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Original Article

Disparities in Nursing Home Use and Quality Among African American, Hispanic, and White Medicare Residents With Alzheimer’s Disease and Related Dementias

Maricruz Rivera-Hernandez, PhD1, Amit Kumar, PhD1, Gary Epstein-Lubow, MD1,2, and Kali S. Thomas, PhD1,3

Abstract Objective: This article examines differences in nursing home use and quality among Medicare beneficiaries, in both Medicare Advantage and fee- for-service, newly admitted to nursing homes with Alzheimer’s disease and related dementias (ADRD). Method: Retrospective, national, population- based study of Medicare residents newly admitted to nursing homes with ADRD by race and ethnic group. Our analytic sample included 1,302,099 nursing home residents—268,181 with a diagnosis of ADRD—in 13,532 nursing homes from 2014. Results: We found that a larger share of Hispanic Medicare residents that are admitted to nursing homes have ADRD compared with African American and White beneficiaries. Both Hispanics

1Brown University, Providence, RI, USA 2Center for Alzheimer’s Disease and Memory Care Hebrew SeniorLife, Boston, MA, USA 3Providence VA Medical Center, RI, USA

Corresponding Author: Maricruz Rivera-Hernandez, Investigator in Health Services, Policy, and Practice, Brown University, Box G-S121-6, Providence, RI 02903, USA. Email: [email protected]

767778 JAHXXX10.1177/0898264318767778Journal of Aging and HealthRivera-Hernandez et al. research-article2018

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and African Americans with ADRD received care in segregated nursing homes with fewer resources and lower quality of care compared with White residents. Discussion: These results have implications for targeted efforts to achieve health care equity and quality improvement efforts among nursing homes that serve minority patients.

Keywords Alzheimer’s disease and dementia, nursing home disparities, Hispanics with dementia, disparities among dementia residents

Introduction

The proportion of Hispanic and African American older adults using nursing homes has increased dramatically since the late 1990s (Feng, Fennell, Tyler, Clark, & Mor, 2011). In 10 years, the proportion of African American and Hispanic residents grew by 10% and 55%, respectively (Feng et al., 2011). Poor quality of nursing home care received by these groups has been docu- mented, with newer studies continuing to report disparities in the quality of care and quality of life in these settings (Hefele et al., 2017; Shippee, Henning- Smith, Kane, & Lewis, 2015; Smith, Feng, Fennell, Zinn, & Mor, 2007).

Recently, a major concern expressed by the Centers of Medicare and Medicaid has focused on the similarly poor quality of nursing home care for persons with Alzheimer’s disease and related dementias (ADRD) and ways to improve the quality of care for these individuals (Centers for Medicare & Medicaid Services [CMS], 2017d). Existing literature suggests that cognitive impairment is a predictor of institutionalization and a large percentage of people with dementia may enter a nursing home before death (Gaugler, Yu, Krichbaum, & Wyman, 2009; Schulz et al., 2004; Yaffe et al., 2002). This may be particularly important among African Americans and Hispanics, who are more likely to have ADRD than Whites (Mayeda et al., 2014; Potter et al., 2009; Samper-Ternent et al., 2012). Despite the increased utilization of nurs- ing homes and the higher rates of ADRD by Hispanics and African Americans, we know little about the quality of nursing home care among African Americans and Hispanics with ADRD and how it compares to Whites, espe- cially in the Medicare program that covers 95% of people with ADRD (Alzheimer’s Association, 2016).

One of the goals of Healthy People 2020 is to improve the quality of life for people with ADRD, which relates to quality of long-term care (Healthy People 2020, 2014; Kane, 2001). However, long-term care is accompanied

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by critical gaps and challenges regarding care for people with ADRD, and addressing these challenges requires implementing practices that promotes person-centered care and enhances the quality of life for every nursing home resident with ADRD (CMS, 2017d; Shih, Concannon, Liu, & Friedman, 2014). In addition, two goals of the National Alzheimer’s Project Act (NAPA) include enhancing care quality and efficiency and improving data to track progress (Khachaturian, Khachaturian, & Thies, 2012). Among the different strategies that NAPA highlighted to achieve these goals are reducing and eliminating disparities in access to quality health care and to increase the availability and quality of data collected and reported on racial/ethnic minor- ity populations (Office of the Assistant Secretary for Planning and Evaluation, 2015). Thus, there is a pressing need to characterize care and outcomes of nursing home residents with ADRD.

Research on ADRD using national samples and diverse populations is limited. In fact, many studies have been published on the difficulty of recruiting minority populations with ADRD to conduct research (Barnes & Bennett, 2014; Grill & Galvin, 2014). The absence of research evidence for this fast-growing group presents significant challenges for formulating appropriate policies and interventions to improve quality of care, health out- comes, and quality of life for minority nursing home residents with ADRD (Alzheimer’s Association, 2004; Khachaturian et al., 2012). The contribu- tion of this study is an examination of national rates and health care dispari- ties in nursing home care among residents with ADRD. Because there are few datasets available to study quality of long-term care for people with ADRD, specifically among Hispanics, using national nursing home assess- ment and survey data is pivotal in understanding patterns of racial disparities in nursing homes.

The present study uses the Institute of Medicine’s conceptual framework applied to mental health (McGuire, Alegria, Cook, Wells, & Zaslavsky, 2006). Under this framework, operation of the health care system and dis- crimination can contribute to disparities among ADRD populations. Sources of disparities include provider practices, insurance plans, and other health care factors that result in lower quality of care for minority groups. In addi- tion, minority groups may be subject to discrimination, receiving lower qual- ity of care by providers (Smith, 1990). There is evidence that racial and ethnic groups have less access to mental health services and needed care, and receive lower quality of care when treated (Office of the Surgeon General, Center for Mental Health Services, & National Institute of Mental Health, 2001). Using multiple national databases containing information about Medicare benefi- ciaries and nursing home measures, our study examines individual- and facil- ity-level characteristics to assess differences in nursing home utilization and

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care among Hispanic, African American, and White Medicare residents with ADRD.

