representation of the black elderly in detroit metropolitan nursing homes

REPRESENTATION OF THE BLACK ELDERLY IN DETROIT METROPOLITAN NURSING HOMES Richard L. Douglass, MPH, PhD, Esmeralda Espino, MD, Margaret A. Meyers, BS, BA, Steven C. McClelland, and Kenneth H. Haller Detroit, Michigan

This paper presents the results of an analysis of the distribution of black elderly patients in the long-term care systems of Detroit City, Wayne, and Oakland counties, Michigan. These areas were chosen because of their proximity to Wayne State University and because Detroit has a large black population. Wayne and Oakland counties are largely suburban areas. Black, long-term care utilization was compared with the black elderly representation of the base population in these three locations. The sex-specific distribution between whites and blacks in long-term care populations revealed that black men utilized the greatest amount of long-term care and were more dependent on Medicaid. One hundred twenty-one licensed nursing homes were contacted by telephone and a follow-up questionnaire was sent to the respondents during the five-month study period. It has been observed nationally that the elderly black population is underrepresented in the longterm care system. The findings obtained in this study, however, are not in agreement with the national trend. In Detroit, the black elderly are represented in nursing homes in approximate proportion to their representation in the larger community. From the Department of Community Medicine, Wayne State University, Detroit, Michigan, and the Department of Biology, Alma College, Alma, Michigan. Requests for reprints should be addressed to Dr. Richard L. Douglass, Health Administration, 328 King Hall, Eastern Michigan University, Ypsilanti, Ml 48197.

This analysis raises questions of need vs utilization of long-term care by the black elderly in urban areas. This is the first study of black elderly long-term care representation in a specific urban area in the United States.

One of the characteristic features of the American long-term care system is the variance of utilization along racial and ethnic lines. The elderly black population has been shown to be underrepresented in the long-term care setting nationally, as noted by the 1977 National Center for Health Statistics National Nursing Home Survey' (Table 1). The number of nursing home residents per 1,000 population stratified by age, sex, and race for 1963 (prior to Medicare/Medicaid) and 1977 (after Medicare/Medicaid) indicates a substantial difference between the nursing home representation of the black and of the white elderly. In the most elderly categories (aged 75 to 84 years and 85+ years), the white population utilization rate (per 1,000) was approximately twice that of the black population representation for 1977. In 1963, for the same age groups, the white utilization rate was three times the black and other populations.2 Although it has been recognized at the national level that elderly blacks are underrepresented in longterm care, the underlying causes for this phenomenon are not well understood. Several hypotheses have been suggested, but none has been tested because of insufficient data and research negligence.3'4

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 80, NO. 3, 1988

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REPRESENTATION OF THE BLACK ELDERLY

TABLE 1. NUMBER OF NURSING HOME RESIDENTS PER 1,000 POPULATION IN THE UNITED STATES IN 1963 AND 1977, BY AGE AND RACE Race of Patients

Age of Patients 1963 (Before Medicare/ Medicaid) Under 65 years 65 years and over 65 to 74 years 75 to 84 years 85 years and over 1977 (After Medicare/ Medicaid) Under 65 years 65 years and over 65 to 74 years 75 to 84 years 85 years and over

Total

White

Black and Other

0.6 25.4 7.9 39.6 148.4

0.6 26.6 8.1 41.7 157.7

0.6 10.3 5.9 13.8 41.8

0.9 37.1 11.6 51.7 203.2

0.9 49.7 14.2 70.6 229.0

0.8 30.4 16.8 38.6 102.0

0.9 31.4 17.1

42.0 106.7

The National Academy of Sciences Institute of

Medicine3 has indicated that if the use of nursing homes was simply a matter of the degree of disability, there would be more black elderly patients in nursing homes. Several reasons for racially distinct utilization patterns in nursing homes were suggested by the Institute of Medicine: 1. The values and living arrangements of black families as well as the black elderly's substantial resources of relatives, neighborhood, and non-relative social support may cause a decline in the demand for nursing home beds by the black elderly. 2. Regional and geographic availability of beds affects utilization. Proximity of the nursing home is often a factor for selection. In addition, nursing home beds tend to be in shorter supply in states with a relatively higher proportion of blacks in their population. 3. Most nursing homes are proprietary and set their own standards for admission, methods of payment, and cost. Therefore, the patients' ability to pay for care and their method of payment may limit the choice of facilities to which they can be admitted. 4. Poverty and dependence on Medicaid may also contribute to underutilization. The 1977 National Nursing Home Survey found that Medicaid was the primary source of support for 72.5 percent of black 284

