Sep 19, 2024
Blog
“Health equity is the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and social determinants of health — and to eliminate disparities in health and health care.”
The definition of health equity above comes from Healthy People 2030, a program from the US Office of Disease Prevention and Health Promotion. As it states, health equity and the forces that affect it extend beyond hospitals and clinics, and even beyond traditional medical centers, into communities, workplaces, and homes. It also applies to a setting many Americans might not think about often: nursing homes. With an aging population, a shortage of healthcare workers, and a struggling healthcare system, these microcosms face the unique challenge of providing quality medical care for their residents and a safe, comfortable, and dignified home. However, behind the stereotypes and media hype, people strive to create a medically competent and culturally responsive environment full of well-cared for residents.
Nursing Homes and Social Determinants of Health
“Nursing homes are people’s homes, so they are socially complex environments,” said Emily Nelson, MetaStar’s Vice President of Healthcare Transformation. “We need to recognize that the injustice of health disparities does not go away once someone begins their journey in a nursing home setting of care.” Many of those disparities can be attributed to social determinants of health (SDOH), which are “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks,” according to the US Department of Health and Human Services. These SDOHs – such as educational background and opportunities, socioeconomic status, housing or lack thereof – significantly impact an individual’s health, functioning, and quality of life.
In nursing homes, “many of these SDOHs have already impacted individuals so greatly,” said Aimee Rasmussen, Nursing Home Program Manager at MetaStar. This presents a challenge to nursing homes—addressing these complexities requires time, understanding, education, and funding. However, she continued, it also presents an opportunity to address these areas of a resident’s ’s life by “providing a community and social environment that identifies these SDOH and takes action to resolve inequities.”
Privilege, Power, and Population Change
Nursing homes often face disparities in patient privilege and power which can lead to a decline in health equity. A 2024 Centers for Medicare and Medicaid Services (CMS) report revealed that in most post-acute care settings, Non-White patients had worse discharge to community and Medicare Spending Per Beneficiary outcomes than White patients, and outcomes worsened as the number of Non-White patients increased. Research also shows that Black, Indigenous, and people of color (BIPOC) experience a lower quality of life than White patients across various domains, such as food, relationships, and caregiving (Shippee et. al, 2022). Additionally, noted Rasmussen, there can be a struggle between short-term and long-term residents due to different goals and care needs.
The payors of nursing home residents can indirectly impact the care they receive, Rasmussen explained. “While residents residing in a nursing home receive the same care regardless of payor type, the organization itself may be impacted by the payor mix within the nursing home.” Private payors usually reimburse more than Medicare and Medicaid. High numbers of Medicare and Medicaid residents can lower reimbursement rates, negatively impacting staff, leadership, training, and resources. Race (or skin color) and payor status are just two of the many areas in which relative privilege and power affect the care and outcomes in a nursing home.
The makeup of nursing home populations is changing as well. A 2021 report from SAGE USA and the HRC Foundation estimates that 5% of people in long-term care communities identify as LGBTQ+. Other populations that were once a small portion of nursing home residents are growing as well, such as those with or who develop opioid use disorder or other substance use disorders; unhoused people who have nowhere to be discharged to; residents with increasing complex mental health needs; residents whose first language is not English, and more. As these minority identities accumulate, they become more ostracized and face more inequities (See Kimberlé Crenshaw’s theory of intersectionality.) These populations are stigmatized, and it can be difficult for staff and other residents to recognize the differences in privilege and power.
Staff language can also contribute to healthcare inequities in nursing homes. Terms like “addict” and “alcoholic” perpetuate the negative stereotypes of people who have substance use disorders. Terms like “the elderly” and “seniors” carry negative connotations for older adults, while referring to residents by their conditions, room number, or other features can be demeaning as well.
Differences in SDOHs, privilege, and power can significantly impact the health care provided to residents in nursing homes. For example, Rasmussen mentions that rashes, pressure injuries, and other skin issues look different on different skin tones, and staff members may not be adequately trained to handle these differences. Other populations may arrive with unfamiliar conditions and medications, requiring additional training.
Helping Nursing Homes Succeed
It is no secret that the nursing home industry faces challenges due to inequities, but organizations like MetaStar, Superior Health Quality Alliance, SAGE (which produces the Long-Term Care Equality Index with the HRC Foundation), CMS, and more are actively working to address these issues.
MetaStar collects data on nursing home outcomes and can “get in front of CMS to share what we’re seeing, hearing, and feeling in [the nursing home community] in a neutral fashion,” said Nelson. MetaStar, along with the Wisconsin Health Care Association and LeadingAge Wisconsin, trained over 2,300 licensed staff and 4,000 direct care staff in Wisconsin about assessing skin and wounds in people with a wide array of skin tones. Superior Health provides a resource library, including specific items about stigma, health disparities, and learning modules for frontline staff. Think Cultural Health, a website sponsored by the US Office of Minority Health, offers the Culturally and Linguistically Appropriate Services (CLAS) standards to help nursing homes create policies and healthcare that consider patients’ cultural and linguistic backgrounds.
There is also a lot that nursing home staff can do within their organization to help ease existing disparities. “Equitable care starts on or before admission,” Rasmussen said. “Providing the nursing home with a social history of the resident is key in this.” She emphasized the importance of knowing the resident’s story, whether it’s shared by the resident, their family, or both. This information helps staff understand who the resident is now and recognize the journey that brought them here. Rasmussen continued, “The more the nursing home staff know about the resident and their goals, preferences, and priorities, the easier it is for equitable care to be provided.”
Involving all staff in promoting health equity in nursing homes is crucial. Life enrichment staff can help identify special days or events for residents, and dietary staff can inquire about special foods or dietary needs. “These are important ways for the staff and residents to better understand and recognize cultural and religious beliefs of the residents they care for,” Nelson said. Nursing home leadership can ensure staff receive training on topics such as CLAS standards and promote an equitable culture across the organization. Policies and procedures should be written and implemented with health equity at the forefront, fostering a more inclusive environment.
Many people overlook the importance of nursing homes until they or a loved one needs to be cared for in one. “There is a lack of acknowledgment of the amazing work that is done in nursing homes in Wisconsin and beyond,” Nelson said. The complex challenges nursing homes face and their commitment to quality care are often overlooked. Despite this, nursing homes continue to find inclusive ways to create a diverse environment and unique community—with some help from outside sources. “MetaStar has long-standing expertise in health equity and nursing homes, creating a great opportunity to support nursing homes in their journey towards improvement,” said Nelson. “We are very confident that the skills, knowledge, and compassion are woven into the hearts of so many staff who have dedicated themselves to working in nursing homes.”