nursing homes close to their old communities, so that it's easy for them to stay in touch with their friends and social networks," Mor said."Especially in cities like Cleveland, residential areas are highly segregated, and thus nursing homes in those communities reflect community demographics. Since a greater percentage of blacks are on Medicaid, which pays less than private insurance plans, nursing homes with concentrated black populations tend to have less money to hire staff, maintain their facilities and develop programs for residents."
Yet Mor said desegregation would not resolve the disparities in quality of care. "(The investigators of the study) are keenly aware of parallels between attempts to improve quality of public schools via desegregation, and clearly, desegregation isn't a viable option for nursing homes," he said.
Mor and his fellow researchers, Senior Research Analyst Zhanlian Feng MA'99 PhD'02, Professor of Sociology Mary Fennell and Temple University professors David Smith and Jacqueline Zinn will continue to research and address segregation in nursing homes. Mor is particularly interested in the effectiveness of states' efforts to eliminate disparities in nursing home care, including closing down dangerously underperforming facilities, instituting and enforcing legislation and regulation on quality of care and directly paying homes in order to hire more qualified health care staff.
"The legacy of 'separate and unequal' is very pressing - empirically and historically, it's difficult to attain and maintain separate and equal availabilities of quality service for blacks and whites regardless of the service," Mor said. "But that's the challenge: to make things equal even though facilities tend to serve separate racial populations."
