Nursing home closures clustered in poor, minority areas

"Regulatory oversight, reinforced by market forces and an increased focus on transparency and public reporting, is designed to eliminate poorly performing nursing homes," the authors write as background information in the article. "A small fraction of U.S. nursing homes closes each year (not more than 2 percent). Perhaps this is a desired outcome, since closure is the ultimate indicator of performance failure. However, the operation of regulatory efforts and market forces are not likely to result in random distribution of closures."

Zhanlian Feng, Ph.D., of Brown University, Providence, R.I., and colleagues analyzed information from a national database of Medicare/Medicaid-certified nursing homes in the United States from 1999 through 2008. The database contained a total of 18,259 unique nursing homes from all 50 states and the District of Columbia in this time period. The researchers used 2000 U.S. census data to define geographic boundaries and map nursing home closures by state, metropolitan statistical area and zip code. They then matched closures to zip code-level population data on poverty and racial and ethnic composition.

Between 1999 and 2008, a total of 2,902 nursing homes closed, or almost 16 percent of all Medicare/Medicaid certified facilities. This included 1,776 freestanding nursing homes (11 percent of all such facilities) and 1,126 hospital-based facilities (50 percent), for a net loss of more than 5 percent of beds.

Among freestanding facilities, the relative risk of closure was about 38 percent higher in the one-fourth of zip codes with the highest percentage of blacks than it was in the one-fourth of zip codes with the lowest percentage of blacks. Similarly, closure rates were 37 percent higher in the one-fourth of zip codes with the highest percentage of Hispanics vs. those with the lowest percentage of Hispanics. Also, the risk of closure in zip codes with the highest level of poverty was more than double that of those in zip codes with the lowest poverty rate. Similar trends were observed among hospital-based facilities.

"Since most failed nursing homes experience a downward spiral in financial and quality performance before their eventual closure, one might argue that the demise of such facilities is not necessarily a concern," the authors write. "However, in the broader context of structural and socioeconomic disparities and persistent racial residential segregation, the clustering of nursing home closures in poor and minority- concentrated urban neighborhoods is troubling. This phenomenon, arguably, resembles similar dynamics of inequalities in public schools, housing, environmental decline and other sectors."

"The cumulative loss of nursing facility beds in the aftermath of closures, combined with the lack of alternative long-term care services in these disadvantaged communities and increasing use of nursing homes among minority elderly people, suggests that disparities in access will increase," they conclude.

Editor's Note: This work was supported in part by a National Institute on Aging grant.

Editorial: Future of Long-Term Care Should Be Home- or Community-Based

"It is estimated that by 2050, 27 million people in the United States will need long-term care (home, community or institutional), an increase from 15 million in 2000," writes Mitchell H. Katz, M.D., then of the San Francisco Department of Public Health and now of the Los Angeles County Department of Health Services, in an accompanying editorial.

"Most of the needed capacity for long-term care should be home- or community-based care. Innovative home-care models and comprehensive care models for the elderly such as PACE (Program of All-Inclusive Care for the Elderly) should be supported. Since assisted living is less costly than nursing home placement, Medicaid should pay for this level of care for those persons who would otherwise require institutional placement."

"At the same time, we must demand for our patients and for our families sufficient availability of high-quality nursing homes in the communities where people have lived," Dr. Katz concludes. "Physicians can play a key role in improving nursing home care. We should advocate for nursing homes that encourage the independence and dignity of our patients. We need to be more present in nursing homes; they are excellent sites for teaching and research and yet are underutilized for both, at least in part due to the lower prestige of these institutions compared with acute care hospitals. This can and must change so that when people require nursing home care, we can all feel that it is the best home possible."