CMS OMH Mission & Vision

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Quality of Health Care Group A Group B 12/6/2017 Understanding and Addressing Health Disparities in Nursing Home Care Sonya Bowen,

populations we represent (racial and ethnic minorities, sexual and gender minorities, rural populations, and people with

Vision All CMS beneficiaries have achieved their highest level of health, and disparities in health care quality and access have

Patient Preferences The Operation of Healthcare Systems and Legal and Regulatory Climate Discrimination: Biases, Stereotyping, and

1 Quality of Health Care Group A Group B 12/6/2017 Understanding and Addressing Health Disparities in Nursing Home Care Sonya Bowen, MSW CMS Office of Minority Health December 15, 2017 CMS OMH Mission & Vision Mission To ensure that the voices and the needs of the populations we represent (racial and ethnic minorities, sexual and gender minorities, rural populations, and people with disabilities) are present as the Agency is developing, implementing, and evaluating its programs and policies. Vision All CMS beneficiaries have achieved their highest level of health, and disparities in health care quality and access have been eliminated. 2 CMS Health Equity Framework What is a Health Care Disparity? Understanding, Solutions, Actions (U.S.A.) Our path to equity in Medicare quality consists of three interconnected domains: Difference Clinical Appropriateness and Need Patient Preferences The Operation of Healthcare Systems and Legal and Regulatory Climate Discrimination: Biases, Stereotyping, and Uncertainty Disparity SOURCE: Figure 1. Differences, Disparities, and Discrimination: Populations with Equal Access to Healthcare. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, Summary. Brian Smedley, Adrianne Stith, and Alan Nelson, Eds. Washington, DC. Institute of Medicine,

Types of Health Disparities Racial and Ethnic Gender Socioeconomic Status Geographic Sexual Orientation Disability Nursing Home Demographics 5 6 United States Population Age 65 & Older by Race &

1% American Indian/ Alaska 0.4% Asian 2% Hawaiian and Other Pacific Islander Multiracial 0.1% 0.3% Black, Non- 9% Black, Non- 14% 8% 78% 5% 79% Total Population Age 65 & Older = 46.

2 Types of Health Disparities Racial and Ethnic Gender Socioeconomic Status Geographic Sexual Orientation Disability Nursing Home Demographics 5 6 United States Population Age 65 & Older by Race & Ethnicity, 2014 Distribution of Nursing Home Residents by Race & Ethnicity, 2014 American Indian/ Alaska 0.5% Asian 4% Multiracial 0.7% Hawaiian and Other Pacific Islander 0.1% American Indian/ Alaska 0.4% Asian 2% Hawaiian and Other Pacific Islander Multiracial 0.1% 0.3% Black, Non- 9% Black, Non- 14% 8% 78% 5% 79% Total Population Age 65 & Older = 46.2 Million SOURCE: U.S. Census Bureau. Annual Estimates of the Resident Population by Sex, Race, and Origin for the United States, States, and Counties: April 1, 2010 to July 1, June Total Nursing Home Population = 1.4 Million SOURCE: Centers for Medicare & Medicaid Services. Nursing Home Data Compendium 2015 Edition. 8 2

3 Who receives care where? Nursing homes more segregated by race and ethnicity than geographically similar hospitals or neighborhoods 1 Nursing homes in poorest geographic areas serve greater proportion of black and Medicaid residents, have fewer resources 2 Growth of racial and ethnic minorities living in nursing homes more rapid than growth of racial and ethnic minorities overall 3 1 Health Affairs, 2007 Sept/Oct; 26(5): Milbank Quarterly, 2004 June; 82(2): Health Affairs, 2011 July; 30(7): Some Disparities Are Present on Admission Much of the research has focused on differences between race and ethnicity in nursing home residents. Black and nursing home residents tend to have greater cognitive and physical impairments when admitted to a nursing home. 1 Black nursing home residents tend to be younger, male, on Medicaid, and less likely to be married. 2 Individuals tend to prefer nursing homes with populations similar to themselves, but the preference appears higher among black nursing home residents. 3 1 Med Care July; 53(7): Alt Econ J September; 37(3): J of Health Economics January; 39: Distribution of Nursing Home Residents by Facility Type & Race & Ethnicity, 2014 Distribution of Nursing Home Residents by Facility Size & Race & Ethnicity, 2014 For-Profit Non-Profit Government <50 Beds Beds Beds >200 Beds 6% 7% 5% 3% 6% 6% 5% 4% 16% 14% 13% 17% 14% 23% 25% 23% 16% 14% 24% 24% 25% 8% 32% 26% 42% 70% 68% 79% 82% 81% 70% 78% 83% 55% 55% 58% 51% 44% 39% 37% 46% Total Black Asian American Multiracial Indian/ Alaska NHOPI 25% 27% 27% 22% 17% 4% 5% 1% 2% 4% Total 12% Black Asian American Multiracial Indian/ Alaska 26% 21% 4% 7% NHOPI SOURCE: Centers for Medicare & Medicaid Services. Nursing Home Data Compendium 2015 Edition. 11 SOURCE: Centers for Medicare & Medicaid Services. Nursing Home Data Compendium 2015 Edition. 12 3

