Racial and Ethnic Health Care Disparities Research in Minnesota Nursing Homes Speaks to Our Times

In June 2020, Tetyana P. Shippee, Ph.D., a social gerontologist, was about to publish work on nursing home disparities when data from the Centers for Disease Control and Prevention showed that COVID-19 was striking the older population at escalating rates. Residents of nursing homes and long-term care facilities were hardest hit, with infections and death rates reaching new peaks daily. Dr. Shippee’s research became immediately relevant to urgent efforts addressing the public health crisis. Her team at the University of Minnesota School of Public Health in Minneapolis had been studying racial disparities and quality of life (QOL) in nursing homes and long-term care facilities in Minnesota and the nation.

“Many factors determine how we age and our quality of life as we age. And as our population gets older and older, long-term care services and supports will become even more important,” said Shippee. “As a social gerontologist, my work focuses on what really matters to people as they age, such as quality of life measures (like social interactions with others and treatment by staff) in long-term care settings and the role of racial, ethnic, and socioeconomic disparities for older adults' quality of life.”

Dr. Tetyana Shippee with her team and community partners standing in a presentation room in a line in from of the podium and screen, which reads, “Community Forum: Racial Equity in Aging Services for Older Adults, November 8, 2019, 10:00 – 1:00
Dr. Tetyana Shippee (third from right) with team and community partners at presentation of findings. Photo courtesy of Dr. Tetyana Shippee.

She and her team published the first of several papers on their work in the June 2020 issue of Innovation in Aging, which examined the QOL for nursing home residents and whether individual race/ethnicity and the racial and ethnic composition of a nursing home affect the QOL of its residents. The research was based on in-person interviews completed prior to the pandemic from a racially/ethnically diverse group of more than 11,000 randomly selected residents in all Medicare/Medicaid certified nursing homes in Minnesota. The survey measured six categories of QOL for nursing home residents: the nursing home environment, social engagement, attention from staff, food enjoyment, negative mood, and positive mood.

Dr. Shippee and her team found that Black, indigenous and persons of color (BIPOC) have a significantly lower QOL when compared to White residents in nursing homes, regardless of the proportion of BIPOC residents at the facility. BIPOC residents also reported lower levels of satisfaction than white residents in all aspects of nursing home life. The largest gaps in satisfaction between BIPOC and white residents were found in food enjoyment, social engagement, and attention from staff.

These differences might be connected to the fact that BIPOC residents are much more likely to reside in high proportion BIPOC nursing homes, which have fewer resources than primarily white nursing homes. Also, on average, BIPOC residents are considerably younger and more likely to have diagnoses of serious mental illness and behavioral problems than white residents, indicating complex care needs. However, white residents also reported a lower QOL when they lived in high proportion BIPOC facilities compared to white residents in primarily white nursing homes. Thus, lower QOL is impacted by the environment of the nursing homes themselves, as nursing homes with more BIPOC residents were typically larger and for-profit, more reliant on Medicaid reimbursement, and had lower staffing levels.

Group of 4 people around cafeteria table. Seated African American man, standing Hmong woman (Dr. Mai See Thao), standing White woman (Dr. Tetyana Shippee) and seated Latino man.
Two nursing home residents with former student team member Dr. Mai See Thao and Dr. Tetyana Shippee during meal time. Photo courtesy of Dr. Tetyana Shippee.

Choice Matters

Shippee says that in some facilities, culturally responsive care is being equated with racial/ethnic similarity between the staff and residents. But in fact, the team found that racial similarity alone did not compensate for the fact that high-proportion BIPOC serving facilities are greatly underfunded and understaffed. Using in-depth qualitative interviews and other forms of qualitative data collection, the team identified a number of additional reasons why, despite staff having the best intentions, residents in these facilities have lower quality of life and quality of care. BIPOC residents have had little choice in the facilities they go to. During their interviews with residents, Black residents in high-proportion BIPOC facilities often said they wanted to be in a different facility. Shippee explained that the lack of choice comes down to hospital discharge planners, where different hospitals have their networks for discharging to primarily Medicaid-funded nursing homes and much depends on which facility has an open bed. Many of these facilities are in large metropolitan areas, like Minneapolis.

In her team’s analyses, as well as of those nationally, most BIPOC residents end up in high-proportion BIPOC facilities. Consistently, they have found that there is a growing disparity, particularly for Black and indigenous residents. Shippee believes the data is showing why and how this disparity is happening. “It’s lack of choice in selection; high degree of understaffing in certain facilities; and lack of resources for basic necessities,” she says. Reflecting on their research, Shippee added, “I am really moved when I disseminate this work publicly, talking about the underlying fundamental cause for this significant and growing gap in QOL for BIPOC residents. It is structural racism.”

Addressing Disparities at the Epicenter of Racial Unrest

Structural racism and discrimination (SRD) refers to macro-level conditions (e.g. residential segregation and institutional policies) that limit opportunities, resources, power, and well-being of individuals and populations based on race/ethnicity and other statuses. There is increasing recognition that SRD contributes to poorer health outcomes for BIPOC and other populations who experience health disparities.

When the COVID pandemic arrived in early spring of 2020, racial and ethnic disparities in nursing homes took on particular significance, since the majority of serious illness and deaths were occurring among older adults, especially those in care facilities. “Long-term care is one of the most racially segregated aspects of health care in this country,” Shippee says. “And it’s been this way for the past 20, 30 years—built for White people, and its culture reflects that as well.”