Method

We used multiple sources of national data from 2014. Information on the rate of admission to nursing homes and nursing home residents’ characteristics came from the Minimum Data Set (MDS). The MDS resident assessment instrument has nearly 400 data elements, including information on cognitive and physical function, psychosocial well-being, mood, disease diagnoses, health conditions, special treatments, and medication use. The assessments are reported for all residents admitted to Medicare and/or Medicaid-certified nursing homes. Repeated evaluations of the reliability of the MDS provided at least adequate values on most scales (Kosar, Thomas, Inouye, & Mor, 2017; Morris et al., 1990; Phillips et al., 1997; Thomas, Dosa, Wysocki, & Mor, 2017). Admission and discharge assessment dates help determine the time period spent in the nursing home and have been validated against Medicare claims (Rahman, Tyler, Acquah, Lima, & Mor, 2014). We identi- fied people with a diagnosis of ADRD by using MDS Section I for Active Diagnoses. We included any individual who had an active diagnosis of Alzheimer’s disease, non-Alzheimer’s dementia, or one of the following ICD-9 codes listed: 290.0, 290.10, 290.11, 290.12, 290.13, 290.20, 290.21, 290.3, 290.40, 290.41, 290.42, 290.43, 294.0, 294.10, 294.11, 294.20, 294.21, 331.0, 331.11, 331.19, 331.2, 331.82, 331.7, or 797 (Thomas, Baier, et al., 2017). The Master beneficiary summary file (MBSF) contains demographics, Medicare Advantage enrollment, and dual eligibility (Research Data Assistance Center, 2017). The Certification and Survey Provider Enhanced Reporting (CASPER) system (CMS, 2017e), Long-Term Care: Facts on Care in the US (LTC focus; 2017) and Nursing Home Compare (NHC) Five-Star Ratings databases provide nursing home-level information on ownership, size, staffing, and 30-day rehospitalization rates (CMS, 2017b). These vari- ables are described below. These files were linked to each other using facil- ity-level identifiers that allow us to create historical person-level utilization records matched to facility characteristics.

Variables

Study measures from the Master Beneficiary Summary File (MBSF). Demo- graphic characteristics include age (less than 65 years, 65-84, and 85 and above), sex, enrolled in Medicare Advantage, Medicaid and Medicare dual eligibility (eligibility for Medicaid coverage for at least 1 month). In addition,

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we used the race/ethnicity variable from this file, which has high sensitivity, positive predictive value, and kappa for Whites, African Americans, and His- panics (Eicheldinger & Bonito, 2008).

Study measures from the MDS Delirium. Delirium was identified using the Confusion Assessment

Method Criteria. This method defines delirium as present if it was indicated that a patient was reported to have shown an acute change in delirium symp- toms, inattention, and either disorganized thinking or an altered level of con- sciousness included in Section C (Inouye et al., 1990; Kosar et al., 2017; Wei, Fearing, Sternberg, & Inouye, 2008; Wong, Holroyd-Leduc, Simel, & Straus, 2010).

Cognitive function. This measure was identified using the Cognitive Func- tion Scale, comprised of the Brief Interview for Mental Status (BIMS) and the Cognitive Performance Scare (CPS) in Section C. The scores identified resi- dents who are cognitively intact (those who completed the BIMS and scoring between 13 and 15 points) or with severe (those who did not complete the BIMS and have a CPS score of 5 or 6), moderate (those scoring 0-7 on the BIMS or a 3-4 on the CPS), and mild impairment (those with a BIMS score of 8-12 or a CPS score of 0-2; Thomas, Dosa, et al., 2017).

Aggressive behavior. This measure was obtained using the Aggressive Behavior Scale (ABS), which is calculated using items from Section E, including verbal abusive, physical abusive, disruptive, and resisting care. Each item receives a score of 0 to 3 indicating that the behavior was not exhibited in the last week (score of 0), or that it occurred 1 to 3 days (score of 1), 4 to 6 days (score of 2), or daily (score of 3). The items were cal- culated with scores ranging from 0 to 12. Then aggressive behavior scores were divided into four categories, including none (residents with score of 0), moderate (those with scores of 1 to 2), severe (those with scores of 3 to 5), and very severe (residents with scores of 6 to 12; Perlman & Hirdes, 2008).

Severe functional impairment. This was indicated when the score of the Activities of Daily Living (ADL) Scale is greater than 23. The 28-point ADL scale includes items for bed mobility, transfer, locomotion on unit, dressing, eating, toilet use, and personal hygiene. Residents were rated from 0 to 4 as being able to do the activity independently, with supervision, with limited assistance, with extensive assistance, or being totally dependent. Scores were summarized to create a composite score, ranging from 0 to 28, to characterize physical function (Wysocki, Thomas, & Mor, 2015).

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Admission source. We characterized residents’ sources of admission using Item A1800 from the MDS, which captures whether admissions came from the community, another nursing home, acute hospital, psychiatric hospital, inpatient rehabilitation facility, hospice, or other.

Long-stay resident. We defined residents as long-stay if they remained in a nursing home for more than 100 days (American Health Care Association, 2017a).

Study measures from LTC focus Rehospitalization rate (adjusted). This measure was calculated at the facil-

ity level using the observed rate of rehospitalization within 30 days, divided by the expected rate of rehospitalizations within 30 days and then multi- plied by the national rate. Expected rate for the facility is calculated using a predictive model that adjusts from 33 demographic and clinical variables from the MDS. These variables included functional status, prognosis, clinical conditions, diagnosis, services, and treatment (American Health Care Asso- ciation, 2017b).