Long-Stay Nursing Home Residents Who Received a Flu Vaccine by Race & Ethnicity, 2013 Nursing Home Quality 91% 92% 89% 91% 91% 90% 90% 88% All Nursing Home Residents Black, Non- Asian American

13 14 Long-Stay Nursing Home Residents Who Received a Pneumonia Vaccine by Race & Ethnicity, 2013 Long-Stay Nursing Home Residents Who Had a Fall with Major Injury by Race & Ethnicity, 2013 94% 95%

4 Long-Stay Nursing Home Residents Who Received a Flu Vaccine by Race & Ethnicity, 2013 Nursing Home Quality 91% 92% 89% 91% 91% 90% 90% 88% All Nursing Home Residents Black, Non- Asian American Indian/Alaska Multiracial Hawaiian/ Pacific Islander SOURCE: Agency for Healthcare Research & Quality. National Healthcare Disparities Data, Long-Stay Nursing Home Residents Who Received a Pneumonia Vaccine by Race & Ethnicity, 2013 Long-Stay Nursing Home Residents Who Had a Fall with Major Injury by Race & Ethnicity, % 95% 90% 91% 94% 92% 92% 93% 3% 4% 1% 2% 2% 4% 2% 1% All Nursing Home Residents Black, Non- Asian American Indian/Alaska Multiracial Hawaiian/ Pacific Islander SOURCE: Agency for Healthcare Research & Quality. National Healthcare Disparities Data, All Nursing Home Residents Black, Non- Asian American Multiracial Indian/Alaska Hawaiian/ Pacific Islander SOURCE: Agency for Healthcare Research and Quality. National Healthcare Disparities Data,

High-Risk Long-Stay Nursing Home Residents Who Had a Pressure Ulcer by Race & Ethnicity, 2013

MDS 2016 8% 7% 11% 9% 7% 10% 7% 7% All Nursing Home Residents Black, Non- Asian American

Quality. National Healthcare Disparities Data, 2013.

Social Determinants of Health 18% 18% All Nursing Home Residents 16% Black, Non- 20% 10% 17% Asian

Healthcare Research & 19 Social Gradient Early Life Social Exclusion Work Unemployment Social

Proficiency Health Literacy SOURCE: Richard Wilkinson and Michael Marmot, eds.

5 High-Risk Long-Stay Nursing Home Residents Who Had a Pressure Ulcer by Race & Ethnicity, 2013 Incidence of Residents with New or Worsened Pressure Ulcers by Quarter for NH/SNFs (NQF #0678), MDS % 7% 11% 9% 7% 10% 7% 7% All Nursing Home Residents Black, Non- Asian American Indian/Alaska Multiracial Hawaiian/ Pacific Islander SOURCE: Agency for Healthcare Research & Quality. National Healthcare Disparities Data, Long-Stay Nursing Home Residents Who Had Antipsychotic Medicine by Race & Ethnicity, 2013 Social Determinants of Health 18% 18% All Nursing Home Residents 16% Black, Non- 20% 10% 17% Asian American Indian/Alaska 14% 14% Multiracial Hawaiian/ Pacific Islander SOURCE: Agency for Healthcare Research & Quality. National Healthcare Disparities Data, Social Gradient Early Life Social Exclusion Work Unemployment Social Support Addiction Food Stress Transportation Environment/Community Health Insurance English Proficiency Health Literacy SOURCE: Richard Wilkinson and Michael Marmot, eds. Social Determinants of Health: The Solid Facts, 2 nd Edition. Denmark; World Health Organization, Available at World Health Organization, Europe. 20 5