Then the Black Lives Matter movement gained momentum, especially after the death at the hands of police of George Floyd in Minneapolis in May 2020. Shippee lived near where a number of protests took place, just as her work on QOL inequities in nursing home was published. Her children were asking questions, not just about her work, but why white people were protesting. It made her, as she described, be more intentional in understanding the broad social impact of her work, that the work of health equity impacts everyone. She reflected, “It shows exactly why white people need to be doing the work of racial reconciliation and fighting against structural racism in this country.”

Dr. Shippee is an immigrant to the United States, with a law degree from Ukraine. After she came to the U.S. in 2000, she was stunned when other students told her about the “other side of the tracks” in the Tennessee town where she attended school. To come to the U.S. and see that there wasn’t equal access to health care or housing because of one’s race seemed unconscionable. Soon, her focus shifted from studying law to health equity, because the reason she studied law in Ukraine was to fight for justice. Her doctoral work focused on issues of racial justice and racial disparities, looking at long-term access to health care and health outcomes for different populations.

Dr. Shippee coupled her early experiences with health inequities in America with her current research and work in Minneapolis, particularly during the pandemic. She has started having bolder conversations, educating herself more, and asking community members, collaborators, and team members to make sure that their language does not add to perpetuate disparities. She is now talking directly about structural racism and connecting it to disparities where they find them, when she talks to students, and when she disseminates this work to a variety of audiences.

Shippee feels that the events of summer 2020, both in Minnesota and nationally, have shown that health equity is not just its own marginal area. The work of health equity is work that must be done by all. “White people must engage in that work, regardless of their area of study, if they truly want to see change. That’s how I see my role as a white researcher doing this work on health equity.”

Recent publications from Dr. Tetyana Shippee, Ph.D., Associate Professor, University of Minnesota School of Public Health and the team on racial disparities in long-term care in Minnesota:

Shippee, T.P., Ng, W, Bowblis, J. “Does Living in a Higher Proportion Minority Facility Improve Quality of Life for Racial/Ethnic Minority Residents in Nursing Homes?” Innovation in Aging 2020; 4(3): igaa014. https://academic.oup.com/innovateage/article/4/3/igaa014/5851608

Shippee, T.P., Ng, W., Duan, Y., Woodhouse, M., Akosionu, O., Chu, H., Ahluwalia J.S., Gaugler, J.E., Virnig, B., Bowblis, J.R. 2020. “Changes over Time in Racial/Ethnic Differences in Quality of Life for Nursing Home Residents: Patterns within and between facilities.” Journal of Aging and Health, Journal of aging and health 2020 12; 32 (10) 1498-1509 https://journals.sagepub.com/doi/abs/10.1177/0898264320939006?journalCode=jaha

Bowblis, J., Ng, W., and Shippee, T. P. 2020. “Decomposing Racial and Ethnic Disparities in Nursing Home Quality of Life.” Journal of applied gerontology: the official journal of the Southern Gerontological Society 2020 Aug 10; 733464820946659 https://journals.sagepub.com/doi/10.1177/0733464820946659

Shippee, T.P., Akosionu, O., Ng, W., Duan, Y., Woodhouse, M., Thao, M., Bowblis, J. 2020. “COVID-19 Pandemic: Exacerbating Racial/Ethnic Disparities in Long-Term Services and Supports.” Journal of Aging and Social Policy. https://www.tandfonline.com/doi/full/10.1080/08959420.2020.1772004

Shippee, Tetyana P., Duan, Yinfei, Olsen-Baker, Mary and Angert, Julie. 2020. “Racial/Ethnic Disparities in Self-Rated Health and Sense of Control among Older Adults Receiving Publicly funded Home and Community-Based Services” Journal of Aging and Health. https://journals.sagepub.com/doi/abs/10.1177/0898264320929560?journalCode=jaha

McCarron, Hayley R.; Wright, Alana; Moone, Rajean P.; Toomey, Traci; Osypuk, Theresa L.; and Shippee, Tetyana (2020) “Assets and Unmet Needs of Diverse Older Adults: Perspectives of community-based service providers in Minnesota,” Journal of Health Disparities Research and Practice: Vol. 13 : Iss. 1 , Article 6. Available at: https://digitalscholarship.unlv.edu/jhdrp/vol13/iss1/6

Duan, Yinfei; Shippee, Tetyana P; Ng, Weiwen; Akosionu, Odichinma; Woodhouse, Mark; Chu, Haitao; Ahluwalia, Jasjit S; Gaugler, Joseph E; Virnig, Beth A; Bowblis, John R. “Unmet and Unimportant Preferences Among Nursing Home Residents: What Are Key Resident and Facility Factors?” Journal of the American Medical Directors Association 2020 11; 21 (11) 1712-1717 https://www.jamda.com/article/S1525-8610(20)30556-9/fulltext

This was the team’s first paper using Minnesota data to examine racial/ethnic disparities in quality of life.

Shippee, T.P., Henning-Smith, C., Rhee, G., Held, R.N., Kane, R.L. 2016. “Racial differences in nursing home residents’ quality of life and the association with facility characteristics.” Journal of Aging and Health, 2016;28(2):199-224. https://journals.sagepub.com/doi/10.1177/0898264315589576

Page updated August 2, 2021