According to a comprehensive study conducted by David Barton Smith, emeritus professor of the Fox School of Business, Jacqueline Zinn, professor of healthcare management at the Fox School, Zhanlian Feng, Mary L. Fennel, and Vincent Mor, of Brown University commonly found nursing home segregation in the U.S. leads to racial disparities in the quality of care.

Smith, Zinn, and their co-authors documented these long suspected inequities in their study, "Separate but Unequal: Racial Segregation and Disparities in Quality across U.S. Nursing Homes," published in the September/October issue of Health Affairs. The study, supported by the Commonwealth Fund, is the first to document the relationship between racial segregation and quality disparities in U.S. nursing homes.

According to their findings, blacks are four times more likely than white Americans to find themselves in poorly funded, understaffed nursing homes that offer substandard care. Nationwide, 40 percent of black nursing home residents live in lower-tier nursing homes, compared with just 9 percent of white nursing home residents. In fact, blacks are grossly overrepresented in lower-tier nursing homes in virtually every state in the country.

“This study shows us that racial segregation has a significant impact on the quality of care received by nursing home residents,” said Smith, lead author of the study.

How is it possible for such disparities to exist today? According to Zinn, “A recurring theme over the past forty years has been the lack of data to document the extent of the problem.” In fact, the study reports that as recently as 1967, nursing homes merely had to post signs that certified that they did not discriminate in order to qualify for Medicare. No written admission or practice information was requested, and according to the study, no federal civil right inspections were performed. “The most important thing is awareness,” said Zinn.

The problem is most acute in the Midwest. However, Pennsylvania (Harrisburg-Lebanon-Carlisle) included some of the most segregated metropolitan statistical areas (MSAs). As of the year 2000, Harrisburg was listed in the top 10 in the nation for “Degree of Segregation among Black and White U.S. Nursing Home Residents”, according to data used in the study collected from the Centers for Medicare and Medicaid Services. Philadelphia (combined Phila PA/NJ primary MSA) ranked as the 26th most segregated MSA out of 147, and Wilmington/Newark DE ranked 84th.

In their analysis researchers looked at racial segregation in 147 MSAs with 7,196 nursing homes that care for more than 800,000 residents. Researchers used the Dissimilarity Index, the most common measure of residential segregation. The index indicates the combined percentage of residents in both races who would have to be relocated for there to be an equal proportion of blacks and whites in the nursing home.

The researchers also found that:

• Blacks were nearly three times as likely as whites to be located in a nursing home housing predominantly Medicaid residents.
• Blacks were nearly twice as likely as whites to be located in a nursing home that was subsequently terminated from Medicare and Medicaid participation because of poor quality.
• Blacks were 1.41 times as likely as whites to be in a nursing home that had been cited with a deficiency causing actual harm or immediate jeopardy to residents.
• Blacks were 1.12 times as likely as whites to reside in a nursing home that was greatly understaffed.
• Lower-tier facilities are significantly more likely to serve residents with psychiatric conditions or those with a history of mental retardation.