Alzheimer's Special Care Units in Nursing Homes: Racial and Ethnic Disparities, Resident Outcomes, and State Policies - PROJECT SUMMARY/ABSTRACT
Alzheimer's special care units (SCUs) are a promising care model for nursing home residents with Alzheimer's
Disease & Related Dementias (ADRD). SCUs provide higher quality care and improve outcomes for residents
with ADRD. Our preliminary analysis further found that, in facilities with an SCU, the disparities in 3-month
hospitalization rates and pressure ulcers between Hispanic and White residents were eliminated or greatly
reduced. Despite the benefits of SCUs, racial and ethnic minority residents are less likely to access SCUs than
White residents, suggesting that lack of SCU access may be a mechanistic pathway responsible for disparities
in outcomes. Currently, SCUs are available in only 14% of nursing homes and access varies substantially across
states. State Medicaid policies and SCU regulations can incentivize or disincentivize nursing homes to develop
SCUs. By analyzing national Medicare claims and resident assessment data, as well as unique Ohio
surveys of SCUs and resident and family satisfaction with care, we propose to understand the extent to
which racial and ethnic differences in SCU access contribute to disparities in outcomes, and the
associations of current state policies and regulations with SCU availability.
The specific aims are: Aim 1) To examine disparities in access to Alzheimer's SCUs among Black and Hispanic
residents with ADRD; Aim 2) To understand SCU access as a pathway to disparities in health outcomes among
Black and Hispanic residents with ADRD; and Aim 3) To investigate which state policies are associated with
increased availability of SCUs.
The primary analyses will study the 819,415 newly-admitted long-stay residents with ADRD in 15,305 nursing
homes from 2011 to 2019. The decomposition method will uncover factors that explain disparities in SCU access
among Black and Hispanic residents, and mediation analyses will assess how differences in SCU access
contribute to racial and ethnic disparities in health outcomes. Dominance analyses will evaluate the contribution
of specific SCU characteristics (physical environment, staffing, and physician involvement) to health outcomes
and resident and family satisfaction, as well as reduced racial and ethnic disparities. We will also analyze 2020-
2024 data to examine whether our findings hold during and after the COVID-19 pandemic. Hierarchical
Generalized Linear Mixed Models and Difference-in-Differences method will explore which state policies (e.g.,
supplementary payments for SCU care, Medicaid payment-to-cost ratios, regulations about staffing or training)
are associated with SCU availability. Understanding the role of SCU access in racial and ethnic disparities in
ADRD-related outcomes can inform policymakers as they seek to mitigate disparities in nursing home care.
