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A December 2015 Health Affairs study of freestanding Skilled Nursing Facilities (SNFs) from 2001 thru 2011 found that registered nurses (RNs) were less likely to work at nursing homes with high concentrations of racial and ethnic minorities.[1] This study reports on significant health disparities for racial and ethnic minority SNF residents.

In the Health Affairs study, facilities with low concentrations of minorities (<.5 percent of a facility’s resident population) were distinguished from SNFs with medium concentrations (5.0-14.9 percent), medium-high concentrations (15.0-34.9 percent), and high concentrations (≥35 percent) of minorities. Although RN staffing levels increased slightly across-the-board for all nursing facilities during the ten-year period, facilities with high concentrations of racial and ethnic minority residents “showed persistently lower RN hours per resident day.”  The study noted that “facilities in the high-concentration group also showed persistently higher [licensed practical nurse] LPN hours per resident day, compared to the low-concentration group.” Regrettably, the authors reported that “facilities in the high-concentration group had a lower nurse skill mix than those in the low-concentration group.”

Additionally, certified nurse assistant (CNA) hours were reduced at facilities with greater numbers of ethnic and racial minority residents in recent years as a result of (1) the greater likelihood for nursing homes with higher concentrations of racial and ethnic minorities to receive relatively lower payments in the form of Medicaid dollars and (2) recent economic trends caused by the recession. With respect to the use of CNAs, the study found that the number of CNA hours decreased in the higher-concentration group from 2.08 to 1.99 hours per day between 2008 and 2011.[2]

Increases in Medicaid payments led to higher nursing hours per resident per day, but “the increase was also associated with lower nurse skill mix – that is, a reduction in RN hours per patient day as a percentage of all nurse hours.”[3]  Moreover, a state’s increased use of case-mix payment methods generally lowered the number of hours worked by RNs across that state.

These findings are significant because certain nurse staffing mixes have been shown to be more likely to produce higher quality outcomes for SNF residents. A 2009 study of California’s freestanding nursing homes published in the Gerontologist found that having a higher concentration of RNs and CNAs promoted positive patient and staff interactions and higher quality outcomes for nursing home residents.[4]  A December 2015 Journal of Nursing Regulation study showed that RNs were more likely than LPNs to identify discrepancies in medication orders involving high-risk medications, noting that “RNs assess orders for discrepancies based on the potential risk to patient safety” and that LPNs were more likely to “follow rote instructions to complete the task of medication reconciliation rather than engaging in cognitive behavior regarding risk.”[5] 

The December 2015 Health Affairs study findings are consistent with previous research concerning the existence of racial and ethnic disparities among SNFs.  According to a July 2015 Health Affairs article, from 2006 to 2011 the number of facilities with care deficiency citations declined overall.  Citations in facilities serving relatively fewer racial and ethnic minorities (<5 percent) dropped from 7.4 deficiencies per survey to 6.8 deficiencies, and citations in facilities serving relatively larger numbers of racial and ethnic minorities (≥35 percent) dropped from 10.6 deficiencies to 9.4 deficiencies. The study’s authors found that an increase in Medicaid payments to nursing homes more than likely led to the decrease in the number of deficiency citations.  Such increases seemed to improve some conditions for minority SNF residents when nursing homes were reviewed nationally. Despite the overall decrease in facility citations, facilities with relatively larger numbers of racial and ethnic minority residents were still almost 40% more likely to receive a citation.[6]

A 2011 American Journal of Public Health study of the 2008 National Nursing Home Minimum Data Set discovered that black patients had a 4.3 percent higher 30 day rehospitalization rate than white patients—18.6 percent, respectively, to 14.3 percent. The 90-day rehospitalization rates were, respectively, for the two groups, 29.5 percent and 22.1 percent. Relative to white residents, black residents had a 40 percent higher chance of rehospitalization in the first 30 days and a 50 percent higher chance of rehospitalization in the first 90 days.[7]

The rates at which persons from different races were given vaccines at SNFs also highlight disparities. One study of 2004 survey data showed that black nursing facility residents were much more likely to get the flu and less likely to receive vaccines than white nursing home residents.[8] In an examination of Medicare patients in various care settings published by Health Affairs in 2008, Asian-American Medicare beneficiaries were also found to be less likely to have received cancer screenings than white Medicare beneficiaries.[9]


Racial and ethnic minority nursing home residents have not been receiving the same quality of skilled care in nursing homes as white patients and the consequences of this disparity have been significant. Based on the findings of the December 2015 Health Affairs study and other research highlighted above, further increases in Medicaid funding for SNFs with high concentrations of racial and ethnic minorities could increase the number of RNs and CNAs on staff and help reduce health disparities.  However, states should be cautious when structuring reimbursement changes to address disparities, to ensure staffing levels and level-of-care disparities are addressed.

January 27, 2016 – M. Hubbard


[1] Yue Li, Charlene Harrington, Dana Mukamel, Xi Cen, et. al. “Nursing Staffing Hours at Nursing Homes with High Concentrations of Minority Residents, 2001-2011.” Health Affairs. December 2015. 34:12. P. 2132-4.
[2]  Id., 2132-4.
[3] Id. 2133.  For more information on the impact of increased Medicaid payments see: Terence Ng, Charlene Harrington, Mary Beth Musumeci, and Erica L. Reaves. “Medicaid Home and Community-Based Services Programs: 2012 Data Update.” Kaiser Family Foundation. 03 November 2015. (site visited December 23, 2015).
[4] Hongsoo Kim, Charlene Harrington, and William Greene. “Registered Nurse Staffing Mix and Quality of Care in Nursing Homes: A Longitudinal Analysis.” The Gerontologist. 2009. 49:1.
[5] Amy Vogelsmeier, Allison Anbari, Larry Ganong, Ruth A. Anderson, Lynda Oderda, Amany Farag, and Richard Madsen. “Detecting Medication Order Discrepancies in Nursing Homes: How RNs and LPNs Differ.” Journal of Nursing Regulation. October 2015. 6:3. P. 54.
[6] Yue Li, Charlene Harrington, Helena Tempkin-Greener, Kai You, et. al. “Deficiencies in Care at Nursing Homes and Racial/Ethnic Disparities across Homes Fell, 2006-2011.” Health Affairs. July 2015. 34:7. P. 1143-4.
[7] Yue Li, Laurent G. Glance, Jun Yin, and Dana B. Mukamel. “Racial Disparities in Rehospitalization among Medicare Patients in Skilled Nursing Facilities.” American Journal of Public Health. May 2011. 101:5.
[8] Yue Li and Dana B. Mukamel. “Racial Disparities in Receipt of Influenza and Pneumococcus Vaccinations among US Nursing-Home Residents.” American Journal of Public Health. April 2010. 100.
[9] Ernest Moy, Linda Greenberg, and Amanda Borsky. “Community Variation: Disparities in Health Care Quality between Asian and White Medicare Beneficiaries.” Health Affairs. March 2008. 27:2. P. 541-2.

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