residents and 46 percent of white residents. On the other hand, personal or family income was the primary support for 40.5 percent of white residents, but only for 13 percent of black residents. 5. Racial and ethnic patterns may develop as persons of similar economic and cultural backgrounds tend to cluster or as persons of different backgrounds are actively excluded. Contributing factors may include language, culture, and religion. 6. Finally, racial discrimination at the level of admission is believed to be the major explanatory factor at the national level. Discrimination can occur at any level-from the federal and state level-and can include the process by which persons are referred and admitted to nursing homes.3 The National Nursing Home Survey suggested that Medicaid patients constitute a large share of the pool of hospitalized patients awaiting nursing home placement.' This conclusion was not discussed in a racial context and no research has been published at a regional or local level on this topic. The general research question addressed by the analyses reported in this paper deals with the representation of black elderly in nursing homes in the Detroit area. Is the underrepresentation that was found to be true elsewhere in the country also true in a specific urban population? Specific questions addressed include the following: 1. Is the racial distribution in long-term care consistent with, or different from, the base population distribution in Detroit, outer Wayne, and Oakland? Further, what is the racial distribution of black elderly in the long-term care system in Detroit, outer Wayne, and Oakland counties? (outer Wayne refers to all of Wayne County outside of Detroit City). Based on national research findings, it would be expected that the black population would be underrepresented at the local level. 2. What is the sex-specific distribution of the white and black long-term care population? 3. What is the availability of Medicaid reimbursement for nursing home care in Detroit City, Wayne, and Oakland counties?

METHODS A list of all licensed nursing homes located in Detroit, outer Wayne County, and Oakland County was compiled from a directory prepared by the Bureau of Health Facilities at the Michigan Department of



Public Health.5 These locations were chosen because of their proximity to Wayne State University and because they represent both inner-city and suburban populations. In the Detroit City area, including Wayne and Oakland counties, there are a total of 128 facilities.5 Seven facilities were considered inappropriate to this study for various reasons and were not contacted. Two of these nursing facilities had exclusive-admissions policies based on religious and ethnic background; two served primarily a younger, handicapped population; one was a hospice; one was a closed-head-injury facility; and one was a resident care facility. The remaining 121 homes were contacted by telephone for an initial interview with either the administrator, director of admissions, or director of nursing. Forty-seven homes in Detroit were contacted, 42 in outer Wayne County, and 32 in Oakland County. Each of these interviews included specific inquiries about Medicaid acceptance, male-to-female ratios, and the number of black patients. Ten nursing homes (all in Detroit or outer Wayne) preferred to respond to these questions in writing and therefore were sent the questions by mail. One hundred-eight (89 percent) of the 121 nursing homes responded to the primary questionnaire. Thirty-two (100 percent) Oakland County facilities took part in this phase of the study, while 41 (98 percent) of the outer Wayne County facilities cooperated. Thirty-five (73 percent) Detroit facilities participated. Following completion of the telephone interviews, a second set of questions, including patient sex and race, was mailed to each of the facilities that responded to the primary questionnaire. To encourage participation, telephone follow-up contacts were established with facilities that did not respond promptly. The information contained in the secondary questionnaire was obtained for 52 (48 percent) of the 108 facilities responding to the primary questionnaire. Fifteen (47 percent) Oakland facilities and 25 (61 percent) Wayne County facilities responded, while 12 (33 percent) Detroit City facilities provided responses to the secondary questionnaire. A stratified-analysis strategy was used to test for differences between predominantly or exclusively white-utilized nursing homes and homes with relatively large numbers of black patients. Nursing hQmes in each jurisdiction were divided into those with less than or equal to 10 percent black patients and those

with greater than 10 percent black patient populations. While arbitrary, the 10 percent stratification level was selected after noting that 25 percent of the facilities reported no black patients. As a means ofestablishing the adequacy ofthe secondary sample data, the proportion of black patients reported by jurisdiction was compared with the same measure in the primary sample. No statistically significant different proportions were identified.