Other variables at the facility level included percentage of Hispanic resi- dents and percentage of African American residents admitted to the facility during 2014, percentage of residents whose primary support is Medicaid, whether the facility is for profit, whether the facility is part of a chain, and whether the facility has Alzheimer’s Special Care Unit (also drawn from OSCAR or CASPER data [CMS, 2017e]).

Study measures from CMS’ NHC Nursing home five-star quality rating. This is a composite measure of three

domains: health inspections, staffing levels, and quality measure. Nursing homes receive a score between 1 (lower quality than average) and 5 (higher quality than average; CMS, 2017b).

Analysis

We examined rates of Medicare beneficiaries newly admitted residents to nursing homes with ADRD, by race and ethnic group. We also explored dif- ferent quality indicators for nursing homes and compared facility character- istics for residents with ADRD stratified by race and ethnic group. Our analysis included new admissions defined as the beginning of a nursing home stay where the person had not had a nursing home stay within the past 2 years. We identified 1,370,123 new admissions among Medicare beneficia- ries in 2014. These were 1,164,714 (85.0%) admissions among White

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beneficiaries, 139,068 (10.2%) among African American beneficiaries, and 66,341 (4.8%) among Hispanic beneficiaries. After merging with the datasets and dropping cases with missing data, our analytic sample included 1,302,099 (880,040 admissions from Whites vs. 106,002 from African Americans vs. 47,876 from Hispanics). There were 268,181 admissions with ADRD diagno- sis (85.1% Whites vs. 10.3 African Americans vs. 4.6% Hispanics) from 13,532 nursing homes in 2014. One-way analysis of variance and chi-square were used to assess differences among groups.

Brown’s Center for Gerontology and Healthcare Research has access to these data under a CMS data use agreement. The Brown Institutional Review Board approved our use of these data.

Results

The results showed that 20.6% of all Medicare beneficiaries newly admitted to a nursing home in 2014 had an ADRD diagnosis. Overall, a slightly higher percentage of Hispanic residents were diagnosed with ADRD compared with African Americans or White residents. Approximately, 22.2% of Hispanic residents had an ADRD diagnosis compared with approximately 20.2% of African Americans and 20.6% of Whites had (p < .001).

Descriptive statistics for newly admitted Medicare beneficiaries with ADRD stratified by race and ethnic group are displayed in Table 1. A higher percentage of White residents with ADRD were older than their African American or Hispanic counterparts. Approximately, 50.1% Whites, 36.9% African Americans, and 39.8% Hispanics were 85 years or older. However, a larger proportion of African Americans and Hispanics had severe functional impairment (i.e., an ADL scale score greater than 23) compared with Whites (18.3% vs. 18.4% vs. 9.6%; p < .001, respectively). In addition, minorities had greater rates of cognitive impairment but were less likely to have severe behavioral disturbances or to have a delirium diagnosis than their White counterparts. For instance, 12.2% of African American and 12.9% of Hispanic were severely cognitively impaired, whereas 9.5% of White residents were in this category. By contrast, African Americans and Hispanics were 1.9 per- centage points (95% confidence interval [CI] = [–2.5, –1.5] percentage points) and 3.9 percentage points (95% CI = [–4.7, –3.3] percentage points) less likely to have delirium.

Hispanics were more likely to become long-stay residents compared with African Americans and Whites (33.9% vs.32.0% vs. 32.2%). In addition, minorities were more likely to be enrolled in Medicare Advantage and to be dually eligible for Medicare and Medicaid. About 20.9% and 22.7% of African American and Hispanic residents were enrolled in Medicare

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Table 1. Descriptive Characteristics of Medicare Beneficiaries Newly Admitted to a Nursing Home With a Dementia and/or Alzheimer’s Disease Diagnosis in 2014, by Race and Ethnicity (n = 268,181).

Whites ~84.9%

African Americans

~10.0% Hispanics

~5.1%

Age, % <65 2.06 5.06 3.47 65-84 47.87 58.06 56.70 85+ 50.06 36.88 39.83 Female, % 63.60 61.72 59.66 Severe functional

impairment, % 9.56 18.28 18.40

ADL Scale Score, M (SD) 17.85 (4.90) 18.63 (5.39) 18.96 (5.20) Cognitive function, %a

Intact 17.90 14.91 14.30 Mildly impaired 26.51 24.63 22.89 Moderately impaired 46.05 48.28 49.87 Severely impaired 9.54 12.18 12.95 Delirium, %a 12.39 10.42 8.42 Aggressive behaviors, %a

None 79.59 81.39 84.00 Moderate 13.38 12.62 10.82 Severe 5.64 4.83 4.15 Very severe 1.38 1.16 1.03 Admitted from, % Community 10.77 6.92 9.60 Nursing home 2.02 1.49 1.81 Hospital 83.94 88.62 85.93 Other 3.27 2.97 2.65 Became a long-stay resident, % 32.23 32.01 33.87 Medicare Advantage

enrollment, % 17.41 20.94 22.70

Dually eligible for Medicare and Medicaid, %

27.16 54.25 68.73

Note. Authors’ analysis of data from the 2014 Medicare Master Beneficiary Summary File, the Minimum Data Set, the Master Beneficiary Summary File, the Certification and Survey Provider Enhanced Reporting system, and Long-Term care: Facts on Care in the US. Differences across groups are significant at the p ≤ .05 level. ADL Score (Scale 0-28 with 0 = complete independence, 28 = complete dependence); ADL = activities of daily living; ABS = Aggressive Behavior Scale; CFS = Cognitive Function Scale. aDelirium, ABS, and CFS contain missing values (84,690 cases, 15,357 cases, and 32,501 cases, respectively).

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Advantage compared with 17.4% Whites. Finally, the large majority of minorities were dually eligible; African Americans and Hispanics were 27.1 and 41.6 percentage points more likely to be dual-enrolled as compared with Whites (95% CI = [26.4, 27.7] and [40.6, 42.5], respectively).

