Environmental and structural factors driving poor quality of care: An examination of nursing homes serving Black residents

Jasmine L. Travers, Nicholas Castle, Susan H. Weaver, Uduwanage G. Perera, Bei Wu, Andrew W. Dick, Patricia W. Stone

Research output: Contribution to journalArticlepeer-review


Background: Poor quality of care in nursing homes (NHs) with high proportions of Black residents has been a problem in the US and even more pronounced during the COVID-19 pandemic. Federal and state agencies are devoting attention to identifying the best means of improving care in the neediest facilities. It is important to understand environmental and structural characteristics that may have led to poor healthcare outcomes in NHs serving high proportions of Black residents pre-pandemic. Methods: We conducted a cross-sectional observational study using multiple 2019 national datasets. Our exposure was the proportion of Black residents in a NH (i.e., none, <5%, 5%–19.9%, 20–49.9%, ≥50%). Healthcare outcomes examined were hospitalizations and emergency department (ED) visits, both observed and risk-adjusted. Structural factors included staffing, ownership status, bed count (0–49, 50–149, or ≥150), chain organization membership, occupancy, and percent Medicaid as a payment source. Environmental factors included region and urbanicity. Descriptive and multivariable linear regression models were estimated. Results: In the 14,121 NHs, compared to NHs with no Black residents, NHs with ≥50% Black residents tended to be urban, for-profit, located in the South, have more Medicaid-funded residents, and have lower ratios of registered-nurse (RN) and aide hours per resident per day (HPRD) and greater ratios of licensed practical nurse HPRD. In general, as the proportion of Black residents in a NH increased, hospitalizations and ED visits also increased. Discussion/Implications: As lower use of RNs has been associated with increased ED visits and hospitalizations in NHs generally, it is likely low RN use largely drove the differences in hospitalizations and ED visits in NHs with greater proportions of Black residents. Staffing is an area in which state and federal agencies should take action to improve the quality of care in NHs with larger proportions of Black residents.

Original languageEnglish (US)
Pages (from-to)3040-3048
Number of pages9
JournalJournal of the American Geriatrics Society
Issue number10
StatePublished - Oct 2023


  • black concentration
  • long-term care
  • racial and ethnic disparities

ASJC Scopus subject areas

  • Geriatrics and Gerontology


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