Marginal nursing home options for poor

BROWN (US) — Nursing homes in the poorest ZIP codes in the country are twice as likely to close as the richest ones, giving residents, particularly minorities, fewer choices for long term care.

Overall, the United States lost 5 percent, or 96,902, of its total nursing home beds between 1999 and 2008, as patients with means sought assisted living or other forms of home and community-based care instead.

Nursing homes were also 1.38 times more likely to close in the most predominantly black ZIP codes than in ZIP codes with the lowest representation of blacks, and 1.37 times as likely to close in the most predominantly Hispanic ZIP codes than in the least Hispanic areas.

The research is reported in the journal Archives of Internal Medicine.

“This is an issue that is not going to go away, precisely because of the aging of the population and the increasing bifurcation of society into rich and poor,” says Vince Mor, professor of community health at Brown University.

Researchers, led by Zhanlian Feng, assistant professor of community health, say in the future people in poor urban neighborhoods will have to travel significantly farther to a nursing home.

In ZIP codes where at least one nursing home closed during the decade, the shortest distance to another home increased to 3.81 miles from 2.73 miles.

“The further the patient is from their neighborhood, the more difficult it is for their family members and their neighbors to come visit them,” Mor says.

In the study period, most nursing homes, whether freestanding or on hospital campuses, in rich neighborhoods and poor ones, have become more economically vulnerable. Homes that depend on Medicare and Medicaid for most or all of their revenue—for instance those serving poor patients—have suffered the most pressure.

When money becomes tight, especially at a somewhat inefficiently run home, quality of care declines, sometimes to the point where officials must consider shutting it down.

“This leads to a moral dilemma,” Mor says. “If the local nursing home is closed because their quality is so poor, that’s good, but the cost of that closure is disproportionately borne by a community.

“How much do you invest in a failing facility and how do you make that investment without rewarding a bad actor who runs a lousy place?”

If finding new money for nursing homes is not the entire answer for preserving access for the poor to long-term care, another option is to shift more money toward alternatives like assisted living, home-based care and community-based care, Mor says.

The new health care law and a system of waivers within Medicaid encourage states to do just that, but they are not targeted specifically to helping the urban poor or minorities, and they are optional programs. By contrast, reimbursements for nursing home care are legally required.

“Given the current budget environment, it is really uncertain how sustainable these alternatives will be,” says Feng.

“Nursing homes are generally perceived as a last resort,” he says, but for millions of Americans desirable options in that undesired choice continue to decline.

The study was funded in part by the National Institute on Aging.

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