Median Per Capita Income among Medicare Beneficiaries by Race & Ethnicity, 2016 Median Per Capita Savings among Medicare

Median per capita savings among all beneficiaries $17,350 $13,650 $16,000 $12,250 Total White Black Total White Black SOURCE:

76% Median among those with savings $92,100 $118,950 $27,300 $27,400 SOURCE: Kaiser Family Foundation, Income and Assets of

languages most commonly spoken by Medicare beneficiaries with limited English proficiency throughout U.S.

Medicaid SOURCE: U.S. Census Bureau, Current Population Survey, 2015 Annual Social and Economic Supplement.

6 Median Per Capita Income among Medicare Beneficiaries by Race & Ethnicity, 2016 Median Per Capita Savings among Medicare Beneficiaries by Race & Ethnicity, 2016 $26,200 $30,050 Median per capita income among all beneficiaries $74,450 $108,250 Median per capita savings among all beneficiaries $17,350 $13,650 $16,000 $12,250 Total White Black Total White Black SOURCE: Kaiser Family Foundation, Income and Assets of Medicare Beneficiaries, , September % w/savings 92% 95% 80% 76% Median among those with savings $92,100 $118,950 $27,300 $27,400 SOURCE: Kaiser Family Foundation, Income and Assets of Medicare Beneficiaries, , September Health Coverage among Older Adults by Race & Ethnicity, 2014 Non-English languages most commonly spoken by Medicare beneficiaries with limited English proficiency throughout U.S. Total Black Asian 93% 94% 92% 88% 88% 53% 48% Medicare 32% 30% 23% Medicare & Private Insurance 19% 17% 13% 7% 5% Medicare & Medicaid SOURCE: U.S. Census Bureau, Current Population Survey, 2015 Annual Social and Economic Supplement. 23 SOURCE: Centers for Medicare & Medicaid Services (2017). Understanding Communication and Language Needs of Medicare Beneficiaries. Retrieved from: CMS OMH Issue Briefs. 24 6

States with highest prevalence of Medicare beneficiaries who are limited English proficient Distribution of Nursing Home Residents by Region & Race & Ethnicity, 2012

Asian American Multiracial NHOPI Indian/ Alaska SOURCE: Centers for Medicare & Medicaid Services (2017).

Nursing Home Data Compendium 2013 Edition.

7 States with highest prevalence of Medicare beneficiaries who are limited English proficient Distribution of Nursing Home Residents by Region & Race & Ethnicity, % 12% 8% Northeast Midwest South West 35% 33% 51% 34% 62% 45% 36% 51% 36% 23% 28% 31% 21% 11% 7% 8% 22% 24% 24% 21% 22% 19% 10% 15% 15% 34% 16% 12% 20% Total Black Asian American Multiracial NHOPI Indian/ Alaska SOURCE: Centers for Medicare & Medicaid Services (2017). Understanding Communication and Language Needs of Medicare Beneficiaries. Retrieved from: CMS OMH Issue Briefs 25 SOURCE: Centers for Medicare & Medicaid Services. Nursing Home Data Compendium 2013 Edition. 26 Percentage of Nursing Home Surveys Resulting in Substandard Quality of Care Deficiencies by State, 2012 What Don t We Know? SOURCE: Centers for Medicare & Medicaid Services. Nursing Home Data Compendium 2013 Edition. Figure 2.9. Percentage of Nursing Home Surveys Resulting in Substandard Quality of Care Deficiencies by State: United States,

