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Disparities in healthcare use and outcomes among assisted living residents has more to do with residents’ socioeconomic status than with discrimination based solely on race or ethnicity, according to a new study.

The findings point to the necessity for providers to consider the increasing needs of residents who may not be able to pay for services and for state policymakers to examine their states’ commitment to serving certain residents, the authors said. At the federal level, the findings also highlight the lack of minimum standards that make it possible to assess quality and transparency, they said.

“The major lesson is probably for states that look to rebalance Medicaid spending from nursing homes to home- and community-based services via assisted living,” Helena Temkin-Greener, Ph.D., a professor at the University of Rochester School of Medicine and lead author on the study, told McKnight’s Senior Living. “States vary in the intensity with which they pay for personal care services for Medicaid-eligible residents of assisted living communities, but it seems that current state generosity in supporting these services may not be sufficient in preventing or delaying institutional placement.”

The research, conducted by researchers from the University of Rochester, Rochester, NY, and the University of North Carolina at Chapel Hill, found significant variations in inpatient hospital admissions, 30-day readmission, emergency department use and nursing home admissions, both within and across assisted living communities, for racial/ethnic minority residents and residents dually eligible for Medicare and Medicaid. The study revealed that assisted living communities with higher proportions of minorities were disproportionately more likely to have dually eligible residents and be located in rural areas. The findings found differences in health outcomes between residents who are dually eligible and those who are not, but largely not by race / ethnicity alone.

Although most assisted living communities offer some level of assistance with activities of daily living such as medication management, the greatest variation appears to be in the intensity and frequency of such services, according to the paper. Communities that predominantly serve dually eligible residents may have fewer resources, and staff members may provide less personal care via core services that could delay or prevent a move to an institution such as a nursing home, the authors said. Dually eligible residents also have fewer financial resources to pay for those services, they added. 

Implications for providers, policymakers

For providers, the authors stated, it is important to consider the increasing needs of residents who likely cannot pay for services as well as the staffing needed to support residents’ care needs.

“Committing to admit this population may require having a different mix of services, such as access to staff with adequate behavioral health training,” they wrote.

“Assisted living providers who agree to take the dually eligible Medicare beneficiaries may need to lobby / negotiate with their respective states for sufficient funds to provide equitable levels of services to all residents, regardless of Medicaid eligibility status,” Temkin-Greener said.

At the state level, although Medicaid HCBS theoretically are available to dual beneficiaries who live in assisted living, the authors stated that, in practical terms, the level of support may not be as frequent or as intense as needed to prevent transitions in care. And most states have sizable waitlists, which restrict access to HCBS, they added.

State policymakers, the authors said, need to realistically assess the extent to which their states are committed to providing LTSS to dually eligible assisted living residents. 

“Without sufficient commitment, delaying or preventing institutional placement of these residents may not be realistic,” they wrote.

At the federal level, an absence of minimum standards make quality assessment and transparency difficult in assisted living, according to the researchers. The authors, however, acknowledged that creating standards is tough, given the variability in the assisted living population.

“This challenge presents an opportunity for researchers to explore appropriate quality measures, and ways of testing and implementing reliable and useful metrics,” they concluded.

First national-level study on this topic

The research, involving 255,564 fee-for-service Medicare beneficiaries living in 24,108 assisted living communities located across the country, was accepted for publication last month by Medical Care Research and Review. It is the first national-level study to report on disparities in healthcare use and outcomes among assisted living residents, according to the paper.

More than 16% of U.S. assisted living residents rely on Medicaid, and almost half of U.S. assisted living communities are Medicaid-certified, according to the authors. The number of residents who are dually eligible for Medicare and Medicaid varies significantly by state, from 6% in New Hampshire to 40% in New York, they noted.

The research was supported by a grant from the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services, which also includes the Centers for Medicare & Medicaid Services.