**5. Examples of policies and practices with the potential to address racial and ethnic disparities in LTCFs**

The root causes of inequities among LTCF residents lie in structural racism and ultimately need to be addressed across multiple domains of economic opportunity, housing, and health care systems. Nonetheless, there are responses at the LTCFlevel that demonstrate promise to reduce the consequences of structural racism. This section presents efforts with the potential to address structural racism and reduce inequities among LTCF residents.

#### **5.1 Universal long-term care coverage**

Across the globe, some high-income countries like the United States provide universal access to LTCF benefits through social long-term care insurance (i.e., Germany, Japan, Luxembourg, the Netherlands, and South Korea) or taxpayer funded long-term care (i.e., Denmark, Finland, Norway, and Sweden) [75]. By making coverage universal, these countries avoid the inequities that arise from relegating long-term care coverage to means-tested programs such as Medicaid in the United States. Universal long-term care helps ensure that all citizens have access to long-term care regardless of their financial circumstances and removes potential stigma associated with receiving public assistance. The countries with universal long-term care coverage do not have the unique social circumstances related to race and structural racism as the United States. However, it is reasonable to expect that the equalizing effects of universal long-term care exhibited elsewhere would include reducing racial and ethnic disparities among U.S. LTCF residents.

Within the United States, the State of Washington is implementing universal social insurance for long-term care within its borders [76]. In 2019, the state legislature passed the Washington Long-Term Services and Supports Act, which funds the Washington Cares Fund. Beginning January 1, 2022, Washington employers will be required to collect 0.58% of an employee's wages as premiums for long-term care insurance. Beneficiaries of the fund can receive up to \$36,500 for a variety of longterm care services and supports including care in assisted living/residential care communities and nursing homes [76]. This program is the first of its kind in the United States and can serve as an example for other states or ultimately for a federal program of universal long-term care benefits.

#### **5.2 Medicaid**

Because older adults of color are more likely to live in LTCFs that are funded predominantly through Medicaid, the states have an opportunity to address racial and ethnic LTCF disparities through their Medicaid programs. Limited Medicaid funding results in residents of color disproportionately living in LTCFs that are under resourced and poorly staffed. However, some states' Medicaid policies have improved the quality of care or life for residents of color. One solution is as straightforward as increasing Medicaid's per diem reimbursement rates LTCFs. In a longitudinal study of nursing home citations for care deficiencies from 2006 to 2011, Li et al. [77] found evidence that increased reimbursement rates reduce disparities between nursing homes with high- and low-percentages of minority residents.

In another example, Hernandez [24] found in 2012 that the state of Oregon provided Medicaid reimbursement for apartment-style assisted living. Compared to states like Florida which, at the time, reimbursed for assisted living units with as many as two to four roommates in a room, the practice in Oregon could provide better quality of life for assisted living residents. A state-by-state comparison of policies for state funding for assisted living/residential care (see, for example, compilations like [78]) can provide additional insights into how state policy can affect older adults in LTCFs.

#### **5.3 Private sector initiatives**

Within the private sector there are also examples of initiatives aimed at awareness, education, and elimination of racial and ethnic disparities in LTCFs. In Canada, the Ontario Centres for Learning, Research & Innovation in Long-Term Care have created resources for LTCFs including a toolkit for embracing diversity; a diversity and inclusion calendar; diversity, equity, and inclusion (DEI) posters for use within LTCFs; and publications, reports, and toolkits related to indigenous culture and care for indigenous residents [79]. The toolkit for embracing diversity includes an instrument LTCFs can use to assess their LTCF and plan DEI efforts [80]. It contains detailed assessment items for DEI in seven domains: planning and policy, organizational culture, education and training, human resources, community capacity building, resident and family engagement, and service provision. It also provides a template for LTCFs to create SMART goals (i.e., specific, measurable, assignable, realistic, and time-bound) related to DEI in their homes. In the United States, the Oregon Health Care Association, the largest long-term care trade association in the state of Oregon, helps connect its member LTCFs to resources related to race and racism, including information on cultural trauma; Black, Indigenous, and other People of Color (BIPOC) mental health; bystander intervention, and racial justice [81]. While these efforts may not dismantle structural racism itself, they can affect change in individual LTCFs or LTCF chains resulting in reduced disparities for residents of color.

#### **6. Recommendations**

The process of eliminating the effects of structural racism among LTCF residents is seemingly impossible without first acknowledging the history and plight of persons of color in the United States. Inequities in access to quality LTCFs have existed since the rise of private nursing homes in the late 1930s. In the U.S. society, systems of economic opportunity, education, housing, health care, and retirement financing have created and perpetuated racial disparities in health outcomes, engagement in health care services, and quality of care. The effects of structural racism accumulate over the life course, resulting in heightened disparities by the time older adults enter LTCFs. Immediate action at the LTCF policy- and practicelevel is needed to reduce the inequities to which thousands of LTCF residents of color are subjected. This section focuses on actionable policy and practice recommendations geared toward the residents and systems directly connected to LTCFs, However, as our conceptual model for understanding and addressing racial and ethnic disparities among LTCF residents suggests, structural racism is a force across the life course. To ensure future cohorts of older adults experience racial equity and justice in LTCF-settings and systems, we must conquer structural racism and its resulting health and economic disparities across the life span.