The characteristics of nursing homes to which these residents were admit- ted are displayed in Table 2. Segregation in nursing homes was high among minorities. African Americans with ADRD were admitted to facilities where 35.3% of residents were also African Americans. Similarly, there was a high concentration of Hispanics (29.2%) in facilities where Hispanics with ADRD were admitted residents. In addition, Whites were more likely to be admitted to facilities with Alzheimer’s special care units (21.5%) compared with either African Americans (16.3%) or Hispanics (12.7%). Finally, White residents were admitted to nursing homes with slightly better quality in several mea- sures than their counterparts. The average nursing home 30-day rehospital- ization rate was 17.1% for facilities where Whites were admitted compared with 19.1% and 18.1% for facilities where African Americans and Hispanics were admitted, respectively. (All differences across groups are significant at p < .001). Similarly, facilities where White residents received care were less likely to be for profit compared with facilities where African American or Hispanic residents received care (69.4% vs. 79.7% vs.81.6%; p < .001). Finally, CMS nursing home star ratings on average were 3.5 for nursing homes where Whites were admitted, 3.5 for nursing homes where Hispanics

Table 2. Characteristics of Nursing Homes Where Medicare Beneficiaries With a Dementia and/or Alzheimer’s Disease Diagnosis Were Admitted, by Race and Ethnic Group (n = 268,181).

Whites African

Americans Hispanics

% Hispanic residents 2.57 (6.39) 4.30 (8.57) 28.71 (29.22) % African American residents 7.37 (11.08) 35.36 (25.80) 11.17 (14.48) Alzheimer’s special care unit 21.47 (41.06) 16.29 (36.93) 12.72 (33.33) For profit 69.44 (46.06) 79.67 (40.25) 81.64 (38.71) Part of a chain 58.24 (49.32) 60.02 (48.98) 49.74 (50.00) % Medicaid primary payer 53.19 (22.78) 62.38 (21.79) 60.07 (21.53) Rehospitalization rate 17.07 (4.66) 19.07 (4.51) 18.11 (4.40) CMS nursing home star rating 3.54 (1.30) 3.26 (1.33) 3.52 (1.32)

Note. Authors’ analysis 2014 of the Minimum Data Set, the Master Beneficiary Summary File, the Certification and Survey Provider Enhanced Reporting system, and Long-Term Care: Facts on Care in the US. Differences across groups are jointly significant at the p < .001 level. CMS = Centers for Medicare & Medicaid Services.

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with ADRD were admitted, and 3.3 for nursing homes where African Americans were admitted.

Discussion

In this national study of rates of ADRD among Hispanic, African American, and White Medicare beneficiaries who were newly admitted to nursing homes, we found that a higher share of Hispanic residents had a diagnosis of ADRD compared with African Americans and Whites in 2014; Hispanics were about two percentage points more likely to be admitted with an ADRD diagnosis than Whites or African Americans. In addition, we found dispari- ties in the facility characteristics and quality of nursing homes to which Hispanics and African Americans were admitted compared with Whites. Nursing homes where Whites were admitted had on average one to two per- centage points lower 30-day rehospitalization rates than facilities to which Hispanics and African Americans were admitted. Hispanic residents were up to nine percentage points less likely to go to facilities with Alzheimer’s units compared with White residents. Another important finding in this study is the large concentration of racial and ethnic groups to which residents were admit- ted. A large fraction of Hispanic residents with ADRD went to nursing homes with a high percentage of Hispanic residents. Similarly, African American residents with ADRD were admitted to facilities with a greater proportion of African Americans.

In the present study, we found that Hispanics and African American resi- dents were more likely to be cognitively and physically impaired as com- pared with Whites. Our findings may be explained by disease severity and caregiver characteristics (Gaugler et al., 2009; Yaffe et al., 2002). This sug- gests that minorities may be admitted to a nursing home at a stage further in their ADRD disease progression. Previous studies have mentioned that African Americans and Hispanics have higher incidence of ADRD than Whites (Mayeda et al., 2014), and at the same time, a higher proportion of them may not receive an immediate diagnosis (Fitten, Ortiz, & Pontón, 2001; Schrauf & Iris, 2012; Wilkins et al., 2007). A delayed diagnosis may influence patient access to support and services, as well as family and care- giver planning (Shih et al., 2014). Others have found that being older and White increases the risk of nursing home placement among people with ADRD (Andel, Hyer, & Slack, 2007), and that up to 70% of African American Medicare beneficiaries may delay institutionalization (Gaugler, Leach, Clay, & Newcomer, 2004). Similarly, Hispanic families are less likely than Whites to use nursing home and other formal care services; yet, institutionalized care is now becoming more common than before among

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these families (Feng et al., 2011). Additional work among nursing home placement for minorities with ADRD is needed to understand the mecha- nisms behind these differences and whether these differences can be attrib- utable to variability in the availability of informal caregivers, cultural, patient, and family preferences or access to services.

These findings also highlight the need to expand the literature regarding delirium prevalence in nursing home settings among ADRD patients. A prior study done of older patients in post acute care settings did not find significant differences in the rates of delirium among race and ethnic groups (Marcantonio et al., 2005). Yet, our results show that African Americans and Hispanics with ADRD have lower rates of delirium by two to four percentage points, respec- tively, despite having higher rates of severe cognitive impairment. Although dementia and delirium are associated, causation is still unclear (Richardson et al., 2017). Delirium may occur due to a complex interrelationship among different factors, including higher rates of cognitive decline (Inouye, Westendorp, & Saczynski, 2014), which needs to be further examined in this group. Other studies have also found that delirium increases the risk of insti- tutionalization, poor health outcomes, and mortality (Kosar et al., 2017; Witlox et al., 2010); yet, we found that Hispanics with ADRD were two per- centage points more likely to become long-stay residents than African Americans or Whites with ADRD.

