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Nursing home closures clustered in poor, minority areas

January 12, 2011--Nursing home closures eliminated about 5 percent of available beds between 1998 and 2008, with closures concentrated in minority and poor communities, according to a report posted online today that will be published in the May 9 print issue ofArchives of Internal Medicine, one of the JAMA/Archives journals.

"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.