8 Demographics of Older Sexual and Gender Minorities Nearly 1 percent of adults age 65+ self-identified as lesbian, gay, or bisexual (LGB) on the National Health Interview Survey (NHIS 2013, 2014). Data from NHIS indicate that sexual minority women age 50+ report higher rates arthritis, asthma, stroke and a higher number of chronic conditions, and sexual minority men are more likely to report angina pectoris or cancer. 1 NHIS data indicate that aging LGB adults have higher rates of poor mental health, disability, and low back or neck pain. What Does Care Look Like for Older Sexual and Gender Minorities? Very little research looking at older sexual and gender minorities. What exists tends to be on gay men and lesbians; thus, the needs of bisexual and transgender people remain largely unknown. The health, social care and housing needs of older sexual and gender minorities are influenced by a number of forms of discrimination which may impact the provision of, access to and take-up of health, social care and housing services. Significant gaps exist regarding the provision of culturally competent care for older sexual and gender minorities. SOURCE: Am J Public Health August; 107(8): Nursing Home Experiences for Older Sexual and Gender Minorities Much of the information is anecdotal. Little to no information on clinical quality. Challenges include: Hostile fellow residents; Denial of visits from families of choice or from friends the staff does not approve of; Refusal to allow same-sex partners to room together; and Refusal to involve families of choice in medical decision making, even when there are legal directives in place. Staff may refuse to place transgender individuals in the ward that matches their gender identity. Problems can worsen when a patient is mentally or physically incapacitated and unable to advocate for themselves. SOURCE: Movement Advancement Project and Sage (Services & Advocacy for Gay, Lesbian, Bisexual & Transgender Elders). Improving the Lives of LGBT Older Adults, CMS Initiatives 32 8

9 CMS OMH Health Equity Innovation Incubator Research Approach Contract with NCQA, subcontract with L&M Policy Research Analysis explored intersection of resident safety and culturally and linguistically appropriate services (CLAS) in nursing homes Research Questions: What are the critical resident and patient safety issues in nursing homes? What safety disparities exist in nursing homes and how might they be addressed by improving the delivery of CLAS? Which data are available to identify or monitor disparities in resident safety in this setting? What key initiatives are underway related to resident safety in nursing homes? 33 Conducted multi-media literature review Identified resident safety issues in nursing homes, particularly those disproportionately affecting vulnerable populations Conducted Federal and industry stakeholder interviews Elicited a range of perspectives on resident safety in nursing homes and explore how delivery of CLAS might be leveraged to improve resident safety Key Resident Safety Issues Limited Attention to Disparities Abundant literature on resident and patient safety issues; interviewees concur key concerns include: Falls, pressure ulcers, medication errors, use of physical restraints, transitions in care, and avoidable hospitalizations Poor staff/resident communications and low cultural competence viewed as significant contributors Interviewees suggest broader focus on improving workforce communication skills Communication is the most difficult thing we face Whether by culture or upbringing, people experience and communicate pain differently and have varied perceptions about whether it s ok to express it. Interviewees knowledge of disparities was generally anecdotal, outside of emphasis on facility-driven factors Most stakeholders do not use data from the MDS or other sources to identify or monitor disparities in resident safety* Improving safety for all residents viewed as higher priority Disparities influenced by facility-driven factors *Exceptions include some federal stakeholders and one academic expert

Interviewee Perspectives on Resource Support Stakeholders Thoughts Existing resident and patient safety resources can be dense and difficult to navigate; large campaigns can be intimidating Many

drives a lot of things, and I think that if the content is worth it, people will find a way to participate in it.

10 Interviewee Perspectives on Resource Support Stakeholders Thoughts Existing resident and patient safety resources can be dense and difficult to navigate; large campaigns can be intimidating Many existing resources lack guidance on cultural competence and building communication skills Nursing home resources must be straightforward, concise, and tailored to the environment I know that time drives a lot of things, and I think that if the content is worth it, people will find a way to participate in it. If you don t have [cultural awareness] in your staff, then they don t understand the residents. The residents get unhappy, they get hard to get along with, they attempt to do more on their own. You re going to have falls [etc.] you re going to have frustration not only on the resident s part, but on the family s part. Offer [training] in 15, 30- minute segments so people can have a choice and be able to flex how they can participate to get the important information Opportunities for Engaging Nursing Homes Implications of Findings for Resource Development The Final Rule on requirements for long-term care facilities emphasizes person-centered care and mentions cultural competence (42 CFR Section ) Recognizing individual preferences/needs, improving communication, and building cultural awareness are intertwined with resident and patient safety Focusing on building cultural competence, and improving communication as a way to improve resident safety and deliver person-centered care resonates more so than discussions around CLAS 39 Content - Direct care workforce cultural competence and communication skills to assist facilities in delivering person-centered care Audience - Nursing homes direct care staff and supervisors are most likely to benefit from educational resources on cultural competence Delivery components - Concise, interactive, multi-mode delivery to accommodate a range of adult learning styles If you review what we ve talked about, you ve covered every way a person learns: visual, video, printed, verbal, tactile (pre- and post-test). If you have information you want everyone to learn, it will have to be in different medias