#### *Addressing Systemic Factors Related to Racial and Ethnic Disparities among Older Adults… DOI: http://dx.doi.org/10.5772/intechopen.99926*

The process of effectively eliminating structural racism can seem like a daunting task. However, the examples in the preceding section demonstrate the potential for tangible results that improve the LTCF experience for residents. Because structural racism is directly and indirectly associated with racial and ethnic disparities experienced by LTCF residents, policymakers and practitioners need to employ a critical lens to understand and rectify its effects for LTCF residents. This critical approach includes four domains: awareness, acceptance, advocacy, and action related to structural racism and its effects. **Table 1** presents these domains with LTCF-related examples. In terms of *awareness*, policymakers and practitioners can increase their own and others' awareness of historical and current racial injustices related to LTCF inequities (e.g., inequitable distribution of wealth and economic opportunity, neighborhood segregation, social insurance, and health care funding). *Acceptance* of the existence of inequities and systemic barriers to affordable and quality LTCF care for people of color is also necessary. Additionally, *advocacy* on behalf of residents and vulnerable resident populations becomes a crucial tool for engaging in a participatory process to create change in systems that perpetuate racial and ethnic inequities in LTCFs. Lastly, if there is to be a reduction and elimination of policies and practices associated with structural racism, there must be *action*.

This chapter concludes with policy and practice recommendations. With diligent advocacy and action, change aimed at equity and racial justice for all LTCF residents is possible.

#### **6.1 Policy recommendations**

Several policy changes have the potential to reduce racial and ethnic disparities among LTCF residents. This section focuses on the action of implementing these policies. However, as described above, awareness, acceptance, and advocacy are preliminary and important steps for enacting these recommendations.


#### **Table 1.**

*Components of efforts to eliminate the effects of structural racism among LTCF residents.*

An ambitious but powerful tool for reversing structural racism in long-term care funding is implementing a universal social insurance for long-term care. In 2018, 70% of Americans over the age of 40 supported this proposal [82]. Although universal long-term care coverage would not eliminate the root causes of current racial and ethnic disparities in LTCFs, it would increase access to care in LTCFs and reduce reliance on Medicaid and its low reimbursement rates for disadvantaged older adults, including many people of color.

Increased Medicaid reimbursement rates for LTCFs are another way to reduce racial and ethnic disparities among LTCF residents [77]. The percentage of Medicaid funding that was spent on long-term care dropped from almost 50% in 1985 to only 30% in 2015 [83], during a time when the percentage of older adults in the United States was increasing. This trend could be reversed and funding priorities could reflect a greater emphasis on supporting LTCFs. To overcome fiscal objections to increasing Medicaid reimbursements for LTCFs, Chisolm et al. [39] suggest increased reimbursement rates could be targeted to LCTFs with high percentages of residents paying for care with Medicaid. Both approaches merit serious consideration, particularly when backed with federal funding as opposed to state funding, which would help LTCFs in states with low levels of income and resources.

Reforms such as a new social insurance program or increased federal funding from Medicaid would require legislative action, but many other policy changes could be made within the executive branches of government (e.g., within the U.S. Department of Health and Human Services). Because the Centers for Medicare & Medicare Services regulates Medicare- and Medicaid-certified nursing homes (as well as some aspects of Medicaid-certified assisted living/residential care communities), it has the ability to transform LTCF practices. For example, regulations could add training in racial and ethnic disparities in LTCFs to the mandatory staff training requirements staff. Similarly, The Centers for Medicare & Medicare Services should add to their current guidance for state surveyors of nursing homes to include information about identifying and reducing racial and ethnic disparities. At the state level, state health departments could bolster regulations for state inspectors of LTCFs to include considerations of racial and ethnic disparities in assessments and reporting.

The Long-Term Care Ombudsman Program has long advocated for LTCF residents [84]. However, reporting practices vary by state and some state programs do not collect and report race and ethnicity data related to the complaints they receive and resolve [53]. The Patient Protection and Affordable Care Act of 2010 requires programs that receive federal funding to collect and analyze data related to their participants' race and ethnicity. We recommend extending the spirit of the Affordable Care Act to regulations for the Long-Term Care Ombudsman Program's reporting responsibilities. If the ombudsman programs were mandated to collect, analyze, and report race and ethnicity data related to the individual complaints they receive, it would facilitate tracking, understanding, and addressing potential racial and ethnic disparities in LTCFs, including assisted living communities, across the United States.

#### **6.2 Practice recommendations**

Organizations and individuals should take steps to increase awareness, acceptance, advocacy, and action related to structural racism and racial and ethnic disparities among LTCF residents. Organizations such as local Long-Term Care Ombudsman Programs, LTCF trade organizations, and LTCF companies can help increase awareness of staff, residents, and the public by including racial justice in their mission statements. They can not only hire staff from more diverse *Addressing Systemic Factors Related to Racial and Ethnic Disparities among Older Adults… DOI: http://dx.doi.org/10.5772/intechopen.99926*

backgrounds or bilingual staff members, but also ensure their staff receive diversity training, including training on the disparities across and within LTCFs and the systemic factor associated with the disparities. As part of acceptance of disparities, LTCF administrators can ensure their organizations analyze and report data related to racial and ethnic disparities among their own residents. Organizations and individuals can advocate for policy reform to their state and federal legislators, officials at their state department of human services, or the U.S. Department of Health and Human Services. It is also potentially empowering for teams across organizations and agencies to form partnerships to address racial and ethnic disparities within LTCF systems. For example, LTCF social workers and Long-Term Care Ombudsman staff and volunteers could work together to reduce disparities and bring cultural inclusiveness to LTCF residents and staff [53]. Finally, within individual LTCFs or LTCF chains, administrators can ensure that their services and group activities are appealing to and affirming of minority residents, that food options and building design are culturally appropriate; and that minority residents are empowered to raise concerns about their care and quality of life [85]. Some of these recommended efforts at the LTCF-level will require careful interrogation of assumptions of what is considered normative in LTCFs (e.g., book collections with only White authors) and could be supported by diversity, equity, and inclusion equity tools such as the toolkit from the Ontario Centres for Learning, Research & Innovation in Long-Term Care [79].