The present study results are consistent with previous work regarding racial disparities in quality among nursing home residents (Fennell, Feng, Clark, & Mor, 2010; Gaugler et al., 2004; Mor, Zinn, Angelelli, Teno, & Miller, 2004; Shippee et al., 2015). These two groups are also less likely to go to nursing homes where residents with ADRD receive special dementia care (i.e., being in a nursing home with a dementia special care unit), which has been documented to provide better quality of life for people with ADRD in different domains (Cadigan, Grabowski, Givens, & Mitchell, 2012; Luo, Fang, Liao, Elliott, & Zhang, 2010). Existing literature on this topic suggests that Whites with ADRD are more likely to receive such specialized treat- ment. This is partially because Whites are more likely to go to facilities with a better payer mix and that are not-for-profit (Sengupta, Decker, Harris- Kojetin, & Jones, 2012). These facilities tend to be linked primarily to special care unit nursing homes (Buchanan, Choi, Wang, Ju, & Graber, 2005; Congress of the United States, Office of Technology Assessment, 1992). This is consistent with our results as we observe that African Americans and Hispanics with ADRD are more likely to go to facilities that are for-profit and highly dependent on Medicaid.

In addition, we found that African Americans and Hispanics are still more likely to go to facilities serving a higher proportion of non-White residents.

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This is relevant as racial segregation has long been associated with quality outcomes in long-term care settings (Davis, Weech-Maldonado, Lapane, & Laberge, 2014; Li et al., 2015; Mor et al., 2004). Although, these patients may be exhibiting race- or distance-based preferences (Rahman & Foster, 2015), and may be actively choosing nursing homes that have patients with similar background or homes that are also located near their communities or family, it could potentially mean that these lower quality nursing homes are located within more segregated neighborhoods (Shippee, Henning-Smith, Rhee, Held, & Kane, 2016). Future research should investigate consumer choice of nursing homes among minority groups with ADRD and the extent to which sociodemographic and geographic characteristics influence access, quality of care, and patient outcomes.

Our results also show that a higher percentage of minorities with ADRD in nursing home are enrolled in Medicare Advantage, at least among those who are newly admitted. Yet, there are no national studies of beneficiaries with ADRD in the Medicare advantage program, despite the evidence that shows that racial and ethnic minority groups are more likely to enroll in man- aged care (Weinick, Haviland, Hambarsoomian, & Elliott, 2014). However, Medicare Advantage may promote disenrollment among patients with ADRD when complex health care needs and high costs are encountered (Rahman, Keohane, Trivedi, & Mor, 2015). Another consideration is that Medicare Advantage Special Needs Plans (SNPs) tailor benefits to patients with com- plex needs. Although Centers for Medicare and Medicaid Services would expect that these specialized plans would achieve better outcomes, little research has been conducted in this area (CMS, 2017c). More work is needed regarding the relationship between Medicare Advantage enrollment and out- comes among the ADRD population. Particularly, whether enrollment into Medicare Advantage reduces utilization of nursing home care and improves quality of care, specifically among Hispanics and African Americans, and SNPs that focus on dually eligible enrollees.

Our study has limitations. First, diagnosis of ADRD is not necessarily based on clinical testing, and racial minorities may be less likely to be diag- nosed (Espino & Lewis, 1998). Yet, despite these potentially lower docu- mented rates of ADRD, Hispanics are admitted with higher rates of ADRD. In addition, the number of people with ADRD in nursing homes is declining as residents with these conditions are more likely to remain in the community for longer (Callahan et al., 2012). We are unable to test which factors are responsible for observed rates. Due to the nature of the data, it is not possible to assess pathways- or time-to-diagnosis because ADRD diagnosis is cap- tured at the time of MDS assessment. In addition, MDS-based Confusion

Rivera-Hernandez et al. 13

Assessment Method (CAM) diagnosis has low sensitivity and delirium diag- nosis may be missed by the MDS (as discussed by Kosar et al., 2017). However, our study has a number of strengths. First, it provides a better understanding about long-term care utilization and quality of care among minority groups, specifically Hispanics, compared with Whites. We also used a number of process and outcome measures to characterize quality of care among facilities. Second, the majority of Medicare-related studies only includes traditional Medicare beneficiaries and often excludes Medicare Advantage enrollees, which represents one third of Medicare beneficiaries (Jacobson, Damico, Newman, & Gold, 2017). Our study included both Medicare Advantage and traditional Medicare enrollees. Finally, this is the first study to examine these disparities in nursing home utilization and care, which is important given the dramatic differences in the incidence and preva- lence of ADRD among Hispanics and African Americans.

There are some policy implications from our study. Beneficiaries in the Medicare program are encouraged to use NHC when selecting a nursing home. This is a publicly available tool that the Centers for Medicare and Medicaid Services provides to enrollees to make informed nursing home choices, and also encourages providers to improve quality of care (CMS, 2017a). At the moment, consumers could select nursing homes based on overall rating, health inspections, staffing, quality measures, and distance (CMS, 2017b). It may be useful if the consumers could filter nursing home quality based on facility use of antipsychotics and/or other quality measures that pertain to the quality of care for residents with ADRD (CMS, 2016). In addition, to enhance the quality of life among residents with ADRD, Medicare recently announced a partnership with different agencies and nursing home providers to improve person-centered care for every nursing home resident (CMS, 2017d). Hence, another policy implication that arises from these results is that efforts to enhance quality of care among people with ADRD should have a special focus on facilities that disproportionally serve African Americans and Hispanics.

Policy makers and health care providers should be informed about dispari- ties in quality of care of Hispanics and African Americans with ADRD. Special attention should be given to the rapid demographic changes and long- term care needs of this population and helping minority residents and sup- porting patient-informed decision-making regarding ADRD diagnosis and care. Given the segregation of care we found in this study, future research and policy efforts are needed to reduce disparities within communities and sur- rounding nursing homes with a high concentration of Hispanics and other minority elders.