Steps for Identifying and Reducing Disparities Data Opportunities and Research Needs Identify Performance Gaps Develop and Implement Initiatives Targeting the Gaps Increase Availability of CLAS

collection Office of Management and Budget (OMB) 1997 standards: White Black Asian American Indian/Alaska Hawaiian or other Pacific Islander Allow multiple selections Ethnicity is asked separately

11 Steps for Identifying and Reducing Disparities Data Opportunities and Research Needs Identify Performance Gaps Develop and Implement Initiatives Targeting the Gaps Increase Availability of CLAS Strengthen Person and Family Engagement Improve Care Coordination Partner with the Community Collect and Analyze Data Using Standardized Categories Self-report is the gold standard of data collection Office of Management and Budget (OMB) 1997 standards: White Black Asian American Indian/Alaska Hawaiian or other Pacific Islander Allow multiple selections Ethnicity is asked separately Expanded HHS Race and Ethnicity Standards HHS Race and Ethnicity Standards What is your race? (One or more categories may be selected) - White - Asian Indian - Black or African American - Chinese - American Indian or - Filipino Alaska - Japanese - Hawaiian - Korean - Guamanian or Chamorro - Vietnamese - Samoan - Other Asian - Other Pacific Islander Are you, Latino/a, or Spanish origin (One or more categories may be selected) - No, not of, Latino/a, or Spanish origin - Yes, Puerto Rican - Yes, Mexican, Mexican American, Chicano/a - Yes, Cuban - Yes, another, Latino, or Spanish origin

Coding for Social Determinants of Health ICD-10 Z Codes Supplemental factors influencing health status and contact with health services (Z00-Z99): Death of a family member Psychosocial circumstances

12 Coding for Social Determinants of Health ICD-10 Z Codes Supplemental factors influencing health status and contact with health services (Z00-Z99): Death of a family member Psychosocial circumstances Spouse or partner relationship problems Primary support group problems Education or literacy problems Low income Acculturation difficulty Personal history of abuse or neglect in childhood Social exclusion and rejection Data Opportunities under IMPACT Act Improving Medicare Post-Acute Care Transformation Act of 2014 requires submission of standardized data across post-acute care settings Implementation of reporting standardized patient assessment data across post-acute care settings using common standards and definitions Standardized measure domains, include functional status, changes in function, incidence of major falls, medication reconciliation, and preventable hospital readmissions Availability of demographic data within existing postacute care (PAC) data sets allows for data stratification, enhancing the ability to identify disparities National CLAS Standards Intended to advance health equity, improve quality and help eliminate health care disparities. Culture includes race, ethnicity, language, geography, religion and spirituality, and biological and sociological characteristics. Emphasize the importance of cultural and linguistic competency at every point of contact along the health care and health services continuum. CMS OMH Resources

13 Tools for Researchers and Health Care Professionals Data Tools: Mapping Medicare Disparities Tool Sexual and Gender Minority (SGM) Clearinghouse Building an Organizational Response to Disparities Disparities Action Statement Resources for Standardized Demographic and Language Data Collection Guide for Implementing National CLAS Standards for Racial, Ethnic, Sexual, Gender and Linguistic Minorities, People with Disabilities Questions? Go.CMS.gov/OMH

Advancing Effective Communication, Cultural Competence, and Patientand Family-Centered Care: A Roadmap for Hospitals

Advancing Effective Communication, Cultural Competence, and Patientand Family-Centered Care: A Roadmap for Hospitals Christina L. Cordero, PhD, MPH Associate Project Director Department of Standards and