RESULTS Findings of specific research questions are reported for three principal areas by (1) racial distributions for black and white nursing home patients in three greater Detroit jurisdictions, (2) sex-specific nursing home utilization as an interacting factor with race, and (3) the distribution of Medicaid reimbursement for longterm care in a nursing home as it relates to racial distribution in these facilities. Nineteen percent of the patients in these nursing homes were black. This is slightly deceiving because jurisdictional stratification indicates large variations. Forty-eight percent of the patients in the City of Detroit nursing homes were black, compared with 9 percent in outer Wayne County, and 3 percent in Oakland County. The most probable explanation for these differences is that the racial composition in nursing facilities is a direct reflection of the racial composition of the elderly in the community. Census data from 1981, projected from 1980, were obtained from the Wayne State University Center for Urban Studies to test this hypothesis.6 For community residents aged 70 years and over it was noted that Detroit's black elderly population comprised 38 percent of the total elderly population while comprising only 5 percent in outer Wayne County and 2 percent in Oakland County. The census data for those aged 70 years and over are compared with the nursing home data by county jurisdiction in Table 2. AM demonstrated by these data for the Detroit urban area, there is no major underrepresentation of the black elderly in nursing homes as suggested by the national data. Do these data suggest appropriate utilization by the black elderly? For such an interpretation to be valid, these assumptions must hold: (1) there must be equal access to long-term care for both racial groups, (2) each nursing home's patients must have been drawn primarily from the surrounding community, and (3) the black and white elderly


285


TABLE 2. PERCENTAGE OF BLACK RESIDENTS FOR THE GENERAL POPULATION (AGED OVER 70 YEARS) AND THE STUDY POPULATIONS STRATIFIED BY COUNTY JURISDICTION

Population

Detroit

Wayne

(%)

(%)

Oakland (%)

37.7

5.0

2.3

47.7

9.1

3.0

51.8

3.8

2.7

1981 Projected census for general population aged over 70 years Nursing homes responding to primary questionnaire Nursing homes responding to secondary questionnaire

in the community must have the same need for nursing care. Research has demonstrated that the black elderly in later years are a less-healthy population and may have a greater need for nursing care.6 It is possible that the slight overrepresentation of the black elderly in Detroit nursing homes is a demonstration of greater medical need. At the very least it is possible to say with confidence that the black elderly are gaining admission to Detroit-area nursing homes in proportion to the racial composition of the elderly community's population-something not found at the national level. In the nursing homes studied, 26 percent of the total number of patients in the three jurisdictions were male, and the variation across the jurisdictions was significant. There was a steady decrease in the representation of men in nursing homes from urban Detroit (32 percent) across outer Wayne County (27 percent) to suburban Oakland County (18 percent). Sex distribution exhibited a dichotomy when stratified by race. The male-to-female ratio for the black nursing home population remained relatively constant across all jurisdictions and approximates a 30 to 70 ratio. In contrast, men constituted a substantially larger proportion of the white population in the urban area (Detroit City 36:64) than in suburban areas (outer Wayne 23:77 and Oakland 18:82) as shown in Table 3. Note that only in the white, suburban areas that the male-to-female ratio approaches the 20:80 figure cited commonly in health gerontology refer-

ences.7 Facilities with proportionately more male patients also had larger black representation (n = 42, P 286

TABLE 3. DISTRIBUTION OF NURSING HOME PATIENTS BY RACE, SEX, AND COUNTY Detroit

Population

(%)

Wayne (%)

Oakland (%)

Black men Black women White men White women

29 71 36 64

32 68 23 77

33 67 18 82