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Author’s Note

Gary Epstein-Lubow is now affiliated to Center for Alzheimer’s Disease and Memory Care Hebrew SeniorLife, Boston, MA, USA.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by National Institute on Aging Grant Nos. P01AG027296-07 and P01AG027296-07S1. The National Institute on Aging had no role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the prepara- tion, review, or approval of the manuscript.

References

Alzheimer’s Association. (2004). Hispanics/Latinos and Alzheimer’s disease. Retrieved from http://www.alz.org/national/documents/report_hispanic.pdf

Alzheimer’s Association. (2016). 2016 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 12, 459- 509.

American Health Care Association. (2017a). Length of stay calculation. Retrieved from https://www.ahcancal.org/research_data/trendtracker/Documents/Length%20 of%20Stay%20Calculation.pdf

American Health Care Association. (2017b). 30-day risk-adjusted SNF rehospi- talization measure. Retrieved from https://www.ahcancal.org/research_data/ trendtracker/Documents/Rehospitalization%20Help%20Doc.pdf

Andel, R., Hyer, K., & Slack, A. (2007). Risk factors for nursing home placement in older adults with and without dementia. Journal of Aging and Health, 19, 213- 228. doi:10.1177/0898264307299359

Barnes, L. L., & Bennett, D. A. (2014). Alzheimer’s disease in African Americans: risk factors and challenges for the future. Health Affairs, 33(4), 580-586. doi: 10.1377/hlthaff.2013.1353

Buchanan, R. J., Choi, M., Wang, S., Ju, H., & Graber, D. (2005). Nursing home resi- dents with Alzheimer’s disease in special care units compared to other residents with Alzheimer’s disease. Dementia, 4, 249-267. doi:10.1177/1471301205051095

Cadigan, R. O., Grabowski, D. C., Givens, J. L., & Mitchell, S. L. (2012). The quality of advanced dementia care in the nursing home: The role of special care units. Medical Care, 50, 856-862. doi:10.1097/MLR.0b013e31825dd713

Callahan, C. M., Arling, G., Tu, W., Rosenman, M. B., Counsell, S. R., Stump, T. E., & Hendrie, H. C. (2012). Transitions in care for older adults with and without

Rivera-Hernandez et al. 15

dementia. Journal of the American Geriatrics Society, 60, 813-820. doi:10.1111/ j.1532-5415.2012.03905.x

Centers for Medicare & Medicaid Services. (2016). Nursing Home Compare qual- ity measure technical specifications. Retrieved from https://www.cms.gov/ Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/ Downloads/New-Measures-Technical-Specifications-DRAFT-04-05-16-.pdf

Centers for Medicare & Medicaid Services. (2017a). Find a nursing home. Retrieved from https://www.medicare.gov/nursinghomecompare/search.html?

Centers for Medicare & Medicaid Services. (2017b, March 22). Five-star quality rat- ing system. Retrieved from https://www.cms.gov/medicare/provider-enrollment- and-certification/certificationandcomplianc/fsqrs.html

Centers for Medicare & Medicaid Services. (2017c). Medicare special needs plans (SNP). Retrieved from https://www.medicare.gov/sign-up-change-plans/medi- care-health-plans/medicare-advantage-plans/special-needs-plans.html

Centers for Medicare & Medicaid Services. (2017d, October 25). National partnership to improve dementia care in nursing homes. Retrieved from https://www.cms.gov/ Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/ National-Partnership-to-Improve-Dementia-Care-in-Nursing-Homes.html

Centers for Medicare & Medicaid Services. (2017e, September 27). Nursing Home Quality Initiative. Retrieved from https://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/index.html

Congress of the United States, Office of Technology Assessment. (1992). Special care units for people with Alzheimer’s and other dementias: Consumer education, research, regulatory, and reimbursement issues. Washington, DC: Government Printing Office, 198.

Davis, J. A., Weech-Maldonado, R., Lapane, K. L., & Laberge, A. (2014). Contextual determinants of US nursing home racial/ethnic diversity. Social Science & Medicine, 104, 142-147. doi:10.1016/j.socscimed.2013.12.009

Eicheldinger, C., & Bonito, A. (2008). More accurate racial and ethnic codes for Medicare administrative data. Health Care Financing Review, 29(3), 27-42.

Espino, D. V., & Lewis, R. (1998). Dementia in older minority populations: Issues of prevalence, diagnosis, and treatment. The American Journal of Geriatric Psychiatry, 6(2, Suppl. 1), S19-S25. doi:10.1097/00019442-199821001-00003

Feng, Z., Fennell, M. L., Tyler, D. A., Clark, M., & Mor, V. (2011). Growth of racial and ethnic minorities in us nursing homes driven by demographics and possible disparities in options. Health Affairs, 30, 1358-1365. doi:10.1377/ hlthaff.2011.0126

Fennell, M. L., Feng, Z., Clark, M. A., & Mor, V. (2010). Elderly Hispanics more likely to reside in poor-quality nursing homes. Health Affairs, 29(1), 65-73. doi:10.1377/hlthaff.2009.0003

Fitten, L. J., Ortiz, F., & Pontón, M. (2001). Frequency of Alzheimer’s disease and other dementias in a community outreach sample of Hispanics. Journal of the American Geriatrics Society, 49, 1301-1308. doi:10.1046/j.1532- 5415.2001.49257.x

16 Journal of Aging and Health 00(0)

Gaugler, J. E., Leach, C. R., Clay, T., & Newcomer, R. C. (2004). Predictors of nursing home placement in African Americans with dementia. Journal of the American Geriatrics Society, 52, 445-452.

Gaugler, J. E., Yu, F., Krichbaum, K., & Wyman, J. F. (2009). Predictors of nurs- ing home admission for persons with dementia. Medical Care, 47, 191-198. doi:10.1097/MLR.0b013e31818457ce

Grill, J. D., & Galvin, J. E. (2014). Facilitating Alzheimer’s disease research recruit- ment. Alzheimer Disease and Associated Disorders, 28(1), 1-8. doi: 10.1097/ WAD.0000000000000016

Healthy People 2020. (2014). Dementias, including Alzheimer’s disease. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/dementias- including-alzheimers-disease/national-snapshot

Hefele, J. G., Ritter, G. A., Bishop, C. E., Acevedo, A., Ramos, C., Nsiah-Jefferson, L. A., & Katz, G. (2017). Examining racial and ethnic differences in nursing home quality. Joint Commission Journal on Quality and Patient Safety, 43, 554- 564. doi:10.1016/j.jcjq.2017.06.003

Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine, 113, 941-948.

Inouye, S. K., Westendorp, R. G. J., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet, 383(9920), 911-922. doi:10.1016/S0140-6736(13)60688-1

Jacobson, G., Damico, A., Neuman, T., & Gold, M. (2017). Medicare advantage 2017 spotlight: Enrollment market update. Retrieved from https://www.kff.org/medi- care/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/

Kane, R. A. (2001). Long-term care and a good quality of life bringing them closer together. The Gerontologist, 41, 293-304. doi:10.1093/geront/41.3.293

Khachaturian, Z. S., Khachaturian, A. S., & Thies, W. (2012). The draft “national plan” to address Alzheimer’s disease–National Alzheimer’s Project Act (NAPA). Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 8, 234- 236. doi:10.1016/j.jalz.2012.04.004

Kosar, C. M., Thomas, K. S., Inouye, S. K., & Mor, V. (2017). Delirium during post- acute nursing home admission and risk for adverse outcomes. Journal of the American Geriatrics Society, 65, 1470-1475. doi:10.1111/jgs.14823

Li, Y., Harrington, C., Temkin-Greener, H., Kai, Y., Cai, X., Cen, X., & Mukamel, D. B. (2015). Deficiencies in care at nursing homes and racial & ethnic disparities across homes declined, 2006–11. Health Affairs, 34, 1139-1146. doi:10.1377/ hlthaff.2015.0094

LTC focus. (2017). Long-term care: Facts on care in the US. Available from http:// ltcfocus.org/

Luo, H., Fang, X., Liao, Y., Elliott, A., & Zhang, X. (2010). Associations of spe- cial care units and outcomes of residents with dementia: 2004 National Nursing Home Survey. The Gerontologist, 50, 509-518. doi:10.1093/geront/gnq035

Rivera-Hernandez et al. 17

Marcantonio, E. R., Kiely, D. K., Simon, S. E., John Orav, E., Jones, R. N., Murphy, K. M., & Bergmann, M. A. (2005). Outcomes of older people admitted to post- acute facilities with delirium. Journal of the American Geriatrics Society, 53, 963-969. doi:10.1111/j.1532-5415.2005.53305.x

Mayeda, E. R., Karter, A. J., Huang, E. S., Moffet, H. H., Haan, M. N., & Whitmer, R. A. (2014). Racial/ethnic differences in dementia risk among older type 2 diabetic patients: The diabetes and aging study. Diabetes Care, 37, 1009-1015. doi:10.2337/dc13-0215

McGuire, T. G., Alegria, M., Cook, B. L., Wells, K. B., & Zaslavsky, A. M. (2006). Implementing the Institute of Medicine definition of disparities: An application to mental health care. Health Services Research, 41, 1979-2005. doi:10.1111/ j.1475-6773.2006.00583.x

Mor, V., Zinn, J., Angelelli, J., Teno, J. M., & Miller, S. C. (2004). Driven to tiers: Socioeconomic and racial disparities in the quality of nursing home care. The Milbank Quarterly, 82, 227-256. doi:10.1111/j.0887-378X.2004.00309.x

Morris, J. N., Hawes, C., Fries, B. E., Phillips, C. D., Mor, V., Katz, S., . . . Friedlob, A. S. (1990). Designing the national resident assessment instrument for nursing homes. The Gerontologist, 30, 293-307.

Office of the Assistant Secretary for Planning and Evaluation. (2015). National plan to address Alzheimer’s disease: 2013 update. Retrieved from https://aspe.hhs. gov/national-plan-address-alzheimers-disease-2013-update

Office of the Surgeon General (US), Center for Mental Health Services (US), & National Institute of Mental Health (US). (2001). Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville (MD): Substance Abuse and Mental Health Services Administration (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44243/

Perlman, C. M., & Hirdes, J. P. (2008). The Aggressive Behavior Scale: A new scale to measure aggression based on the Minimum Data Set. Journal of the American Geriatrics Society, 56, 2298-2303. doi:10.1111/j.1532-5415.2008.02048.x

Phillips, C. D., Morris, J. N., Hawes, C., Fries, B. E., Mor, V., Nennstiel, M., & Iannacchione, V. (1997). Association of the resident assessment instrument (RAI) with changes in function, cognition, and psychosocial status. Journal of the American Geriatrics Society, 45, 986-993.

Potter, G. G., Plassman, B. L., Burke, J. R., Kabeto, M. U., Langa, K. M., Llewellyn, D. J., . . . Steffens, D. C. (2009). Cognitive performance and informant reports in the diagnosis of cognitive impairment and dementia in African Americans and Whites. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 5, 445-453. doi:10.1016/j.jalz.2009.04.1234

Rahman, M., & Foster, A. D. (2015). Racial segregation and quality of care dispar- ity in US nursing homes. Journal of Health Economics, 39, 1-16. doi:10.1016/j. jhealeco.2014.09.003

18 Journal of Aging and Health 00(0)

Rahman, M., Keohane, L., Trivedi, A. N., & Mor, V. (2015). High-cost patients had substantial rates of leaving Medicare Advantage and joining traditional Medicare. Health Affairs, 34, 1675-1681. doi:10.1377/hlthaff.2015.0272

Rahman, M., Tyler, D., Acquah, J. K., Lima, J., & Mor, V. (2014). Sensitivity and specificity of the Minimum Data Set 3.0 discharge data relative to Medicare claims. Journal of the American Medical Directors Association, 15, 819-824. doi:10.1016/j.jamda.2014.06.017

Research Data Assistance Center. (2017). Master beneficiary summary file. Retrieved from https://www.resdac.org/cms-data/files/mbsf

Richardson, S. J., Davis, D. H. J., Stephan, B., Robinson, L., Brayne, C., Barnes, L., . . . Allan, L. M. (2017). Protocol for the Delirium and Cognitive Impact in Dementia (DECIDE) study: A nested prospective longitudinal cohort study. BMC Geriatrics, 17, Article 98. doi:10.1186/s12877-017-0479-3

Samper-Ternent, R., Kuo, Y. F., Ray, L. A., Ottenbacher, K. J., Markides, K. S., & Al Snih, S. (2012). Prevalence of health conditions and predictors of mortality in old- est old Mexican Americans and non-Hispanic Whites. Journal of the American Medical Directors Association, 13, 254-259. doi:10.1016/j.jamda.2010.07.010

Schrauf, R. W., & Iris, M. (2012). Very long pathways to diagnosis among African Americans and Hispanics with memory and behavioral problems associated with dementia. Dementia, 11, 743-763. doi:10.1177/1471301211416615

Schulz, R., Belle, S. H., Czaja, S. J., McGinnis, K. A., Stevens, A., & Zhang, S. (2004). Long-term care placement of dementia patients and caregiver health and well-being. Journal of the American Medical Association, 292, 961-967. doi:10.1001/jama.292.8.961

Sengupta, M., Decker, S. L., Harris-Kojetin, L., & Jones, A. (2012). Racial differ- ences in dementia care among nursing home residents. Journal of Aging and Health, 24, 711-731. doi:10.1177/0898264311432311

Shih, R. A., Concannon, T. W., Liu, J. L., & Friedman, E. M. (2014). Improving dementia long-term care: A policy blueprint. Rand Health Quarterly, 4(2), Article 2. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5051994/

Shippee, T. P., Henning-Smith, C., Kane, R. L., & Lewis, T. (2015). Resident-and facility-level predictors of quality of life in long-term care. The Gerontologist, 55, 643-655. doi:10.1093/geront/gnt148

Shippee, T. P., Henning-Smith, C., Rhee, T. G., Held, R. N., & Kane, R. L. (2016). Racial differences in Minnesota nursing home residents’ quality of life: The importance of looking beyond individual predictors. Journal of Aging and Health, 28, 199-224. doi:10.1177/0898264315589576

Smith, D. B. (1990). Population ecology and the racial integration of hospitals and nursing homes in the United States. The Milbank Quarterly, 68, 561-596.

Smith, D. B., Feng, Z., Fennell, M. L., Zinn, J. S., & Mor, V. (2007). Separate and unequal: Racial segregation and disparities in quality across U.S. nursing homes. Health Affairs, 26, 1448-1458. doi:10.1377/hlthaff.26.5.1448

Thomas, K. S., Baier, R., Kosar, C., Ogarek, J., Trepman, A., & Mor, V. (2017). Individualized music program is associated with improved outcomes for U.S. nursing home residents with dementia. The American Journal of Geriatric

Rivera-Hernandez et al. 19

Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 25, 931-938. doi:10.1016/j.jagp.2017.04.008

Thomas, K. S., Dosa, D., Wysocki, A., & Mor, V. (2017). The Minimum Data Set 3.0 Cognitive Function Scale. Medical Care, 55(9), e68-e72. doi:10.1097/ MLR.0000000000000334

Wei, L. A., Fearing, M. A., Sternberg, E. J., & Inouye, S. K. (2008). The confusion assessment method: A systematic review of current usage. Journal of the American Geriatrics Society, 56, 823-830. doi:10.1111/j.1532-5415.2008.01674.x

Weinick, R., Haviland, A., Hambarsoomian, K., & Elliott, M. N. (2014). Does the racial/ethnic composition of Medicare Advantage plans reflect their areas of oper- ation? Health Services Research, 49, 526-545. doi:10.1111/1475-6773.12100

Wilkins, C. H., Wilkins, K. L., Meisel, M., Depke, M., Williams, J., & Edwards, D. F. (2007). Dementia undiagnosed in poor older adults with functional impairment. Journal of the American Geriatrics Society, 55, 1771-1776. doi:10.1111/j.1532- 5415.2007.01417.x

Witlox, J., Eurelings, L. S., de Jonghe, J. F. M., Kalisvaart, K. J., Eikelenboom, P., & van Gool, W. A. (2010). Delirium in elderly patients and the risk of postdis- charge mortality, institutionalization, and dementia: A meta-analysis. Journal of the American Medical Association, 304, 443-451. doi:10.1001/jama.2010.1013

Wong, C. L., Holroyd-Leduc, J., Simel, D. L., & Straus, S. E. (2010). Does this patient have delirium? Value of bedside instruments. Journal of the American Medical Association, 304, 779-786. doi:10.1001/jama.2010.1182

Wysocki, A., Thomas, K. S., & Mor, V. (2015). Functional improvement among short-stay nursing home residents in the MDS 3.0. Journal of the American Medical Directors Association, 16, 470-474. doi:10.1016/j.jamda.2014.11.018

Yaffe, K., Fox, P., Newcomer, R., Sands, L., Lindquist, K., Dane, K., & Covinsky, K. E. (2002). Patient and caregiver characteristics and nursing home placement in patients with dementia. Journal of the American Medical Association, 287, 2090-2097.